HomeMy WebLinkAboutAL CROSS BLK 1 LT 8
GAAB-HD-I
GLOATER ANCHORAGE AREA BOROm-U't,-H
HEALTH DEPARTMENT
327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
SEPTIC TANK:
MAILING
ADDRESS PHONE
z... r
DISTANCE FROM WELl
LIQUID CAPACITY /
GALLONS.
~ NUMBER OF
MATERIAL d -~'~ /["[ ~ I¥' ] COMPARTMENTS
INSIDE LENGTH INSIDE
LIQUID
DEPTH
SEEPAGE SYSTEM: SEEPAGE PIT:
NUMBER OF PITS
LINING MATERIAL
NEAREST LOT LINE
/ OUTSIDE DIAMETER ORWIDTH
("~' ,~'"~, P '~'"~) DISTANCE FROM WELL / % '-~ !
"~ ~) TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA)
,LENGTH /'~ , DEPTH g
, BUILDING FOUNDATION "'7--~--,
~,) .-'~) ~ SQ. FT.
TILE DRAIN FIELD:
DISTANCE FROM WEL[
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
IN. ABOVE TILE
WELL: TYPE "~ i,"' I //~' d DEPTH ~'~) ''/ DISTANCE FROM ~- J WATER
. , , BUILDING FOUNDATION. ~,.~.,r) SAMPLE
LOT LINE .~C~/ NEAREST 2'~--' I SEPTIC ~r~ L~ j SEEPAGE /.~ 5' /
__ , SEWER LINE , TANK ! SYSTEM , CESSPOOL
DIAGRAM OF SYSTEM
NEAREST
OTHER
, SOURCES__
DISTANCES:
DATE
APPROVED
2.
3.
4.
5.
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
c. Casing Size
(Fill out in Triplicate)
mn~. ,of person requesting approval
Water Ansly. sis :~~ ~
Depth~ /~ ~ '~
Distance from well to closest existing or proposed:
1. Sewer line
2. Septic tank
3. Seepage Area
4. Cesspool'
5. Property Line
houses, barn, draina[e ditch, etc.
Sewage disposal system.
a. Age of system
b. Septic tank capacity in gallons
c. Name of septic tank manufactum~r
Other sources of Possible contamination, i.e., creeks, lakes,
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, Pefco] ation, Test 'results
f. Percolation Test performed by
Use the reverse side of this form to show diagram. Diagram should include
the following information: p~operty lines~well location, house location,
~,t~c tank location, disposal area location, location of percolation test,
a~ direction of ground slope.
9. The i~£,~rma~[on on this form is true and correct to the best of my knowledge.
'S'~gnature 'of A'pplicant
Date Signed
TO BE FILLED OUT BY HEALTH DEPAET~.~ENT PERSONNEL
~?~e above described sanitary facilities are hereby approved, subject to the
~llowing conditions:
Conditions: ~ ~
The above described sanitary facilities are disapproved for the following
reasons:
Signature Of ~f~i'ei;R',l.
Date
Approval is valid for one year following the date of approval.
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