HomeMy WebLinkAboutSHELL #1 LT 9to .*
SHzIl SID
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.
"AAE HD I GF"'#TER ANCHORAGE AREA BORO' "H
HEALTH DEPARTMENT
327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAMEMAILING
ADDPHONE
LOCATION.fJJ�J// `� O</1CJ LEGAL DESCRIPTION��'J
SEPTIC TANK:
NUMBER OF
DISTANCE FROM WELL MATERIAL G G'/✓//CAA TS CTPARTMENTS
(/: -S' d- rr J
LIQUID CAPACITY GALLONS. INSIDE LENGTH_ _INSIDE WIDTH
SEEPAGE SYSTEM: SEEPAGE PIT, X.;z,yX/6x-2ex9�;e'
LIQUID
DEPTH
NUMBER OF PITS OUTSIDE DIAMETER � OR WIDTH--,
l
LINING MATERIAL C'r1NC.'f1EJE �'//✓efs- — �i, DISTANCE FROM WELL �r•� BUILDING FOUNDATION 3-0
Q J
NEAREST LOT LINE /U TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) z'�?/'4 SQ. FT.
TILE DRAIN FIELD:
DISTANCE FROM W
NUMBER OF LIN
ABSORP N AREA
DEPM: TOP OF TILE TO FINISH GRADE
FOU DATION
(STANCE B WEEN LINES
—SQ. FT. LENGTH OF LINE
NEAREST LOT LINE
WIDTH
DEPTH OF FILTER MATERIAL BENEATH TIL
TOTAL LENGTH
OF LINES ,
ABOVE TILE
IVE
WELL: , BUILDING FOUNDATION. % DISTANCE FROM' WATER
DEPTH
TYPE��/G��='G' .1 SAMPLE /I/G9 NEAREST
� NEAREST SEPTIC / / i SEEPAGE
LOT LINE SEWER LINE TANK /�`U SYSTEM ZOTHER
�f/ CESSPOOL ` SOURCES=
DISTANCES:
DATE
DIAGRAM OF SYSTEM
C
y
.t
h• W4 ''''I Jiri�
GAAs-11D-2 GREATEI 1NCHORAGE AREA IROUGH Case No.&i_
HEALTH DEPARTMENT
327 Eagle St, Anchorage, Alaska 99501 279.2511' J )
SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT
NAME OF APPLICANT MAILING i%. Jw,Tv MAILING ADDRESS/�3�1�;/�_ PHONE AV
RESIDENCE ADDRESS Ceti u6rn', LOCATION OF INSTALLATION oll e f�
LEGAL DESCRIPTION ✓i1N�1" ��Gl�z/`I J�Zir�/
APPLICATION TO INSTA��// LL: SEPTIC TANK___d.�__, SEEPAGE PIT_yDRAIN FIELD , OTHER_
TO SERVE THE FOLLOWING FACILITY '�`eC�2G�ii, �2D12tE�
FINANCED THROUGH_,Z9t TO BE INSTALLED BY
PERCOLATION TEST RESULTS_- _ ANTICIPATED DATE OF COMPLETION
`f� BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT _
THIS IS TO SERVE AS / "/ L'���`� PERMIT TO INSTALL A��'r
A DESCRIBED BELOW. SIZE OF UNIT TO BE SERVED ��L��CG�c}T�rtiv
SEPTIC TANK SIZE �U TYPE _'! SEEPAGE AREA°' �'� TYPE --7 /
fiL��wr��vtn✓ DIAGRAM OF SYSTEM
DISTANCES:-
1��/ icc l7 ✓G ii
Me
O�i`r� AZO`
p J
HEALTH AUTHORITY IV
OR
LICENSED DESIGNERI certify that I am familiar with lhe'cquire, Anchdi-age Area Borough Ordinance No. 28-68 and that the
above described system is in acco•Banc +1't .
, / /�
GLEEU C 1 �
DATE -APPLICANTS SIGNATURE
REATER ANCHORAGE: AREA BOROUGH
HEALTH DEPARTMENT CASE !
327 EAGLE STREET
ANCHORAGE, ALASKA 99501
Performed For H q e, (,(Yt I- Date Performed '- / g- 7o
LF.gal Descrip'L-ion: I:_of____0 Block sub c'�"iv oin
This Form Reports a -
Depth .s LoI/
erc�tion Tes7:
Depth
Feet Soil Characteristics
t Pso
`I
Z.
tt
Sc�,c't'inN G'AVCS�uI�
3 P,?imcx2id of a rn�x}uF;�.
o� 5tfi� xrd antic�PAvo--�
&►"1'I �P_R[ I S YKal t (k nkoi.0 r(+6 0('
1� Seen.' f or k COAQ-0"
is rKoci(ikai'e u)(+k c2orks
djsappaafz:na�n-h4-ce- f
sm
e AW -
Ke e.vL I",, PP -0911e vials_
tC-orllSls I r�r0.nd rzompac
Location Sketch
o'✓Yt ie� •Rd '
""Posed Installation -Seepage Pit�� � /� � Drain "i.el.d
Depth Of Inlet ®� �_ De >
, �, _ � th To Bottom Of Pit Or '!.'rencii
COMNIENTS • _ 7i r m .;,, I– vvi � 7 .c -7 n'i L_ -I , _
vC'41.nmI���MmYe6ia.^e++t�.'.fmu-en.yea-.a.�...n-...�w,wns.TVYimltewswlflATf.Lcavi� u `_
"� tiTSI.��uev m[Ne+R'.Tv[a-wpm....^+, W<a.un..®�W Po'.�.McvAueu�ahs.
Test Performed By:
Data Certified By
Dat
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C" St., Anchorage, Alaska 99503 - 274-4561
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
1. Type of Inspection: CMRO
K,
3
4.
5
Property Owner:
Mailing Address:
Name of Buyer:
Mailing Address:
Name of Lending Institution:
Mailing Address:
Name of Realtor or Agent:
Mailing Address:
VA FHA
Day Phone
C 0 N V
3 /"/- /6'/?
/h\
Da Phone
a
i
Phone
Phone
6. Legal Description: f �% _c-) 14V) <./Z'.%;;
Location: /�'�iiZ%
I
9
Type of Facility to be inspected: No.
Water Supply
Type of Supply: Public Utility Individual��'1J
Bdrms.''
If Individual, number of dwellings presently served
If Individual, depth of well / S
t`
Sewage Disposal System
Type of System: Public Utility Individual (on-site)
If Individual, date of installation
IQ -037 (1/74)
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C" Street, Anchorage, Alaska 99503 274-14561
V
� a
Date Received 5 -
Time
Time of Inspeo;tion' O
Date of Inspecijion l 75
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
FOR
1. Approval requested by: ,t_f.,C,&(F- 1/
Mailing Address: /O/ �j (�(�, a�e Phone: 3V _3
2. Property Owner: Phdne: .3
Mailing Address:
3. Legal Description:
4. Location: _XXz
5. Type of facility to be inspected >,E',�- r -r rs No. of I bedrooms
6. Well Data: f
A. Type B. Depth
C. Construction D. Bacterial Analysis
7. Sewage Disposal System:
0,
A. Installed 7-- 3-7o B. Installer
C. Septic Tank: 1
D. Seepage Pit: 1
E. Disposal Field
8. Distances:
Size i o o o 2. Manufacturer
Absorption Area 2. Ma
Total length of lines
A. Well to: Septic tank // % , Absorption area
Nearest lot line Other contamination
B. Foundation to septic tank��f 5i Absorption area
C. Absorption area to nearest lot line I
(A)61
EQ -034 (1/74) "o
P -i<
al
i
Sewer Lines ,
3,0 f
Page 1 of two pages
Page 2 of two pages - Rek for Approval of Individual : & Water Facilities
Legal Description
Comments J—P-WL. _W �.�� ova. �C tA'Ja Vk,
Approved Disapproved Date 5 0
Approval.,Valid for one year from date signed
Greater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
i cert [ Ty LnaL tine i nruriud u mn (xima i neu in ones request. i ur aNNruva i ou ue a out= airu
accurate representation of the subject sewer and water facilities and these facilities
are operating satisfactorily.
SIGNED
EQ -034 (1/74)
Date