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Time
SOILS LOG
Material~ ~nd Remarks
.?
CASING LOG
633 CAST 8IIT AVCNUC
ANCHORAGE, ALASKA 99502
SUBSURFACE EXPLORATION
Shift Report of Operations
Addre~
I
Static Level GPM-YIELD
Depth-Begin Shift
Depth-End Shift
Depth Drilled
TIME DISTRIBUTION HOURS
Drilling Pull Casing
Pumping Standby
Surg;ng
Size
LABOR EQUIPMENT
Name Item
Drill-Rig
Houri
Truck
PumD
No,.
Sample Description
INSPECTOR ,,
.~ DATE RECEIVED
.,~ INSPECTION APPOINTMENTS
DATE
MUNICIPALI~ OF ANCHO~G~
MUNICIPALITY OF ANCHORAGE DEPt. OF HEALTH &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTE~iRO~ENTAL
825 L Strut · Ancho~a~, Al~ka ~1
( ENVIRONMENTALSANITATION DIVISIONI AY 1 1981
Tele~one ~7~
2. BUYER PHONE
3. LENDING INSTITUTION I PHONE
I
MAILING ADDRESS
4. REALTOR/AGENT J PHONE
I
MAILING ADDRESS
STREET LOCATION
6. TYPEOF RESIDENCE NUMBER OE~BEDROOMS
r-'l One r-1 Four r-I Other
~ SINGLE FAMILY
[] Two [] Five
I-'1 MULTIPLE FAMILY {~, Three · [] Six
7. WATER SUPPLY
INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled
COMMUNITY since June 1975. For wells drilled prior to that date, give well
[] PUBLIC UTI LITY depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
1-1 INDIVIDUAL/ON-SITE*' YEAB ON-SITE SYSTEM WAS INSTALLED.
~ PUBLIC UTILITY
NOTE: THE 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 NUMBER OF BEDROOMS
[--I SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] .FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[]INDIVIDUAL/ON -SITE DATE INSTALLED ~.
[]PUBLIC UTILITY
Connection Verified INSTALLER
[]Septic 'l~a,nk or [] Holding Tank
Size: If Tank is homemade SOILS RATING
glve dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4, DISTANCESwELL TO: Septic/Holdin9 Tank IAbsorption Area Sewer Line I Nearest Lot Line
I
I
Absorption Area to nearest Lot Line
5. COMMENTS
'APPROVED FOR g BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED /~
72-010 (Rev. 6/79)