HomeMy WebLinkAboutTOOMEY LT 6AOnsite File
Municipality of Anchorage
Community Development Department
On -Site Water and Wastewater Program
4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 • http://www.muni.org/onsite • (907) 343-7904
Well Decommissioning Log
Legal Address:
Subdivision 7_00m,U L f 6A Block Lot
T R Section Lot
On-site Water & Wastewater Program certified contractor performing the well decommissioning:
Name: `tiW1 " I xe� Signature:
Company: P.O. Box112130
Artdwmge, Ax99511
Well decommissioning date _ ! 7' 1 Method of decommissioning: AMC 15.55.06OL1
a. ❑ b. ❑ C. IX
Location: Use the space below to provide a drawing of the property showing the following items;
• North arrow
• Decommissioned well,
• Other water wells on the property,
• Two separate swing -tie distances for each well shown on the drawing,
Note: The swing -tie distances shall be measured from either permanent structures Ior the property comers.
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Uacommunity uevelopment\uevelopment Services\Building Satety\On Site Water and Wastewater\Forms\Client Forms\Well Decommisioning form.doc