HomeMy WebLinkAboutZODIAK MANOR ALASKA BLK 5 LT 5o-'K
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
Pump Installation Log
Well Drilling Permit Number: _______________ Date of Issue: ____-____-____
Parcel Identification Number: ____-____-____
Legal Description Block Lot Property Owner Name & Address:
Pump Installation Date: _____-_____-_____
Pump Intake Depth Below Top of Well Casing: __________ feet
Pump Manufacturer’s Name: ___________________________ Pump
Model: _____________________________________
Pump Size: ____________hp
Pitless Adapter Burial Depth: _________ feet
Pitless Adapter Manufacturer’s Name: _________________________
Pitless Adapter Installer: ____________________________
Well Disinfected Upon Completion? XX Yes No
Method of Disinfection: _____________________________
Comments:
Pump Installer Name: __________________________________
Company: ___________________________________________
Mailing Address: ______________________________________
City: ___________________ State: __________Zip: _________
Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation.
PERIdZ T NO.
[)IEPFIRTMEI",I-I- Cfi:' 14EFIL.'T'H I=llqB, EIq'v'IRONt"IEIqTFIL PRO'TEC'T'];ON
S2!5 "L. '" ~;TI~:EE"I", I=INCHEIf,?.FIGE., FIE.
2E;4.-,:t72C~
]...~1 EE Il...._. L Il::" IE F.~." Ih-Il Z "It"
FIF'I='I_ I C:FINT
L.O CI:::IT I IZl[q
I..EI31=II..
I;;: CIN I<L I NI<HRHMER
L5BS"; ZO[)IF:iI< I"IFIF,ICI]:~,:
83:;;~E~ E~-,',ETER Df*';.':
LOT S;IZE
3: 4-S,-. ::L :~: ,q. !5
99999:~ S6iUFIRE FEE(T
H I I",I I I','11...11,1 D ]: STFtI',IC:E E:E'rP.IEEN F:I I.,.IELI.. FIN[) FIN"r' Olq-~:; l"rE: SEI.,.IFIGIE [:, I
'J. EIEl FEET FOR FI I='RIVFITE NEL. L. 0[~'. ::L.SEi TO [:_.'EIC1 FEEET FROM FI PUBL. IC: NEL. L [:,EF'ENE:,ING
UF'ON THE T'¢PE OP" F'UE:LIC: HEL. I ....
MINIHUI,1 [:,I:STFINC[C FF::ON Fi F'F?.I',,,'FITE 1.4E:"LL TO FI F'RIVFtT[:: '.SEI.qER LINE :IS ;25 FEET i::IN[:,
TO FI C:OMfdL.INIT'¢ SEIqlEI:~: L. II',IE IS 75 FEEl".
NELL L..CtG~'.:; FI[~'.E: [~'.E).:.!LIIF['.IF:[:, I=ff.,I[:, I,'II.]'..ST E:E [~:E;TUI~'.P,IE;[:, TO THE DEF'FII~'.THENT P~I'I-HIN ~:C~ DF:I"r'S~
L31= THE: P.IEL. I_ COHF'L.ETION.
O'I"I4EER RE(i:!I...I:[IR[~:MENT-~S I"IFI'¢ FIF'F'L."r'. ':'~;PECIF'ICFITION¢:; laN[:, CONSTRUCTIOI',I [:,IFIGRFIM$ FIRE
FIVF:IIL. laE:LE TO INSUI~'.E Pt~:OPER IIq:STFIL. LF:tTIOI"~.
I CERTIF"r' THFIT
:1.: I FIH FFII'II l._. ]:laf~: FI:[ TH TI"IE R[.:.~;:!LI I I:~:EI"IENTS; FOR OF,I-S I TE 5;EI.,IEI;;:$ FIN[:' P.IEL_I._S I:I:S
FORTH 8"r' THE I"1LINICIPlaI..:[T'¢ OF F'INC:HCIRFIG[:-'.
2: I I.,.IILL. INSTFIL. L THE S'¢STEM If',l FIC:CORC'FINC:E P.II'T'H THE E:O[:,ES.
S";E:'T
',,,' q.. la
Property Owner
Mailin9
Buyer = ~
Address
NT FILLS OUT UPPER HAl_ ONLY
zip Code
Zip Code
[_ending Institution
Address
Zip Code
Zip Code
Phone
fype o[ Residence
~ Single Eamily
[ ~ Multiple Family No, of Bedrooms
( 3 Other
Water Supply
~lndividual ATTACH WELL LOG. A well log is required for a~l wells drilled since June 1975.
Iq Community Eot wells drilled prior to that date, give well depth (attach log if available),
C] Public Utility
Sewer Disposal
~ Individual Year Individual Installed:
J'~. Public Utility L 4 ,) ~'~ ~) ~¢-~-~ When Connected to Public Utility: "
[] BoldingTank ~'°0'°
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE FROCESSING CAN BE IN11-IATED.
Time
Date
Inspector
Field Notes:
Time
Date
Inspector
TiFfs8
Date
Inspector
Time
Date
Inspector
) DISAPPROVED
( ~ CONDITIONAL APPROVAL'
I DATE
'CONDITIONS OF APPROVAL
Well LogReceived ~/J~-~-b --
Septic Tank Size
Soils Rating j ~)ate S~wer Installed Weft To Absorption Area
CHEMICAL & GL
TELEPHONE ~907) 562-2343 ANCHORAGE NDUSTRIAL CENTER
5633 B Street
/t ' /" >,~ (
Drinking Water,Analysis Report for Total Coliform Ba ~teria
LOGICAL LABORATORIES 'ALASKA, INC.
TO ~E'coMPLETED.BY WATER SUPPLIER
t/ ? I.D. NO
Water System Name
Mailing Address
City
SAMPLE DATE: [-:1
MO. Day Year
SAMPLE TYPE:
[3 Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
[] Treated Water
[] Untreated Water
SAMPLE
NO. LOC^Tm"
1 ~ "'-~ ' ~
Time Collected
Collectea By
2 '.,: f>~' .ti
TOrSE COMPLETED BY LABORATORY
Analysis shows mis Water SAMPLE to be:
,[~' Satisfactory
~] Unsatisfactory
[] Samole too long in transit; sample should
noz ce over 48 hours old at examination
[o nmca[e re, acm results. Please send
new samole,
/
Time Received . , -~ ~'~
Analytical Method:
[] Fermentation Tube
D~Membrene Filter
Lab Ref. No. Result* Analyst
,+ :~
L J EZ3
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
oe.z3go (~) BACTERIOLOGICAL WATER ANALYSIS RECORD
C._~nflr metory
Final Membrane Filter R~IulII ~'~
C,i ] ,i / o j / i:: 2