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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
PHONE NEW - -
NAME IIP`
r L_— �— JUPGRADE
_l ---- --- ---
MAILING ADDRESS / i �- A
5 /�J 'G
LEGAL DESCRIPTION
LOCATION NO. OF BEDROOMS
Y
lN!FW �� Absorl,<�n VY Dwelling/
DISTANCE TO: 7NV /�J �-- �_O--�
MaFeria
PES ).7
No, of compartrr>e2s
P:Z
Manufacturer / ! _
in
Liq. in,gllons IF HOMEMADE: Inside length Width
(�CJ (
Liquid depth
O �
z
�
Well
DISTANCE TODwelling
:
PERMIT NO.
Q
7: F-
Manufacturer Material
Liyuid capacity in gallons
O
Well Foundation Nearest lot line
PERMIT NO. r
Jy
DISTANCE TO:
a a z
No. of lines tg �� ch line Total length of lines Trench width
Distance between lines
Z w
inches
_
CC
F.
Top of tile to finish grade
Material beneath file
Total effective absorption area
p
�__� inches
w
Length 67) (,.,�
Width •_ %`�-.
Deptl ,1�— / e PERfTi Fa1�QJ
Type of crib
Crib diameter
Crib depth Total effective abso ptvon area
rylfV�l^
V)
DISTANCE TO:
Well
/V
dNearest lot line
Building , aiiej�
�—
®
w
Z
Class
_ �� e �? G
DISTANCE TO:
Depth
iU <�
Building fo ndation
_
Driller Distance to lot line — PERMIT NO.
__
Sewer line Septic tank Absorption area (s)
OTHER
—
-
PIPE MATERIALS
U!
SOI L TEST RATI G
INSTALLER
S
REMAR KSRobert
AJ
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A.
No. 1457-E}h--
i6-
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D�
APER / PATE LEGAL
`1 . 1 .
r-
TYPE OF SOIL RBSORPTION SYSTEM IS� TRENCH
MHXIMUM NUMBER OF BEDROOMS = ] SOIL RRTING (SQ FT/BR)310
THE REQUIRED SIZE OF THE SOIL HBSORPTION SYSTEM IS�
�H F, -Y KH �,, Y, ��1 YND J. 003 ICA Ent wou "? W L. ������ -4
IT: up: 10 51 v EVE Fn 1 - X L. L-����
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPHRTMENT DURING THE
INSTHLLHTION INSPECTIONS OF HNY WELLS 6DJMEMT TO IN 191 PROPERTY HND THE
NUMBER OF RESKENCES THAI THE NEL. NILL SERVE
~__ "! - R"T 11 :211 70
31
H91 -B :1
1=0 n a do: BEE wit HJ X wit
K T? �~~�
BHCKFILLING OF F11 -1Y SYSTEM
NITHOUT FINAL INSPECTION HND HPPROVHL BY
THIS
DEPHRTMENT WILL BE SUBJECT
TO PROSECUTION
HINIMUM DISTANCE 8ETWEEN
H
NELL RND ANY ON~SlTE
SEWHGE DISPOSHL SYSTEM
15
100 FEET FOR H PRIVHTE
WELL
Cl,'*.: 150 TO 200 FEET
FROM H PUBLIC WELL
DEPEN�ING
UPON THE TYPE OF PUBLIC
MINIMUM DISTHNCE FROM
NELL�TE NEW. TO H pRIyHTE
H PRIVn
SENER iINE IS 23
'
FEET AND
TO H COMMUNITY SEWER
LINE
IS 75 FEET.
OTHER REQUIREMENTS MAY
SPECIFICATIONS
AND CONSTRUCTIUN DIOGRHMS
HRE
RVHILHBLE TO INSURE PROPER
INSTALLATION,
yj KEE g;7� Tv j H: -4- T�E T -a um
:1 To!
FH�E� ED- FEY � ET MEN &
F V
' I CERTIFY THHT
l� I HM FHMILIHR HIM
PQ
REQUIREMENTS FOR OM
-SITE SEWERS 011"' WELLS
HS SET
FORTH BY THE MUNICIPALITY
OF 8HCH01RHGE.
2I WILL INSTRLL THE
SYSTEM
IN HCCORDHNCE NITH
THE CODES
]` I UNDERSTHND THAT
THE
ON~SITE SEATER SYSTEM
MHY REQUIRE ENLHRGEMENT
IF THE
RESIDENCE IS REHODELED
TO
lNCLUDE MORE THAN ]
BEDROOMS
HPPLICHNT IND
ISS11ED BY_~�~~y.
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❑ SOILS LOG
MUNICIPALITY OF ANCHORAGE
PERCOLATION
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION TEST
625 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST
PERFORMEDFOR:Y<Y�V✓��rly�t �WC`"t/VLZ�/PS( DATE PERFORMED:%�72T�
LEGAL DESCRIPTION: &k
&k
SLOPE SITE PLAN
f ffffl (3R&AN'Tc f—f-TT-7
2 ,t
.Q-
3
6— i
7
8
9 - ,41
10-
J
11
12
13
14
15
Ff e
16
�y
17
18;
19
20
COMMENTS
SnrI)Y '�-rz-,r •J- 61 -Ay
330 �1,6,v
9�
OF A C
a"
/ a".ae nava oo
HOY•1M ^'! e Q'
one A. Sh t a 'o
9
No, 1A57-
WAS GROUND WATER �.�V/ S
ENCOUNTERED? L
a
P
E
IF YES, AT WHAT
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
n
T z-oU
� a
_ /3
5-0
L
I I
: 00
10
y
�l
63,t
41 1
316
PERCOLATION RATE__.[CICJ/t�Lp/Ln--(minutes/inch)
TEST RUN BETWEEN e — FT AND �-` - FT
PERFORMED BY: r;,_ ,,;�-'__�� CERTIFIED
DATE: —6�1684lq z
c\C-- V r ; - k
Time
APPLIC IT
FILLS OUT UPPER MEAL :)NLY
_--
Property Owner
Phone
Zip Code
Mailing Address
Date
-
Date
Date
Buyer Idr
Inspector
Inspector Inspector
Inspector
Zip Code
Address
MUNICIPAI.ITY OF NCHORAGE
Lending Institution
�r /(j„ �, i�e`f-yam �`
r)
`. c: `.� v/c,
Phone
Address
./j
Zip Code Z
Realty Co. &Agent
I�� I , nD
Phone
'CONDITIONS OF APPROVAL
(�) DISAPPROVED
LIS" >-�
( ) CONDITIONAL APP i/AL'
_
1. _
Zip Code % / r C? G--
Address
-5(/- r4}-
Legal Description
Soils Rating
Date Sewer Installed
Well To Absorption Area
Street Location
i
�/ /�� , l r ,�� (; '.'
<. .7 / i�--�•. !�.y'-- -
Type of Residence
Single Family
Septic
Tank Size
Multiple Family
No. of Bedrooms ->
❑ Other
Water Supply
ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
❑ Individual
For wells drilled prior to that date, give well depth (attach log if available).
L3 Community
❑ Public Utility
Sewer Disposal
II , ,1
�LC.,'Y (C� (l.
Icer' Year Individual Installed:
Ind
❑ Public Utility
Public
(�c��t��,,C;6,
II
�Gl N
When Connected to Public Utility:
[I Holding Tank
O.f-1..:.-. 7,1 o t S
rit
NOTE: THE INSPECTION FE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
c\C-- V r ; - k
Time
Time
rime
Time
Date
Date
Date
Date '-�
Inspector
Inspector Inspector
Inspector
Field Notes:
-•/f-- 1�
QiC(�
MUNICIPAI.ITY OF NCHORAGE
I '6rc,v
_
ENVIR j,!;, -i,.?.. .-; --,-TION
I�� I , nD
( ) APPROVED BEDROOMS
'CONDITIONS OF APPROVAL
(�) DISAPPROVED
( ) CONDITIONAL APP i/AL'
DATE _
C
BY: _
Soils Rating
Date Sewer Installed
Well To Absorption Area
Well
Log Received
Well to Tank
Septic
Tank Size
72023 (31821