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G~R ANCHORAGE AREA BORO?~
HEALTH DEPARTMENT
327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-25! 1
N? 558
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME ~'/~LZ_ ./(;/,~.,6'~7~/..~'~/.Z~2'xP/~'-',,/~//~C~>'/.,~rf.z~'
L O C A T ID N /~./~.~:~///-/ ./~
SEPTIC TANK:
DISTANCE FROM WELL .-~ MAIERIAL
LIQUID CAPACITY ~"~"~ GALLONS. INSIDE LENGTH
MAILING .
A D D R E S S~.,j~.~.. ~.~.~/<~ /~.~r.~. p H 0 N E~.~V'~-,
NUMBER OF /
~/~ COMPARTMENTS
INSIDE WIDTH DEPTH
SEEPAGE SYSTEM:
NUMBER OF PITS.
LINING MATERIAL
NEAREST LOT LINE
SEEPAGE PIT:
OUTSIDE DIAMETER ~ OR WIDTH
DISTANCE FROM WELL
TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA)
BUILDING FOUNDATION ~'~
SQ. FT.
TILE DRAIN FIELD:
DISTANCE FROM WELL , FOUNDATION , NEAREST LOT LINE
DEPTH: TOP OF TILE TO FINISH GRADE DEPTH OF FILTER MATERIAL BENEATH TILE
T Y P F~/,.,"~-'2~ ..~'~",/'~/~'-~7.~, DEPTH
LOT LINE _/~ '"'7~ NEAREST
SEWER LIN[~'~
TOTAL LENGTH
OF LINES
IN. TOTAL EFFECTIVE
IN. ABOVE TILE
~4~ ISTAN CE FROM / WATER
., BUILDING FOUNDATION, ~'- SAMPLE. /~//~ ., NEAREST
SEPTIC ~ SEEPAGE / OTHER
., TANK :'~/~.~ , SYSTEM .~;~ , CESSPOOl/../x~/f~/.~-,
DISTANCES:
DIAGRAM OF SYSTEM
APPROVED
GREATER ANCHORAGE AREA BOROUGH
DEPARTMENT OF ENV,.ONMENTA - QU^LI
3500 TUDOR ROAD POUCH 0-650
SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT
SOIL TEST RESULTS /'~///~
SEEPAGE PIT , DRAIN FIELD ~ OTHER
NOTE: THI~ PERMIT IS NOT VALID WITHOUT SOIL
FINAL INSPEC:TION~ 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
HEALTH DEPARTMENT AUTHORITY WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCES, REQUIREMENTS
FOUNDATION TO SEPTIC TANK ~'~
SEPTIC TANK TO SEEPAGE PIT WALL
WELL TO SEPTIC TANK ~/~--~ / SEEPAGE Pit
SEPTIC TANK, '~, SEEPAG£ PIT /'""-~, DRAIN FIELD
DIAGRAM OF SYSTEM
GRAVEL SACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
HEALTH AUTHORITY
OR
LICENSED DESIGNER
I CERTIFY THAT I AM FAMIL[AR WiTH THE REQUIREMENTS OF GREATER ANCHORAGE AREAREA BOROUGH/Q4~DINANCE NO. 28-68 AND THAT THE ABOVE
DESCR[BED SYSTEM IS IN ACCORDANCE WITH SAID CODE. t:) ( BOROUgH~ .
3REATER ANCHOP~GE AREA BOROUGH
HEALTH DEPARTbENT
527 EAGLE STREET
ANCHORAGE, ALASKA 99S01
279-2Sll
DATE RECEIVED
INSPECT:
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
FOR
1. Approval Requested By .~-./~'~2/~'/:~</_z~---/'//~2/~'~;W~'
Phone ~ 7~- ~/~
2. Property O~er~f~/Cf~.~/~f~f Phone
3,
Number of B~drooms ~
Well Data:
A, Type
B. Depth
c. Si~e ~//
D. Construction
E. Bacterial Analysis
6. Sewage Disposal System:
Septic Tank (If homemade? show diagram on back)
2. Age,, ./?~/
3. Nanufacturer>~/'~ __c~
~pproval Request for SeW ~ ~ Water Facilities
Two ;~'
E. Seepage Pit
2. Lining
C...Disposal Field
1. Number of Lines
2. Total Length
Required Measurements
A. Well to Septic Tank
B. Well to Seepage Pit
C.
D.
Well to Sewer Line
Well to Property Line
E. ~Vell to Other Possible Contamination/~/~2//~<~/~/ffz///
P. Foundation to Septic T~nk ?~b~//
/
G. Foundation to Seepage Pit ~0
H. Seepage Pit to Property Line
8. CO?~ENTS:
/
APPROVAL VALID FOR ONE YEAR FRO~.! DATE SIGNED·
DISAPPROVED:
DATE:
GREATER ANCHORAGE AR~A BOROUGH HEALTH DEPARTMENT
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