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t~ MUNICIPALITY OF ANCHORAGE ('~
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
LEGAL DESCRIPTION
DISTANCE TO: I Well
LOCATION
L. iq. capacity in gallons IF HOMEMADE:
D~STANCE TO: We,
Manufacturer
L:eilgt h of each line
IAbsorpt~on area D~lling
Material
Insldelength Width
Dwelling
IPHONE I ~[~N EW
[] UPGRADE
NO.~ BEDROOMS /
PERMIT NO.
No. of compartments
Liquid depth
PERMIT N0(~
APPROVED
72-013 ( RL/v. 3/78) /J
PIPE MATERIALS
SOIL TEST RATING
REMARKS
DATE
Distance to lot line PERMIT NO.
· ~,'~l~k t~O4-~'O,~ Absorptlonarea(s)
DISTANCE TO: Building foundation Sewer line
OTHER
LEGAL
DISTANCE TO:
No. of lines Total length of lines Distance between lines
inches
Top of tile to finish grade Material beneath tile Total effective absorption area
inches
Length Width Depth PERMIT NO.
Type of crib Crib diameter Crib depth Total effective absorption area
Well Building foundation Nearest lot line
DISTANCE TO:
Depth Driller
Liquid
PERMIT NO.
~MUNICIPALITY OF A. NCHORAGE,-~ .
~, Department6 'f Health and Envzronmenta: ~rotectzoD
o--'-~ :, . 825 ., Street, Anchorage, AK. 99501 'o
~'., ' ,, 264-4720
Locatxon ,~. ~0p ;.~3 "' ~ ~*~Phone N~er:
T~e of So~l ~sorption System Is:
Trench: ~ Drainfieldr ~ Seepage Bed~ ~ Holding
Max~ N~ber of ~ms: Soil Rating (sq. ft/br)
· The Required Size of the Soil Absorption System Is: '
DEPTH '"----·' LENGTH
GRAVEL DEPTH -------- WIDTH
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED ~LAmM"~:(HOLDING) TANK SIZE = --..~000 GALLONS * *
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system without final inspection.and approval by this department
will be subject to prosecution.
Minimum ~istance betwee_A a well and any on-site sewage disposal system is 100 feet
f~r a ~vate well ?~5~ ~? 200 fe~t from a.public well depending upon the.type
o: public well. M~n~mum o~stance zrom a private well to a private sewer lane
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31, 1 9 8 1 ' * *
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I un~er~tand t~at the on-site sewer system ma~,require enlargement if
the $$~idence is/T%modeled to include more that 3
Signe~: ~~~/~ Issued by: ~~~m~
Date: //-.~-J~'~
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