HomeMy WebLinkAboutSIEFKER #3 LT 8A MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPI--CTION REPORT
NAME
MAI LING ADbRESS
PHONE
~NEW
[~]UPGRADE
LEGAL DESCRIPTION
DISTANCE TO:
Manufacturer
Abs orptic}~ ~area
ngth
HOMEMADE:i \]..~ I Dwelling
Well
We]l~
DISTANCE TO:
Length of each,~i~e
No. o~/lines
Top of tile to finish grade~
Length
Type of crib
DISTANCE TO:
DISTANCE TO:
Class
Width
WellCrib diameter/L~/4.
Depth
Building foundation
Foundation .)
Total lea tb ~l'nes
Material beneath tile
Depth
Crib depth
Building foundation
Driller
Sewer line
NO. ,~/B E DR OOMS
IDwellings.
/
Material
Width
Material
Nearest, lot I.i~ ~
ITrench width
~ ~,~-~ inches
¢~ inches
PERMIT NO. ~
No. of compartments
Liqu?d~depth
PERMIT NO,
Liquid capacity in gallons
PERMIT NO.
Distanc.~.//~ween lines
Total effective absom, tion area
PERMIT NO. x
Total effective absorption area
Nearest lot line
Distance to lot line
Septic tank
PERMIT NO. t
Absorpt'ion ar~a (s)
OTHER
PiPE MATERIALS (~/~
SOIL TEST RATING
INSTALLER
REMAF~KS ,
A P PJ;~'O~ E D
72-013 g~v. 3/78)'
DATE LEGAL
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2204 Cleveland Anchorage, Alaska 99503
Peiformed For J~rry C,o,llings .Date Performed
Leeal Oescrt.tton: Lot Block__
Thts Form Renorts 5otls LDo .... Yes
6-14-7'L
Subd~¥~StOn Siefker #3 Tract 8-~
Percolation Test
Feet Sotl ~haractertst~c[__
Peat
Brown Silty Sand
10--
12---
14---
Bottom of Test Hole
- --
Was Ground Water Encountered?
If Yes, At what Depth?
Read,hq Date Gross Time Net Time Depth to H20 Net Dron
~'- 13il ' 0 - 4"
I 6-14 10 hrs. No water ......
b-14 ' 3I 5 I N O water
~ " 6-14 Add more water 0 . . ,' 4, %/4"
. . 6_~4 _ ~ --., · 5 ....
Percolation Rate 1"/15 Utnute
prn*.osed InSt~11atto~: 'Seenaae Pit Drain Fteld
Depth of Inlet · " _:__.Depth To aott~om Of Pit OF-Trench
Te cf rmed By . ~ Data Certified B~:. CT~ . -~z~
.,ei!i i~o,':
O---!71.s ! ltl/ cia:./ wit}
! DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTQR~ INSPECTOR INSPECTOR
-, ~'~, ~_ ,MUNICIPALITY OF ANCHORAGE
D£PT. O/~ IlC/~LIH &
MUNICIPALITY OF ANCHORAGE FNVIRONMENTAL PROTECTION
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 L Street-Anchorage, Alaska99501 00T 2 5 1979
(~t ENVIRONMENTAL SANITATION DIVISIONTelephone 264-4720 RECE~ED
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete ali parts on page 1, Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERT¥OWNER %,/e/// C'~// //,-~,~J P_~ONE
PROPERTY RESIDENT (if different from above) PHONE
2..UYER PHONE
MAILING ADDRESS
3. LENDING INSTITUTION J PHONE
I
MAILING ADDRESS
4. REALTOR/AGENT J PHONE
I
MAILING ADDRESS
5. LEGAL DESCRIPTION
STREET LOCATION
,~/'~NG L E FAMILY
[] MULTIPLE FAMILY
NUMBER OF~BEDROOMS
~ 0 ~ Foo'r E;~' ~
~o ~ Fivo
~ Three ~ Six
Other
7. WATER SUP~P~Y
~ INDIVIDUAL* *ATTACH WELL LOG. Awell Icg is required for all wells drilled
[] COMMUNITY since June 1975. For wells drilled prior to that date, give well
[] PUBLIC UTILITY depth (attach Icg if available.)
8. SEWAGE~POSAL SYSTEM
[] INDIVIDUAL/ON-SITE** /~ 7~'" YEAR ON-SITE SYSTEM WAS INSTALLED.
[] PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79) J ~ ·
THIS SIDE FOR OFFICIAL USE ONLY
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: .~r.~ ..If Tank is homemade SOILS RATING
give dimens/ions.
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line f Nearest Lot Line
I
WELL TO: .
Absorption Area to nearest Lot Line
5. COMMENTS
[~APPROVED FOR ,~"-~'~ B E D RD0 MS
[] CONDITIONAL APPROVAL (letter must)~company certificate)
//
[] DISAPPROVED ¢(.
72o010 (Rev, 6/79)
CLEO
A VENUE
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