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TER ANCHORAGE AREA BOROL H
DEPARTMENT OF ENVIRONMENTAL 0. UALI'I/-
3000 TUDOR ROAD ANC:HORAGE, ALASKA gg!~07 27g-8686
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
SEPTIC TANK: ' '
DISIANCE FROM WELL_ ~ ~ MATERIAL C O~i'"'C~.J'r~''' blC)("~k NUMBER OF
~ COMPARTMENTS.
LIQUID
LIQUID CAPACITY~. GALLONS. INSIDE LENGTH_ INSIDE WID]H DEPTH ~
SEEPAGE SYSI'EM: SEEPAGE PIT:
NUMBER OF PI15__ / OUTSIDE DIAMETER ~ OR WIDTH ~(~} £ ,LENGTH__ I ~__,/ DEPTH
/ X / X / TO~L LENGTH
DISp~ FR~ WEX F~T$~ ~ NEAREST [O1 LINE / '~ [X~
g9~
d~ ' I, le~ O,STANC~ PROM 0 ~ WATER.
WELL: TYPE_ ~l .___ DEPTH ,BUILDING FOUNDATION.. _SAMPLE_~0~'/(~-~* ., NEAREST
.~ NEAREST + J0 SEPTIC ~ t SEEPAGE J J J / OTHER
LO1 LINE ~_ , SEWER LINE . [AN~_ , SYSTEM~ , CESSPOOL~ , SOURCES'~
DIAGRAM OF SYSTEM
DISTANCES:
~ ~'2 ~TIc TANK'S,
" - FI' ' '
G.A.A.B.
GREA,ER ANCHORAGE AREA BOF~,_,UGH
DEPARTMENT OF ENVIRONMENTAL, QUALITY
3500 TUDOR ROAD POUCH 6-650
ANCHORAGE. ALASKA 99502
TELEPHONe 279-8686
SEWAGE DISPOSAL SYSTEM ~ APPLICATION AND PERMIT
NAME Of APPLICANT --. '~ ~A MAILING ADDRESS ~ ~"~
perMIT NO. /~--7~)~
PHONE
iNSTALLATION LOCATION
TYPE AND SIZE OF FACILITY TO ~3E SERVED C~{/~ ~/{~ ~ ~ ~ ~ ' ~.~' ;~/~
SOIL TEST RESULTS
NOTE= THIS FERMIT IS NOT VALID WITHOUT SOIL 'rest
COMPLETION DATE ANTICIPATED
FINAL INSPECTION= 24 HOUR NOTICE ~EQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
HEALTH DEPARTMENT AUTHORITY WILL BE ~UBJECT TO pROSECUTION.
SEPTIC TANK SIZE TYPE SEEPAGE AREA SIZE TYPE
MINIMUM DISTANCEB, REQUIREMENTS
FOUNDATION TO SEEPAGE PIT.
SEPTIC TANK TO SEEPAGE PIT WALL.
SEPTIC TANK ., SEEPAGE PIT
TO NEAREST LOT LINE.
WELL TO SEPTIC TANI(
DRAIN FIELD
WATER MAIN TO SEPTIC TANK
DRAIN FIELD
. SEEPAGE PIT
SEPTIC TANK, . , SEEPAGE PIT DRAIN FIELD
TO RIVER, LAKE, STREAM.
CAST IRON INT~AND OUt OF SEPTIC TANK A~L~Q~C*~LI~ ' G
EXCAVAT]ON 5 Feet iNTO UNDISTURBED SOIL.
4~CH diameter cast IRON SIPHON PIPES ON SEPTIC TANK AND seeP:~ge
f]ttED WITh AIRTIGHT REMOVABLE CAPS.
GRAVEL BACKFILL
DIAGRAM OF SYSTEM
--I
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO, 28-68 AN[> THAT THE ABOVE
DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE' E~
DATE ~)d/~ ~'/~:~ ~'/ APPLICANT'S SIGNATUR
GREATEI~ ANCHORAGE AREA ~ 9ROUGH
HEALTIt DEPARTMENT
327 Eagle St. Anchorage, Alaska 99501
279-2511
Case N o. ~----~~
SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT
/
RESIDENCE Al]DRESS .~')/..'¢--'~r,--,~ ~ LOCATION OF INSTALLATIDN.
LEGAL DESCRIPTION
APPLICATION TO INSTALL: SEPTIC TANK__~, SEEPAGE PIT ~ ~DR~IELD-~,OTHER-
// // ~ ~
PERCOLATION TEST RESULTS ~ ~/~- ANTICIPATED DA TEOF COMPLETION ~
BELOW TO BE FILLED OUT BY HEAL'rH DEPARTMENT ..,.
~ms m TO SU~W ~S~/~. '~z~Z~ , ¢[~U~ ~0 mS~[~ ~
_ASDESCRIBED~LOW.TANK_~)~ SIZEOFUNITTO
SIZE~[d ./.TYPE SEEPAGE AREA. __TYPE
, SEPTIC
DIAGRAM OF SYSTEM
)ISTANOES: /
HEALTH AUTHORITY
OR
LICENSED DESIGNER
I certify that 1 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 /
Isrt 'let ANCHORAGE! AREA BOROUGH
DEPAi..dENT OF ENVIRONMENTAL QUAL~Y
3500 TUDOR ROAD
ANCHORAGE, ALASKA 99502
CASE #
Performed For _~- J~z ~];~s~ Date Performed
Le§al Descrip~]on~---.:-' Lo-T~lo--~k Su----~d]v~-~ion _~1~
This Form Reports Soils--[-~g__~{ ~rc~-T-~ Test
Depth
Feet Soil Characteristics
Reading Date
~-~-~-61ati°n Rate
Proposed
Depth Of
Gross Time
Instal-T~-]on:
Inlet
Minute
Seepage Pit
Net Tim
Depth
Depth to H20
Drain Field
To Bottom Of
'Data C~rtTFTe--d-By:
Net Dro
Pi t ~ Tren-~=~
Da te: