HomeMy WebLinkAboutFIRE LAKE TR F & UNLETTERED POR DESC BY DEED
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
NAME PHONE | [~'"'E ~/
LEGAL D E~ ~Ip~q
LOOATION NO. OF BEDROOMS
Well Absorpti~ ~re~ Dwelling ~ ~ PERMIT NO.
~ ~ Manufacturor Materia~ ~o. o[ compartmants
~ ~ Liq, capacity in gallons inside length Widt~ Liquid depth
/~ IF HOMEMADE:
~ ~ DISTANCE TO: Well D~lling PERMIT ~O.
~OZ
O Z ~ Menufacturer Material L~quid capacity in gallons
~ N°'°flines / Length of each ljne Tota3¢~oJlines
- ~ ~ inches
~ ~ ~ ~p of tile to finish grade .~ ~ ~ Material beneath tile - Total effective absorptioGarea
Length Width Depth PERMIT NO.
( N Type of crib Crib diameter Crib depth Total effective absorption area
~ Wall Building foundation Nearest lot line
~ DISTANCE TO:
~ Class ,~JO'~ /~ De~t-~E~ j~:~ ~ [(TDriller~. Distance to lot line PERMIT NO.
~ Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
PIPE MATERIALS
SOIL TESTRATING ~/~5~1~ ~ ~41J~- rO
REMARKS ~
~ _ t ,': '-~-
72-013 (Rev. 3~78)
MUNICIPALITY OF ANCHORAGE
Department ~ Health and Environmenta' ~rotection
825 ~ Street, Anchorage, AK. ~501 ~... /.~.~ ~
264-4720
* * * HANDWRITTEN PERMIT * * * ~ ~6~,~ ~/"~
Permit 9' ~
WELL AND/~ ON-SITE SEWER PERMIT
Applicant: ~0~ /~'//'J~S~/J/ Mailing Address:Bo` EX ~Y ~ /~
Location: ~ , Phon~ N~mber: ~ - ~-~-~
Legal Description: ~ ((,~-,~&~N£~) ~ Lot Size:
Type of Soil Absorption System Is:
Trench: : Drainfield: Seepage Bed: Holding Tank:
Maximum Number of Bedrooms: Soil Rating(sq.ft/br) ~-
The Required Size of the Soil Absorption System Is:
DEPTH LENGTH
GRAVEL DEPTH ~-- ~
WIDTH
The length dimension is the length(in feet) of the trench or drainfield. 'The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * ~EQUIRED SEPTIC(HOLDING) TANK SIZE = /000 GALLONS * *
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 1 9 8 3 * * *
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
. include more that 3 bedr~o~s.
the residence is ~emodeled to
Signe~, ~f~~//~/ Issued by: ~~~~
Applicant
Date: F--/~- ~'~
SWP/024 (1/81)
~SOtLS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
PERCOLATION
TEST
PE.EORMED EOR:
LEGAL DESCRIPTION:
3
7
8
9
10
11
12
13
14
15
16
17-
18-
19-
2O
SLOPE
DATE PEREORMED: z i'
SITE PLAN
WAS GROUND WATER I~'
S
ENCOUNTERED? L
O
P
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
(minutes/inch)
TEST RUN BETWEEN FT AND
PERFORMED BY: ~%/~ {' CERTIFIED
~ FT
DATE: ,¢'Zl- Ct
72-008 (6/79)
N 0004`00" W
N 0°04'00'' W
N 0° W
RETURN TO: Dlvlslon of Geological and C yslcal Surveys (DGGS)
3001 Porcupine Or~ve (Tele~ a: 277-6615)
Anchorage, Alaska 99501
WATER WELL RECORD
Orillir,g Company Name
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURCES
U.S.G.S, Local tlo.
Drilling Permit No.
OCATION OF WELL I Please complete either la, lb, or lc. M,u,L.
la. ~orough Subdlvisionl Lot Block lb. Fraction Section No. Township Range Meridian
/ / / N/S E/W
lC. Distance and Direct[on From Road Intersections 3. OWNER OF WELL:
Address:
Street Address and Area of Well Location
2, WELL LOG Feet Surface Below 4. WELL DEPTH: (completed) Surface Elevation CompletlonDate of
Material Type Top Bottom ft.
5, E~]Caale t°°l E~R°tary []Driven
r--]Auger [=-]Jetted ['-~ Bored E~ Other:
6. USE: m--1Oomestlc E~PublIc Supply ["~)ndustry
~"~lrrlgatlon I--1Recharge [~Commerclal
[]Test Well [~Other:
7. CASING: [--')Threaded ~-~Welded
In. to ft. Depth Weight lbs/ft.
in. to ft, Depth
8, FINISH OF WELL:
Type: O{ameter:
Blot/Mesh Size: Length:
Set between ft. and ft,
Fittings:
9. STATIC WATER LEVEL: ft.
~j[U~:~,:~L~.~, ~ ~ke~-~O~,A~l E-JAhove E~selow land surface
~FPT_ OF HEALTH &
EkNIRON~ENTAL PROTECTIOF Type of MeasureJ~ent:
I0. PUMPING LEVEL below lend surface
~AA~ ~, '~ I';~-~'''' ~ ft. after __hrs. pumping g.p.m.
ft. after hrs. pumping g.p.m.
R r-~m~ C I~ ~'~ [~ In Approved Pit
I,,~,.. L I ¥ i..i.e 11. WELL Hr-AD COMPLETION:
[~]Pltless Adapter ~ inches above grade
12, GROUTING: Wet) Grouted: [--~Yes [~No
Material: [--]Neat Cement [] Other:
13. RUMP: (if available) HP
Length of Drop Pipe ft. capacity g.p.n
Type: ~]Submerslble E]Reclprocatlng
[]Jet [~]Other:
14. REMARKS:
15. WATER WELL CONTRACTOR'S CERTIFICATION:
Thls well was drilled under my jurlsdlctlon and this repor~ ls true to the best of my knowledge and belief:
Registered Business Name Contract License Number
Address:
Signed: ~' ~ ~ , Date:
' Authorized Representative
IForm 02-WWR Copy. Distribution: WHITE - State DDGS, PINK - Driller, CANARY - Customer
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geolo~}icol 8, Geophysicol Surveys
Orilling Permit No.
LOCATION OF WELL (Pleole complete either la, lb or lc.) A.D.L. No. __
__of__of of-- sE3 wE]
ic.JlDISTANCE AND DIRECTION FROM ROAD INTERSECTIONS :5. OWNER OF WELL:
Street Address and Area of Well Location
Feet Below 4. WELL DEPTH: (final) 5. OATE OF COMPLETION
2. WELL LOG Surface
6. []Cable tool []Rotary [] Driven []Dug
· ~1~ , r ,~ : ~ ' ~i 7. USE: [] Domeltic [] Public Sapply [] Industry
, . ..,./~.! ,. ; ,.~. ~ ,, [] Irrigation [] Recharge [] Commerical
; ~ ' 8. CASING: [] Threaded [] Welded
, ~, ?,,, .' ~ [{~ ': ~ diam.__' in to ' r ff. Depth Weight _ lbs./fl,
I , Set between ft. and fl.
:'' ~ ~ i ' i "~ Backfilling _ Grave~ pock
4, ' ~ Ia. STATIC WATER LEVEL:. ' fl.
'.... ' l'" ~ I : '~J ' ' [] Above or [] Below land surface Date
, . ' ' II. PUMPING LEVEL below land surface and YIELD
ft. after hra. pumping g.p.m.
ft. after hre. pumping g.p.m.
12.GROUTING Well Grouted: [] Yes [] No
J ' r I ' ' ~, .' ' i ' Material; [] Neat Cement [] Other:
IS. PUMP: (if available) HP
Length of Drop Pipe __ ti. capacily _g.p,m.
14.. REMARKS:
16, WATER WELL CONTRACTOR'S CERTIFICATION: 15. Wafer Temperature o [] F [] C
This well was drilled under my jurisdiction and this report is true to the best of my knowledge and ballet;
· Dote:
Authorized Representative
Form O~-WWR (11/81) Copy Distribution: WHITE-Stole DGGS~ PiNK'Driller, CANARY-Customer