HomeMy WebLinkAboutSIEFKER #3 TR 5 LT 11LoT
5
GRE'
:R ANCHORAGE AREA BOr' JGH
Department of Environmental Quality ~
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
SEPTIC TANK:
DISTANCE
FROM WELL
MANUFACTURER.~ ~//~) ~ 0~,
M A T E R i A L C~).~,,~.~. ~2/,_~ NUMBER OF
COMPARTMENTS
INSIDE LENGTH INSIDE WIDTH ,LIQUID DEPTH
SEEPAGE PIT: / ~ "~'//q~/ -- '
NUMBER OF PITS / DIAMETER OR WID~ --,z LENGTH
LINING MATERIALC~ ~;C~ CRIB SIZE: DIAMETER DEPTH
BUILDING FOUNDATION
ADDITIONAL ABSORPTION
LIQUID CAPACITY /O~f/C~GALLONS.
DEPTH
NEAREST LOT LINE
t
. DISTANCE FROM: WELL
TOTAL EFFECTIVE
ABSORPTION AREA (WALL AREA)
SQ. FT.
WELL.:
TYPE //
BUILDING
FOUNDATION
CESSPOOL
APPROVED
CONSTRUCTIQN
NEAREST NEAREST
LOT LINE SEWER LINE
OTHER SOURCES.
DISAPPROVED REMARKS
DEPTH ~47~> z
DISTANCE FROM:
SEPTIC SEEPAGE
TANK SYSTEM
DISTANCES:
DIAGRAM OF SYSTEM
INSTALLED BY:
PIPE MATERIAL:
LOT SLOPE:
REMARKS:
Form No. LQ-031
DATE 7-1~'- '7¢ APPROVED ~--h/~. ~
G./~.A.B. '
C_~REATER ANCHORAGE AREA BOROUGH
DEPARTMENT OF' ~'NMIRONMENTAL QUALITY
3330 "C" STREET ANCHORAGE, ALASKA 99503
TEt. EPHONE 274-4561
PERMIT NO...
SEWAGE DISPOSAL SYSTEM ..... APPLICATION AND PERMIT
LEGAL DESCRIPTION
TO BE INSTALLED SY ~0~
, OTHER
NOTE: 'i'Hl$ PERIVIIT I~ NOT VALID WITHOUT ~OIL TE~'t
¢
FINAL INSPECTION: 24 HOUR NOTICE RE:QUI~F~D, BACKFILLING OF ANY SYSTEM WITI-iOUT FINAL INSPt::CTION BY THE
DEPARTMENT OV ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT l'O PFtOSECUTION.
MINIMUM DISTAN(:E5, REQUIREMENTI~
FOUNDATION TO SEPTIC 'rANK
SEPTIC TANK TO SEEPAGE Pit WALL ___
SEPTIC TANK . SEEPAGE PIT
WELL TO SEPTIC TANK SEEPAGE PIT __
DRAIN FIELD
/
TO RIVER, LAKE, STREAM.
GRAVEL BAr~KFILL
CONFORM 'FO BOROUGH REGULATIONS REGARDING INSTALLATION.
LIC:E~SED DESIGNER
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA [3OROUGH ORDINANCE NO. 20-68 AND THAT THE ABOVE
DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE,
DATE--~- /~--- APPLICANT'S SIGNATURE
GR':AYER ANCHORAGE AREA BOROI"~H
HEALTH DEPARTMENT
327 EA,~LE ST. ANCHORAGE, ALASKA 99501 2/9-2511
INSPECTION REPORT ON-SITE SEWAGE DISPOSAl. SYSTEM
SEPTIC TANK:
DISI'ANCE FROM WELL
LIQUID CAPACITY
d
/
SEEPAGE SYSTEM: SEEPAGE PIT:
GALLONS.
MAILING /'~t~.),~..~://~,.~/.~.~./ PHONE
ADDRESS __
MATERIAL ( '" C')/VI"/~ ~-7'~'- _COMPARTMENTsNUMBER OF
INSIDE LENGTH .~INSIDE WIDTH _DEPT~
NUMBER OF PITS // OUTSIDE DIAMETER ~-' OR WIDTH // Y
LINING MATERIAL (-?F--)///id~/~-~,* '>' ' r
/--('///J/~'/~' DISTANCE FROM WELL /~',~=: '/
NEAREST LOT LINE ~"~'/' TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA)
,LENGTH (/V_, DEPTH ~(~,
BUILDING FOUNDATION ~'~:~ ,
i:~ ~:~ ~ SQ. FT.
TILE DRAIN FIELD:
DISTANCE FROM WELL
NUMBER OF LINES
ABSORPTION AREA
DEPTH: TOP OF TILE TO FINISH GRADE
FOUNDATION
DISTANCE BETWEEN LINES
SQ. Fl. LENGTH OF EACH LINE
DEPTH OF FILTER MATERIAL BENEATH TIL[~
· NEAREST LOT LINE.
TRENCH WIDTH
TOTAL LENGTH
OF LINES
.IN. TOTAL EFFECTIVE
IN. ABOVE TILE
WELL: TYPE /-)/e/~-~' k~/ , DEPTH ~O X
LOT LINE ~=~ '/ NEAREST ~/~/,/~., ,/ SEPTIC
, SEWER LINE__ - , TANK
DISTANCE FROM ~7"" / WATER
, BUILDING FOUNDATION
_SAMPLE ~ NEAREST
,5~' (~' / SEEPAGE //~ .,~j- / OTHER
, SYSTEM , CESSPOOL
DISTANCES:
,=~ b~ ~ ..~ I ~
G ::
DATE
APPROVED (HEALTH AUTHORITY
GAAB-HD-2
GREATEI
327 Eagle St.
t, NCHORAGI~' AREA
HEALTH DEFARTMENT
Anchorage, Alaska 99501
Case No.
-)ROUGH
279:2511
SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMI'i'
._ MAILING AD S_ .- '-/ PHONE NO
t:?' , SEEPAGE PIT /" ~
, DRAIN FIELD , OTHER
RESIDENCE ADDRESS
LEGAL DESCRIPTION
APPLICATION TO INSTALL: SEPTIC TANK
TO SERVE THE FOLLOWING FACILITY
FINANCE[] THROUGH ~{ I , , TO BE INSTALLED BY_ ¢)g2.~__/~: _
.PE'R.OOk~N TEST RESULTS Z~5~ :~ E~' ANTICIPATED DATE 0¢~ cOMPLETiON ~ ~,
BELOW TO BE FILLED OUT BY HEALTH DEpARTMEnT
T.IS IS T0 SERVE AS_~' , ¥"'V _ --, PE,M.T TO INSTALL A
AS DESCRIBE[) BELOW. SIZE
. SEPTIC TANK SIZE
DISTANCES:
\ ,, I
TYPE ~ SEEPAGE AREA:,~_TYPE
DIAGRAM OF SYSTEM
/ Health Authority
/ o
I certify that I am familiar with the requirements 9f Greater Anchorage Area Borough Ordinance No. 28-68 and that the
above described system is in accordance with said code.