HomeMy WebLinkAboutGREENLAND BLK 5 LT 4
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quellty
3500 Tudor Road, Anchorage, Alaska 99507 279-8686
Time Inspecuon_Zj ?
Date of Inspection
REQUEST FOR APPROVAL' OF
INDIVIDUAI. SDNER & WATER FACILITIES
FOR
Address: Phone:
Type of Facility to be Inspected:
Well Data. ,~-?/~.~/~~-
e
Sewage Disoosel System: ~
Septic Tank, 1o ~ _/L~-~ ~ Manufacturer ./~.~' ~, /~ .~h~/t
Ce
E. Disposal Field: Total Length of
8. Distances:
/
A. Well To: Septic Tank c/~ ~' Absorption Area //-z~ , Sewer Lines
~Zh Nearest Lot Line ~-,~f
, , Other Contamination . .
B. Foundation to Septic Tank /~/ "~ Absorption Area ~/
/
C. Absorption Area to Nearest Lot Line
Approval of ~,~dividual Sewer & Water Faoilittes
I( 4, ' ' /
Approv, A, ¢¢/ ~s~C~pr oved Date /~¢? --~--/~-
Approval Valfd for One Year From Date S~gned
Greater Anchorage Area Borough, DeFar%ment of Environmen%al Quality
DIAGRAM OF SYSTEM
I certify that the information contained in this request for appreval to be a true
and accura~,e repre,'3entatfon of the subject sewer and water facilities located at."
Signed Date
REQUEST FOR APPROVAL OF
IN'ulVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate)
Name of person requesting approval ]~
~am~ of propepty~ owner ..... ~ ~
Numb~ ~ b~drooms in house '~ .
Wate~ ~.nalysis:
b. Dete~ent ,
W~ll data:
a,
b.
C,
d,
Distance from well to closest existing or
1. Sewer line ~--/
2. Septic t ank~_~_.
,. 3. Seepage Ar.e a~~.
5. Property L ine___~ /
6. Other sources of possible contamination, i.e.~ creeks, lakes,
houses~ barn~ dralna~e ditch, etc. ~--'
7. Sewage disposal system,
b. Septic tan]< capacity in
1. If "home made" show diagram on reverse aide of this form.
pisposa fie d pit
Distance to property lln~, ~! to house f'o~mda'tion ,~O~
e. PercoJ.ation, Te'st 'results
f. Percolation Test performed by
Use 'the reverse,side of this form to show diagram. Diasran{ should include
,[the following information: ppoperty lines; .well location, house location,
.~?~ic tank location, disposal area location, location of percolation test,
a~,d, direction of ground slope.
The ~Y~s~on on this form is true and correct to the best of my knowledge.
~'[gnature of Applicant
Date SiFned
~0 BE FILLED OUT BY HEALTH DEPARTt.~ENT PEBSONNEL
above described sanitary facilities are hereby approved, subject to the
rollowzn? conditions:
Conditions:
The above described sanitary facilities are disapproved for the followin~
reasons: - _
Ap d the date of approval.
CPJ: cw
