HomeMy WebLinkAboutPOGGAS BLK 21 LT 12/v2.
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GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
[udor Road, Anchorege, Alaska 99507 279-8686
Date Received , ,~-
Time of Inspection
Date of Inspection
REQUEST FOR APPROVAL OF
INDIVIDUAL SE~ER & WATER FACILITIES
FOR
1. Aoproval Requested By:
5. Type of Facility to be Inspected:
Number of Bedrooms:
6. Well Data:
A. Type
C. Construction
7. Sewage Disoosal System:
B. Depth
D. Bacterial Analysis'
A. Installed B. Installer
C. Septic Tank: 1, Size' 2. Manufacturer
D. Seepage Pit: 1. Size 2. Material
E. Disposal Field: Total Length of Lines
Distances:
A. Well To: Septic Tank
, Absorption Area
· 'Sewer Lines
, Nearest Lot Line , Other Contamination
Bo Foundation to Septic.Tank "~ AbSorption Area
C. Absorption Area to Nearest Lot Line
R~Jes. t for Approval of Inf~,idual Sewer & We%er Faeflitissf-~
Page Two
9. Comments
Approval Valid for One Year From Date Signed
Greater Anchorage Area Borough, Department of ~nvironmenta] Quality
DIAGRAM OF SYSTEM
I certify that %he information contained in this request for approval to be e true
and accurate representation of the subject sewer and water facilities located at:
Signed Date
{,~s. Co. rol O. ^lTea
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>:nvirom:mntal ConLroi
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Officer III
DEPARTMENT OF ENVIRONMENTAL QUALITY
PLATTING OR PLANNING
TITLE
Date Case Received
Suspense Date Comments to Planning Department
For' Planning & Zoning Commission Meeting Date
ROUTING
COMMENTS:
Environmental Engineering
Air Pollution
Noise
Environmental Sanitation
ZONING CASE REVIEW
.. ~ ~' ~ REQUEST FOR APPROVAL OF
]! INDIVIDUAL SEWAGE AND WATER FACILITIES
l~a~ of person requesting approval ~ ~/~,~ ,
c. Casing Size
d. Distanc~ from well to closeat existing or proposed:
ep~c tank
5. Property Line_ ,
6. Other soum~es of possible contamlnation~ i.e., creeks, lakes,
houses~ bamn~ ra~nage ditch, etc.
d '
Sewage disposal system.~ '' '
~eptic tank capacity ]'~lions ~ ~
1. If "home made" sh~ dia~ ~verse side of thls fomm.
e. Percolatlonx T~st
f. Percolation Test performed by
Diagra~ should include
~. Use the reverse .side of this form to show diagram.
'.'~'%he foil.owing Jnformatlon: property lines~.Well location, house location,
~i~t~c tank location, disposal area location~ location of percolation test,
au~ direction of ground slope.
The ~n~t;on On this form is true and correct to the bes~ of my knowledge.
S~gnature of Applicant Date Signed
- ,escrmbed sanitary f ' ' '
........ ~w_~ acllltles are hereby approved, subjett to. the
C°nditi°ns: __~ ~'f_~ ~j ~o_
The above described sanitary facilities are disapproved for the following
reasons:
''"' - alzd for one year following the date of approval.
~ CPJ:cw
6. Well data:
INDIVIDUAL SEWAGE AND WATER FACILITIES
' ~dau (Fill out in Triplicate)
~-.of person requesting approval . ~.--~
2. ~lame of property.owner
a~ bedrooms in house
Water Analysis:
Bacterial
Detergent_.
= '~ b. Depth.
Casing Size
Distance from well to closest existing or proposed:
1. Sewer line ,,'?
~. Cesspool'
5. Property Line .
houses, barn, drainage ditch, etc.
Sewage disposal system~
b.
c0
Other sources of ~osslble contamination, i.e., creeks, lakes,
Septic tank capacity in gallons..
Name of septic tank manufacturer
1. If "home made" show diagram on reverse side of this form.
Disposal field or seepage pit size and type , :.'
1. Distance to property line ~' to house foundation
e, Pe~coiation~TesT ~esults
f. Percolation Test performed by . ..
Use the reverse side of this form to show diagram, Diagram should include
,%he foilowing information: property lines;.Well location, house location,
~otn. c tank location, disposal area location, location of percolation test,
and direction of ground slope.
The lnfoY.~ration on this form is true and correct to the best of my knowledge.
, $ignature~/of Applicant ~ ' ~te Signed
TO BE FILLED OUT BY HEALTH DEPART~ENT PERSONNEL
~e above described sanitary facilities are hereby approved, subject to the
........... ~llowing conditions:
Conditions: ~\7~O. ._.
The above described sanitary facilities are disapproved for the following
"Signature of ~¢i'~&.¢ '.~' .,, s ;. ~&t'e .:~'.,
Approval is valid fop one year following the date of approval.
CPJ:cw