HomeMy WebLinkAboutRAYMOND TEDROW BLK 5 LT 2A2O¢
NAME ~/~ ,-~
MAILING ADDI~SS
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 INSPECTION REPORT
! pHONE .
~w
Z) -
LOCATION ~_{~_.~'(~ ..,.~,Z~,_~ NO OF BEDROOMS.
DISTANCE TO:
~Liq. capacity in g~llons Inside length
iDwelling ' PERMIT NO.
Material No. of compartments
Width Liquid depth
DISTANCE TO:
Well Dwelling
Foundation
DISTANCE TO: ~ /
No. of lines Length of eacl~ line Total length of lines
grade ,,~ ~ ~ ~
Material beneath tile
Length Depth
PERMIT NO.
galloes
Trench wiclth lines
.~, ~.,,.~'~,/~ Total effec absorption area
PERMIT NO.
Type of crib
TO:
DISTANCE TO:
iib diameter Crib depth
Total effective absorption area
Driller
Building foundation Sewer line
Distance to lot line
tank
PERMIT NO.
Absorption area(s)
OTHER
-ERIALS
INBTALLE~ / '
REMARKS
API~-~) ED //2 DATE
LEGAL
F'EF;:M I T Nr3.
F:IPF'L I I]:l':ff',FI~
i_OT 2FI BL.K tl F:FI'.,.'MONE:, 'TEE:,I-~:OH E;IJ
T"r'PE OF'" SO :1: L. F:IE::5ORF"I"I ON S"¢E;TE:M I S: TF.:ENE:H
I~'IF:I::.::]:MLIM I'.,IUME:[.EF~: OF; E:E;[::,I:;.:OOMS =: ~:
Tt-IE P.[EQUIRED SZZE OF' THE: SOIl.... RE,'SOI:RF'I"ZON S'¢%TEM t:E;:
'THE: LENGTH E:,IMEN:E;ION IS I"HE I_ENGI"I-I ,:lIN FEET) OF' "I'HE: TRENCH OF;'. DRFIINFIEL.[:,.
THE [::,EF'TH OF' FI TRENCH OF:: F:'IT IS 'f'HE E:, i[ E;'T'IaNE:E E~Ei"I"!,.!EEI'.,t THE SUI;;:FF~E:fE OF:' THE:
GFi:OIJIq[:, FIND THE BErT'TOM OF THE: EXCF:IVFITION ,.'lIN F'EiE'T::,.
THEJRE I E; NO SEq" t.,.I I C, TH F'Of';;: I"[~:ENCHES.
THE GF..'FIVEL DEPTH IE; THE: MII",I]iMUM I)IEF'I"H OF EiI~'.FIVEL E',ETHEEJq THE OIJTFFILL. F:'IF'E
FIND THE E:OTTOM OF THE EXCFI',,,'FITI'ON ,:: IN FEET).
I:::'E[;;:M ii: T F:tPF'L ~ E:FtN'T' HRS THE RE:SPOI",I:51 E', .T.L. I T'T' TO I t'.,IFORM TH.I'. :5 DEF'FIRTMENT DUi'4: I lq(iii THE
INE;'f'FIL. LFtTION INSF'ECT'IONS ElF; I:::IN'¢ HELLS FID.irRCENT TO THIE; F'r4:OF'EF~'.T'.r' FIN[:, THE
NI...IME:E[~: OF' [;:E:.'.E;IDEiNC:ESH; "f'HRT THE I.,.IEL..L HILL SERVE.
EiJI~aE:I.:.'.'F I I....L. I t'.,IG OF FIi'.,l'.r' 'ii;"r'STEM 1.4 1 Tt-ICEJT I:z I t",!RL I N:':';F:'EYL':T I 01",t f.':li'.,IB, FIPPF.:OVFIL. E3"/ "I"H I S
[:,EiF'F:It:;i:"FI',IEN"F I.,.t:I:L.I... E',E E;I..IE:..irECT TO F't~'.OSEC:I.JTIOI'.4.
t','11 I",1 :[ MI.JM Ii:I ]: :~;TF:INGE'i: E:I:.:.':I"t.,.IE.'".E:I'-,I I::1 I.,.IELL FINE:, RN"r' ON-'S t TE SEtl. IFII]iE .fl.', I :E;I":'OE;FII.... :~,'.:.':.:.!;'T'[EM I E;
:]..IZIE! F:'IJEET F'OF.'. FI F'F:IVFITE: HELL O[;~: :1. E51~.1 TI.~I 2[:.:.~llEI F:'EET F'F..'OM I::;1 F'LIEiL. IC: I.,.1E:LL. [:,EI::'ENE:'INEi
I..IF'ON T'HE T"r'F'E OF PUE,'L I C HE'Ll ....
M I N ] MIJM I::' I ~TF:INCE F'F.'.OM FI F'I:;~: I VFITE' HELL.. TO FI [::'Fi'. I ',,,'I::tTEE :iii;EI4EF~: L Z hiE: Z 'Z; ;.i.'~!][ F'EE:'T' F::]N[:'
'T'O FI E:OMMLIN.'[T"r' SEI.,-!E:R LINE :[:~; T:'!]i FEET.
(]TH.fEf;~: l:;;:E:(;!lJ :[t:~:EM[EN'f'S MR"r' FIF'PL.."/. ii;PEtE: l F l F:I::I'T I OI'.,1S FINE:, COI'.4ST[E:LICT I ON [:, i F!C.i[;~:FII'"I:E; FIRE
I:-I',,,'R :[ LI::IE::L..E 'f'O :[ I",I':';LIRE: PF.'.OPEF~: ! N%TI::IL..LF:ITZ
F:> EZ IF;i;:: I1""'~ % -1F' EE 2~..::; F" Z FE: EE.; :S3E; iE:::, lEE C: ~E ~"1 E','. El;: IF;;: %i: :111 ...... :i. %'~ :EE: :dl ....
I Iii:E~]-;?.TIF'¢ 'THI::IT
:1.: I FtM F'F:IMZL. IFIF'.': I.,.II'f'H THE F::EQLlIf4%I'dEN'f".'E; FOR ON-':F.,ZTE SEI.,.IEF~:S Rf',tD HEL. I..S FI.S :Fi;ET
F'OF::TH E?'r' THE; MIJNIC:IF'IqL.!T? OF FIIqC:HOI:;~:FIGE:.
:2: I !.,.I I I....L. I NSTFILL THE ?'r'STEi"l I t",1 F:IC'COf;~:I::'FII",ICE l,.I I TH THE CODEL"'i;.
]!]:: :1: UF,![."E:F?.:'];TFIN[:' 'I'HI:::IT THE: ON-IS.T."I"E: 5:;EI.,.IEF.': :S"r':%;T.E":I"I i"11:::I¥ I:;::EL:.:!UII:;i:E E?',IL. FII:,~:C'iEMEi",IT I1:::' '['HE
[;i:E:ii; I DEJ",tE:E ].' S RE:MO[:'E:L.E[::' TO ] i",tCI...U[)F I"IOF;'.E THFIN S
E; l C. iNED ' ............... ~ ~.~ ...... ~...~,~~ .....................
:~ ..]'E:FINNE I':'.
MUNICIPALITY OF ANCHORAGE
ENVIRONMENTAL ENGINEERING DIVISION
~'~Y~-- 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAl. SYSTEM AND/OR WELL INSPECTION REPORT
PGRADE
MAILING ADD.SS
LEGAL DESCRIPTION
Absorption area
DISTANCE TO:
L q. capac ty- n gallons
Inside length
Dw~T~iTg
IMaterial
.LWidth
Well Dwelling
DISTANCE TO:
DISTANCE TO:
No. of lines
Length of each line
finish grade
p~PEERNO. OF BEDROOMS/.
~TX6.-'-
INo. of compaltments
Liquid depth
PERMIT NO,
capacity in gallons
PERMIT NO, ~ ~./
Foundation "~' Nearest lot line '¢'- ~O
Total length of lines Trench width lines
Material beneath tile ,~'~ Total effec~ ption area
Depth PERMIT NO.
Length Width
Type of crib ib diameter Crib depth
Total effective absoH)tion area
DISTANCE TO:
Depth
DISTANCE TO: Building foundation
OTHER
SOIL TEST RATING
'NSTALLE~ /
REMARKS ,I ¢
Driller Distance to lot line PERMIT NO.
Sewer line Septic tank IAbsorption area(s)
DATE LEGAL
[] SOILS LOG
PERFORMED FOR:
LEGAL DESCRIPTION:
10
11
12
13
14
15
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG- PERCOLATION TEST
PERCOLATION
TEST
16
17
18
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date
Time Time Water Drop
72-0O8 (6/79)
QGREATF ANCHORAGE AREA BOROL"H
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME
MAILING ADDRESS ¢;,'(:~:'¢ / ((2((: "' ''
LEGAL DESCRIPTION /~"/~'~/~ (~/'~( -(~'
SEPTIC TANK:
DISTANCE
FROM WELL
INSIDE LENGTH
MANUFACTURER
MATERIAL '~"
' f' {-' L
INSIDE WIDTH
LIQUID DEPTH __
NUMBER OF
COMPARTMENTS
.LIQUID CAPACITY /~]~/ GALLONS.
SEEPAGE PIT:
NUMBER OF PITS
LINING MATERIAL
BUILDING FOUNDATION
DIAMETER ~?~ OR WIDTH /~' LENGTH ///, DEPTH
(?t
CRIB SIZE: DIAMETER ~ DEPTH (i) DISTANCE FROM: WELL
TOTAL EFFECTIVE
__., NEAREST LOT LINE ABSORPTION AREA (WALL AREA)
SQ. FT.
ADDITIONAL ABSORPTION
WELL:
BUILDING
FOUNDATION
CESSPOOL
APPROVED
CONSTRUCTION
NEAREST
LOT LINE
OTHER SOURCES
DISAPPROVED
NEAREST
SEWER LINE
REMARKS
DEPTH
SEPTIC
TANK__
DISTANCE FROM:
SEEPAGE
SYSTEM
DISTANCES:
DIAGRAM OF SYSTEM
INSTALLED BY:
PIPE MATERIAl..
LOT SLOPE:
REMARKS:
Form No. LQ~031
APPROVED
DATE
·/G.A.A.B.
GREATER ANCHORAGE AREA BOROUGH
DEPARTMENT OF ENVIRONMENTAL QUALITY
3330 "ti' STRr~ET ANCHORAGE:, ALASKA 99503
TELEPHONE g74-4561
SEWAGE DISPOSAL SYSTEM _.n APPLICATION AND PERMIT
PERMIT NO.
NAME OF APPLICANT ~//~
INSTALLATION OF: SEPTIC TANK
FINANCED THROUGH
SOIL TEST RESULTS
NOTE~ THIS PERMIT IS i~lOT VALID WITHOUT SOIL TEST
COMPLETION DATE ANTICIPATED
FiNAl. INSPF:CTION: 24 HOUR NOTICE REQUIRED. BACKI~"ILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION.
SEEPAGE AREA SiZE
SEPtiC TANK
TO NEAREST LOT LINE.
WELL TO SEPTIC 'FAN}( .
WATER MAIN TO BEPTIC TANK
DRAIN FIELD ___
SEPTIC TANI'(, _7~ ,~ , SEEPAGE PIT _/,~L
TO RIVER, LAKE, STREAM.
ALSO CONSIDER AREA WELLS.
,SEEPAGE Pit
· DRAIN FIELD
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF
EXCAVATION 5 FEET INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST iRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRTIGHT REMOVABLE CAPS.
DIAGRAM O~
GRAVEL BACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
LICENSED DEBIGNER
I CERTIFY THAI' I AM FAMILIAR VVITB THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO, 28-68 AND THAT THE ABOVE
DESCRIB D SYSTEM IS IN ACCORDANCE WITH SAID CODE.
DATE APPLICANT'S SIGNATURE __ ~
E~AT-E RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR
MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH& ENVIRONMENTAL PROTECTION DEPT. OF HEALTH &
825 L Street - Anchorage, Alaska 99501 ENVIRONM.'.NTr~L F,,'C~TECTION
ENVIRONMENTAL SANITATION DIVISION /~[:)l) ~r ~
Telephone 264-4720 '-" ~ ~ ~ i~.~
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SE~A~I~I~
DIRECTIONS: Complete all parts o~l page 1. Incomplete requests will not be processed. Please allow ten (10) davs for processing,
P~OPE~TY ~ESIDR~T Jif ditfere~t from above) PHONE
PHONE
3. LENDING INSTITUTION PHONE
MAILING ADDRESS
4. ~ALTOR~AGENT P ON ,
MA~NG AflDRE88 ~ ~
5..J.~F-1GA L iD ESC R I PTI O N
STREET LOCATION
6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS
,~_. [] One [] Four
SINGLE FAMILY E~] Two [] Five
[] MULTIPLE FAMILY ~ Three [] Six
[] Other
7, WATER SUPPLY
[] INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled
~ COMMUNITY since June 1975. For wells drilled prior to that date, give well
[] PUBLIC UTI LITY depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
.~ INDIVIDUAL/ON-SITE** /q(~)/ / 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)
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: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4, DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line
WELL TO:
Absorption Area to nearest Lot Line
5, COMMENTS
[~APPROV ED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED ~
DATE BY
72-010 (Rev. 6/79)