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47
G~TER ANCHORAGE AREA BORO~'~H
' HEALTH DEPARTMENT ~,
327 EAGLE ST. ANCHORAGE, A~ASKA 99501 279-2511
" INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
SEPTIC TANK:
DISTANCE FROM WELl
LIQUID CAPACITY /,
SEEPAGE SYSTEM:
NUMBER OF PITS
LINING MATERIAL
NEAREST LOT LINF
SEEPAGE PIT:
! /7'
OUTSIDE DIAMETER. '-'"--OR WIDTH J/ ? LENGTH , DEPTH
/~£'
DISTANCE FROM WELL BUILDING FOUNDATIONPd
· TOTAL EFFECTIVE ABSORPTION AREA jWALL AREA) ~7~ SQ. FT.
TILE DRAIN FIELD:
TOTAL LENGTH
DISTANCE FROM WELL , F , NEAREST LOT LINE ~
ABSOR SQ. FT. LENGTH OF EACH LINE
DEPTH: TOP OF TILE 1'0 FINISH GRADE.
DEPTH OF FILTER MATERIAL BENEATH TILE
IN. ABOVE TILF
· . BUILDING FOUNDATION. __
SAMPLE o NEAREST
,,NE /~ ,~ NEAREST , q,~ t / _~,
SEWER LINE ~'~D SEPTIC SEEPAGE OTHER
· TANK , SYSTEM ~ , CESSPOOL '" , SOURCES~
DISTANCES:
~-~ :log'
DIAGRAM OF SYSTEM
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DATE
.~.<AB'~0~'''GREATEI ~NCHORAGE AREA ROUGH Cas, No.
IIEALTII DEPARTMENT ac.
· ' 327 Eagle St. Anchorage, Alad~a 99501 · 279-2511 //f; C'v- ~
SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT
-'"' -- ~
NAMEOF APPLICANT~/~"/~//'~/ /~,/~,~"CC'-Z.,~"~:'-£A/I~AILING ADDRESS~Y "Z/"~C"LO,Jr'/~'~Z,/PHONE NO.
APPLICATION TO INSTALL: SEPTIC TANK, /r,'''''/ , SEEPAGE
, OTHER
TO SERVE THE FOLLOWING FACILITY ,~L ~7"'~lr')~____.
FINANCED THROUGH~ .TO BE INSTALLED BY
~ TEST RESULTS ANnC~PATEO DATE OF CO.PL~T,ON
BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT
T.,S ,S TO SERVE
As DESCmBED BELOW. S~ZE OF UmT TO BE SERVED__~~~.
· SEPTIC TANK SIZE~ ' TYPE~EEPAGE AREA~--~--~--~--~--~--~--~--~--~'/
~ DIAGRAM OF SYSTEM
I certify that I am familiar with thc requirements of Greater~Anchorage Area Borough Ordinance No. 28-68 an~that the
above described syste, m is in accordance with said code. /~/' . _ .../ .~.~. ....~...~,,,..-~
~REATER ANCHORAGE AREA BOROU,,H
HEALTH DEPARTMENT
327 EAGLE STREET
ANCHORAGE, ALASKA 99501
CASE #
Performed For ~/'~c ~'fzr~'~ ~O~.~/~/C~ Date Performed
Legal Dcscription~ Lot~Block ' ~ ~'' ~
This Fcrm Reports a: Soils'- Log ~ Percolation 3es,
Depth
Feet
Was Ground Water Encountered?
If Yes, At What Depth_
Reading Date Gross Tlme
Net Time
Location Sketch
Depth To H20
Net Drop
Proposed Instal~Seepage Pit f Drain Field
Depth Of Inlet ~/~
COMMENTS:~~ /~// ~x .... ~.--. De~tn To Bottom Of Pit Or Trench' /,/ ,
Test Performed By:_~,,[,~
i
ME!~EIAGE
TRIP
REPLY
SIGNED
'~E~O~S 4S 472
SIGNED
DETACH AND FILE FOR EOtLOW-UP
POLY PAK (SO SETS1 4P472
' '"': "'' Certified
- ------. ---.--.~~,~.~, ~'or.,q~nn...nq~l~,~ ' ,' - , . '..'
w~.e_. ' ' '" ' :"
D~nce
~, .. :~.: 7%. I- the above true and correct. '
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..,,...~- , .... :' · ' .: Driller, .'.,~ ........ :::.,~:
· :' · "" :. FOSS DRILLn',IG '" .,'
P.. ' :-. 1326 INGRA, ?H. 279-284f~ '.: :' : .. .
'-- ANCHORAG,% ALA$IUL 89501 '
%Ve advhe you to attach this certificate to yot~r deed.
