HomeMy WebLinkAboutT12N R3W SEC 9 LT 59
Gl:'-~TER ANCHORAGE AREA BOROI'"SH
HEALTH DEPARTMENT
327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-251
INSPECTION REPORT ON-SITE SEWAGE DISPOSAl. SYSTEM
SEPTIC TANK:
DISTANCE FROM WELL
LIQUID CAPACITY__
SEEPAGE SYSTEM:
NUMBER OF PITS
LINING MA I'ERIA[
MATERIA[
__GALLONS. INSIDE LENGTH
__OUTSIDE DIAMETER
PHONE____
/
~'~}lt.'~Zi-~ I ~ ~ LIQUID
_ INSIDE WIDTH _ DEPIH
OR W DTH
DISTANCE FROM WELL___
__, LENGTH ___, DEPTH
~ ~; BUILDING FOUNDATION '7~'., /
TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA)
SQ. FT.
TILE DRAIN FIELD:
DISTANCE FROM WELL
NUMBER OF LINES
ABSORPTION AREA
FOUNDATION .- N EA'R~'~ T LINE
DISTANCE BE1WEE~4-Llfq~'~' .......... __TRENCH WIDTH
........--~Q"FT. LENGTH OF EACH LINE
TOTAL LENGTH
OF LINES
IN. TOTAL EFFECTIVE
DEPTH: TOR OF TILE TO FINISH GRADE
_DEPTH OF FILTER MATERIAL BENEATH TILE
IN, ABOVE TILE
WELL:
LOT LINE
TYPE
NEAREST ,~.~., / SEPTIC
SEWER LINE _, TANK
DISTANCE FROM ~ / WATER
_, BUILDING FOUNDATION _ SAMPLE .~'~' NEAREST
~-~ ! SEEPAGE OTHI_:R ~,
, SYSTEM ~'~" , CESSPO0t .... , SOURCES_
DIAGRAM OF SYSTEM
DISTANCES:
DATE APPROVED
)ROUGH No.
GREATEIt tNCHORAGE AREA. 1,
itEALTIt DEPARTMENT
327 Eagle St. Anchorage, Alaska 99,'i01 279-2511
SEWAGE DISPOSAl.. SYSTEM - APPLICATION & PERMIT
NAME OF APPLICANT_~?,~'/_ /l/ _ MAILING
RESIDENCE ADDRESS //,~,¢ ?),¢~/-- ~. LOCATION. OF I~STALI.ATIO~/~2-~
APPLICATION TO INSTALL: SEPTIC TANK ~ ,SEEPAGE PIT_ ,DRAIN FIELD
TO SERVE THE FOr. LOWING FACILITY ~
FINANCED THROUGH
PERCOLATION TEST RESULTS__
PHONE N 0. ~,.¢~/'F~/
.,OTHER
I/A TO BE INSTALLED BY.
~ .z~ . ANTICIPATE[] DATE OF COMPLETION.
BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT
THIS iS TO SERVE AS -- /~/1~/ '~¢~/~1 , PERMIT TO INSTALL A
AS DESCRIBED BELOW. SIZE OF UNIT TO BE SERVED.
· SEPTIC TANK SIZE /~7]
DISTANCES:
DIAGRAM OF SYSTEM
Authority
I am familiar with the requirements of Greater Anchorage Area Borough Or,
I
above described system is in accordance with said code.
/
:e No. 28-68 and that the
2.
3.
5.
6.
Casinv. Size ..~/!
Distance from well to closest existinff or. proposed:
Sewer l~ne ~-~ /
Septic tank '~b / ,
Property Line_~.possible contamination,
Other, sotwoes of
, creeks, lakes,
houses, barn, drainage ditch, etc. ...~
a. Age of ..... : ~
system ~-' ' ~Z-.
b. Septic ta.k capacity in gal~ons~~__, .~~~_
c. llame of septic tank manufac'tu~e~
1. If "home made" show dlagmam on reverse ~ide of this foPm.
d.' Disposal field oP seepage pit size and type
1. Distance to property ]_the /_~_ to house fmmdation..'?~/
e, Percolat.[o~ Test r'~ul.ts
f. P-rcolation Test performed by._
Use the reverse .side of this form to show diagram. Diagram should ]nclude
'tbe fo]lowing ]nformation: p?opePty lines; .well location, bouse locatien,
~o4n']c tank location, disposal area ]ocation~ location of percolation test,
eld direction of gr'ound slope,
The ~'~f',,'.'..~-;,,n on this form is true and correct to the best of my knowledge.
.p_ ~E jILl, ED OUT BY HEALTH DEPA£T~ENT PERSONNEL
The above described sanitary facilities are hereby approved subject to ~
~.lowf. n g c ' - ,
The above described sanitary facilities are disapproved for the followin~
reasons:
' V
Approval is valid for, one year followin~ the date of approval,
CPJ: cw
DATE
D' '~RTMENT OF HEALTH AND WEL' qE
DIVISION OF PUBLIC HEALTH
BACTERIOLOGICAL WATER ANALYSIS
NAMF
SAMPLE COLLECTED BY_
DATE COLLECTED TIME COLLECTED
[] Cemer' __
Yes ~ No
[] Of Well E] Olher --
6, Improve you* [] spring [] dug well ~] driven well
BI drilled well C~] cislern.
9. Contacl your nearesl ]~] Local Health Deparlment or [] Alasl~o
SANITARIAN'S REMARKS
READ INSTRUCTIONS
ON
REVERSE SIDE
BEFORE
COLLFCTING SAMPLE
BACTERIOLOGICAL WATER ANALYSIS RECORD
Otc
I Oct I Oct J Oct 1 Oct 1 .Otc 0.1cc
24 hours
48 hours -
Brillia nl Green
24 hours
48 hours
EMB _ AGAR