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GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C" Streets AnChorage, Alaska 99503 274-4561
Time of Inspection
Date of Inspection
1. Approval requested by:
Mailing Address:
2. Property Owner:
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
FOR
Phone: u:~cx ......~ ~,. z.
Phone:
Mailing Address:
/ .
4. Location: "/
5. Type of facility to be inspected
6. Well Data:
A. Type .... ~ ,,
?:, , ,¢ (, No. of bedrooms
C. Construction ~
Sewage Disposal System: ,~ ,
A. Installed ~-.2 x,-~/~ B.
C. Septic Tank: 1. Size
B. Depth //
D. Bacterial Analysis
'" "" ,'
Installer
2. Manufacturer
D, Seepage Pit: 1. Absorption Area
2. Material
E. Disposal Field: Total length of lines
8. Distances:
A. Well to: Septic tank
, Absorption area -- , Sewer Lines ___,
Nearest lot line~?,~ _J Other contamination
B. Foundation to septic 'tank ~" , Absorption area
C. Absorption area to nearest lot line
Page 2 of two pages Request for Approval of .~ndividual Sewer & Lat~, Facilities
Legal Description
Comments
Approved (,:~u,~//,~_~ ~,~)JJ~J~,,~ Disapproved Date .L~/~_.~_.~'
-~ ~ ~; ~ · ..... .
¢ ~ ~roval Valid for oneyear from date signed
Greater A~chorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
certify that the information contained in this request for approval to be a true and
accurate representation of the subject sewer and water facilities and these facilities
are operating satisfactorily.
SIGNED Date
ALA~ UEPARTMENT OF HIALTH ANO SOCIAl.. SL CES
DIVISION OF FUBLIC HEALTH
INDIVIDUAL Am SEMI.PUBLIC
BACTERIOLOGICAL WATER ANALYSIS
iNDIVIDUAL []
NAME
SEMi-PUBLIC (~] CHLORINE RESIDUAL PPM - - ~
REPORT RESULTS TO
ADDRESS
CITY
ZIP CODE
ADDRESS
OF SOURCE
SANITARIAN'S REMARKS
COMPLETE THIS SECTION
ONLY IF WATER IS AN INDIVIDUAL SUPPLY
AMPLE COLLECTED BY
ATE COLLECTED ' Ti6&E COLLECTED
~EAD INSTRUCTIONS
REVERSE SIDE
48 Hours
BEFORE
,LECTING SAMPt,E
BACTERIOLOGICAL WATER ANALYSIS RECORD