HomeMy WebLinkAboutT15N R1W SEC 30 LT 77A x-- MUNICIPALITY OF ANCHORAGE ' DEl ~TMENT OF HEALTH AND HUMAN SER'~ Environmental Heallh Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Nameq / D'ST^"CES ~L~4~_/~ ~ SEPTIC ABSORPTION Addres~ ' / TANK FIELD WELL Phone(s) Permit No. '-- NO. gl Bedrooms WELL ~ ~ ~ ~ ~ ~ 0~ ~ LOT LINE LEGAL DESCRIPTION AS-BUILT DIAGRAM (Show Iocabon of well, septic systed , prope[ty lines, foundation, TANKS ~P ~NJ ~ SEPTIC ~ HOLDING Material~~ NO of Compadments~ ~j ~J~)~ g TRENCH g W. DRAIN ~ OTHER Fill added above original grade G~avel depth benea[h pipe ~ ~ ET ~,~FTj ~ Gravel lenglh Grave~ w,dth / ~ WELLS J ~RIVATE ~ OTHER fldentifv) 5 REMARKS: ..~, ~ ,. . , ~;' J  Scale: [ I ~ E~GINEERING~r L~P Road No. 204 I .... P~ 0g~77 cedil~at this in~clJon was peflorn18d according to all Mu.icipal and State guidelines in ellen, on ,his date: ¢/~ ¢/ff ~ 72-013 (3/85) ._S~o._q Gi' ave I ........ D~., . (fl.) :', " ' gt. ~.., . Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 'L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: DATE Township, Range, Section:-.~,..~ '~..\\~_.~ SLOPE SITE i[LAN -- 4- 5- 6 - 7 8 9- 13- 14- 15- 16- 17 18 19 WAS GROUND WATER ENCOUNTERED? iF YES, AT WHAT DEPTH? I]eplh to Water Alter Gross Net Depth to Net Reading Date Time Time Water Drop 2O PERCOLATION RATE T STRU BET EEN ~FTAND '-~ FT PERFORMED BY: I ~4 ~,~le RI~ L~ R~ No. 2~1 /~ ( / CERTIFY THAT ~lS T~T WAS PERFORMED IN iver Alaska ACCORDANCE~""~ST~TEANDMUNICIPALGUIDEL~~HISDATE. DATE: 72-008 (Rev. 4185) Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Services Division 'l-elephone: 264-4744 ON-SITE SERVICES FEE DOCUMENTATION Date Paid: ~"- '"~"=~- -- ~ ~' Name of Payer: (Name,on Check) Mailing Address: (Off of chec) Legal Description(s): Permit Number: Receipt#: Check #: Type of Payment: (indicate Amount Paid Health Authority: Sewer & Well Permit: Well Permit: Sewer Permit: . ~2/L.~ ~ Copy Request: 72-O34 {10/86} DISTRIBUTION: Excavator Permit: Engineer Permit: Pumper Permit: Well Driller Pe~'mit: ,Tank Manufacturer: (Waste Treatment) WHITE--MASTER FILE