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GI~.~,~TER ANCHORAGE AREA BORO~U~jH
HEALTH DEPARTMENT
327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
SEPTIC TANK:
DISTANCE FROM WELL
LIQUID CAPACITY ,/"',O
GALLONSL
MATERIAL
INSIDE LENGTH_
MAILING
ADDRESS ~'"'~'~'~ .~-~" '"'~'~:'/'/ PHONE~
LEGAL DESCRIPTIO~/~~z ~//~aC~ ~, ~%,
~ ~[~ COMPARTMENTS
INSIDE WIDTH - DEPTH
SEEPAGE SYSTEM: SEEPAGE PIT:
NUMBER OF PITS / OUTSIDE DIAMETER
LINING MATERIAl ,/~ O ~ ~'
NEAREST LOT LINE
OR WIDTH '/,~"~ j "'~'~'~g / '~ /
, LENGTH , DEPTH
DISTANCE FROM WELL /"-~ ~ ~' BUILDING FOUNDATION "~""~ '~,
TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) ~7/'/--'~;'' SQ, FT.
TILE DRAIN FIELD:
~ '- ~"~10 TOTAL LENGTH
DISTANCE FROM WELLs FOU N .NEAREST LOT LINE OF LINES
.
NUMBER OF S rWEE~ LINES ~ TH N. TOTAL EFFECTIVE
ABSO
DEPTH: TOP OF TILE TO FINISH GRADE
DEPTH OF FILTER MATERIAL BENEATH TILE'_
IN. ABOVE TILE
WELL: [YPE ~,~.-~'~'-~'~'~:'L~ DEPTH // ~ "' DISTANCE FROM WATER
_ . BUILDING FOUNDATION. "~"¥~" / SAMPLE /J.,/~ NEAREST
LOT LINE ,:::,~O "z~ NEAREST SEPTIC ~ z' SEEPAGE ," ~ OTHER
SEWER LINE ~ . TANK , SYSTEM /,.--~') . CESSPOOL SOURCES
DISTANCES:
DIAGRAM OF SYSTEM
DATE
HEALTH AUTHORITY
APPROVED
(
~^~-~'~ GREATER-.,t'NCHORAGE AREA r~OROUGH
HEALTH DEPARTMENT
327Ea~eSt. Anchorage, Alaska99501 279-2511
Case No.
SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT
RESIDENCE ADDRESS ~t//~/~r- LOCATION OF INSTALLATION /~.z .,/z~- ~//'/2:'
APPLICATION TO INSTALL: SEPTIC TANK 1,- ,SEEPAOE PIT ~-~ , DRAIN FIEL~ z.~A, ,., ~Eaz. ."-
TO SERVE THE FOLLOWING FACILITY
FINANCED THROUGH
PE~N'TEST RESULTS·
TO BE INSTALLED BY. ?/'7/
ANT, C PATEB BATE OF COMPLETION .~'fh//,.//~ . ~-'¢';//£ /:-
BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT
THiSiSTOSERVEAS/~'~,(', /;(.(..,,/ //~'.; g; "~ ,PERMiTTOiNSTALLA L-li..'cJ( .) ¢, . /~/,!
AS DESCRIBED BELOW. SIZE OF UNIT TO BE SERVED
TYPE(~.V~'( ,("b /~-SEEPAGE AREA :';q(' //.5i TYPE____
· SEPTIC TANK SIZE L~[:'~::'¢
DIAGRAM OF SYSTEM
o. ~... . , 42 ,
I certify that I am familiar with the requirements of Greater Anchorage Area Borough Ordh~ance No. 28-68 and that the
above described system is in accordance with said code. /Il,??' t, , 7~ / D / ~./, ~ / /'? ~4.z L i ~: ,
DATE (" APPLICANTS SIGNATURE~(~.~; .... /c. c c
· . ,: ~ .. ~...//,
JJEALTH
327 EArL-
Depth , . i,oaat ion Ske'tch
Feet Soil Cha~c:cl;e~'~s~ lca
Was Ground. Water Encountered?..~.
'if Yes, At %~hat Depth .............
Reading
"'¢- .Oe;.~b To H20 Net Drop
OMMERVIL
,RILLING.~
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
,
/,
DATE DATE 3ATE
INSPEC OR INSPECTOR INSPECTOR
~UNICIPALITY OF ANCHORAge
MUNICIPALITY OF ANCHORAGE DEPT. OF H~ALTH &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEL~I~NMENTAL p,~OTECTION
825 L Street - Anchorage, Alaska 99§01
ENVIRONMENTAL SANITATION DIVISION OEO 2 0 1979
Telephone 264-4720 R CEIVED
E 'ILiTI ES
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FAC
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
MAiLiNG ADDR~ /~ /1 ~,/~) *'~ /
REAL rOB A, NT · PHONE
MAILING ADDRESS
6. TYPE OF RESIDENCE
~ SINGLE FAMILY
[] MULTIPLE FAMILY
7, WATER SUPPLY
~fi~ INDIVIDUAL~
[] COMMUNITY
[] PUBLIC UTI LITY
NUMBER OF~SEDROOMS
[] One [] Four [] Other__
[] Two [] Five
! ', 'J~ Three [] Six
,v
* A.T.~TACF~E L~L LONG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.}
8. SEWAGE DISPOSAL SYSTEM
~ INDIVI DUAL/ON-SITE~*
[] PUBLIC UTILITY
/'? 70 YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
THIS SIDE FOR OFFICIAL USE ONLY I
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[~] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[]INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified INSTALLER
[]Septic Tank or [] Holding Tank
Size:. /~J¢~)C) ~ If Tank is homemade SOILS RATING
give dimensions: I ~ '~ ·
TYPE OF TANK MANUFACTURER
4. DISTANCESwELLTO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
i '/
I-~APPROVED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY
72-010 (Rev, 6/79)
C _I~____IC_.J,___ &~EOLOGICAL LABORATORIES OF AI. ASKA,. INC.
4649 BUSINESS PARK BLVD.
P.O. BOX'4-1276'~ ANCHORAGE, ALASKA 995~9 ~,
Drinking Water Analysis Report for Total Colif(~m Bacteria
TELEPHONE
(907) 279-4014
T0 BE COMPLETED'BY WATER SUPPLIER
I.D. NO,
Public Water System Name ~ _ .~
Mal~ --_~ ~'.
City State Zip Code
MO. Da~,~¢ Year
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine
with lab ref. no,
[] Special Purpose
sample
3 Treated Water
[] Untreated Water
SAMPLE
NO. ~j LOCATION
3
5
Time Collected
Collected By
TO'BE COMPLETED BY LABORATORY
BORATORY:
NAME
ADDRESS
CITY
Received
Ti:me.., Received
A~:a!ytical Method:
!! ~L3/ermentation Tube
:: /L~,~embrane Filter
[~b Ref. No. Result* Analyst
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Form NO. 18-310 [3-78)
06-1220 (b) BACTERIOLOGICAL WATER ~I'ALYSIS RECORD
Rev. 1978
· 10ml Tubes Positive/Total Z0ml Portions
Multiple Tube Report= ~' Collform/lOOmt
Membrane Filter= Direct Coun~ *
verification= LmB , BOB'
Reoor ted By Date . r '