HomeMy WebLinkAboutBURLWOOD TERRACE BLK 3 LT 1
;RE/kTER ~NCHORg. GE ~RE/~ BOROUGH
!~LI~,I DF. P3R15, ~NT
327 EAGLE STREET
g.NCHORAGE, ALASKA 99501
279-2511
DATE PECEIVED )-"
INSPECT:
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
FOR
Appr0val Requested By
Address ~.~f
Phone ,.y,.~'~-~/
Number of Bedrooms
Well Data:
2. Property Owner ~z~ . .. Phone ~.,~
3. Legal Description ZO7~ /., /?/~ ~ ~ Z~, ~/0~
4. T~ e o f Faci 1 ity to be Inspected/- ~/eY /'-~/~X STREET:
A. Type ~/~xy/&o/
B. Depth /,q,O 2
C. Size.. ~
D. Construction
E. Bacterial Analysis
6. Sewage Disposal System:
Septic Tank (If homemade, show diagram on back)
2. Age 4
3. Hanufacturer
4. Installer
,Approv~l Request £or Se~
Page Two
Water Facilities
B. Seepage Pit
1. Size
2. Lining
C Disposal Field
1. Number of Lines
2. Total Length
7. Required Measurements
A. Nell to Septic Tank
B.. Well to Seepage Pit
C. ~ell to Sewer Line ~O ~
D. Well to Property Line
E. Nell to Other Possible Contamination
F. Foundation to Septic Tank
G. Foundation to Seepage Pit
H. Seepage Pit to Property Line
8. COMMENTS:
DISAPPROVED:
DATE:
APPROVAL VALID FOR ONE YEAR FROrI DATE SIGNED.
GREATER ANCHORAGE AREA BOROUGH HEALTH DEPARTMENT
EDll70
REQUEST FOR APPROVAL OF
~'~D/VIDU^L SE~IA_~E' (~ AND WATER FAClI, IT~fZ$
(Fill out in Triplicate)
~. Name of person requesting approval
2. ~am~. of property-~ owner
~. Numb~ o~, ~dr~ms in house_2 .
Wate~. ~anal~sis:
a.
b. Detergent . " .
6, W~.]I data:
a. 'lype
b. Depth~:
c. Casing
de
Distance from well to closest existing or proposed:
1. Sewer line $0'
2. Septic tan~
3. Seepage Area~3$
Cesspool'
5. Property Line
6. Other sources of possible contamination, i.e., creeks, lakes,
houses, barn, drainage ditch, etc. .
Sewage disposal system.
a. Age of system · BORO[~ $~WZR'
b. Septic tank capacity in gallons .
c. Name of septic tank manufactu~gm
1. If "home made" show diagram on reverse ~ide of this form.
d.' Disposal field or seepage pit size and type
1. Distance to proper~y lJn~ to house f~undation
· e. Percolatio~ Test
f. Percolation Test performed by
Use the reverse .side of this form to show diagram. Diagram should include
'[[-the fo]Aowing information: ppoperty lines;.well location, house location,
m~ptic tank location, disposal area location, location of percolation test,
a~ direction of ground slope.
The ln'['~,~m+{on on this form is true and correct to the best of my knowledge.
Si?nature of Applicant
'Da~e $i~ned'
~O~B.E FILLED OUT BY HEALTH DEPARTHENT PEPSONNEL
The above described sanitary facilities are hereby approved, subject to the
.......... ~6~llowing con~i~ons: - ~
Conditions:
The above described sanitary facilities are disapproved for the followin~
measons: -
Date :"?' . ~!? ~'~ -..q
Approval/is valid for one year following the date of approval.
CPJ: cw
REQUEST FOR APPROVAL OF
I~D~VIDUAL $EWA.~E AND WATER FACILIT'f~S
(Fill out in Triplicate)
~,... Name ,of person requesting approval
2, %tan~ of property,- owner
Numbmz ~,~ bedrooms in house
Water Analysis:
a. Bactgr~.a ]
b. Detem~ent
6, 1,I~=11 data:
Casing Siz~
Distance from well to closest existing, or proposed:
~. Sept~ c tan~
3, Eeepa~e Area /~ ·
Cesspool'___
5. Property Line
6.
Other sources of possible contamination, i.e., creeks, lakes,
houses, barn, drainage ditch, etc,
Sewage disposal system.
a. Age of syste~
b. Septic tank capacity in gallons
4:' ~Qu uI'
Name of septic tank manufacture, m, , M/~ AJ
1. If "home made" show diagram on reverse side of this form·
d' Disposal field or seepage pit size and type
- 1. Distance to pr~per~l. ' ~
to house fcmndation
f. Percolation Test performed by
Use the reverse ,side of this form to show diagram. Diagram should include
'[[~,he following information: p.~operty lines, .well location, house location,
~I~t~.c tank location, disposal area location, location of percolation test,
a~d. direction of ~round slope.
The i~,~~ on this ~ true cor~ct to the best of my knowledge.
., Si~m~ture of ~pplicant ' Date signed ~
~0~ BE FILLED OUT BY HEALTH DEPAP, T~.~ENT PEP, SONNEL
above described sanitary la. iii%les are hereby approved, subject to the
The above described sanitary facilities are disapproved for the following
r~asons:
^~P~'rlv/4.y' valid for one year followi~ the date of approval.
CPJ ~w ' .