HomeMy WebLinkAboutKWIK LOG BLK 4 LT 1
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3500 Tudor Road, Anchorage, Alaska 99507 279-8686
Date Received /
Time of Insoection
Date of Insnection___~' >~
REQ.JqST FOR APPROVAl., OF
INDIVIDUAL SEi~EW & WATER FACILITIES
FOR
Aoprovat Requested By: ....... ~/~~
Address:
Phone:
5. Type of Facility to be
Number of' Bedrooms
6. Well Data: ~-~
Size
Installer
Size
2. Manufacturer
2. Material
Total. Length of Lines
A. Type
C. Construction
Sewage Disposal System:
A. Installed
C. Septic Tank: 1.
D. Seepage Pit: 1.
Disposal Field:
Distances:
A. Well To:
Septic Tank ................. , Absorption Area , Sewer Lines
, Nearest Lot Line , Other Contamination
Foundation to ,..ep.~c Tank__ ;. Absorption Area
C. Absorption Area to Mearest Lot Line
,.:or Approval of .... dividua] Sewer & Water Faciliti ....
Page .,'m
9. Comments~
Ap,~-ova]~_ Valid for One Year From Date Sioned.
Greater Anchorage Area Borouoh, Deoartment of Environmental Quality
D~AGR^M OF SYSTE~
I certify that the information contained in this request for approval to be a true
and accurate representer:iCh of the subject sewer and water facilities located at:
Signed Date
~~-~-(.1 GREATER ANCHORAGE ARF-A BOROUGH
Department of Environmental quelfty
3500 Tudor Road, Anchorage, Alaska 99507 279-8686
Date Received /~
Time of Inspection Z~*'~)
' ~
Date In eotion_Z_ .
RBQUBST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
FOR
Legal ·
Location: i~~~ ~ ........
Type of Facility to be Inspected:
Number of Bedrooms:
Well Data
C. Construction
7. Sewage Disoosal System:
A. Installed
B. Depth. ........ ~
Installer
C. Septic Tank: 1. Size__
2. Manufacturer
D. Seepage Pit: 1. Size
2. Material
Disposal Field: Total Length of Lines
J
Distances:
A. Well To~
Septic Tank
, Nearest Lot Line
Foundation to Septic Tank
Absorption Area to Nearest Lot Line __.
, Absorption Area , Sewer Lines
, Other Contamination ·
"~ Ab'~orption Area ·
Request for Approval of ~ndividual Sewer & Water Faeflities
Page Two
9. Comments~
Disapproved
Date
Approval Valid for One Year From Date Signed
Greater Anchorage Area Borough, Department of Environmenta} Quality
DIAGRAM OF SYSTEM
I certify that the information contained in this request for appreval to be a true
and accurate Yenre~;entation of the subject sewer and water facilities located at:
Signed Date
GREATER ANCHORAGE AREA BOROUGH
DEPARTMENT OF ENVIRONMENTAL QUALITY
3500 TUDOR ROAD
ANCHORAGE, ALASKA 99507
279-8686
DATE RECEIVE[):
INSPECT:
TIME:
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER AND WATER FACILITIES
FOR
APPROVAL REQUESTED BY:
ADDRESS:
PHONE:
PROPERTY OWNER:
LEGAL DESCRIPTION:
NUMBER OF BEDROOMS:
WELL DATA:
A. TYPE
B, DEPTH
C. SIZE
D. CONSTRUCTION
,1" ( (
t
E. BACTERIAL ANALYSIS
SEWAGE DISPOSAL SYSTEM: ' 'i,~ ,-,,,?'
A. SEPTIC TANK (IF HOMEMADE, SHOW DIAGRAM ON BACK)
1. SIZE
2. AGE
3. MANUFACTURER
4. INSTALLER
APPROVAL REQUES FOR SEWER & WATER FACILIT~
PAGE TWO .-
B, SEEPAGE PIT
1 . SIZE
2. LINING
C, DISPOSAL FIELD
1. NUMBER OF LINES
2, TOTAL LENGTH
7, REQUIRED MEASUREMENTS
A WELL TO SEPTIC TANK
B WELL TO SEEPAGE PIT
C WELL TO SEWER LINE
D WELL TO PROPERTY LINE
E WELL 'FO OTHER POSSIBLE CONTAMINATION
F FOUNDATION TO SEPTIC TANK
G FOUNDATION TO SEEPAGE PIT
H SEEPAGE PIT TO PROPERTY LINE
8. COMMENTS:
_ · ...... ::': 1: ~-.: :,-,,: ........ ,~- ·
....... ./
.< .... ... .--.-' /
'...~':""..:":'_!:_FPROVE~: _ . ., ~__-~,.
l-
DISAPPROVED
APPROVAL VALID FOR ONE YEAR FROM DATE SIGNED.
GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY