HomeMy WebLinkAboutWICKLUND LT 24ELoT
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3500 Tudor Road, Anchorage, Alaska 99507 279-8686
Time of Inspection /C5: ~ (~
Date of Inspection ~/~5
/
IREQUEST FOR APPROVAL OF.
~ C~'~ ~.~INDIVIDUAL SEt~ER & WA/~R FACILITIES
Aoproval Requested By:
Address~ ~,0' ~ ~00 ~ ~ Phone:~~ ~
Number of }~edrooms:
Well Data:
A.
C. Construction~ ~0~-- %~Od~)iD.
Sewage Disoosal System:
B. Depth ell~
Bacterial Analysis
Installer
A. Installed
C, Septic Tank: 1. Size
2. Manufa ~tursr
D. Seepage Pit: 1. Size
2. Uaterial
E. Disposal Field: Total Length of Lines
Distances:
A. ~ell To: Septic Tank , Absorption Area , Sewer Lines
__, Nearest Lot Line , Other Contamination
B, Foundation to Septic Tank "~ Absorption Area
C. Absorption Area to Nearest Lot Line
Request~for Approval ~/~/ndividua] Sewer & Water Faeili'~'%s
Page Two
9.-Comments:
Ap,~oval Valid for One Year From Date Signed
G-tearer Anchorage Area BoroUgh, DeFartment of Environmenta! Qua!.t~y
DIAGRAM OF SYSTEM
~ cert.~fv that the information contained in this request for approval to be a true
and accurate representation of ~he subject .~ewer and water facilities located at:
Signed Da~e
DEPt 'MEriT OF HEALTH AI~D SOCIAL SF'""!CES ~..o,
~:'~" DIVISION OF PUBLIC flEALTll "-"
BACTERIOLOGICAL WATER
SANITARIAN'S' REMARKS
READ INSTRUCTIONS
ON
REVERSE[ SLOE,
BEFORE,
COLLECTING SAMPLE
05-1220 {b)
BACTERIOLOGICAL WATER ANALYSIS RECORD
06-1220
~ DIVISION OF PUBLIC HEALTH
[] Y~' ' [] No
[] y~ ~ No
-ySaLtSfactory [] Questionable [] Unsa~sfacto~y.
I~ ~ '~fa~' pr "~on~le*' st~ ~ ~ ~ve
8. ~pmve yo~ ~ ~nng ~ d~ web ~ ~ven weH
SANITARIAN'S REMARKS
READ INSTRUCTIONS,
ON
R --EVERSE; SIDE
BEFORE,
COLLECTING, SAMPLE,
06-1220 (b)
BACTERIOLOGICAL WATER ANALYSIS RECORD
DEP/'"TMENT OF HEALTH Ai~D SOCIAL SF"qiCES
DIVISION OF PUBLIC HEALTH
BASTERiOLOGICAL WATER AflALY$ $
ADD. SS ~' i / J.c
' f/,,.. </~-.' L>~'
SAMPLE COLLECTED BY
Well [] Dug E] Driven C D~I ~ ~red '
D~g Weli or C/stem C~ltstmctiom Brick o]:~
M~.'t'ERIAL: Building Sewez o [~ ~ ri woo~ [] Tile [] Ftbm []Cement
OP~CE
SANITARIAN'S REMARK5
READ INSTRUCTIONS
ON
REVERSE; SID ,E,
BEFORI~,I
COLLECTING, SAMPLE
08.1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD