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C~e~ATER ANCHORAGE AREA BOROI'"~H
HEALTH DEPARTMENT
327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME L ~'/"~ I' ~ ~ ~'~'. ~L~/~'-- MAILING
ADDRESS /~x
LOCATION LEGAL DESCRIPTION ~.~)~'
SEPTIC TANK:
DISTANCE FROM WELL (~.,D~;
LIQUID CAPACITY ///-900 GALLONS.
MATERIAL
INSIDE LENGTH
NUMBER OF /
COMPARTMENTS
INSIDE WIDTH ~" / DEPTHLIQUID
SEEPAGE SYSTEM:
SEEPAGE PIT:
NUMBER OF PITS / OUTSIDE DIAMETER
El NING MATERIAl. LO (~....~
i
NEAREST LOT LINE '~ (~
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
TOTAL LENGTH
OF LINES
TRENCH WIDTH
IN. TOTAL EFFECTIVE
DEPTH OF FILTER MATERIAL BENEATH TILE
tN. ABOVE TILE
WELL:
TYPE ,.~,-,,~,~v'vx, ,, , DEPTH
NEAREST
LOT LINE SEWER LINE
SEPTIC
., TANK
DISTANCE FROM
., BUILDING FOUNDATION
SEEPAGE
, SYSTEM
WATER
.. SAMPLE_
, CESSPOOL
NEAREST
OTHER
, SOURCES__
DISTANCES:
DIAGRAM OF SYSTEM
DATE
APPROVED
HEALTH AUTHORITY
GREATEL ANCHORAGE AREA . OROUGH Ca,,N0.
HEALTH DEPARTMENT
327 Eagle St. Anchorage, Alaska 99501 279-2511
SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT
NAME OF APPLICANT
RESIDENCE ADDRESS
MAILING ADDRESS z~o~ ~/5-- PHONE NO
LOCATION OF INSTALLATION d,.-p~'/.~..~ ~;;-.,~-~.-- ~?~/~"~.,~
LEGAL DESCRIPTION
APPLICATION TO INSTALL: SEPTIC TANK
TO SERVE THE FOLLOWING FACILITY
SEEPAGE PIT. ~ , DRAIN FIELD , OTHER
FINANCED THROUGH ~ L /c/- \ TO BE INSTALLED BY
· '"~ER CO LATION TEST RESU LTS ~/~9 ANTICIPATED DATE OF COMPLETION
, PERMIT TO INSTALL A
AS DESCRIBED BELOW. SIZE OF UNIT TO BE SERVED
.. SEPTIC TANK SIZE J~ TYPE ~~ SEEPAGE AREA '~ g,~ ~ I,TYPE
~~,~i.( ~. DIAGRAM OF SYSTEM
DISTANCES:
ealth Authority
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 . 7 APPLICANTS SIGNATURE-.-~%-~>---~-~,?Y---~:g'-~-,-~-" '"
GREATER ANCHORAG~ AREA BOROUGH
3500 TUDOR ROAD
ANCHORAGE, ALASKA 99507
279-8686
DATE RECEIVED:
'~'~' REQUEST FOR APPROVAL OF
INDIVI'DUAL SEWER AND WATER FACILITIES
FOR
PHONE:
2. PROPERTY OWNER:
3, LEGAL DESCRIPTION: Z<9'//-_.~ y~Zoe
4. TYPE FACILITY TO BE INSPECTED:
NUMBER OF BEDROOMS: ,~N. ~'£/~/Z~R
4
STREET:
WELL DATA
A, TYPE
B. DEPTH
C. SIZE
D. CONSTRUCTION
E. BACTERIAL ANALYSIS
SEWAGE DISPOSAL SYSTEM:
SEPTIC TANK (IF HOMEMADE, SHOW DIAGRAM ON BACK)
2. AGE
3. MANUFACTURER
4. INSTALLER
APPROVAL REQUEST FOR SEWER & WATER FACILITIES
PAGE TWO
B. SEEPAGE PIT
1. SIZE
2. LINING
C. DISPOSAL FIELD
B.
C.
D.
E,.
F.
G.
1. NUMBER OF LINES
2. TOTAL LENGTH
REQUIRED MEASUREMENTS
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
H. SEEPAGE PIT TO PROPERTY LINE
COMMENTS:
APPROVAL VALID FOR ONE YEAR FROM DATE SIGNED.
GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY