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'rER ANCHORAGE AREA Be'" UGH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INS~,~CTION REPORT ON-SITE SEWAGE DISPOSAL S.)'STEM
LOCATION
DISTANCE C ~
FROM WELL ~I~)0 MANUFACTURER,
MAT E R i AL ~,,~ ~.,~F''
NUMBER OF
COMPARTMENTS
INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY~Oc~ O GALLONS.
SEEPAGE PIT:
NUMBER OF PITS __
LINING MATERIAL
BUILDING FOUNDATION__
ADDITIONAL ABSORPTION
DIAMETER __OR WIDTH
CRIB SIZE: DIAMETER__
NEAREST LOT LINE
LENGTH DEPTH
.DEPTH DISTANCE FROM: WELL
TOTAL EFFECTIVE
ABSORPTION AREA (WALL AREA)
SQ, FT.
TYPE _
BUILDING
FOUNDATION
CESSPOOL
APPROVED
CONSTRUCTION
NEAREST
LOT LINE
OTHER SOURCES
DISAPPROVED
NEAREST
SEWER LINE
DEPTH
TANK.
· DISTANCE FROM:
SEEPAGE
SYSTEM
REMARKS
D,STA' CES:
INSTALLED
PIPE MATE RIAL: ~----~,~-
LOT SI_OPE:
REMARKS:
Form No. EQ-031
DIAGRAM OF SYSTEM
DATE LO "."~O~ h'~-- APPROVED
G,A,A.B.
GR["~'ER ANCHORAGE AREA BO"'UGH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
LOCATION
MAILING ADDRESS '~:) ~O~;
LEGAL DESCRIPTION_/?~,
, /
SEPTIC TANK:_
r)ISTANCE
FROM WELL
INSIDE LENGTH
MANUFACTURER.
INSIDE WIDTH
NUMBER OF
COMPARTMENTS
LIQUID DEPTH __
.LIQUID CAPACITY
.GALLONS.
SEEPAGE PIT:
NUMBER OF PITS__
LINING MATERIAL
BUILDING FOUNDATION__
· DI'/~MF~LE R~._ OR WIDTH , LENGTH DEPTN
CRIB SIZE: DIAMETER -~D~P-TI=I~. DISTANCE FROM: WELL
TOTAL EFFECTIVE~-~
. , NEAREST LOT LINE ABSORPTION AREA (WALL AREA)
.SQ. FT.
ADDITIONAL ABSORPTION
WELL:
TYPE
BUILDING
FOUNDATION __
CESSPOOL
CONST R UC~ION-~_ DEPTH DISTANCE FROM:
N E A R E ST~"~"'""~-~ SEPTIC SEEPAGE
NEAREST
LOT LINE SEWER LINE ,~.!~.~_~ , SYSTEM
OTHER SOURCES
APPROVED DISAPPROVED REMARKS
DISTANCES:
INSTALLED BY:
PiPE MATERIAL:: ~')~&'/ -~X/2/V'
LOT SLOPE:/)~'/~/~-
REMARKS: ....
_ t
Form No. EQ.O31
DIAGRAM. OF SYSTEM
DATE
APPROVEDC
G.A.A.B.
GREATER ANCHORAGE AREA BOROUGH
DEPARTMENT OF ENVIRONMENTAL QUALITY
3330 "C" STREET ANCHORAGE, ALASKA 99503
TELEPHONE 274-4561
PERMIT NO.
SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT
coco i
MAILING ADDRESS (~_~/--__ PHONE
FINAL INSPECTION: 2.4 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEIVl WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION.
MII~IMUt~I DI,STANCEB, REQUIREMENTS
FOUNDATION TO SEPTIC TANK ~-
WATER MAIN TO SEPTIC TANK -~ ~ _, SEEPAGE PIT
TYPE
DIt~GRAM OF SYSTEM
GRAVEL BACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
LICENSED DESIGNER
I CERTIFY THAT I AM FAM]LIAR WITH THE REQUIREMENTS OF GREATER ANCNORAGE AREA BOROUGH ORDINANCE NO. 28~68 AND THAT THE ABOVE
