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HEALTH DEPARTMENT N? 894
327 EAGLE ST.
ANCHORAGE, ALASKA 99501 279-2511
INSPECTION REPORT
ON-SITE SEWAGE DISPOSAL SYSTEM
NAME �-?
MAILING �eef�l e/ 121P .
PHONEADDRESS
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LOCATION �C "-J ///�� �-' -
LEGAL DESCRIPTION � i
SEPTIC TANK:
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DISTANCE FROM WELL /f��
MATERIAL -yl COMPARTMMENTS
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LIQUID CAPACITY GALLONS.
'57%�J LIQUID
INSIDE LENGTH INSIDE WIDTH DEPTH
SEEPAGE SYSTEM: SEEPAGE PIT:
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NUMBER OF PITS OUTSIDE DIAMETER
LENGTH DEPTH
OR WIIIDDTT```H
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BUILDING FOUNDATION
LINING MATERIAL
- . DISTANCE FROM WELL ` C��
NEAREST LOT LINE 75 f fu TOTAL
EFFECTIVE ABSORPTION AREA (WALL AREA) �� �� SQ. FT.
TILE DRAIN FIELD:
TOTAL LENGTH
DISTANCE FROM WELL , FO TDNU IA O NEAREST LOT LINE OF LINES
NUMBER OF LINE DISTANCE BETWEEN LINES TRENCH WIDTH IN. TOTAL FECTIVE
ABSORPTION' AREA SQ. FT. LENGTH OF EACH LINE
DEPTH: TOP OF TILE TO FINISH GRADE
DEPTH OF FILTER MATERIAL BENEATH TILE IN. ABOVE TILE
WELL:
DISTANCE FROM WATER
TYPE DEPTH
BUILDING FOUNDATION. SAMPLE , NEAREST
NEAREST
SEPTIC SEEPAGE OTHER
LOT LINE , SEWER LINE
, TANK , SYSTEM CESSPOOL SOURCES_
DIAGRAM OF SYSTEM
DISTANCES:
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[iAAG-HL_r, hlthAl .1 ,. A1'1UJ[1VnAlTL' Alii'.A ,, ;utcvUtyn Case No.. cLd,1,
HEALTH DEPARTMENT
327 Eagle St. Anchorage, Alaska 99501 279-2511
SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT
MAILING ADDRESS,4 / L ='� l'�•'%
NAME OF APPLICANT,7) PHONE NQ:
RESIDENCE ADDRESS
_", 6 .f_ LEGAL DESCRIPTIO
LOCATION OF INSTALLATION
APPLICATION TO INSTALL: SEPTIC TANK SEEPAGE PIT F DRAIN FIELD , OTHER
TO SERVE THE FOLLOWING FACILITY
FINANCED THROUGH /;�
/,,'r'� > � i Lei' �<I TO BE INSTALLED BY - > � ' I) <,, , ._ . .r
PERCOLATION TEST RESULTS ANTICIPATED DATE OF COMPLETION_
THIS IS TO SERVE AS
DISTANCES:
BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT
, PERMIT TO INSTALL A
AS DESCRIBED BELOW. SIZE OF UNIT TO BE SERVED
. SEPTIC TANK SIZE TYPE
SEEPAGE AREA
DIAGRAM OF SYSTEM
TYPE
HEALTH AUTHORITY
OR
LICENSED DESIGNER
I certify that I am familiar with the requirements of Greater Anchorage Area Borough Ordinance No. 28-68 and that the
Above described system is in accordance with said code.
DATE ,Z -Z APPLICANTS SIG NATURE,