HomeMy WebLinkAboutT12N R3W SEC 9 LT 54 E95 W195' S200',St,.'C.
GP, TER ANCHORAGE ARt:A BMRU' "-
H EAL'rH DEPARTMENT
327 EAGLE ST. ANCHORAGE, ALASKA 99501 27%2511
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
SEPTIC TANK:
DISTANCE FROM WELL_
LIQUID CAPACITY
GALLONS,
MATERIAL__ ....~' ?pcr~ //'
,NS,DE
INSIDE WIDTH DEPTH.____
SEEPAGE SYSTEM: SEEPAGE PIT:
NUMBER OF PllS / OUTSIDF DIAMETER .... OR WIDIH_
LINING MATERIAL ;~_ ~',~ ~.~' DISTANCE FROM WELt
NEAREST LOl LINE___ k&>~,~"~2 / TOTAl EFFECTIVE ABSORPTION AREA (WALL AREA(
LENGTH /~'~ --. DEPTH
, BUILDING FOUNDATION
TILE DRAIN FIELD:
DISTANCE FROM WELL
NUMBER OF LINES_
ABSORPTION AREA_
FOUNDATION _
.DISTANCE BETWEEN LINES
_SQ. FT. LENGTH OF EACH LINE
NEAREST LOT LINE__-
TRENCH WIDTH
DEPTH: lOP OF TILE lO FINISH GRADE.
.DEPIH OF FILTER MATERIAL BENEATH TILE
TOTAL LENGTH
, OF LINES__
IN. TOIAL EFFECTIVE
IN. ABOVE lite
WELL: 'rVPE__~'~_Pl#i'~dL, DEPTH &':/
SEWER LINE---~[-2
LO[ LINE ,~) ,' NEAREST . ¢ SEPTIC
, lANK_
DISTANCE FROM ~ / WATER .~ .~..~- NEAREST
, BUILDING FOUNDATION. ~- SAMPLE_
~ SEEPAGE -- ~' .~ OTHER
.5~/ SYSTEM___////*~'p , CESSPOOL_ SOLIRCES ~
DISTANCES:
DAlE
DIAGRAM OF SYSTEM
-~-~"~"--- ~UNIC. JPALITY OF ANCHORA/~r' "--]'
rVIUNICIPALIT~-tORAGE DEPT. OF HEALTH & , J
~----~-- DEPARTMENT OF HEALT -I & ENV BeN VIENTAL PBOTECTiI:~IitONM:i'NTAL PROTECTION / 'Jd.~t~'''~ ~/
ENVIRONMENTAL ENGINEERING DIVISION 00'J' 4 1978
DIREOTIONS~ Oomolete all parts on page 1. Inc~m~lela reqa~st~ will not b~ pro~ss~d, Please allow ten (lB) days for ~roae~sing,
PHONE
344 3533
~-. -PROPEBTY OWNER
FORT1ER~ James R, and Shar(ln M,
MAILING ADDRESS
3121 W, 84th Ave, ~ Anchorage, Alask?
~-~OPERTY RESIDENT ( ~ different fram abova~
99507
J DHONE
PHONE --
349 4894
BUYER '~
BAKER~ garvin and Joan
MAILING ADDRESS
3106 E. 84th Ave.~ Anchora§e~ ALaska 99507
:3. LENOING INSTITUTION
Spokane MOrtga§e Co.
3201 'Ca.Street, Suite 2_50, Anchora.qe~ Alaska
~? REALTOR/AGENT
vlAI LING ADDRESS
99503
PHONE
277 0543
JPHONE
5. L~I~AL O ESC-RI P'rlON --
~ast 95' of West lgS' of the South 200' of Gow~rnment lot 54, Section 9
S~'REET LOCATm~4 Township 12 North Range 3 West
_ 3121 .~84th Ave.~ Ancherage_; Alaska 99507
S, TYPE: OF RESIDENCE NDMBER OF BEDROOMS
~ One r-] Four
[~ SINGLE EAMILY ~1 Two [] Five
[] MULTIPLE FAM'LY [~,J Ti~ree [] Bix
Other
t, WATER SUPPLY
~ INDIVIDUAL+ ~ ATTACH WELL LOG, A well log is required for al Wells drilled
[] COMMUNITY since June 1975. For wells drilled prior to that date, give well
[] PUBLIC UTI L'TY depth {attach log f availableJ ..,
8, SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL 'ON-SITE~' ~'lf individual/on-site, give installation date .
PUBLIC UTI LITY
If s'ystem is over two (2) years old an adequacy test is required .
by this Depar[m~n~.
NOTE: THE INSPECTION FEE MUSTACCOMPANY EACH REQUEST BEFORE PFIOCESSING CAN BE INITIATED,
,
THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
I NSP ECTOR I NSP ECTO--R INSPECTOR
DIRECTIONS:
1, TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
2. WATER ~UPPLY PERMIT NUMBER
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDI VI DUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified
INSTALLER
[]Septic Tank or []Holding Tank
Size: . If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCESwELLTO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
COM +s
~].~',~P P R 0 V E D FOR BEDROOMS
~'"'~ONDITIONAL APPROVAL (letter mu~a)company certificate)
DISAPPROVED
LEGAL DESCRIPTION
72-010 (Rev. 3/78)
P.O. BOX 4-1276 4649 BUSINESS PARK BLVD.
ANCItORAGE, ALASKA g~309
TELEPI4ONE
(997) 279-4014
D.~lnklng Water ,&r~aly~s Report for Total Coil[erin gacteria
TO iA: CO[aPLETED BY WATEFI SUPPLIER
Mo. Day Year
,qAkl PI.E TYPE:
13 Routine
t3 Chock Sample (for routine sample
with lab rof. no.
[] Special Purpose~ ~ ,'}k/
ID Treated Water
[3 Untreated Water
SAMPLE
NO.
1
2
3
4
5
Time Collected
Collecled By
'i'O BE COiViPLIZI'ED BY IJ'd]O~ATOFtY
LAF. IORATOItY:
C!!FM &_.G_EO__L~S_ OF AK~H~C.
NAM6
46~9 BUSINkSS PARK BL~D.
ADDRESS
P-NCltORAGE , ALASKA
CITY
Date Received __
'rime Received ~: (_'~_~'~.____
Analytical Method:
[] Fermentation Tube
~ Membrane Filter
Lab Ref. No. Result* Analyst
I J I-F1
t
J
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Form NO, 18 310 (3-78)
06-1220 (0) BACTERIOLOGICAL WATER ANALYSIS RECORD
Rev, 1978
o~t. co.,.*o, 10-9-78 s ........
~ 8 837-_g2
Da~a~¢.N~.___I_OT~--7--7--7- B .,-~,,,o,0~0~0,~ 3:00 L,~ No