HomeMy WebLinkAboutNORTH WOODS BLK 3 LT 41
! , ' 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
NAME ~-"~t/ PHONE [] UPGRADE
IF HOMfi~DE: Inside length ~idth Liquid depth
DISTANCE
TO:
~z
t~ Manufacturer 'Material Liquid capacity in gallons
Tren~ widt ~-/
~ m Z No. of lines
~ ~ ~ Top of tile to finish( grade / ~_ M~terial ben.th tile
Total effeT/~ion area
inches
Length Width 'Depth f PERMIT NO.
~ ~ Tg~e of crib Crib diame Crib depth Total effective absorption area
m Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth , , / Driller Distance to lot line PERMIT NO.
Building~u~n~' Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
PIPE MATERIALS
SOI~ TEST ~ATI~G
NSTAELER
REMARKS
PEF::M I T NO.
RPPLIC:RNT STE',/E SI<FIGGS PO B',:.:', D CHUGIRK
LOCRTION NOF.'.THI.,.tOODS D.R
LEGFIL LT. 4t BL.KZ: NORTHI.,.IOODS S,."'D LOT SIZE
DEPRRTMENT OF' HERLTH RN[:, EN',.,'IRONMENTFIL PF..:OTECTION
825 "L" STREET., RNCHORRGE., FIK. ~S'~50::L
264-4720
( 8t07:~:7 )
.....
2E'u-.]00 'S L.]UFIF.'E FEET
'-' "- IS ·
T'¢F'E OF :=-;01 L FIBSOF..:F'T I ON .:, ~ z, TEM [:,RR I NFI EL.E:,
MFtXIMUM N_F1BER OF: EE[:,F.'()E~MS = E: qF~II h["l] IF,I.~ ,:":.,K~ FT,.'"E,'R)= _~:]:O
THE F.:EQIJiF.:E[:, SIZE OF 'THE SOIL RESORF'TION S?STEM IS'
L~.F..'. ~_ -~- ~L_
£:. E~-: F' 'T H ==
THE L. ENGTH DIMENSION IS THE LENGTH (IN FEET.'." OF THE TRENCH OR DRRINF'IEL[:,.
)'HE [:,EPTH OF FI TRENCH OR PIT IS THE DISTRNE:E BETNEEN THE SURFRCE OF THE
GROUN[:, RND THE BOTTOM OF THE E;:.:',CFI',?RTION (IN FEET).
THE GRRVEL [:,EPTH IS THE M!NiMUH DEPTH OF GRR'./EL BETNEEN THE OUTFRLL PIPE
RND TPIE E:OTTOM OF ]"HE EXCRVRTION ,::IN FEET).
F'EF.:HIT RPPLICFINT HRS THE RESPONSIBILIT'¢ TO INFORM THIS [:,EF'FIF.':TMENT [:,LIF.:ING 'rilE
INSTRLLRI"ION II',I:,FE..I I31'.~S ]F P]l'.,t'¢ P.IELLS RDJFtCENT TO )'HIS FF..FbF. T~ FIND THE
NLM~:,EF.'. OF F.:ESI[:,ENCES "FHF. tT '['HE NELL HILL SERVE.
E:RBKFILLING OF RN'¢ S"r'STEM 14ITHOU]' FINRL IN'~iPEE:TIEff'4 RN[:' RF'PREVRL B"? THIS
[:,EF'RF.'.TMENT !.4ILL BE _":,UE,...IE_.] TO F'R]SE]_TION..
MIN!MLIM DISTBNCE BETI-,.IEEN R NELL RND RN'¢ ()N-BITE SENRGE DISF'OSRL S'¢STEM tS
ZCiO FEET FOR FI F'RI',,,'FI'i"E NELL OF.'. :;L50 TO 200 FEET FROH R PUBLIC NELL [:,EPENDING
UF'ON THE TYPE OF PUBLIC P.tELL.
MINIMLIM B,I':.;TFtNCE FROM Ft PRI',,,'RTE t.,.IELL TO R PRI',/RTE SENER LINE IS 25 FEET FIND
TO R COMMUNIT'¢ SEI.,.!ER LINE I"-.; 75 FEET.
OTHER REQUIREMENTS MR'?' RF'F'L'¢. SPECIFICRTiONS FIN[:, CONSTRUCTION [:,IFtGRRMS RRE
R',,,'RILRBLE 'to INSURE PROPER INSTRL.LRTION.
F'EF~:P! ][ 'T E,:-=,F Z F,':.E.S [:,EC:EI',IE:~]F.'. -'~-::..I.Z.., :.IL.::.~ .=,:'IL
I CERTIFY THRT
:1: ! R['I FRMILIRR HITH. THE REQUIREMENTS FOR ON-SITE SEI.qERS RND I.,!ELLS RS SE]'
FORTH B'¢ THE MUN. ICIPFILIT'¢ OF RNCFIORRGE.
2: ! HILL INSTRLL THE SYSTEM tN RCCOR[:,RNCE NITH THE CODES.
3:: I UNDERSTRND THRT 7'HE ()N-SITE SEI.4ER S'¢STEM MR'¢ REQUIRE ENLRRGEMENT IF THE
RESIDENCE IS REMODELED TO INC:LLIDE MORE THFIN 3: BEDROOMS.
................
0
~/, ,,%,/ [] SOILS LOG
PERF ~
SLOPE PLAN
1
2
3
4
5
6
7
8
9
10'
11
12
13
14
15
16:
17
18
19
2O
COMMENTS
PERFORMED BY:
72-OO8 (6~79)
--!
/
/
WAS GROUNO WATER
ENCOUNTERED?
DEPTH?
Reading Date Gross Net Depth to Net
Time Time ,,Water Drop
~ ,, ~,'~p /~ /~" ~/~,~
RATE ~0 minutes/inch)
RUN BETWEEN ~ FT AND ~ FT
~) ~ " ' 'fl
9
't'.' D~'r'E RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR I NSP ECT/D~R
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTI(~PT' OF HEALTH &
825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL P~OTECTION
E.WRO. EUTAL SA. TAT O" D V S O. AU6 ? I981
Telephone 264-4720
DIRECTIONS: Complete ali parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
MAILING ADDRESS
PROPERTY RESIDENT [If different from above) PHONE
PHONE
MAILING ADDRESS' ' '
MAI LING ADDRESS
STREET LOCATION
6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS
~ One ~ Four ~ Other~
~SINGLE FAMILY ~ ~Two ~ Five
~ MULTIPLE FAMILY ~ Three ~ Six
7. WATER SUPPLY
i~ INDIVIDUAL*
COMMUNITY
[] PUBLIC UTILITY
*ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
~ INDIVIDUAL/ON-SITE~
[] PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
E~ SINGLE FAMILY
[] MULTIPLE FAMILY
2, WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTILITY
Connection Verified
3, SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON -SITE
[]PUBLIC UTILITY
Connection Verified
[~Septic Tank or [~]Holding Tank
Size: If Tank is homemade
give dimensions:
NUMBER OF BEDROOMS
[] ONE E] THREE [] FIVE
[] TWO [] FOUR [] SIX
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
SOILS RATING
OTHER
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line
I
WELL TO:
Absorption Area to nearest Lot Line
5. COMMENTS
DATB
[;[~'/'APPROV ED FOR ,~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
E] DISAPPROVED
72-010 (Rev. 6/79)