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GPrATER ANCHORAGE AREA BOR01I03H No 5�
HEALTH DEPARTMENT
327 EAGLE ST. ANCHORAGE, ALASKA 99501
INSPECTION REPORT ON-SITE SEWAGE DI5Hv5HL �OTa.. IClvl
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'�7C�r' ^ 'P/ MAILING ��, ` �L9�1�
NAME_. PHONES
' �� /� ADDRESS �Lr
LOCATION/C% 616/ ?`1 !� LL �� LEGAL DESCRIPTION Q
_ �
—7
SEPTIC TANK:
% / / ! NUMBER OF
DISTANCE FROM WELL—T —MATERIAL_ �f / �--COMPARTMENTS
DISTANCE
,S Lt C/f-jj i/ _}. e& � / ' /I LIQUID
LIQUID CAPACITY
�C _GALLONS. INSIDE LENGTH --INSIDE= WIDT __DEPTH--
SEEPAGE SYSTEM: SEEPAGE PIT:
_OUTSIDE DIAMETER OR WIDTH LJ LENGTH / DEPTH_ —,
NUMBER OF PITS f aG c�
U G S
LINING MATERIALDISTANCE FROM WELL BUILDING FOUNDATION_
__--
1` ����
NEAREST LOT LINE
C9 ti b^ .7 i6 TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA)_— — SQ. FT.
TILE DRAIN FIELD:
DISTANCE FROM WELL
NUMBER OF
ABSORPTION AREA
DEPTH: TOP OF TILE TO FINISH GRADE
WELL' TYPE--
NEAREST
YPE —
NEAREST
LOT LINE , SEWER LINE
DISTANCES:
CE BETWEEN LINES
SQ, FT. LENGTH OF EACH LINE
TOTAL LENGTH
OF LINES_
TRENCH WIDT_ /'IN�TS�TAL EFFECTIVE
_ DEPTH OF FILTER MATERIAL BENEATH TILE_ IN. ABOVE TILE—
DISTANCE
ILE DISTANCE FROM WATER
DEPTH -, BUILDING FOUNDATION.-- SAMPLE_ , NEAREST
SEPTIC SEEPAGE OTHER
TANK , SYSTEM CESSPOOL , SOURCES__
nler,RAM OF SYSTEM
f(F'/ /PIC) iT
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Y f S e
IV,
DATE
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GREA'TE1 ANCHORAGE AREA OR®UGI� Case No. � 2�
HEALTH DEPARTMENT
327 Eagle St. Anchorage, Alaska 99501 279-2511
SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT
MAILING ADDRESS= /' PHONE N0.
NAME OF APPLICANT=I —
RESIDENCE ADDRESS'' Lt
'V E V LOCATION OF INSTALLATION, 3 L—
LEGALDESCRIPTION-SL 17,
APPLICATION TO INSTALL: SEPTIC TANK
SEEPAGE PITy DRAIN FIELD_ , OTHER
TO SERVE THE FOLLOWING FACILITY
FINANCED THROUGH c , TO BE INSTALLED BYE�112� I erg r= X --v—
PERCOLATION TEST RESULTS-�7f �'c{✓17L ANTICIPATED DATE OF COMPLETION— �—
BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT—
THIS IS TO SERVE AS ��' �'r -)c17 rhe f rS PERMIT TO INSTALL A _ � Y > 5 �'
AS DESCRIBED BELOW. SIZE OF UNIT TO BE SERVED
SEPTIC TANK SIZEI�—)L) LC TYPE J Ll ., SEEPAGE AREA--eTYPE
DIAGRAM OF SYSTEM
DISTANCES:
Health Authority
I certify that I am familiar with the requirements of Greater Anchorage Area Borough Ordinance No. 28-68 and that the
above described system is in accordance with said code.
DA -FE
APPLICANTS SIGNATURE