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Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
N AM E(. Jtl~ll~t-H
LOCATION
MAILING ADDRESS ~.~:~ ~)~'~ ~c~[,~ J/~l.~J~' PHONE
SEPTIC TANK:
DISTANCE
FROM WELL
INSIDE LENGTH
MANUFACTURER ~T'~JCK
INSIDE WIDTH
NUMBER OF
~-'F~-.~,~. MATERIAL ~'r-~elL~ COMPARTMENTS ~--~
LIQUID DEPTH LIQUID CAPACITY J~)00 GALLONS.
SEEPAGE PIT:
NUMBER OF PITS I DIAMETER ~J~' OR W,DTH/~~, LENGTH /Z--r, DEPTH I0'
LINING MATERIAL /01~ CRIB SIZE: DIAMETERJ~DEPTH DISTANCE FROM: WELL
'~ TOTAL EFFECTIVE
BUILDING FouNDATION ~, NEAREST LOT LINe 2(~1 ABSORPTION AREA (WALL AREA)
SQ. FT.
ADDITIONAL ABSORPTION
WELL:
BUILDING
FOUNDATION
CESSPOOL
APPROVED
CONSTRUCTION
NEAREST NEAREST
LOT LINE SEWER LINE
OTHER SOURCES
DISAPPROVED REMARKS
DEPTH DISTANCE FROM:
SEPTIC SEEPAGE
TANK SYSTEM
DISTANCES:
INSTALLED BY:
PIPE MATERIAL:
REMARKS:
0
Form No, EQ-031
DIAGRAM O F ~Ti~E~'
~r..'.,.~' ~'
GrEATeR ANCHORAGE AReA BOROUGH
SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT
NAME OF APPLICANT
PERMIT NO.
INSTALLATION LOCATION
,NA'CE'THRO'g TO BE 'NSTALLED '/
~OIL TEST RESULTS ~ NOTE: THIS PERMIT I~ NOT VALID WITHOUT SOIL
FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION.
SEPTIC TANK SIZE I vvv~lP~
MINIMUM DISTANCES, REQUIREMENTS
FOUNDATION TO SEPTIC TANK ~/
FOUNDATION TO SEEPAGE PIT "~/'
SEPTIC TANK TO SEEPAGE PIT WALL /~/
SEPT,C TANK ~/ . SEEPagE PIt
TO NEAREST LOT LINE.
WELL TO SEPTIC TANK ~/ DRAIN FIELD
TYPE ,'~
SEEPAGE PIT
DIAGRAM OF SYSTEM
WATER MAIN TO SEPTIC TANK . SEEPAGE PIT
DRAIN FIELD .
TO RIVER. LAKE. STREAM.
~CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF
EXCAVATION 5 FEET INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC: TANK AND
FITTED WITH AIRTIGHT REMOVABLE CAPS.
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
I ~;ERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE A~EA BOROUGH ORDINANCE NO. 28-ยง8 AND THAT THE ABOVE
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