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#051 cm I 54A" am 59
MUNICIPALITY OF ANCHORAGE
DE ;ITMEN'r OF HEALTH AND HUMAN SER' -'S
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SIF. WAGE DISPOSAL SYSTEM AND/OR WELl_ INSPECTION REPORT
DISTANCES
'"-~.~ -TO SEPTIC ABSODPTIO"
WELL
IONI ~...._ _ TANK FIELD
Address
TANKS
~ SEPTIC ~ HOLDING
TYPE OF SYSTEM
~BED ~ W. DRAIN [~ OTHER
Dep[h [o p~pe boHom horn l oral depth [rom or[gmat gCade
or,ginal grade ~ ' ~ FT ~ FT
~,~ FT
D,s~mce bmween Imnes
FT
Dale Installed
WELLS
~PRIVATE ~ OTHER (Idenlifv)
/
FT
RE~ARKS:
rAunicipal ~nd Slale guidelJlleS itl LBeCI 011 this dale: /
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72 013 (3/85)
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PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION 'rEs'r
DATE
1
2
4-
5
6
7
8
9
10
11
Township, Range, Section: _'"['~,~1,.~ '~-I%/.~
SLOPE SITE I~LAN
17
18
20-
~' ~-~1;:~.~ WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Oeplh to Water Aller ri /
MoniloriflD?
S
PERCOLATION RATE ___ _/~ (minutes/inch) PERG HOLE DIAMETER
Reading Date Gross Net Depth to Net
Time Time Water Drop
TEST RUN BETWEEN __ FTAND
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE.
CERTIFY THAT THIS TEST WAS PERFORMED IN
[)ATE:
72-008 (Rev. 4~85)