HomeMy WebLinkAboutLot 01, 02Lq"
BL.K
IA
HOME OFFICE
2'~5 EAST ~TH AVE
ANCHORAGE, ALASKA
Ie. O. BOX 721
0!
15'
W~3-177~
Percolation
Test Location: Lot~ Block
Test Hole Log
Test
//~' _Subd.
Test
Hole Location
1
approximate
of water and
of water and
1st. Filling:
Bottom of hole filled with
to drain out.
2nd. Filling:
Bottom of hole filled with
~ min./in.
Percolation Rate:
Remarks: ~-'~ ' ....
These re~ult~ are only the ~sual ~o~1 co~t~on~
percolation rate ~n th~8 date for this test hole.
slope
allowed
test run.
and theoretical
P~.EQUEST FOP APPROVAL OF
INDIVIII!AL SE!-iAGE AND !'fATIiR FACILITIES
(Fiji out in T~i~!cate)
Water Analysis:
e
a. Bacterial_
b. Deter~ent
Well data:
a. Ty~e ~
b Depth (j(~
c. Casing Size
Distance from well to closest existin~ or proposed:
1. Sewer, line
Property Line ~/~' ~.~
6. Other sources of possible contamination, i,e., creeks, lakes,
houses, barn, drainage ditch, etc. ~¥_3~ .
Sewage disposal system· ~[~'~.~ ,V~ ~/~A: -'~
a. Age of system
b. Septic tank capacity in ~f~llons__~¢-- .
c. Name of septic tank manuf~u~er
t. If "home made" show diaffram on reverse side of this form.
d. Disposal field or seepage pit size and type
Distance to :-ro~erty lin= ,~ -/f~to house foundation__,.
-7¸
e, Percolatiom Test results '-
f' Percolation Test performed, by / ·
,U. se the re.v=~s.e ~tde of this.form to show diagram. ~ Di,:gram should inc! '
the followzn. ~nformat~on: prop~r,t · ud
se~tzc tamk location, dis~o,~'~ 2.~ Y~.hnes~.well location, ho~,== ~ ..... e
and dip ..~., . - , - ...... ~ea location . ~ ...... ~uzon
ect~ .... of grouna slope. , locatzon of percolation tes~,
The information on this form is true and correct to the best of my knowledge·
Date Signed
TO BE FILLED OUT BY HEALTH DEPAP. TqENT PERSONNEL
Ti~e above described sanitary facilities are hereby approved subjec~______~t to the
Conditions: --
The above described sanitary facilities are disapproved for the following
reasons:
Approval is valid for one yea~ following the date of approval'.
CPJ:cw ~- , .