HomeMy WebLinkAboutT12N R3W SEC 33 LT 204
GREAi :R ANCHORAGE AREA BORUuGH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska gg503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME
LOCATION ,~*Z>cJm~'' /¢~. ~¢F ~/~¢'~¢'J~- ~/~'- LEGAL DESCRIPTION
MAILING ADDRESS
SEPTIC TANK:
DISTANCE .¢- ¢//~/J~% ,¢~:/4¢~_r~ NUMBER OF
FROM WELL ~(~ ~¢/~MANUFACTURER //~-~ MATERIAL ~--Z~¢-.¢-¢' COMPARTMENTS
INSIDE LENGTH ~ INSIDE WIDTH LIQUID DEPTH ~ LIQUID CAPACITY /J~ GALLONS.
SEEPAGE P'f-T7
NUMBER OF PITS -~ DIAMETER -- OR WIDTH ~,/ LENGTH '~'/~,, /DEPTH
LINING MATERIAL~,/~///~//~/¢~ CRIB SIZE: DIAMETER ~ DEPTH ~; DISTANCE FROM: WELL ~/'~ ~' /~--
BUILDING FOUNDATION ,~'/? NEAREST LOT LINE ,~ ~ TOTAL EFFECTIVE
· ABSORPTION AREA (WALL AREA) '~ ~' SQ. FT.
A,:, ITIONAL ABSORPTION
WELL:
TYPE /~/~///~¢¢/~/~ CONSTRUCTION
BUILDING NEAREST
FOUNDATION- LOT LINE
CESSPOOL OTHER SOURCES
APPROVED ~/" DISAPPROVED
DEPTH 7~ / DISTANCE FROM:
NEAREST SEPTIC ? SEEPAGE
SEWER LINE /~ ~ "'~) /"'~ ~
TAN K SYSTEM
REMARKS
DISTANCES:
INSTALLED BY: ,/~/~~¢/~/~/r'/-)~-
PIPE MATERIAL'
LOT SLOPe:
DIAGRAM OF SYSTEM
DATE ~'~ APPROVED ~/¢z//~e~ /~'~/
G.A,A,B.
GrEATEr ANCHORAGE AREA BorougH/¢.'c~, A~ %~x ~ %¢
/ ~-//~ ~~
SEWAGE DISPOSAL SYSTEM -- APPLICATION AND 'P~~
iNSTALLATiON LOCATION
., DRAIN FIELD
OTHER
TYPE AND SIZE OF FACILITY TO BE SERVED
TO BE INSTALLED BY
NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL~ TEST
COMPLETION DATE ANTICIPATED
FINAL INSPECTION: 24 HOUR NOTICE REQUIRED· BACKFILLING OF ANY. SYSTI~M WITHOUT FINAL iNSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION.
sePTIC TANK SIZE /J-~ TYPE SEE"A~E ~ ~'~ ~O
DIAGRAM OF SYSTEM
MINIMUM DISTANCES, REQUIREMENTS
SEPTIC TANK '~ /
WELL TO ~;EPTIC TANK
DRAIN FIELD
· SEEPAGE PIT (O ~
ALSO CONSIDER AREA WELLS.
· SEEPAge PIT
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENT~ OF GREATER ANCHORAGE AREA BOROUGH ORD]NANCE NO. 28-68 AND THAT THE ABOVE
DATE ~--~_~jC~ APPLICANT'S SIGNATURE ~'-~
204, Sec ~}3,.T. 1.2_N.,' R3.~...
~5 - SP
16- SP
17 - SP
18 m SP
~,~ds 9rou.d WdLL'r cllcou~iLcr~.'d? ............ ~olf .VL'5, ,IL whdL dt';~Lh't
~. Page'2 of two pages - Read-it for Approval
'~ ~gal Description
of Individual .' !r & Water Facilities
Comments
Approved ~. ~~'Cv _ Disapproved Date ~/~
Approval Valid for one year from date signed
Greater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
certify that the information contained in this reouest for approval to be a true and
accurate representation of the subject sewer and water facilities and these facilities
are operating satisfactorily.
SIGNED
Date
EQ-034 (1/74)
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C" Street, Anchorage, Alaska 99503 274-4561
Date Received
Time of Inspection
Date of Inspection
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WAT~ER,FACILITIES--~..
Approval requested
Mailing Address:
2. Property Owner: Phone:
4.
5.
6.
Mailing Address:
Location:
Type of facility to be inspected
No. of bedrooms
Well Data:
A. Type ~)?~,~y~-Ut ~,?~/)B. Depth
.
C. Constructio~..._r...'. ...~, ...! ....... ~,,,-~N'~. Bacterial Analysis~
7. Sewage Disposal System: ~
A. Installed ~ B. Installer
C. Septic Tank: 1. Size 2.
D. Seepage Pit: 1. ~9~s~pti~, / / 2. M~te~al
E. Disposal Field: ~1~0 n ~/~
8. Distances:
A. Well to: Septic tank
, Absorption area
, Sewer Lines __
Nearest lot line
, Other contamination
B. Foundation to septic ~ank
, Absorption area
C. Absorption area to nearest lot line
EQ-034 (1/74) Page 1 of two pages
3330 "C" St., Anchorage, Alaska 99503 - 274-4561
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
1. Type of Inspection:
2. Property Owner:
Mai-ling Address:
3. Name of Buyer:
Mailing Address:
4. Name of Lending Institution:
Mailing Address:
5. Name of Realtor or Agent:
Mailing Address:
CMRO VA
FHA CONV
Day Phone
Day Phone
Phone
Phone
6. Legal Description:
Location: OLO
Type of Facility to be inspected: No. Bdrms.
Water Supply
Type of Supply:
If Individual,
If
Public Utility
Individual
number of dwellings presently served
!
Individual, depth of well 7~
Sewage Disposal System
Type of System: Public Utility Individual
If Individual, date of installation
(on-site)
EQ-037 (~/74)
06-1220~(r* Rev 1973
DATE BACTER)OLOG I CAL
INDIVID~A~ ~ SE~I.PUBLIC ~ CHLORINE RESIDUAL PPM
REPORT ~ESULTS TO
CITY ZIP CODE
ADD~ESS
KA DEPARTMENT OF U~LTH AND SOCIAL S,. ~.C~ES
' DIVISION OF FUBLIC HEALTH ,~f:?. [abNo
INOIVIOUAL ANO SEMI-PUBLIC
WATER-"ANALYSIS O F,CE
COMPLETE THIS SECTION
ONLY I&WATER IS AN INDIVIDUAL SUPPLY
SAMRL~>~OLCECTED.¥ ~-,~'~"
~] Olhegt usr~
[] Tile Brick or
[] aden Too [] Concrefe
[] T,le [] Fibre [] Asbestos
0 ~es 0 No
Basement [] Room
Length of
)UMP LOCATION: ~ In We 0 Bosement
READ ",IST RUCTIO NS
ON
REVERSE SIDE
BEFORE
"COLLECTING SAMPLE
[] 1Jnso~isb~lorv
SANITARIAN'S REMARKS
0 Y~s [] No
0,~ I~B0]e~ Iwslbl BAC)-ERI~0GICAL W-Al-ER ANALYSIS RECOzR D
Loctose Broth 10cc 1 Otc 1 Otc I Otc 1 Oct I Otc 1 .Otc
24 Hours
48 Hours ~
EMB AGAR
_octose Brolh 24 hrs ~ / 48 hrs. __.Groin's store
Co florin Densil .IMost grobable No. per 100cc
] Thisenalvsis~ndicolesColiformOrganis~s~mstobe/:~"