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Home My WebLink AboutZODIAK MANOR ALASKA BLK 6 LT 17MUNICIPALITY 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. INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSpECTOR TNSPECTO R INSPECTOR MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE DEP'F. OF HEALTII DEPARTMENT OF HEALTH & ENVl RONMENTAL PROTECTION 825 L Street - Artchorage, Alaska 99501 ENVIRONMENTAL PROTEC[ION ENVIRONMENTAL SANITATION DIVISION NOV 2~ Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FA~IVE~ DIRECTIONS: Compl0te all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) clays for processing. 1, PROPERTY OWNER ~ PRONE PROPERTY RESIDENT (If different from above) PRONE PHON~ 3, LENDING IN~ITUTION PRONE MAILING ADDRESS ,.. / ~, ~g~l .... 6. TYPE OF RESIDENCE / ~UMBER OF~BEDROOMS [] One Z] Four [] Other.___ ~ SINGLE FAMILY [] Two [] Five [] MULTIPLE FAMILY E~ Tnree ~_- Six 7. WATER SUPPLY ~[;~ NDIVI DUAL* ' ATTACH WELL LOG. A well IDS ~s required for all wells drilled [] COMMUNITY since June ' 975. For wells drilled ~r~or to that date, give well [] PUBLIC UTI LITY depth (attach log if available.] 8, SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON-SI'TE** YEAR ON-SITE SYSTEM WAS INSTALLED, [] PUBLIC UTILITY NOTE: TH[': INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72 010 (Rev. 6/79) THIS SIDE FOR OFFICIAL USE ONLY 1, TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY 2. WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTI LITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM [] INDI VI DUAL/ON -SITE []PUBLIC UTILITY Connection Verified []Septic Tank or [] Holding Tank Size: If Tank is homemade give dimensions; TYPE OF TANK TOTAL ABSORPTION AREA 4. DISTANCES WELL TO: NUMBER OF BEDROOMS [] ONE [] THREE [] FIVE [] TWO [] FOUR [] SIX PERMIT NUMBER DEPTH OF WELL DATE ORILLED LOG RECEIVED PERMIT NUMBER DATEINSTALLED INSTALLER SOILS RATING MANUFACTURER MATERIAL [] OTHER Septic/Holding Tank Absorption Area Sewer Line JNearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS [] APPROVED FOR BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY 72-910 (Rev. 6/79) APPLI( NT FILLS OUT UPPER I'IA[ ONLY Pioperty Owner Merlin K. ~;rickson Mailing Address 8571 Jupiter Di~ve Anchor~ge Zip Code IPhone 3~9-4718 Buyer Walter R. Wa. rren Star Route A Box 17013 Anchorage Address Zip Code 99507 Lending Institution Address First Alaska Mortgage & Escrow 5609 B~siness Park Boulevard Zip Code 99503 Realty Co, & Agent Grace Mo Brown 2702 Gamble Street A~chorage Address Zip Code 99503 Legal Description LOt 17 Block 6 Zodiak Manor Subdiuision ~571 Jupiter Drive Street Location Type of Residence ~'~ Single Family [] Multiple Family No. of Bedrooms_ three L} Other Phone 562-2013 Phone 276-2761 Water Supply rE~:,~dividuaI ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. Q Community For wells drilled prior to that date, give well depth (attach log if available). [] Public Utility Sewer Disposal [] Individual NOT FILLED ]~3 FOR ~iS'lE Yea~ individual Installed: ¢E~ PublicU~ility r~PE O~ ~E~',~]};~ Fz'%Q~'~EG~WhenConnectedtoPubgcUtility: [] Holding Tank NOTE: THE iNSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Date Date Inspector Inspector Time Date Time Inspector (~) APPROVED BEDROOMS ( ) DISAPPROVED ( ) CONDItIOnAL APPROVAL* MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTII ENVIRONMF-N1AL PROTECTION RECEIVED *CONDITIONS OF APPROVAL Soils Rating Date Sewer Installed Well To Absorption Area Well to Tank Well Log Received Septic T,'mk Size MUNICIPALITY OF ANCHORAGE DEPAr{TMENT OF HE,~ LTH & ENVIRONMI=NTA(. PROTECTION 825 L Street - Anchora~je, Alask~ 99§01 RFQUFST [:OR APPROVAL OF INDIVIDUAL WATER AND SEWER FACI LITI ES ENVIRONMENTAL E ~!GINEERI ~IG DIVISION Telephone 264-4720 DIRECTIONS= Cemplete all paris on ~age 1 IncontDlete recitmsts will not be processed. Please allow ten (10) davs for processing, 1, .PROPERTY OWN PHONE IESIDENT Ill a PHONE BUYER ADDRESS 3. LENDIN¢ PHONE MAILING AD ~SS MAll-lNG ADDRESS ~:'-I~ 'hAL DESCRIPTION ' t TYPE OF RESIDENCE ~UMBER OF SEDROOMS [~ One [] Four '[~ SINGLE FAMILY [] Two [] Five [] MULTIPLE FAMILY ~ Three [] Six [] Other 7. WATER SUPPLY INDIVIDUAL~ ' ATTACH WELL LOG. A wel log is required for all wells drilled · COMMUNITY since June 1975. For wells drilled prior to ttlat date, give well [] PUBLIC UTI LITY aepth (attach log if available. I 8, SEWAGE DISPOSAL SYSTEM E~] INDIVIDUAL/ON-SITE** N PUBLIC UTILITY --[f individual/on-site, give installation date_ __, If system is over two [2) veers old an aoequacy lest is renuired by this Department, NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOINTMENTS TIME TIM~ TIME DATE DATE DATE INSPECTOR I NSP ECTO R INSPECTOR DIRECTIONS: I. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX 2. WATER SUPPLY PERMIT NUMBER [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTI LITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER []INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER []Septic Tank or [] Holding Tank Size: If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AR EA MATERIAL 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS ~'~APPROVED FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY ITitle) i ~, LEGAL DESCRIPTION 72-010 (Rev. 3/78) ~~ ~~ GREATER ANCHORAGE AREA BOROUGH ~~~"~'~'~'~ 3330 "C" Department of Environmental Quality ~~..~qY'x ooou ~ Street, Anchorage, Alaska 99503 274-4561 Date Received __ Time of Inspection Date of Inspection 1. Approval requested by: Mailing Address: 2. Property Owner: Mailing Address: 4. 5. 6. REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR Phone: Phone: Legal Description: Location: Type of facility to be inspected ~__~,__~. No. of bedrooms / Well Data: A. Type ~x~--- C~/jc~~. B. Depth C. Construction 7. Sewage Disposal A. Installed B'. Installer C. Septic Tank: 1. Size 2. Manufacturer D. Seepage Pit: 1. Absorption Area 2. Material E. Disposal Field: Total length of lines Distances: A. Well to: Septic tank Nearest lot line , Absorption area , Other contamination , Sewer Lines ___ B. Foundation to septic 'tank , Absorption area C. Absorption area to nearest lot line __ EQ-034 (1/74) Page 1 of two pages Page 2 of' two pages - Red_est for Approval of Individual . ~er & Water Facilities Legal Description Comments ' - ~Approval Disapproved Valid for one year from datE! signed Greater Anchorage Area Borough, Department of Environmental DIAGRAM OF SYSTEM Quality 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 (1/7q)