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HomeMy WebLinkAboutZODIAK MANOR ALASKA BLK 6 LT 14Lo-r Municipality of Anchorage Community Devellipment Department On -Site Water and Wastewater Program 47OOE|monaSt.~P.O.Box1QGG6OAnchoraga.AKQQ51Q-S85U^h#p://wwvv,muni.org/unmite^(QO7)343-78O4 Legal Address: Subdivision Block Lot SectioDLot ________ On-site Water & Wastewater Program certified contractor performing the well decommissioning: Name: KrL`� Signature: Company: 0� 0 Uv�xuec decommissioning dateme�n of decommissioning: AMC 15.15.55.0601-1 8. F� ��. �� �� C. X 0 Location: Use the space below mprovide odrawing ofthe property showing the following items; ° North arrow ° Decommissioned well, ° Other water wells onthe property, ° Two separate swing -tie distances for each well shown on the drawing, Note: The swing -tie distances shall be measured from either permanent structures or the property corners. nuni0 GervicemBuimm aafety\0Gite Water and Forms\welloecommisionino forr-T Certified We~ Distallce to water. L..i.'~,, ~......:,...:.., :..~-.....::. ......... : ................. Distance to water wixile of ..... boa ....... ~tion of $©MMERV~LLE WELL I)RILL~NG Star Pt. A, Box 1~73 Anchor~ge~ We advise you. to attach ti~is certificate te your deed. j GREATER ANCHORAGE AREA BOROUGH ~-'--~ Department of Environmental Quality 0'-' J3330 "C" Street, Anchorage, Alaska 99503 27444561 ~ I)~ ~ Date Received July 14, 1976 , \.2~~ ~0 ~'~ ~ Tm .... ~ ~ .~ ' .~ ~ ~' ' e of Inspection ~I'~0 ~ FOR 1. Approval requested by: Mailing Address 2. Property Owner: Mailing Address 3. Legal Description: 4. Location: CoI1v. Totem Realty Inc. % Violet Hulce 724 East 15th Avenue Morris L. Lee 8541 Jupiter Lot 14 Block 6 Zodiak Manor 8541 Jupiter Phone: 272-0571 Phone: 344-3654 Type of facility to be inspected Single Family No. of bedrooms 2 Well Data: Individual A. Type ~~) B. Depth C. Construction {]_~/~~ D. Bacterial Analysis Sewage Disposal Y ~ : Public utility B. Installer 1. Size 2. Manufacturer 1. Absorption Area 2. Material Total length of lines A. Installed C. Septic Tank: D. Seepage Pit: E. Disposal Field: Distances: , Absorption area , Other contamination , Absorption area A. Well to: Septic tank Nearest lot line B. Foundation to septic tank , Sewer Lines C. Absorption area to nearest lot line __ EQ-.034 (1/74) Page 1 of two pages Page 2 of two pages - Re( it for Approval of Individual S ~r & Water Facilities Legal Description Lot 14 Block 6 ~odiak Manor Comments Approvgl );alid for one year from date signed Greater Anchorag~Borough, Department of Environmental Quality DIAGRAM OF SYSTEM certify that the information contained in this request for approval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating satisfactorily. SIGNED Date EQ-034 (1/74) 06-1220(a) Rev. 1973 DATE ALA{ DEPARTMENT OF HEALTH AND SOCIAL SE ~ES : UIVISION OF PUBLIC ItEALTH ,ab No. INDIVIDUAL AND SEMI-PUBLIC BACTERIOLOGICAL WATER ANALYSIS omcE INDIVIDUAL [] SEMI.PUBLIC [] CHLORINE RESIDUAL PPM REPORT RESULTS TO ADDRESS CITY - ~ t :, ~ ZIP CODE ~ "' j AnaJysis shows tMs Water SAMPLE to be: [] Satisfactory [] Unsatisfactory [] Questlonabie E] sample too long in lranslt; sample should nol be o-er 48 ; hours old at examination 1o indicate reliable results, Please send new sample~ [] Bottle broken in transit, please send new sample. SANITARIAN'S REMARKS COMPLETE THIS SECTION ONLY IF WATER IS AN INDIVIDUAL SUPPLY SAMPLE COLLECTED BY DATE COLLECTED '[~ / ~' TIME COLLECTED ~" GENERAL: Does Water Become Muddy or Discolored? [] Yes [] No D[ameter of WeB Depth Well Casing Material Diameter Depth [] Of Well [] Other . PURPOSE OF EXAMINATION~ IlJness Suspected? [] Yes 06.1220 (b) Rev. 1973 READ INSTRUCTIONS Oo,e Received BACTERIOLOGICAL WATER ANALYSIS RECORD 24 Hours ON REVERSE SIDE 4B Hours BEFORE COLLECTING SAMPLE Reported by MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 2510 East Tudor Road, Anchorage, Alaska 99504 276-2221 REQUEST FOR APPROVAL OF INDIVIDUAL SEWER and WATER FA(;ILITIES d i976 RECEIVED ~. Type of Inspection: CMRO VA _FFIA CONV..__~~-- 3. Name of Buyer:_ ~*¢- ¢. ~<,~,Z~,¢ MailingAddress:_~ ~ ~ ~ -~ DayPhone: ~¢¢ ~¢~ 4. Name of Lending Institution: Mailing Address:_ ~-~ _ PhoneL Name of Realtor or Agent'.. o~¢-,~//.~-.w*-~2, ~2t.~.-, Mailing Add tess:_ Z ~ /'¢%~ ~ ~, ~-" hone:. . ..z /i- _' ,/' . 7. Type of Facility to be Inspected: 8. Water Supply Type of Supply: Public Utility If Individual, number of dwellings presently served _. If Individual, depth of well //¢;~ / NO. Bdrms. Individual Sewage Disposal System Type of System: Public Utilit /~ If Individual, date of installation ~ Individual (on-site)_ ~]~l~ __ 72-003(3/76)