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MUNICIPALITY OF ANCHORAGE
DE RTMENT OF HEALTH AND HUMAN SER ES
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name DISTANCES
^ddres~ ~~r~T ~/~ ~0 SEPTIC ABSORPTION WELL
~ TANK FIELD
~ ? ~'~ ' JNo. of Bedrooms WELL ~/~
I LOT LINE 1~/~ i~/~
~ N& ~U/~ Ye., ~2t T~, C FOUNDATION
Township, Range, Section
' ~ ~ () AS-BUlLTDlAGRAM(Showlocat,onofwell. septicsystem, propertyl,nes, foundat,on.
TANKS ~ ~, U
~EPTIC ~ HOLDING ~ ~,
'~nula'cturer Capacity m gallons ~ ~'~ I
~ TRENCH ~ BED ~. DRAIN ~ OTHER ~'~'~c
Depth to p~pe bottom from Total depth from original grade ~
or,ginal grade ~ FT ~ FT ~ ~ ~ ~l ~
Fill added above original grade Gravel ~epth beneath p~pe ~ ~ ~
D, - /,o FT / FT N, ,¢~
/
Gravellength ~/ FT Gravelw~dth ~ FT ~
Total absorption area Distance between lines ~
~ SO FT ~ FT
Number of hnes Sod rating P~pe material
Installer Date Installed ~
WELLS
~ PRIVATE ~THER (Identify) ~ ~ ~/, V~ .,-)~ ~ ~ ~ ~;~, iJ i~l ~ ~,~ :, ~'~
' :,: ~ ,:, ,,,,~ , FTI FT
i InstaHe~ ' , . , Dat~ Installed:
REMARKS: . ~ ~
..... '";' '('; Scale: ~%~ ENGIN~R'8 SEAL
~ ~ E~ ~ /~ U~A~. ~/~ Z'- Z~I Inspections Pedormed by:
~ ..... ~ ..... "~7'~/'..~' ' ", ~ .,. ~,~ ....... 4
I 17034 Eagle Ri.v~ L~ R~d Ne. 204 cedily that this inspection was pedormed according to all ' ~~%.~ ~: ...... ' ........... ~'.,. '~;
Municipal and~tate guidelines in effect on this date: / / ¢
Health Depadment Approval: Date:
72-013 (3/85)
S &. S ENC-'):[IqEER:[NG
17034 E,, R. LC)OI::' :1.~204
EAGL..E R:[VER .~ AK 9957'?
PHCINqE ~6,94-....2979
ROBERT W. I..{Uf::'t::'
9.5U:7 END I COTT
AIqCH, AK 99557
C::OIq'I"A(:.:'I' I::'HOIqE: 243-55:1.4
LEGAl .... DESCRII::'I"IC)N: S 1/2 'T'RACTT' C Iq[i:: :1./4 NW 1//.t.
..... R 4 W
SEC 1, ~'T':I. 2N ~
I....C}]" S]:Zli!::: :1.',:5 (,S[~;! I:::"T' 01:;: AC:RI!ES)
MA×. IqUME.:EI::i'. 01:::' BI!ii:DI::;,'OOMS: 3
SOil .... F;:A"I']:IqG: :1.3'..'::.;i S(:~} t::'T/BI::;~
S 0 :[ I '1" Iii!. S T D [!iii:::' T H: :1. 2 ,, 5 I:::' T
IqO WA"I"EF;.'. I:':'I::;,'Ei:SI!:5]'-.I'T' il:N TES'T' I"'IC}t....E,
"f'H]:S :lis AN UI:::'GF;~ADE 01":: 3 BEDF:(OOM "FO 'THE E×IS'TiIqG Sliii:P"l ICi: SYS"IEM
'I'RENC;:H BED W, DRA :[ NF::' I ELD
Ii!!: I:::'t:::'li!!: C]" I V Iii: D E PF H 0 0
COVER ):}E F:'"i" H () 0 4
'FCI"f'AI .... DI!!!:t:::' '/" H 0 ,'.:) 5
l.. E N G'T H () 0 7 i
W I D"H"'I 0 0 5
S (:.;} I:::" f' ,. C:' 0 4()5
SCALE
,SCALE
PERFORMED FOR:
Municipality of Anchorage .., ~
DEP RT ENT OF HEALTH SERV,OES
SOILS LOG PERCOLATION TEST ~~'.
LEGAL DESCRIPTION: / ~CT ~ ~/d ~y., ~t~ ~Township, Range, Section:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
5,
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT -- O
DEPTH? p
E
Depth to Water .Afl,er
Monitoring? r,d oN~ Date:
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE __ {minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN ~ FT AND ~ FT
COMMENTS L1 ~. I ~ ~/"~J'~_ /C"~. /~.~,,~/../ ~ ~~:
PERFORMED ~034 ~!~ BIy~ I ~ B----J ...... {J / ~ / CERTIFY THAT TH~ TEST WAS PERFORMED IN
72-008 (Rev. 4~8~) ~ /