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` HEALTH DEPARTMENT i NG 895
_ 327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME
LOCATION
SEPTIC TANK:
MAILING
LEGAL DESCRIPTI
PHONE
NUMBER OF
DISTANCE FROM WELL MATERIAL -COMPARTMENTS-
LIQUID
/�` COMPARTMENTSSLQUID J
LIQUID CAPACITY C� GALLONS. INSIDE LENGTH INSIDE WIDTH DEPTH
SEEPAGE SYSTEM: SEEPAGE PIT:
NUMBER OF PITS ( 1 OUTSIDE DIAMETER OR WIDTH LENGTH DEPTH
LINING MATERIAL ZeIJVI�;C DISTANCE FROM WELL lIf�, BUILDING FOUNDATIONLJ
NEAREST LOT LINE -�C TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) �Of i SQ. FT.
TILE DRAIN FIELD:
DISTANCE FROM N
NUMBER OF LINES
ABSORPTION AREA
L391A
]STANCE BETWEEN LINES
—SQ. FT. LENGTH OF EACH LINE
NEAREST LOT LINE-
-TRENCH WIDTH
TOTAL LENGTH
OF LIN9S_
IN. TOTAL EFFECTIVE
DEPTH: TOP OF TILE TO FINISH GRADE DEPTH OF FILTER MATERIAL BENEATH TILE IN. ABOVE TILE
WELL:J�J��� DISTANCE FROM �- WATER
TYPE DEPTH BUILDING FOUNDATION. SAMPLE , NEAREST
NEARESTSEPTIC SEEPAGE - OTHER
LOT LINE SEWER LINE e , TANK SYSTEM — CESSPOOL , SOURCES_
DIAGRAM OF SYSTEM
DISTANCES:
1"w)
DATE
H
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HEALTH DEPARTMENT
327 Eagle St. Anchorage, Alaska 99501 279-2511
SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT
'�%J i�" %�'`i PHONE N0: 4'-l�-6/,'
NAME OF APPLICANTMAILING ADDRESS
S��`t�ii=/, i)��' •:w �'',1� � il,�
RESIDENCE ADDRESS
LOCATION OF INSTALLATION
i` '- ✓-� LEGAL DESCRIPTION
APPLICATION TO INSTALL: SEPTIC TANK. SEEPAGE PIT— , DRAIN FIELD , OTHER
TO SERVE THE FOLLOWING FACILITY
FINANCED THROUGH/�
j:• %l�
' i);�'- '� TO BE INSTALLED BY %-
PERCOLATION TEST RESULTS
ANTICIPATED DATE OF COMPLETION_
aci mm Tn RF Fn I Fn nUT BY HEALTH DEPARTMENT
THIS IS TO SERVE AS , PERMIT TO INSTALL A
AS DESCRIBED BELOW, SIZE OF UNIT TO BE SERVED
SEPTIC TANK SIZE TYPE SEEPAGE AREA
DIAGRAM OF SYSTEM
DISTANCES:
TYPE
HEALTH AUTHORITY I I I I I I 1 1 1 1
OR
LICENSED DESIGNER
I certify that I am familiar with the requirements of Greater Anchorage Area Borough Ordinance No
above described system is in accordance with said code.
I
28-68 and that the
DATEi �i . /J - j'.�__, APPLICANTS SIGNATURE '''
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