HomeMy WebLinkAboutWENTWORTH BLK 1 LT 1LoT
GR~R ATER ANCHORAGE AREA BOROUGH
DEPARTMENT OF ENVIRONMENTAL QUALITY
3500 TUDOR ROAD
ANCHORAGE, ALASKA 99507
279-8686
DATE RECEIVED:.
INSPECT: '07~x~'O
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER AND WATER FACILITIES
FOR
1.APPR(~VAL REQUE~TE~D BY:
ADDRESS: · ~ ~
2. PROPERTY OWNER:
/
/
4. TYPE FACILITY TO BE INSPECTED:
NUMBER
OF BEDROOMS:
5. WELL DATA:
PHONE:
STREET:
e
A. TYPE
B. DEPTH
C. SIZE
D. CONSTRUCTION
E. BACTERIAL ANALYSIS
SEWAGE DISPOSAL SYSTEM:
A, SEPTIC TANK (IF HOMEMADE, SHOW DIAGRAM ON BACK)
1. SIZE L'b-c'~ ~L~
2. AGE
3. 'MANUFACTURER
4. INSTALLER
APPROVAL REQUESTk----aR SEWER
PAGE TWO
& WATER FACILITIE~---j
B. SEEPAGE PIT
1. SIZE
2. LINING
C. DISPOSAL FIELD
1. NUMBER OF LINES
2. TOTAL LENGTH
7. REQUIRED MEASUREMENTS
A. WELL TO SEPTIC TANK
B. WELL TO SEEPAGE PIT
C. WELL TO SEWER LINE
D. WELL TO PROPERTY LINE
E. WELL TO OTHER POSSIBLE CONTAMINATION
F. FOUNDATION TO SEPTIC TANK
G. FOUNDATION TO SEEPAGE PIT
H. SEEPAGE PIT TO PROPERTY LINE
8, COMMENTS:
APPROVED:
DATE:
APPROVAL VALID
GREATER
FOR ONE YEAR FROM DATE SIGNED.
ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL
QUALITY