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INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM /
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Name F SJr-« �N Mailing Address rink !� eK Ph.#
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LocationM,'iS y /�ia��a/ ,S>` Legal Description DoT D,/,,,nom , c
SEPTIC TANK: Distance from well 7/ 'Material!'ire«-ie'i.iVumber of compartments /
Liquid capacityll d;7"gallons. Inside length 7,2 -'Inside widthAW Liquid depth 3.S
SEEPAGE SYSTEM: Seepage Pit: Number of pits_LOutside diameter or
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width len8th 1.5 , depth G. `J_ 4" I , lining material id c'! Distance from
well ,building foundation 36 ' , nearest lot line /D' Total effective
absorption.area (wall area) sq. sq, ft.
TILE_DRAIN FIELD: Distance from well , foundation , nearest lot line
Total length of lir.oa Number of lines Distance between lines Trench
width in. Total effective absorption area sq, ft. Length of each line_
Depth: Top of tile to finish grade Depth of filter material beneath
tile in. Above tile
WELL: Typt_N,i a, depth (7 distance from building foundation7,S /, nearest
lot line s nearest sewer line Y/ , septic tank SU , seepage system // ,
cesspool 1 , other sources
DISTANCES:
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DATE: (Seel i —30, 1 Q t,19
DIAGRAM Or SYSTEM iJ" '
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APPROVED rl ijlli�
Health Authority
GAAD-IID-2 GREATE'�ANCHORAGE AREA ��OROUGH
f 0 IiEALTII DEPARTMENT
327 -Eagle St. Anchorage, Alaska 99501 279-2511
SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT
NAME OF APPLICANT S1'64111z4dfo
Case No.
MAILING ADDRESS df 19 fJKiZ PHONE NO.R 7. 3-9/
RESIDENCE ADDRESS X041 Q'C-PA LOCATION
LEGAL DESCRIPTION Lo-' /(J
NSTALLATION
APPLICATION TO INSTALL: SEPTIC TANK /! , SEEPAGE PIT , DRAIN FIELD OTHER
TO SERVE THE FOLLOWING FACILITY ��d'Lnt� �1Y,-c-i1i.,
FINANCED THROUGH
PERCOLATION TEST RESULTS
TO BE INSTALLED BY
ANTICIPATED DATE OF COMPLETION
BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT
THIS IS TO SERVE AS It/i- S'617!11 S , PERMIT TO INSTALL A ! FFa)' V l /A
AS DESCRIBED BELOW. SIZE OF UNIT TO BE SERVED
SEPTIC TANK SIZE TYPE SEEPAGE AREA TYPE
DIAGRAM OF SYSTEM
DISTANCES:
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HEALTH AUTHORITY 1 1 1 1 1 1 I I 1 I 1 1 1 1 1 1 I 1 1 1 1 1 I
OR
V LICENSED DESIGNER
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.
DATE fill
I /� 1L/ APPLICANTS
SIGNATURE ` �t� j� itt'-�
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