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Gr?""-'~ER ANCHORAGE AREA BOROU~H
" HEALTH DEPARTMENT
327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2'511
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
SEPTIC TANK:
DISTANCE FROM WEL[
LIQUID CAPACITY /?
GALLONS.
(~./~[~ NUMBER OF
MATERIAL "~ ~/~'~" COMPARTMENTS
~, .~, ~L. ~-.-, LIQUID
INSIDE LENGTH .INSIDE WIDTH DEPI'H
SEEPAGE SYSTEM: SEEPAGE Pit:
/,-/
NUMBER OF PITS ./ OUTSIDE DIAMETER - ' OR WIDTH.
UNING MATERIAl ? ~-~"'~'~"/C~/~' I~/W~'?~. DISTANCE FROM WELl ./~ '~ /
¢'
NEAREST LOT LINF TOTAL EFFECIIVE ABSORPTION AREA (WALL AREA)
/
, LENGTH //'~ DEPTH
TILE DRAIN FIELD:
DISTAN~ELL
NUMBER OF LINEIS ~ANCE BETWE~ LINES ~.~_
//
ABSORPTION A A~C~.~_/ SQ. FT.
DEPTH: TOP OF TILE TO FINISH GRADE
TOTAL LENGTH
, NEAREST LOT LINE ~ , OF LINES
LENGTH OF EACH LINE
DEPTH OF FILTER MATERIAL BENEATH TILE
IN. ABOVE TILE
WELL: T Y P ~"~,/~/Z~ ~. 4~=,~ )cpm
~ NEAREST SEPTIC
LOT LINE ./~ ~ , SEWER LINE ~ ,TANK
DISTANCE FROM / WATER
BUILDING FOUNDATION '~ SAMPLE , NEAREST
.~ /' SEEPAGE //~.~,,~ , ~ OTHER
, SYSTEM_ CESSPOOl SOURCES
DISTANCES:
DATE
DIAGRAM OF SYSTEM
APPROVED HEALTH AUTHORITY
GREATEF , ,NCHORAGE AREA F-'3ROUGH
HEALTH DEPARTMENT
327 Eagle St. Anchorage, Alaska 99501 279-25
SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT
NAME
OF
LOCAT,0N 0F,NSTALLAT'0N
MAILING ADDRESS. ~' ~.--~'~/'~-/~-~'~7-¢' . PHONE NO.~
RESIDENCE ADDRESS
LEGAL DESCRIPTION
APPLICATION TO INSTALL: SEPTIC TANK
TO SERVE THE FOLLOWING FACILITY
FINANCED THROUGH ~
PERCOLATION TEST RESULTS
, SEEPAGE PIT_
, DRAIN FIELD , OTHER
TO BE INSTALLED BY_
ANTICIPATED DATE OF COMPLETION
BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT
THIS IS TO SERVE AS .z~. Z-~"Z.-(.-~' , PERMIT TO INSTALL A .¢zr~.4.~W/L_~ ~-~-
AS DESCRIBED BELOW. SIZE OF UNIT T~SEHVED 4 ~ ~
. SEPTIC TANK SIZE /~ TYPE ~-~'~'SEEPAGE AREA ~ ~ TYPE DIAGRAM OF SYSTEM'
DISTANCES:
/
I certify that I am familiar with the requirements of Greater Anchor3ge Area Boro._ugh/.Or¢inagd~ No. ~8-68 andethafi:)t~Ie ~L
above described system is in accordance with said code. ,,-//~*J:>/~ c/fl/~ ~ ",o~'~-