HomeMy WebLinkAboutUS SURVEY 3043 LT 5 OF LT 11 T10N R2E SEC 18Onsite File
US Survey 3043
Lot 5 of 11
#075-092-33
MUNICIPALITY OF ANCHORAGE
J ~ F 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 /1
/., F_IVE
PHONE
� NEW
❑ UPGRADE
MAILING ADDRESS
9ax 30Y
i1e1)40a0c!
LEGAL DESCRIPTION
/ o /✓ R z F_
4-U&S �b�{
LOCATION -
d Bc7 Q /-AW
NO. OF BEDROOMS
13
Uy
DISTANCE TO:
Well
Absorption area
Dwelling
PERMIT NO.
H Z
aQ
wF
Manufacturer
Material
No. of compartments
N
Lie. capacity in gallons
IF HOMEMADE:
Inside length
Width
Liquid depth
6 y
J0Alb
DISTANCE TO:
Well ,/ �
Dwelling S f
PERMIT NO. n ?®/
2 z F
Manufacturer
e e
Material
Liquid capacity gallons
O
m=
DISTANCE TO:
Well
Foundation
Nearest lot line
PERMIT NO.
u Z
F Z w
No. of lines
Length of each line
Total length of lines
Trench width
I inches
Distance between lines
p
Top of tile to finish grade
Material beneath tile
inches
Total effective absorption area
w
Length
Width
Depth
PERMIT NO.
QF
at
Type of crib
Crib diameter
Crib depth
Total effective absorption area
W
DISTANCE TO:
Well
Building foundation
Nearest lot line
J
J
Class
Depth
Driller
Distance to lot line
PERMIT NO.
w
�
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATERIALS
"
SOILTESTRATING
INSTALLER
D
REMARKS
f- o
/o
t 1,0AS
n
C*r av
APPR ED
DATE LEGAL
1
72-01 3(Rev. 3/7-87 r)
T'd p L3 P-4 1: 0--, 1 �I�� ���� F��A�E�
",�� � 8��]
DEPHRTMENT O| lEHLTH AND ENVIRONMENTAL F 'TECTION 4
/ /cx/ /
� 825 /L STREET, HNCH0RHGE/ HK� 99501 �
x ` 264-4720
^ �C"DE,"I X -v- RE SET EEO T,A RE En k J F-"" R,.=" K.".:n RE FA K F& Pi XI-
PERMIT NO. ( 790175 )
APPLICANT HRLEHE CHEIFER 13K]04 349-4644
LOCATION GIRDuOOD _
LEGHL T10NR2ESEC18&19 LT11 LOT SIZE 10000 SQUARE FEET
TYPE OF SOIL RBSORRTlOW SYSTEM IS: DROINFIELD
MAXIMUM NUMBER OF BEDROOMS = ] SOIL RATING (SQ FT/8R)= 40
/
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
Ex EEC Fo" K 1-1 120 �ETT �Sol ��� CA Ca FZ FA %0 EE L. EA EE F" -r wA — v011
THE LENGTH DIMENSION IS THE LENGTH (lN FEET) OF THE TRENCH OR DRHINFIELD.
THE DEPTH OF H TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND HND THE BOTTOM OF THE EXCAVATION (lN FEET).
"T_ hi IE`1 E4111:1-1-1-11 1: c A' 11"D CA E ---E F
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF TIE EXCAVATION (IN FEET).
lot wE oil k -T I FA"En C> Jbilh= I- it PA K �1 02-_" EFO ��11-4�
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NOMBER OF RESIDENCES THAT THE WELL WILL SERVE.
0- 14 NO C- 1: 54 AT Fs ET CT -r x n PA w FA FT EE FIK C;1 L 1 1: 071 ERE F?
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN H WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR H PRIVATE WELL/ OR
150 TO 200 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
�K FG? Rol 1: 'y ��F�1 :111_1
I CERTIFY THAT
1: I RM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS
FORTH BY THE MUNICIPALITY OF ANCHORAGE.,
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
7: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE
RESIDENCE IStREMODELED TD INCLUDE MORE THAN 3 BEDROOMS.
SIGNED: ....
�` �
ISSUED BY
~ _ /
���s-0
AND WELLS AS SET
ENLARGEMENT IF THE
SOILS LOG
MUNICIPALITY OF ANCHORAGE
a c DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
TEST
Pouch 6650, Anchorage, Alaska 99502 276-2225
SOILS LOG - PERCOLATION TEST
PERFORMED FOR: Ms. Arlene Cheifer DATE PERFORMED: May 9, 1979
LEGAL DESCRIPTION: Portion of Lot 11, Girdwood Small Tract, U.S. Survey 3034, Girdwood;
J,gE_TOrganics, Brown 0.5' - SLOPE SITE PLAN nv
1 0 Coarse Gravel & Cobbles l
-` w/ silt (GP) 2.0' — I
�2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Sandy Silt w/clay &
gravel (SM -ML)
Very Wet, Dk. Brown
7.0
Gravelly Silt w/sand &
some clay (GM -ML)
Moist, Dense
WAS GROUND WATER L
ENCOUNTERED? O
12.0'`= E
.D. IF YES, AT WHAT r'' 20'
.
DEPTH? 1/{
OF
Stephen D. Shrader
. No. 4148-E -
Reading
Date
Gross
Time
Net
Time
Depth to
Water
I
�
Test
oc
at'
o
i
aPpr
3
meth
_pit
xima
e -d
ds.
-bt
e
L
on
or
y.
Not
_jTes
t
Pi
-I
-�
20
I
-
-
Reading
Date
Gross
Time
Net
Time
Depth to
Water
I
�
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
. L .
20 PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN FT AND FT
COMMENTS Unable to perform percolation test due to water running into pit from
2- to 7 -foot depth; and sides of pit sloughing in. 1 -foot plus of water
accumulatedin pi o om in -minute period.
PERFORMED BY: S. Shrader CERTIFIED BY: S Shrariar DATE: 5/in/79
72-008 (7/76)
STUE u F AL�� �� p BILL SHEFFIELD, GOVERNOR
DEPT. OF ENVIRONMENTAL CONSERVATION
Ev�St�ev��ti
�Y,5 7 7
uIve_r �'�iZv..��/ ./�t_�^
�GJ �4 �p �cr �o / ���° Jc��]�oi, ��� �%i' 7—/ OA,/ '
l�� �� �✓ la i r�Gw bpi (��� i—lv� — 0 S`2 �
c -
tai
/V 67r
///S -/8 vGG—
May 4, 1979
Health and Environmental Protection
Sewer and Water Section
825 L Street
Anchorage, Alaska 99501
Attention: Les N. Buchholz, R.S.
Subject: Waiver Needed for Holding Tank
I am requesting a waiver on the Municipal restriction on
septic holding tanks. I am the resident and title holder
of Lot 11 Girdwood Small Tract. The lot on which my home
stands is ninety(90) feet wide and one -hundred twenty(120)
feet deep.
I would like to aquire a Title I National Housing Act Home
Improvement Loan to install a water well and a self contained
septic tank, with regular pumping service provided by local
businesses.
My home is log and frame structure, valued at $28,000
replacement value, eight hundred(800) square feet. There
is no external plumbing and sewer has never been on this
home.
I would appreciate your inspection and approval of my plan
to thus improve my home until Municipal sewer facilities
are accessable for my lot.
Sincerely,
Arlene Cheifer
Box 304
Girdwood, Alaska 99587
Phone #: 783-6682(h)
349-4644(w)
279-0522(w)
May 10, 1979
Ms. Arlene Cheifer
Box 304
Girdwood, Alaska 99587
i1
ASI No. 01979
Re: Soils Log for Portion (Metes & Bounds Description) Lot 11,
Girdwood Small Tract, U.S. Survey 3043, located within
Sections 18 & 19, T 10 N, R 2 E, Seward Meridian, Alaska.
Dear Ms. Cheifer:
At your request, our office logged a test pit on the above-described
property on May 9, 1979. The purpose of this investigation was to
determine the general subsurface soil condition at the subject site.
The site is gently sloping. Ground cover consists of an organic
mat approximately -,-foot thick. The site is covered predominantly
with a thich growth of coniferous trees.
A test pit was excavated to a depth of 12 feet with a Case Model 580C
backhoe. A very wet sandy, silty soil was encountered from the 2- to
7 -foot depth of the pit, and was underlain by a gravelly silt to the
bottom of the pit. Water running into the pit from the 2- to 7 -foot
strata, coupled with the pit walls sloughing in, prevented a percolation
test from being performed. A foot or more of water, plus sloughed
material, raised the level to the 9 -foot depth in a 30 -minute period.
Water continued to seep into the pit after this period. There was
no indication of the water level subsiding in the bottom of the pit.
We appreciate the opportunity given to log this test pit. If .you
have any questions, please contact this office.
Very truly yours,
ALASKA SOILS INVESTIGATIONS
Stephen D. Shrader, P.E.
Project Manager
S
DtStreet vJ
Alaska 9950
278-1915
May 10, 1979
Ms. Arlene Cheifer
Box 304
Girdwood, Alaska 99587
ASI No. 01979
Re: Soils Log for Portion (Metes & Bounds Description) of Lot 11,
Girdwood Small Tract, U.S. Survey 3034, located within
Sections 18 & 19, T 10 N, R 2 E, Seward Meridian, Alaska.
Dear Ms. Cheifer:
This letter is our invoice for the above -referenced project:
INVOICE NO. 01979
Professional Services
Engineering Technician (Travel
& Standby) 3.0 hr @ 427.25
$
73.50
Engineering Technician (Field
- log test pit)
1.5 hr @
27.25
40.88
Draftsman (Prepare soils log)
0.3 hr @ $18.00
5.40
Registered Engineer (Project supervision;
prepare letter
report)
0.6 hr @
$40.00
24.00
Subtotal
Professional Services
$
143.78
Incurred Expenses
Mileage, 78 miles @ $0.25/mile
$
19.50
Subtotal
Incurred Expenses
$
19.50
TOTAL INVOICE NO. 01979
$
163.28
r�.
'Ms`. Arlene Cheifer
May, 10, "1979
Page -2-
Please note our invoice number on your remittance. If you have any
questions,'please contact this office.
Very truly yours,
ALASKA SOILS INVESTIGATIONS
'A4 0, A'A6
Ste hen D. Shrader, P.E.
Project Manager
Terms of Payment:
$75.00 to be paid on delivery of soils log.
B an a of $88.28 due and payable on May 18, 1979.
Acknowledgement:
A ne Cheifer
5--- t < -I I
Date
--ORDWOOD SERVICES- - - -- - - - ---
- P. O. Box 674 1
1033
GIRDWOOD, ALASKA 99587-0674
SALESP9RSON '-.
DATE SHIPPED
SHIPPEDVIA
OB PO1Ni TERMB: % '_
1
If
.a�OUANTITV
7,
1S
_
, TOTAL
nrrwl&-7-
0
YEAR
.� Other E)escription:
Size: —
I.
Area "
Year of Valuation
Use Zone:-
-- — —
-- Unit Price__
_
INFLUENCES: _ _
Depth
_dPLUS
- __
---.---
--
M1NUS
_- -_
Topography____-__
Irregular Modification
View-----
Drainage
Physical Barriers
Access ----
--
Corner -- -
Water
Sewer--.--
Sidewalk_paving—
50c�
Curb & Gutter,
Curb
Other �_-�-
TOTAL
Net L t )
10
UWNtR
/
.. ..._�........ KCH �UIV
Land Bldgs. Total FOR CHANGE
zf S
'0
9f
M-0
Z 5
r/G/10
17.800
j(1Q
X0 Z5 --
1.25
--
50c�
czs
llzS
10
L'RW MAY 191969
zf S
'0
9f
M-0
Z 5
r/G/10
17.800
I
that this is acopy of
1 -real orolDertV record.
Ifflenn M. "Pat" McKee
irector
REMARKS PICTURE: PROPERTY APPRAISAL DIVISION
l _
/✓' C'
3o
�o! o
� E//still r J �/int F_o�/ 1,21 ��•v�i�%��nJ r t7�1 s'
1' r
r
Ke-
(.-
Unilllitc: \ ---
Other Description:—.-
- _ --
Size. use ZOnC -----
Area -- --- — — —
Year of Valuation-
---
:AR
-_. - UWNtK
..
INFLUENCES:
PLUS
MINUS
Depth__---_
Bldgs.
Total
Topography
Irregular Modification_
View4-
Drainage
Physical Barriers
Access
Corner--
aoc
Water--
Sewer----
Sidewalk--
5�c
2- G7
Paving—
—
Curb & Gutter___.
---
Other
TOTAL
Net -I (---)
:AR
-_. - UWNtK
..
..._.......,..
KCH�VIV
FOR CHANGE
Land
Bldgs.
Total
!6
aoc
;s-
5�c
2- G7
z
—
W MAY 19 1969
Ad Go
kt oe)
EMARKS
J - C' ///GG i{ ,
/ V
i
e) L.,e
L -3o 2n
� �✓/slid P� � J NiV Ea,/ Ln( :��)oirin.rJ
(9oHV[ e ZP
I certify that this is a copy of a
r r
e/afl prope"rty record.
Glenn M. "Pat" McKee
C . Director
v
'F PROPERTY APPRAISAL DIVISION
n+
Y
0.
r.
,vnar
adrng Address _ / F -% _. -___. Property Address
rmits Date Built /��'� ., - • - -
17S
i
Total Replacement Con
Coat Conewslon Factor
Ad(usbd Raplscement Cort $
0068 (4/78)
i I
s SUMMARY OF APPRAISED I
Principal Building
Appraisal
Other Principal
Buildings Appraisal
Accessory Buildings
Itir�il
i
l �
P'
P�
r
Total Replacement Con
Coat Conewslon Factor
Ad(usbd Raplscement Cort $
0068 (4/78)
i I
s SUMMARY OF APPRAISED I
Principal Building
Appraisal
Other Principal
Buildings Appraisal
Accessory Buildings
Itir�il
l �
1
_1
Total Building
Appralul
Total Lend
Appraisal
TOTAL APPRAISED
VALUE $
I
I
i
J
C�
1
ALUE
Municipality of Anchorage
On -Site Water & Wastewater Program '
(907)343-7904
7i -
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 075-092-33 Expiration Date:
1. GENERAL INFORMATION
Complete legal description
Location (site address)
Current Property owner(s)
Mailing address
Real Estate Agent
2. TYPE OF DWELLING:
USS 3043; LOT 5 OF 11
137 TELEMARK WAY'GIRDWOOD, AK 99587
FRANK KOMAREK Day phone
137 TELEMARK WAY "GIRDWOOD, AK 99587
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
227-1700
3. NUMBER OF BEDROOMS: 1
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL
Individual Well
®
Individual On-site
❑
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
❑
Public Sewer
WiiverNariance request for
Received by:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 6R(o
Date of Payment 101 aJ_11
Receipt Number 11617- P6�
COSA# U6cl(O('bz
Date: Z ° 1 a 7 `/ 6
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
Distance: -
If more than 1 septic system is on the lot:
COSA Checklist # of
Structure served by this system
Certificate of On -Site Systems Approval Checklist
Legal Description
.. USS 3043; LOT 5 OF 11
Parcel ID- 075-092-33
A. WELL DATA *PER GEG INSPECTION **PER NEIGHBORING WELL LOGS
Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N) NO
Date completed PRE -1984 Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES
Total depth *41+ ft. Cased to **40+ ft. Casing height (above ground) 12+ in.
FROM WELL LOG
Date of test NO WELL LOG
Static water level ft.
Well production 9.p -m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 ml
Arsenic: NO ug./L.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material
AT INSPECTION
10/12/16
41.6
Nitrate ' 0.116 mg./L. Collected by: GEG, Ltd.
Date of sample: 10/12/16 & 10/19/16 ( BACTERIA ONLY)
PUBLIC SEWER
Date installed
Tank size gal. Number of Compartments Cleanouts (Y/N)
Foundation cleanout (Y/N) _ Depression over tank (Y/N) High water alarm
Date of pumping
C. ABSORPTION FIELD DATA
Date installed
Length ft.
Total depth ft. Eff.
Date of adequacy test
Pumper
Soil rating (g.p.d./ft2or ft2/bdr System type
Width ft. Gravel below pipe ft.
bsorptio ea ft2 Monitoring tube Depression over field
Results (Pass/Fail) Forbedrooms
Fluid deptA�abso n field before test _ in. Water added _gal.
Elapsed_n. Final fluid depth _ in. Absorption rate >=
New depth in.
rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
...
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)—
"Pump on" level at in. "Pump off' level atwa er alarm level at
Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES.FROM WELL ON LOT TO:
Septic tank/lift station on lot N/A On adjacent lots
Absorption field on lot N/A On adjacent lots
100'+
100'+
Public sewer main s+ Public sewer manhole/cleanout 100'+
Sewer /septic service line 25'+ Holding tank 75'+
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation
Water main
Wells on adjacent lots
Property line_
Water service
SEPARATION DISTANCE FROM ABSORPTION FI
Property line
Water service line
F. COMMENTS
G. ENGINEER'S CERTIFICATION
Surface water
Wells on adjacent lots
I certify that / have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this
.date.
Engineer's Printed Name JEFFREY A. GARNESS.
Date 10l2q,&.
(Rev. 10/12/12)
Absorption field
Surface water
TO:
Water main
Driveway, parking/vehicle storage
LICENSE
#AECC884
..........
pAnrrrc 1(1NP'_
Y.TCSD M91`D n_pq' I
Pi:pQi'L SJlDlll.^"...F
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FP.'JNt T.bOIIC. Y1CnC
1—
90E HPJMxG XRT
,A
UNDER NO CIRCUTASTANCES SHOULD AN AS -BUILT BE USED FOR CONSTRUCTION OR FOR ESTABLISHING BOUNDARY OR FENCE LINES.
THE SURVEYOR TAKES RESPOMS151UTY FOR 111C INITIAL TRANSACTION ONLY AND ASSUMES FINANCIAL LIABILITY ONLY FOR THE COST OF THE SURVEY.
LISTED DISTANCES PREVAIL OVER SCALING. REPRODUCTION MAY CAUSE ERRORS IN SCALE.
LOT SURVcv
PwrvDA11ON As-91JuT
FlNAL SMUCTURE AS -BUILT
PLOT PLAN . .. AS -BUILT .
PLOT PLANS &
I.YEA/il
SURKr . "OPOORA14iv
IT IS THE RESPONSIBILITY OF THE BUILDER OR OWNER, PRIOR TJ
CONSTRUCTION. TO VERIFY PROPOSED BUILDING CRADE RELATIVE !
TO FINISHED GRADE AND UTILITY CONNECTIONS AND TO DETERMINE
THE EXISTENCE OF ANY EASEMENTS. COVENANTS OR RESTRICTIONS
'WHICH DO NOT APPEAR ON THE RECORDED SUBDIVISION PLAT. j
SURVEY CERTIFICATION i nOPK6gpOk
PLOT PUN
. wI ba Aver . bw . I
v a r �1¢Lnq�N M M u1 esn�
41
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evww.eA.
as and
w en .n.<L
( All
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FOUNDATION AS—BUILT
{
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RNAL STRUCTURE AS—BUILT
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RGBERT E .DHrs..R
0
412 1 '- S
. O
•5�6
�s�°Te°siJn of �e00
SYMBOLS r
SET REBAR msrb° L ASPHALT
DRAW AGE
o FOUND REBAR WOOD FENCE CONCRETE
L00� ASSUMED ELEV.-g--X—k- ME IAL FENCE LCGL/J WOOD DEC
ONLY !HOSE IMPROVEMENTS ABOVE GROUND AND VISIBLE WILL BE
SHOWN. FENCES, WELLS, SEPTIC CLEANOUTS, SIDEWALKS, DRIVEWAYS,
ETC.. ARE SHOWN IN THEIR APPROXIMATE LOCATION, ONLY. SNOW
.VAY PREVENT SOME IMPROVEMENTS FROM BEING SEEN AND LOCATED.
ALL DISTANCES ARE RECORD UNLESS OTHERWISE NOTED.
Prepared by
Robert E. Johns, Jr. & Assoc
Professlonoi Land Surveyors
1700 Brink Drive.
ANCRORACE, ALASKA 99004
Sault: 1 U = 30 Rec. Lot S.F. Rea Plot File No.
acI° Surveea: 09/19/16 IDT°»° by REJ Nm°k.e OJMK
°ote °` 09/21/16 °" SE4913 W.D. 16-360
Legcl Descrip2l°�.: US SURVEY 3042
LOT 5 OF LOT 11 T1 ON R2E SEC 18
MUNICIPALITY OF ANCHORAGE SEWER
WATER & WASTEWATER UTILITY
3000 ARCTIC BOULEVARD
PHONE 786-5557
LOT/TRACT
SUBDIVISION
TAX CODE _
S of 11
CONNECT FhKMIT
DATE OF APPLICATION Oct. 28+ 1987
SCHEDULED COMPLETION DATE OC -t-. 37
C} SINGLE FAMILY
❑ MULTI -DWELLING
No. APTS
0 COMMERCIAL
BLOCK
Section 10/19 T10N, R2E, SNi
095-092-33
GRID` 912-13 AS -BUILT No.
STREET ADDRESS Alyeska
OWNER
Frank Komarek
IJ:L8I►T
MAIL ADDRESS P. O' Box 598 Girdwoo i, Alt. 99587
CONTRACTOR: c.zcs
i 1�>r'IliZ2a1l1ct
•s
C`_i ON PROPERTY ONLY
❑ MAIN TAP—TO PROPERTY LINE ONLY
(MOA or State ROW Permit Required)
❑ MAIN TAP & ON PROPERTY CONNECT
RVIOA or State ROW Permit Required)
❑ R -O -W NO.
CONNECTION SIZE 4"
INSPECTION -
PERMIT
REIMBURSIBLE
NUMBER
REMARKS:
ASSESSMENT!
❑ Main extension agreement
9 Improvement District
❑ Extend connect agreement
❑ Pending
CHARGE $
FEE $ 10.00
FEE $ 5.00
Georgia Lee
❑ PAID ❑ CASH
❑ CKY_
INSPECTED BY:
DEPOSIT S t/% f
TOTAL $15-00 DATE: ZZ- j d'7-4
x rant: �'i`o;aa Oft 1; x t
PERMITTEE (Please Print) PHONE
MAILADDRESS P. 0. Boxz590. GirC`1wood, AiaSka 99587 I
1 HAVE READ THE CONDITIONS AND REGULATIONS ON THE REVERSE SIDE OF THIS PERMIT AND AGREE
TO COMPLY WITH THEM, f4 '
POST IN A CONSPICUOUS PLACE AT THE JO
80.02' (Rc 11,86) AWWU INSPECTOR
,,U bt) IV I '5iQN: S'c�G%%ojj BLOCK LOT:
STf?EET
ADTATE
NORTH
:SEWER SERVICE 4.iMV: SKETt;i-d
SHOW LOCATION OF CONTROL l ie;NHOLESICL'"EAINOU i'S
AL1.ET
-F'
,'PE- MAIN:: .(5-_..___ fPE MAIN: /fir!' COVlPdFCT DEf'TI7 AT IM0:EH _1/6 _ j
Ci`dRC:;_;l ill=f"?i-i A1 E,rt_jI}. t -ml,-!
Ct?i*lt i i"T LC?GnliUtl.-5%r.tli.p.u%-,��-c..cTec���S_f'J-..�.Is%�-.lc_�,7
r �
G'aw�ircTr..../PZ-.G Xr_._fXls�iilq
Plc(/�I/CI/l--1 f- �!_cIJC ...,. iCnT-. 117S�ac cT_fa% ��1,2�/S/)--�jcc/_S.Cc✓2" _lCF'c�uc �ii�E
DATE:
SEP -14-21337 E2:28P FROM:
Pump Installation
TD:3491934 P•1
Log /*lee e ofk Rd. ;V-Itrolcl
rut
.5-" A , t
DATE
0-244, O
Pitless Adapter Manalactarer's Name:
�IPitkas Adapter Installer.A
1
RrW T
--Su]bj-7e1r4le
,r MAKE 11 tit' / , 0 7 r
`
amea._ J P~50
-3
SMALL 9
1
<� r-
,^� Mesar _
' COM TW-- Ta»_sr. t A,
« ti
G/ood(
Le„eac+. �?OoG1
I!�
antor,1, var. 3b
wLT[a TAMa Tya. I,--,
*e
snL envrc ss..__ �� ow. J[
Ax" mr:
I
CO�WDITS
well was disinfected upon completion.
method: calcium hypochlorite.