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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
LEGAL DESCRIPTION
~ DISTANCE TO: [0~ ¢0 [0
i i ~ DISTANCE T~: Well Dwelling PERMIT NO.
O Well Foundation Nearest lot line PERMIT NO~
gZ DISTANCE TO: '[ OO tO ~b
;~i~. ~" No. of lines~ Length of each I~, Total length of ,in~. Trench widt~.~¢inches Di'ta"°~ betw~el ~s,
~ ~ Top of tile to finish grade Material beneath tile Total effective a rea
Q ~' ~0 inc.es b~o~a
Length Width Depth PERMIT NO.
T~ of crib r ~pth Total effective absorption area
~ Cica ~ ~~'.~v Depth ~ Driller Distance to lot line~ PERMITNO~
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATING
INSTALLE~~
REMARKS I I '--' -
" DATE LEGAL
72-013 (Rev.
4,_W DRILLINC,, .......
D~ILIL~NG
Well Owner_
'N- !7,':.'::
MUN1CiPALIYY "'F '~ "~
DEPT. : ": '
I!;" i'¢! R(.3'~ ,:','J ~
RECEIVED
Use of \'Vell____D°~_,.t ......
t.ocation (address of: Township, RanL~e, Section, if kno;vn; n,' dis!.ance main road
............... L~_I~_ .__2._J~ lock .. 1. I)i. ck.'.s~. Subcl_ i:'V~ s ion,_ A'achorage
Size of casing ....... ~'_'.._.Deplh of Hole 80' . feet Cased to. ~6 ._.6/ .... i'cet
Static water level ..... 3_~ ft. faY-~v~.) (beh~w) J:.md surface. .Finist; of wc, ll (c}:eck one) open end ( ~2 );
Screen ( ); Perforated ( xx )'
Describe screen or perfo:'ati:m ....... 40. p.e_%f-_qraf.L_:_ignp . f.¥om
Well pumping test at:_~..0 .... galh)ns per (hba~ (,minute) for of draxvdown front static level.
I)ate of completion
WEI.,L LOG
l)cplh m feet from
~round surface Give details of for'matJons penc'!rated~ size of mnlerJal, color and hardness
... 3. ~TO ........
.3 8__ _.TO
.. 4~ _.TO
· 50.._TO .....
54_ TO ......
TO
..... TO
............... TO
.............. TO.
....... TO.
............... TO__
................. TO.
...... Ca~ing_. s. tickup ..............................................
_ ___0rg n!cs
.W_at~ e¥ _graye.1
....... S_i! .t_y l~ard __pan
__Soft _bedrock
.. _Be d r_ec_k: g~ a y.,
LhrouglnouL
1--CUSTOMER
PERMIT NO.
DEPARTMENT OF HEALTH AND ENVIRONMEr.~AL PROTECTION
825 'L' STREET, ANCHORAGE, AK. 99501
264-4720
L.JFSLL Rr-JE:. C~r-d--'_.-~ITE SEL4E~:
( 78i0~ )
F'EF.:r-1 ! T'
APPLICANT DICK WRIGHT SRR BOX 15858
LOCR"FION OFF RLRTNR & DICKS ST
LEGAL T12N R3N SEC 24 SM LOT SIZE
TYPE OF SOIL ABSORBTION SYSTEM IS: TRENCH
MR::.::IMUM NLIMBER OF BEE,ROOMS = ~/~/~ SOIL RATING (SD FT,)BR)=
THE REQUIRED SIZE OF THE SOIL RBSORPTION SYSTEM IS:
50250 SQUARE FEET
150
[:. E'. F"-IF H = :1.¢2~ L E I'-.I (~'T' H = 4~:2; C-i F-: R"./[E l_ [:., E F" TI-I= 5
THE I_ENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRFIINFIELD.
THE DEPTH OF A TRENCH OR PIT IS TFIE [)ISTFINCE BE"FWEEN THE SURFACE OF TFIE
GROUND RND THE BOTTOM OF THE E',:'-',CAVRTION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRR',/EL DEF'TH IS THE MINIMUM DEPTH OF GRFIVEL E:ETWEEN THE OUTFFtLL. PIPE
""1-' - ', ""
RN[:' I'HE BOTTOM OF THE E,,, _,H ,' FIT I ON '::IN FEET::',
E:ErZ,];.,kl I E'E[:, ?_-:;EF'T I !:.'. TRI'...I[-::: S I ZE=
PERMIT RPPL. ICRNT HRS THE RESPONSIBILITY TO INFORM THIS DEPRRTMENT DURING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
-- ---- Z.~,~...,~ L"-I t-~i (: 2 ::' I 1"4 Lt';- F' E '~: T I I:1 ~",1 "~- I::1 E: E E: E r2-." I_l ][ F-". E
BACKFILLING OF RN"r' SYSTEM WITHOUT FINAL INSPECTION RNE:, RF'PROVRL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN R WELL AND ANY ON-SITE SEWRGE DISPOSAL SYSTEM IS
100 FEET FOR R PRIVATE WELL; OR
i50 TO 200 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 2:0 DAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVRILRBLE TO INSURE PROPER INSTALLATION.
F'ERI""I I T E-'=-::F' I RES [:,EC:-Er'IBEE: 2~:::L..
I CERTIFY THRT
i: I RM FRMIL. IAR WITH ]'HE REQUIREMENTS FOR ON-SITE SEWERS RN[:, k~EL...L.S RS SE'['
FORTH BY THE MUNICIPALITY OF ANCHORAGE
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CO[:,ES.
]:: I L~.~DERSTRND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF' TFIE
RESIDENCE IS R~ODELED TO~NCLUDE ME~E '%HRN~ B~OROOMS.
/
',/3. ;7
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MUNICIPALITY 0 F ANCHORAGE
, DEP/~iRTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
~ ~., ,~" ', ..: Pouch 6,,650, Anchorage, Alaska 99602 276-222'l
· ' SOILS LOG -- PERCOLATION TEST
DATE
SLOPE
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
PERCOLATION RATE (minuteS/inch).. '
CERTIFIED BY:
'i'hi~ form reports: ~s io<! v~ Percolatio~ Lest v~
Depth
Feet
J
1t-
t~13 ,
Was ground water
at wilaL
r,ProPosed installat~orl: 'Seep:i,je Pit. ~~ fichu ...... ~_. :':,: ..........
DUpLh of Inlet . t)opth to bottom oF )i t or tre)}cr, /~ ..' .
DATE RECEIVED
'INSPECTION APPOINTMENTS^ ~-]~ ~_~f~)~L ~__'
DATE DATE'/'~--~'~'~~'V~~~) DATE ~)_,._~_~_'O~'~, ~'~',~
MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIO~IEPT' OF
825 L Street - Anchorage, Alaska 99501 ENVIRONMENL,.~d~ ; .alu ECTION
ENVI RONMENTAL SANITATION DIVISION
Telephone 264-4720 ~ ~ u
. ou s.
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OWNER|' I PHONE
MA'I L-"I'I~ G ADDRESS
PROPERTY RESIDENT ('if different from above) 0 "' PHONE
2. B~I,3~'ER_/,~ . / ~ PHONE
MA~UNa ADDRESS ~ d .'
3. LE NDI-NGr I~IST~ TUTION ~ '2 PHONE
M^TLI NG ADDRESS
4, REALTOR/AGENT ~' I PHONE'
I
MAI LING ADDRESS
STREET LOCAIION
6. TYPE OF RESIDENCE
SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OF~BEDROOMS
[] One ~ Four
[] Two [] Five
[] Three [] Six
[] Other
7. WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
* ATTACH WELL LOG. A well log is required for all wells drilled
since June 197§. For wells drilled prior to that date, give well
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
INDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
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
[] SINGLE FAMILY
[] MULTIPLE FAMILY
2. WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTI LITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
[] INDIVI DUAL/ON -SITE
[]PUBLIC UTILITY
Connection Verified
['-ISeptic Tank or i--IHolding Tank
Size: I-~ ~-~ If Tank is homemade
give dimensions:
TYPE OF TANK
TOTAL ABSORPTION AREA
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
NUMBER OF BEDROOMS
[] ONE
[] TWO
[] THREE [] FIVE
[] FOUR [] SIX
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
SOl LS RATING
MANUFACTURER
MATERIAL
Septic/Holding Tank ~Absorption Area
Sewer Line
[] OTHER
INearest Lot Line
5. coMMENTS
I~[~-'~APPROV ED
FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE
72-010 (Rev, 6/79)