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HomeMy WebLinkAboutHANSON ACRES #1 BLK 3 LT 14 GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY 3500 TUDOR ROAD ANCHORAGE, ALASKA 99507 279-8686 - DATE RECEI.VED: INSPECT: TIME: REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES FOR APPROVAL REQUESTED BY: ADDRESS: PHONE: .377 3. LEGAL DESCRIPTION: / 4. TYPE FACILITY TO' BE INSPECTED: o NUMBER OF BEDROOMS: WELL DATA: '-,/;' B. DEPTH /~Z ! D. CONSTRUCTION f . SEWAGE DISPOSAL S'YSTEM: A. SEPTIC TANK (IF HOMEMADE, SHOW DIAGRAM..ZBA~?9~ 4. INSTALLER APPROVAL REQUEST FOR SEWER & WATER FACILITIES PAGE TWO SEEPAGE PIT 1. SIZE 2. LINING C. DISPOSAL FIELD 1. NUMBER OF LINES 2. TOTAL LENGTH REQUIRED MEASUREMENTS A WELL TO SEPTIC TANK B WELL TO SEEPAGE PIT C WELL TO SEWER LINE D WELL TO PROPERTY LINE E WELL TO OTHER POSSIBLE CONTAMINATION F FOUNDATION TO SEPTIC TANK G FOUNDATION TO SEEPAGE PIT H SEEPAGE PIT TO PROPERTY LINE COMMENTS: APPROVED DISAPPROVED: APPROVAL VALID FOR ONE YEAR FROM DATE SIGNED. GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALIT I 4 ~ ....... .~ GREATER ANCHORAGE AREA BOROUGH '"' '\ Department of Environmental Quality ~/ /~ ~330 "C" Street, Anchorage, Alaska 99503 274-4561 Date Received Time of Inspection Date of Inspection REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR 1. Approval requested by: Mailing Address: 2. Property Owner: Phone: Phone: Mailing Address: 3. Legal Description: ,~_./~_~ 4. Location: ,~? 5. Type of facility to be inspected 6. Well Data: A. Type ~,~. ' '~ ~'~"~'~:--~.-~--~'~- C. Construction 7. Sewage Disposal System: A. Installed / B. Depth D. Bacterial Analysis B. Installer C. Septic Tank: 1. Size 2. Manufacturer D. Seepage Pit: i. Absorption Area 2. Material E. Disposal Field: Total length of lines 8. Distances: A. Well to: Septic tank~~., Absorption area ~.~,,Sewer Lines Nearest lot line , Other contamination B. Foundation to septic tank , Absorption area C. Absorption area to nearest lot line EQ-034 (1/74) Page 1 of two pages Page 2~of two pages - Req_~st for Approval of Individual . r & Water Facilities Legal Description Comments Approved ~..~ ~/~-~ Disapproved Date ~// ~7~ Approval .Valid for one year from date signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM certify that the information contained in this request for approval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating satisfactorily. SIGNED Date EQ-034 (1/74) - / ' ~,o'[ ~{ ~ \ I~DIVIDUAL SEWAGE AND WATER FACILITIES / ..... i~ ~ ) 1 (['ill out in Triplicate) erCy; owner. 6, w~]] data: / c. Casin~ d. Distance from well to close[t existing or proposed: / 2. Septic tank, /,~ . ,. 3. Seepage A~ea ~. Cesspool~ .6~ ~ / 5. PPopePty Line 6. OtheP sources of possible contamina%ion, i.e.~ cPeeks, lakes, houses, baPn, dPainage ditch, etc. Sewage disposal system. b, Septic tank capacity in gallons.,,~z ~ . 1. If "home made show dlagPam on reverse 'aide of This foPm. d.' Disposal field oP seepaKe pit size and type. 1. Distance to proper~ ~n~ to house fo~dation Percoiatical Test Percolation Test pePformed by Use the reverse .side of this form to show dia£ram. Diagram should include -'.'-~he foilowing information: p?operty lines; .well location, house location, v~ptlc tank location, disposal area location, location of percolation test, a~d direction of ground slope. 9. The ~r~-~untlon Dn %his form is true and correct to the best of my knowledge. 'S'igJature of Applicant Date Signed TO~B_E FILLED OUT BY HEALTH DEPARTMENT PEP~SONNEL ~The above described sanitary facilities are hereby approved, .sub. ject to the i z~°-~!Ow~ng cond..il~ons: Conditions: The above described sanitary facilities are disapproved for the following reasons: - App,'ova Pb :' ~. ~..! ' ' is valid for one year following the date of approval. 2. 3. 5. REQUEST FOR APPROVAL OF INDIVIDUAL SEWAGE AND WATER FACILITIES (Fill out in Triplicate) ~[au~ of person requesting approval %~au~e of property owner /~,-29© Well data: c. Casing Size d. Distance from well to closest existing or proposed: Sewer line Septic tank Seepage Area Cesspool' Property Line 6. Other sources of possible contaminations i.e., creeks, lakes, houses, barn, dralna~e ditch, etc. 7, Sewage disposal system. b. Septic tank capacity in gallons c. Name of septic tank manufactu~e,r ~)ag'tu~V ~'~O~w~5', 1. If "home made" show diagram on reverse side of this form. Disposal field or seepage pit size and type.,,.4~,-,~'~Z~ 1. Distance to pmoperty llne to house foundation e, Percol~=~tlon, Test ~es~Llts f. Percolation Test performed by , Use the reverse side of this form to show diagram. Diagram should include ,the foilowing infor~atlon: p.roperty lines~ .well location, housD location, ~pt.lc tank location, disposal area location, location of percolation test, an~ direction of ground slope. The i~for~tion on this form is true and correct to the best of my knowledge. S~gnature. -: . '6f Appl~c~nt~ .... Date S~gned TO BE FILLED OUT BY HEALTH DEPART~-JENT PERSONNEL ~ The above described sanitary facilities are hereby approved, subject to the ........... ~611owing con~],i~'ions: Conditions: The above described sanitary facilities are disapproved for the following reasons% S~gnature of ~f~e.za:~l , Approval is valid for one year following the date of approval. CPJ:cw