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GI~"'~,TER ANCHORAGE AREA BO~OI' ""H
HEALTH DEPARTMENT
-?27 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
MAILING
ADDRESS
LEGAL DESCRIPTION
DISTANCE FROM WELL
LIQUID CAPACITY
GALLONS.
__MATERIAL
INSIDE LENGTH
NUMBER OF
COMPARTMENTS /
INSIDE WIDTH
LIQUID ~ ,'
DEPTH ~.'
SEEPAGE SYSTEM: SEEPAGE PIT:
NUMBER OF PITS
LINING MATERIAL
NEAREST LOT LINE
OUTSIDE DIAMETER OR WIDTH
DISTANCE FROM WELL
TOTAL EFFECTIVE ABSORPTION AREA (WALL AREAl
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
DEPTH OF FILTER MATERIAL BENEATH TILE
NEAREST LOT LINE.
TRENCH WIDTH
TOTAL LENGTH
OF LINES
IN. TOTAL EFFECTIVE
IN. ABOVE TILE
WELL: DISTANCE FROM WATER
TYPE DEPTH BUILDING FOUNDATION SAMPLE
NEAREST SEPTIC SEEPAGE
LOT LINE SEWER LINE , TANK SYSTEM , CESSPOOL
DIAGRAM OF SYSTEM
NEAREST
OTHER
, SOURCES__
DISTANCES:
DATE
APPROVED
HEALTH AUTHORITY
GAAB-HD-2
GREATEb. ANCHORAGE AREA )ROUGH
HEALTH DEPARTMENT
327 Eagle St. Anchorage, Alaska 99501 279-2511
Case No.
/<13
SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT
NAME OF APPLICANT
RESIDENCE ADDRESS
'[ <:~/"~ [? MAILING ADDRESS
LOCATION OF INSTALLATION
LEGAL DESCRIPTION. ~---~7-- ~ ~ '7
PHONE NO..
L~.. O~~v '~,
APPLICATION TO INSTAL , SEEPAGE PIT ~ , DRAIN FIELD
TO SERVE THE FOLLOWING FACILITY r...)//~'y /~'~c,,,~,.,,O,~;~.
FINANCED THROUGH TO BE INSTALLED BY
,OTHER
PERCOLATION TEST RESULTS
ANTICIPATED DATE OF COMPLETION.
BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT
THIS IS TO SERVE AS
PERMIT TO INSTALL A /'-/~&O,/,,;~' ',7-/?~,J,.~ ,
DISTANCES:
Health Authority
AS DESCRIBED BELOW. SIZE OF UNIT TO BE SERVED
. SEPTIC TANK SIZE '~O TYPE (?c,~,'~) . SEEPAGE AREA ~'~r~'~ ~ TYPE
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.
DATE APPLICANTS SIG NATU R E