HomeMy WebLinkAboutTract 04 (2)O5O
MUNICIPALITY OF ANCFIOFLAGE
DEPAFITMENT OF HEAl. TH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorege, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELl. INSPECTION REPORT
LEGAL DESCRIPTION
Well ~ -- ,,~lAbsorption~rea I D~e i~g
~ ~ Manufacturer t , Maten'
~ /LicT~ll 'FHOMEMADE Inside length 7dth -
M~terial '
No. of lines / ~e ~2f~ Total l~5of
~ 5 ~ ~ inches
]fade Mated benea h tile
Width Dopth
Crib depth Total effective aDsorpOon area
Well - ~unOation Nearest lot line
DISTANCE TO:
OTHER
PIPE MATERIALS /g~rC- /_
~ ~ ~]ATIN~
,.
REMARKS
PNONE ~EW
NO. OF BEDROOMS
Liquid depth
PERMIT NO,
Liquid capacity in gallons
PERMIT NO.
DATE LEGAL
F'ER1."I I T i,E.L
11-d~ IL.~i ~-,.11 ZE C:: Z 11:
!::, E F'FI R T' H E;I'.,I T E,
IS:IF'I::' L ]: CFIf. I'I'
I...ISIC:FII' :[ CIJ'.,I
LE:~2iFIL..
..:1' L-I H Iq
TlR. 4- 'THC P1FI'::
I:,_,.., 4.4.!3 E. FL
[~1 [: OF :!!;OIL. E .... F:.FI'I_N ....... rLn II.Eiq. H
E;C!UFIR]~!: F'EIET
HFI::.:i]:HL.IM F,IIJM[~:E:F;;: E)F' DEE:,F~:EIE)M!~; = :!i:
'T'HE IRE:C!UII'REE:, :B:I:;~:E CF THE: .:,UIL E,._,LE.[ T:[UI,I_,r...,IE. tl ZE; :
"['HIZ LE]I",!GTH D ]: ME:P.,I~T, [ CIP.,t I ~: ]"FIE I~EF,IG'T'H ,:: I f',l F'EET) OF T'E.IE: 'T'RENC:H CIF] [.':,I:;~]FI I NF :1: EL.E:,.
TI~IE DEF'TH OF FI TI~'.Ei",ICH OtR F'tT Z!E; THE DZETT'f'INE:~ E:ETI,.IEEi'.~ TFIE ~;LIF::F'FIC:E OF 'I"HIZ
EiI'~'.OUND FINE:, THE .P.,OTI"OE1 OF' TEIE E]:'::C:F~',/FFF[ON ':::IN FEET>.
'FHEF~:E ]:E: NO SET I.,.I:[f2TH FOE: TRE:NOHE:E;.
THE Gf:]:F~VEL E:,}ZF'TH :SS THE I"l:[NZI'q11Ji"l DEF'TI40E:' ~3RFI',,,'EL BETHEEiq THE OI...ITFFtL..L. F:'IE:'E:
F:IN,[:, THE: E:O TTOH OF' -f'HE Ei:':',CFI',,,'FIT ): OBI ,:: Z N FEE T ::,.
F'E:[;~1.,I:[T -11 I-LJ _.Ph,I] I~.lFl_C_:, THE: ,qE..F_i'I_l.11E, IL.[ FT 'TC~ IiqFC~F;?M TH:ES E:,EF'FIRTHE[qT E:,I.JF:II'.,IC~ THE:
....... ': '": ....... '- I I I.[ .., F'F FE11..'11 FINE:, THE[
]t,I=:,FI..ILL.HI.[_N IhL..FE......II_I'4:, iSlE:' FIN'T' IIELLz FIE:,..;FFII::ENT' -I'(:1 ""-."'= :','"' ; '
N P1E,[ [. OF: I:;?.EE':~;ZI)ENCE'::; ...... 'T'HFIT 'I"HE ~,JELL.. I.,J:[LL ':"-:'E. FA E.:
I',IZNII',IUH E:,IST'FINCE E:ET'FIEE;I'.,I P~ IdELL RI'.~[:.', FIP.,I',r' OF,I--SZTE E;IE[dR(3E [:,ISPCL-'5.,FtL.. S'T'E;TEH lei;
:rE,El F'EET FOP. Fl F'F?I',,,'FYFE HELL OF;;: :l....=.a~s 'TO ;2CIEi FEE'T FRrIZIl"1 I::1 F'LISL..IC 1.4ELI.... E:'EF'E~NDZI'.,IG
I..IF'ON "I"FIE! T'T'E:'E OF' F'UE",LZC: I.qELL
I'"I]:NIHI...IH DIS'I'FINC:E FF:OH FI PF11I',,,'fYFE FIELL 1"0 FI PF~tI',/FI-FE :~;E;[,.IEf~'. L. INE: Z['Z:, 2]!:3 FE:E'F FIND
TO FI COP'IHLlJ'.,I]:Ty' SEIqE:[;~: L):NE IS Sss'E:; FIE:ESS'.
11,.IEL. L LOG'.E; F~RE: 11~tEiC!11..II~:E::D F~I'.,ID HI..I'.'E:T BE:: RETURI'.,IED TO THE DEF'FIfeT1."IEI'.~T I.,.I]:THII'.,I
OF' THE I.~IELL C:OI'qF'L..E:TICff.,I.
OTI.tE:Fi: F!EC!LI]:F~!EHENT:E; 11"IF]'T' F~F'F'L'T'. SPECiFICIflTIONE; FIND C:OI",IE;TRUCTICd'.~ [:,IFICJRFff"IS F~RE
FrI',,,'FIIL. FIE&.E TCI INL"E;UIRE: Pr~:OPEE'. II'.J:STE:iL..I...i~:iTZON.
I
::1.:
F:'O[;~TI..I f3'T' 'I'HE HUN I C: I [:'FI[... I -F'T' OF' FINC:HOF;~:F:IE~E.
2: :[ NILL.. :[f',ISTFILL THE S'~'STEH IN FIC:CCff;?[:'FINC:E I.,.IITH 'T'HE C:O[:,E::B.
]~:: I LIN[:,ERSTFINE:, TFIFIT THE C~N-":~:I'FE E;EI.,IER S"r'S"l-El'q Hi::l"r' RE:C]UIF~:E ENL. FIRG[~P1ENT iF' THE
RES I DENC:E
SIGI'.,IE:[::,: f31~C:f:~ ..:I'OHN
........ .........................................
...[.I. I 1F THFIT
]: FIH FI Ii'1.11 I.. [ I I[.. I,.1:[ TH THE t~:EI::!IJ :[ [~'.EHE:P'4TE', [ JF. Oi",!--': :[ T E' E';EFE:Fi:~; IRf',E:, t- IEL. L...":, ::: ': ': ....
[] SOILS LOG
PERFORMED FOR:
LEGAL DESCRIPTION:
11
12
13
14
15
16
17
18
19
20
COMMENTS ~,~ ~
PERFORMED BY:
72-008 (6/79)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTN AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 2.64-4720
SOILS LOG - PERCOLATION 'rEST
PERCOLATION
TEST
SLOPE SITE PLAN
IF YES, AT WHAT E
DEPTH?
Reading Date Gross Net Depth to Net
Time Time Water Drop
/
(minutes/inch)
PERCOLATION RATE
TEST RUN BETWEEI~ FT AND FT
',/'
by
DOC CO, dba
SULLIVAN WATER WELLS
P,O, BOX 272, 0HUGIAK, ALASKA 99567 · TELEPHONE 688-2759
OWNER OF LAND
ADDRESS ?' '
t,
_ Ended
LEGAL
DESCRIPTION
DATE - Started /
PERM1T NUMBER
DEPTH OF WELL ~ ,., t'
STATIC LEVEL OF WATER FT, ~ )' '
-DRAW DOWN FT. { D
GA[~. PER HR ~(~ ~,~:
KIND OF CASING ~'~ ~.f _~
KIND OF FORMATION:
From Ft. to_ ,) _Ft.
From ,;~ Ft. to ?,' Ft.
From Ft. to Ft.
From :~ Ft. to / '7 _Ft.
From i ', Ft. to_ · ~ Ft
From ____ Ft. to_ , Ft.
From_ ::,~ Ft. to - [ t Ft.
From Ft. to _Ft.
From / / ! Ft. to_/ I ~Ft.
From Ft. to Ft.
Fromm"', Ft. to t~ .1 Ft.
From Ft. to Ft.
From Ft. to_ _Ft,
Frmn Ft. to Ft,
From__.Ft. to Ft.
From Ft. to Ft.
From__Ft. to Ft.
From
From Ft, to
From Ft. to
From Ft. to __ Ft.
From __ Ft. to _Ft.
From_ Ft. to_ Ft.
From __Ft. to_ Ft
From Ft. to Ft,
From __Ft. to _Ft,
From __ Ft. to Ft,
From Ft. to Ft.
Frmn____.Ft. to Ft.
From Ft. to____Ft.
.Ft. to Ft,
Ft. to Ft, . ,COnR~,GE
Ft. to_~ ..' I~e~, o~
_Ft. to ~" ~t~
Ft. to -Ft
MISCL. INFORMATION:
F , . / DATE ~EOEIVED
INSPECTION APPOIN'rMENTS
~-ME TIME TIME!
~-ATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR
MUNICIPALITY OF ANCHORAGE
~UNICIPALITY OF ANCHORAGE DFPT, OF i;
O DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEC'rlO~NVIROI,4~V~ENI,~,I. k, ,Dl~ ETLON
. 825 L Street - Anchorage, Alaska 99501
) V RO. .TAL SAUITAT O. OCT g 8 981
UEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
BISEOTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (~0) days for processing.
PHONE --
MAI LING ADDR~S ' '
~BUYER//~ ~ PHONE
~AI LING A~D~SS
~ ~GFNG INSerTION I PHONE
~X D ~S~ ~
MAILING AD DR ES,~
S LEGAL DESCRIPTIOI~.
STREET/L/OCATiON -
61.¢¢~'YPE OF RF'.SIDENCE ~ SINGLE FAMILY
[] MULTIPLE FAM LY
NUMBER OF,BEDROOMS
E] One [] Four
[] Two [] Five
~' Three [] Six
[] Other
~,7. WATER SUPPLY
,[~ INDIVI DUAL* * ATTACH WELL LOG. A well log's reuuired for all wells drilled
[] COMMUNITY since June 1975. For wells drilled prior to that date, give well
~ PUBLIC UTI LITY oepth (attach log if availableJ
'~. SEWAGE DISPOSAL SYSTEM
INDIVIDUALrON-SITE** //'//~f~ / YEAR ON-SITE SYSTEM WAS INSTALLED.
[] PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTI LITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
I~INDIVIDUAL/ON -SITE DATE INSTALLED
[] PUBLIC UTILITY
Connection Verified INSTALLER
~]Septic Tar~ or [~Holding Tank
Size: /C2{~~] If Tank is homemade BOILBRATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
[~2~APPROV ED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL {tetter must accompany certificate)
[~ DISAPPROVED
DATE BY ~ '~
72 O10 (Rev. 6/79)