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MUNICIPALITY OF: ANCHORAGE
DEPARTMENT OF HEAl-TH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELl_ INSPECTION REPORT
NAME
MAILING ADDRESS
LEGAL DESCRIPTION
IPHONE ~;]NEW
~ ~/~ ~]UPGRADE
Well ~/[;. Absorption area Dwelling
D,STANCE TO: ]Lo_,L~ ~,->/ ~.,:?
Manufacturer Mater' I
Liq. cspac]W in gallons ~ HOMEMADE: Inside Iongth
OISTANC~ TO: Well Dwelling
PERMIT NO.
Liquid depth
PERMIT NO.
Manufacturer Liquid capacity in gallons
Foundation PERMIT NO,
Total length of lines Distance between lines
Material beneath tile
DISTANCE TO: Well ~..m_.~ ~_~...~
No, of lines ~ Length o each line
Top of tile to finish grade
Nea}est3ot line
.~% inch es
Length
Width
Depth
PERMIT NO.
Type of crib Crib diameter Crib depth Total effective absorption area
Well Building foundation
DISTANCE TO:
Class Depth Driller
DISTANCE TO: Building foundation Sewer line
OTHER
/Nearest lot line
Distance to lot line
Septic tank
PIPE MATERIALS
P
SOIL TEST RATING
INSTALLER
[REMARKS
~ 5',, ;1, ~./,~ t./_2. /~iI~M' 44
APPROVED
DATE LEGAL
72-013 (Rev. 3/78)
I::1F::' ~::' L ]i C F:li",l T
LCICFI]' I I]1 I",1
L. E G FIL.
DIE? FIR TM E i",IT L,,
C:LFIRK!i~;S ..... I"1':=~ 'F:' F T t' ON
klL FI::'I"lt:II"I (:il...[::, SF'ZI',Ii::IRD
LOT c ;r ?E 4-~s;Er :E ~;:Z
Cfi:' E:Et::,RC~(:)HS =
]=.;CI ! L ~;,~1=1T ]: I",1(] ( S;~:! F' F,-'"E:F?, )=
T'HE: I:;d::]:!l.I l' RE[) ., .1. ,:J::. OF THE '~O I I_ I--IE ... _ Ir,..f I I ~ 14 S"r'STEH :
......... FB Ef',I
THE I_I:1.,1~111 DIi"IL=]".ISiON IS THE LEN(:fT'I-I (IN [::'[CE]'[':) OF:' ]"FIE ......
THE I]:,EPTH OF FI Tf.LIII...[t CIR PIT
GROUI"~[:, FII",ID THE E ... Iff .. I I OF:' THE EXCFI;,,'FrT' I O1'.,I (
. '= I [ .E.f,I .. I- I[ .::,.
TH[CI:;'F .L.. Iq(} SET !,1:[[:,"1"1.'-I FOR ..... ' .........
THE GF;q::I',,,'EL [:,EF'TH IS THE i"!INIHUi"I t}EF']'I-! OF (3F;~:FI'v'EL. E~ET!41~EN THE OIJTF'FtLL F'IF'!~
I:!I'~II} TI-~E EIOTTCIH C F 'THE E:?,X:!f~,~F!'F I i:]N ,' I I'.,t I::'[!:E-':T).
PERPII]" RPF'L.IC:iaNT l--II::l~ THE RESF:'OI'.,!:'~;IE:IL.I-I"'~' rfc[ INFOf"~:M TI'"IZ::~;[:'EF'F:IRTME!",!'Ir' DI..llq::[t",!C!i I"HE!:
ZNS'T'FII.J..FITZON !I",ISPEC"t"IOI~,f'_'5 Cfi::: l=lt".?'r' klELL:t~; I=ID..)'I:::I(]Ei",I]" ]'0 TH]:S F:'F?.OPE:R'rF'~.' Fff']l} THE
NIJH.[!i~ER OF' I:;i:E'.i~;IDENCE:~:; THI=IT THE !,.IEI.L I.,.IILL SERVE .
L,/ ..I...F Lt..L!.I'~] CIF= FIN'-t ._,~'_,l-Lfl I.,.III'HCIIJT F'INFII._. ].II_.FE.L.I.I.u[',I FII'.,I[) I:::IPF::'RO',,,~F~L ['? THZ
E:,EI::'F!RTHEi'..I-F I.,!:!:...L.. DE: :i!;I._l[~l..]l~':l:_~:']'' ]"'][ ......... [,._=,E.L.I._I []...I,].
\
I"I I I",! Z I"lUi',l [:, :[ ~;TI=II'.,tl]:E BE:THEE N FI I,IEI...L I":IN[) I::1i'.,!~' ON-~'-:~; Z -rE_': S[i[[,.IFll]E D Z :~i;F'l::[S[::ll... ~L:,'.r':E;'!"Ehi
::[.17.~12~ FEET FOR FI F'RIVFITE I,E-ZL..L OF;: ::l. Se~ TO 2(~11.~ FEET FF'.OM FI PUE'&.IC HELL
UPON THE 'T'-r'PE OF PLIE&..IC I,.IEL. L
I','IIN]:Mt_IM DI'.:~;TI:::INCE FROH FI PRI'v'FrrE !4E]....L. TO FI F'RI'v~FITE SEklEE'. Lii'.,IE IS 2~':i !=EIF.':T FIi'.,ID
TO Ih OOI',IHUNIT'~.' :L:;E.-].,.IE::R L.:[I'.,IE Z!5 7'5 FEE]".
!.,.IE].J_... LOG'_::: t:::IF'.E RE(:!UZREI} FIN[:, Mt..I::~;T DE RE]'IJRNE[) "['C~ THE D, EPF!RTHI!!:N"r 14iTI~II['.J ]~:el DFf'~-"_'5
OF THE 14ELL C:OMF'LETION.
O'I'HL::F~: F'.EI]!UIREHEi'.,I"I':~; MFI"r' I-I[ F~_..~ ...... F E. ... .[ F .~ ... -t I .( ... N::, I'::IN[:, CCq",V"Z',TF;?.I..IC:]'ICff',I [:'iFIGRFIH'_;~; I
"¥/ /
~ ~[L [:,1...[. TO II",k.:JUI'~E I:.f...[ [=I'.. ZN'E,"t'T-'ILL. FITICff..I.
): Cfi:RI' I F:'M TFII:::IT
· _I..: I FIi"I I::FIFJIL.!I:aF~: !,.II"tH THE RL:)]:!UIFIEM[EIqT:i~:: F:OI:,~: ON-S]:]'E SEI,.tERS i:=II'.,I.F.:, h.!Et..LS F:ff.~; SET
FOR]'H [', ~ THE MI..IN :[ C '[ F:'FIL. Z 'f".t OF: faI'.,!CHCIF~:I.":IGE. '"
2: ! I.,.III..L It-,!::EFF:IM... I"HE S'-tS]"B:]',I !!'.,I F:IC:C:C~R[)FII'.,IC:E I.,.II-FH THE CO[:,ES.
ii:: I UN[)[~::RSTFff..[) TFIFIT THE ON-'_'~I-FE SEI,.IER S'.r'STEr'I I'"FF? FREC. L_IIF~:E li~:P,II..F:IR~r~C~'-I~.,!T :IF= THE
RES I[:,EI'.,I(3E: IS F. EPIO[)EL[:~:[:, TO I iqC:I...IJ[)E r, IORE THFtI'.,I }J: !..2, EC, I:~:OOH.i~;. . ~t,'~¥'~'
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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG -- PERCOLATION TEST
{~}"~SO ILS LOG
[] PERCOLATION
TEST
PERFORMED FOR: ~ J~' [,'~,~'~ CLY'~
LEGAL DESCRIPTION: ~-.~'-~' '~L~
4
7
DATE PERFORMED:~~' I~ ~ '~::~ )
_.~,~, 10
11
12
13
14
15
16
17
18
19
20
WAS GROUND WATER
ENCOUNTERED?
~,- IF YES, AT WHAT
/ ~ ,[-~/.~ :~ DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
· ,,/Ix) ~l
PERCOLATION RATE
(minutes/inch)
COMMENTS
TEST RUN BETWEEN
CERTIFIED BY:
FT AND FT
72-008 (6/79)
APPL~ T FILLS OUT UPPEr{ HA ')NLY
Property Owne~'~_ ~[ . ,_~,~ ..... ! Phone
^ddres~ /~'~ Zip Code
Address ,,~/:7 Zip Code
Type of Residence
..~ Multiple Family ~.-~J ~,~ No. of Bedroom~
U Other
Water Supply
.~. Individual [ / ATTACH WELL LOG. A well log Is required for all wells drilled since June 1975.
'Community /" ~'~ ·~L(£ For wells drilled prior to that date, give well depth (attach log If available).
Sewer Disposal
~?ndlvldual Year Individual InstalleO:_ 0~_~_.
[~ 'Public Olility When Connected to Public Utility:
[] Holding Tank
NOTE: THE INSPECTION PEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Date,;i;;:'l~*,.~ J. ~' IgS~.
,~ .~ ~ -,~ Date Date Date
