HomeMy WebLinkAboutPRATOR BLK 7 LT 10 0
I
8
·
]~
~ -~ .
HEALTH DEPARTMENT
327 EAGi~ ST. ANCHORAGE, ALASKA 99501 27~'-'~511
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME
LOCATION
SEPTIC TANK:
MAILING --~'~J'",
ADDRESS
DESCRIPTION
PHONE
DISTANCE FROM WELL
LIQUID CAPACITY
/ NUMBER OF
MATERIAL C/~/~.t ¢7~/~ ¢'~/,,~_~'- COMPARTMENTS
GALLONS. INSIDE LENGTH INSIDE WIDTH
LIQUID
DEPTH__
SEEPAGE SYSTEM:
NUMBER OF PITS
LINING MATERIAL
NEAREST LOT LINE
SEEPAGE PIT:
I
OUTSIDE DIAMETER OR WIDTH
DISTANCE FROM WELL
TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA)
,LENGTH / f~ , DEPTH
, BUILDING FOUNDATION ~- ,/'
-3 ~'~ ',~ SQ. FT.
TILE DRAIN FIELD:
DISTANCE FROM WELL
NUMBER OF LINES
ABSORPTION AREA
FOUNDATION //~"~ T LINE
DISTANCE ~ TRENCH WIDTH
.y LENGTH OF EACH LINE
DEPTH: TOP OF TILE TO FINISH GRADE DEPTH OF FILTER MATERIAL BENEATH TILE
TOTAL LENGTH
OF LINES
IN. TOTAL EFFECTIVE
IN. ABOVE TILE
'~, ~.'Z/j DISTANCE FROM
WELL: TYPE P ~ I(..J~ DEPTH ., BUILDING FOUNDATION,
NEAREST SEPTIC ,~j~',.,~ / SEEPAGE
LOT LINE ,~ ~ / ~ , SEWER LINE '~'~ j , TANK . SYSTEM
/.~ ~ WATER
· SAMPLE //~/~ , NEAREST
/~ ~ I ~--~ OTHER
, CESSPOOL , SOURCES
DISTANCES:
DIAGRAM OF SYSTEM
DATE
· HEALiR AUI'HORITY /
,, HEALTH DEPARTMENT
327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
ADDRESS
;'!/,~,'%'~C' LEGAL DESCRIPTION
SEPTIC TANK:
PHONE __
~>~,~ /r
DISTANCE FROM WELL
LIQUID CAPACITY
GALLONS.
MATERIAL (~ ~J[,'C;/~'//~ ~?' NUMBER OF
COMPARTMENTS
INSIDE LENGTH. ~ INSIDE WIDTH ~
LIQUID
DEPTH
SEEPAGE SYSTEM:
NUMBER OF PITS
LINING MATERIAl
NEAREST LOT LINE
SEEPAGE PIT:
OUTSIDE DIAMETER
OR WIDTH
DISTANCE FROM WELL
TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA)
LENGTH , DEPTH
BUILDING FOUNDATION
.SQ. FT.
TILE DRAIN FIELD:
DISTANCE FROM WELL
NUMBER OF LINES
ABSORPTION AREA
DEPTH: TOP OF TILE TO FINISH GRADE
FOUNDATION.
DISTANCE BETWEEN LINES
SQ. FT. LENGTH OF EACH LINE
, NEAREST LOT LINE
TRENCH WIDTH
TOTAL LENGTH
OF LINES
IN. TOTAL EFFECTIVE
DEPTH OF FILTER MATERIAL BENEATH TILE'.
IN. ABOVE TILE
WELL:
DISTANCE FROM · WATER
TYPE ,j~'),~j/_L,~ DEPTH , BUILDING FOUNDATION.. . SAMPLE ., NEAREST
NEAREST SEPTIC SEEPAGE OTHER
LOT LINE , SEWER LINE. , TANK. , SYSTEM , CESSPOOL , SOURCES
DISTANCES:
DIAGRAM OF SYSTEM
DATE APPROVED
HEALTH AUTHORII'Y
GAAB-HD-2~
GREATEK .,NCHORAGE AREA. L)ROUGH
HEALTH DEPARTMENT
327 Eagle St. Anchorage, Alaska 99501 279-2511
Case No.
SEWAGE
NAME OF APPLICANT ~--~ ha ~ I~ ~
RESIDENCE ADDRESS
LEGAL DESCRIPTION
APPLICATION TO INSTALL: SEPTIC TANK
TO SERVE THE FOLLOWING FACILITY
DISPOSAL SYSTEM - APPLICATION & PERMIT
~9//~. MAILINSADDRESS ~'0'~ ¢~,~ PHONENO.
LOCATION OF INSTALLATION. '~~~
FINANCED THROUGH ~.~'e~ ~ r~ TO BE INSTALLED BY
PERCO LATION TEST RESULTS ',/~,~ ~/~',A~ ANTICIPATED DATE OF COMPLETION
( ·
BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT
, OTHER
.SEPTIC TANK SIZE /2~ TYPE d~/SEEPAGE AREA ~~ TYPE
DISTANCES:
Health Authority
DIAGRAM OF SYSTEM
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.
BATE
~-~2REATER ANCHORAGE AREA BOROU~Hk~_~J
HEALTH DEPARTMENT CASE #
' 327 EAGLE STREET
' ANCHORAGE, ALASKA 99501
Lega~ Descript;oTM LO~ ._~_~__~lock ~[. 3ubdlvl~!o-'-~--~n Pf~tO~ ' -X , '
~:~ Pnrm R.n s a: So~ls Lox - -percol~[bh ~est ' -- ', ,
3
7
0
Depth
Feet
Was Ground Water Encountered?
If Yes, At ~hat Depth~
Rate 1"/ ' ' M~nut~ ' '
Location Sketch
Net Drop
Prop,~sed Installation: Seepage Pit Drain Field
Depth Of/Inle~t ......... Depth T'o BOttom O~'~'it Or TPench '
/ ~INDIVIDUAL SEtNER & WATER FACILITIES
×" FOR
GREATER ANCHORAGE AR£^ BOROUGH
Department of Environmental Quslity
3500 T"?dor Ro~d, Anchorage, Alaska 99507 279-8686
Date Rece~ve~
" '
I05o
5. . . -- / ' ~ .... I
Number of Bedrooms: ~ '
Well Data:
A. Type ~ B. Depth J)-'~'t .C/~'"mz'~ 7
A. ~ns~alled 8. ~nst~ller ....
C. Septic Tank: 1. Size /~--0~. ~anufacturer ~~ ,
5. Disposal F~eld: Total Length of L~nes ~/~, ..
Distances:
A. ~ell To:
Septic Tank p~q' , Absorption Area /~/ , Sewer Lines
; Nearest Lot Line P.O~ , Other Contamination ~-/~
Foundation to Septic Tank ~'-~ ",'Ab'~orption Area
I
Absorption Area to Nearest Lot Line ~ ~ ·
Request for Approval of Individual Sewer & Water Facilities
· 'Page Two
9. Comme n t s :~' ~ ~.~~
ApprovedI .f Disapproved Date //-~- ~_~
Approval Valid for One Year From Date Signed
Greater Anchorage Area Borough, Department of Environmental Quality
~DIAGP~qM 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 located at:
Signed Date
~.....ATER ANCHORAGE AREA BOROU~ ....
DEPARTMENT OF ENVIRONMENTAL QUALITY
3500 TUDOR ROAD
ANCHORAGE, ALASKA 99507
279-8686
DATE RECEIVED: '-' ~-/,~"'
/,_~ --71
I N S P E C T:
TIME:
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER AND WATER FACILITIES
FOR
APPROVAL REQUESTED BY:
ADDRESS:
PHONE:
WELL DATA:
A. TYPE
B. DEPTH
C. SIZE ~' ~'
D. CONSTRUCTION
E. BACTERIAL ANALYSIS
SEWAGE DISPOSAL SYSTEM:
A. SEPTIC TANK (IF HOMEMADE, SHOW DIAGRAM ON BACK)
FAC I L ii-~ES
APPROVAL REQUE~¥ FOR SEWER & WATER
PAGE TWO
B. SEEPAGE PIT
l. SIZE
2. LINING
C. DISPOSAL FIELD
NUMBER OF LINES
2. TOTAL LENGTH
REQUIRED MEASUREMENTS
B.
C.
D.
E.
F.
G.
H.
WELL TO SEPTIC TANK
WELL TO SEEPAGE PIT
WELL TO SEWER LINE
WELL TO PROPERTY LINE
WELL TO OTHER POSSIBLE CONTAMINATION
FOUNDATION TO SEPTIC TANK ~'~/"
FOUNDATION TO SEEPAGE PIT
SEEPAGE PIT TO PROPERTY LINE ~ ~/'"
8. COMMENTS:
DATE: /~-~. - /'7-- .'?/ DATE:
/
APPROVAL VALID FOR ONE YEAR FROM DATE SIGNED.
GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY
i(, ~/~/' REQOEST FOR AP?ROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate)
. _ ~amo .of person requesting approval_ ~.~/~~ ~
2 ~"'~e' of p~ope~y: owne~ ~~f ~ ~~~,
L~, desc~ip~oq
Num~r-~.~bedrooms in house
~ate~.Ar~alysis:
Bacterial
Detergent
We/1 clat a:
b. Dept~l. ,, ._~
c. Casing Size ....
de
Distance from well to closest existing or proposed:
1. Sewer line ~-~
2. Septic tank
3. Seepage Area, //~?~ /
4. Cesspool:~
5. Property Line
houses, barn, drainage ditch, etc.
Sewage disposal system.
ao
b.
C,
Other sources of possible contamination, i.e., creeks, lakes,
^ge of s ste _//X? .
Septic tank capacity in gallons ....
Name of septic tank manufacturer
1. If "home made" show diagram on reverse side of this form.
d.' Disposal field or seepage pit size and type
Distance to property~ line ~// /~ ,to house foundation,
e. Percolatioa Te~t h~esu3_ts
f. Percolation Test performed by
~Use the reverse .side o.f this form to show diagram. Diagram should include
...~he following information: property llnes~.well location, house location,
t~ptic tank location, disposa~ area location, location of percolation test,
a~..~ dtrectlon of ground slope.
g. The l~for~ation on this form is true and correct to the best of my knowledge.
'Signature 'of Applicant ....... Da~e Si~ned'
T,Q BE FILLED OUT BY HEALTH DEPARTMENT PERSONNEL
~"~he-~r ~ab°ve described panitary facilities are hereby approved, ...... s~ubject to the
!"'-',,ro, l~owing con~ions:
Conditions:
The above described sanitary facilities are disspproved for the following
reasons:
" 1 is valld for one year following the date of ~i~oval.~
-r' CPJ:cw