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- HEALTH DEPARTMENT , ~-.-~-?
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME_
LEGAL DESCRIPTION
MATERIAL
',5'EP"FI~" TANK:
DISTANCE FROM WELL
LIQUID CAPACITY /.~4 "c¢) E~ GALLONS.
NUMBER OF /
. f'~'"~..,'2F ~'.~ COMPARTMENTS.
INSIDE LENGTH ,~"- INSIDE WIDTH " ..... DEPTH__
SEEPAGE SYSTEM:
NUMBER OF PITS
LINING M~:ER'I A L
NEAREST LOT LINE
SEEPAGE PIT:
,-~/~%~1~'; DIAMETER
~-' "~ OR WIDTH , LENG~ ,-~ .... :-DEPTH~
_. DISTAN M WELl ~ .~-/ , BUILDING FOUNDATION__
TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) .SQ. FT.
TILE DRAIN FIELD:
DISTANCE FROM WELL
NUMBER OF,.~ ES./~
ABS R T~ON AREA
DBp~TOTH: TOP OF TILE TO FINISH GRADE
, F OUN DA fl~O j-~'"-x
.~/~'~ , NEAREST LOT LINE
DISTANCE BETWEEN LINES ~ IRENCH WIDTH
SQ. FT. LENGIH OF EACH LINEx~'~. .-~///
DEPTH OF FILTER MATERIAL BENEATH TILE
TOTAL LENGTH
., OF LINES
IN. ABOVE TILE
WELL:
LOT LINE
TYPE ,,'~;':,~ ,,-'=/':' ., DEPTH .,¢;////c'. , BUILDING FOUNDATION (~" SAMPLE. /¢'~ , NEAREST
NEAREST ' SEPTIC w SEEPAGE OTHER
,/..-./~) / ./:, , SEWER LINE ?:'~"-;," ' TANK ,/~"~ J , SYSTEM //',¢/d/~¢ , CESSPOOL ./'~//)/V~-~_, SOURCE~
DISTANCES:
DIAGRAM OF SYSTEM
GREATER ANCHORAGE: ARE:A BOROUGH
'q¢' I r, EPARTMENT OF ENVIRO.MENTAI. QUALm' ~'ERMIT NO. /~ /'-'~
~:~1 __ -- ANCHORAGE, ALASKA 99502
4- ¢~eE DBPO~L SYSTEM -- APPLICATION AND PERMIT
TYPE AND SIZE OF FACILITY TO BE SERVED ~ ¢~'~¢ ¢/¢¢
COMPLETION DATE ANTICIPATED
FINAL INSPECTION= 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL [NBPECTION BY THE
HEALTH DEPARTMENT AUTHORITY WILL BE BUBJE¢[T TO PROBECUTION.
SEPTIC TANK S ZE .///~ ~ Type ~{~7~ ~'2~¢E~PAGE AREA'SIZE TYPE
MINIMUM DIST. A,I~I,C,E...~. REQUIREMENTS
WATER MAIN TO SEPTIC TANK
SEPTIC TANK, "~'~/- , SE~~=~RAIN FIELD
· DRAIN FIELD
SEEPAGE PIT
ALSO CONSIDER AREA WELLS.
SEEPAGE PIT
CONFORM ~ BOROLIGH REGULATIONS REGARDING INSTALLATION.
~ EALTH AUTHORITY
OR
LICENSED DESIGNER
DIAGRAM OF SYSTEM
[ CERTIFY '['HAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE A~OVE
D~ '~"~'~ '~,~ 7/ APPLICANT'SSIGNATLIRE ~ '