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Gr 'JER ANCHORAGE AREA BORC' `H
HEALTH DEPARTMENT N° 354
327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511 _
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
i. MAILING,� e,
NAME ����% GC//G�a/C/� ADDRESS I �T ,- �� PHONE. %
LOCATION ��C{' .E/G/ice LEGAL DESCRIPTION
cFDTIr- TANIV.
Cr NUMBER OF
DISTANCE FROM WELL—MATE RIAL%"Gr✓,�1� LU/y�.'y G�—COMPARTMENTS-
LIQUID _
LIQUID CAPACITY ` CLQ GALLONS. INSIDE LENGTH INSIDE WIDTH " _DEPTH__
SEEPAGE SYSTEM:
SEEPAGE PIT:
NUMBER OF PITS / -OUTSIDE DIAMETER OR WIDTH LENGTH DEPTH ,
LINING MATERIAL �'1>/✓GS�/�G-J' . DISTANCE FROM WELL �� BUILDING FOUNDATION
/J
NEAREST LOT LINE '� TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) SQ. SQ. FT.
TILE DRAIN FIELD:
DISTANCE FROM WELL
, FOUNDAT
NUMBER OF LINES DISTANCE BETWEEN LINES
ABSORPTIO AREA SQ. FT. LENGTH OF EACH LINE
DEP*I: TOP OF TILE TO FINISH GRADE
TOTAL LENGTH
NEAREST LOT LINE OF LINES_
TRENCH WIDTH
DEPTH OF FILTER M`ATERIAE_NENEATH TILE IN. ABOVE TILE.
W ELL:T
TYPE�'�/�j'
DEPTH
DISTANCE FROM
BUILDING FOUNDATION.
i WATER
.SAMPLE
, NEAREST
i
/U
NEAREST
.-SEPTIC
v
SEEPAGE
i
ems. --OTHER
LOT LINE
'� SEWER LINE
, TANKSYSTEM-�_,
CESSPOOL_
,SOURCES__
DISTANCES:
DIAGRAM OF SYSTEM
C C -`-t /��-•-c�-cue_ �,
DATE / APPROVED HA _�
HEALTH AUTHORITY
GAAB-1ID-2 GREATER iNCHORAGE AREA )ROUGH Case No. LOI
IAEALTH DEPARTMEN,r
327 Eagle St. Anchorage, Alaska 99501 279.2511
SEWAGE DISPOSAL SYSTEM a APPLICATION & PERMIT
NAME OF APPLICANT MAILING ADDRESS 4f .F- NE N0.�IL-2d6
RESIDENCE ADDRESS IQ k, LOCATION OF INSTALLATIONv_F� e _
LEGAL D CRIPTION 6T
APPLICATION TO INSTALL: SEPTIC TANK_�� SEEPAGE PIT_4�_saBAU-F4E+--6v—
TO SERVE THE FOLLOWING FACILITY
FINANCED THROUGH_ TO BE INSTALLED BYJ`�Z_ C z �
PERCOLATION TEST RESULTS ANTICIPATED DATE OF COMPLETION
BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT
THIS IS TO SERVE ASPERMIT TO INSTALL A �otn
AS DESCRIBED BELOW. SIZE OF UNIT TQ, BE SERVED�-
�i?�c�c-*
v SEPTIC TANK SIZE lZ� TYPE:5�-,.,=AL EEPAGE AREA_2 TYPE
DIAGRAM OF SYSTEM
DISTANCES:
)2 `-
_ /V
HEALTH AVTHORITY
OR
LICENSED DESIGNER
v
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. APPLICAN'fSSIGNATURE. "ter ''—� C �f�
/�
_ /V
HEALTH AVTHORITY
OR
LICENSED DESIGNER
v
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. APPLICAN'fSSIGNATURE. "ter ''—� C �f�
/�
GREAI,� ANCHORAGE AREA BOROUGH
DEPARTMENT OF ENVIRONMENTAL. QUALITY
3500 TUDOR ROAD
ANCHORAGE, ALASKA 99507
279-8686 Yo
DATE RECEIVED :.1p r
INSPECT:_ �"�'`1 ,�� 71
TIME: Noll _a_ _-
REQUEST FOR APPROVAL. OF
INDIVIDUAL SEWER AND WATER FACILITIES
FOR
1. APPROVAL REQUESTED BY: Uta T 1u
ADDRESS:
PHONE:
2. PROPERTY OWNER:
3. LEGAL DESCRIPTION: LYS lu/"'M
4. TYPE FACILITY TO BE INSPECTED:5�
NUMBER OF BEDROOMS:
5. WELL DATA:
A. TYPE Glrtlle
PHONE
Ayv 2 4
'5� gvrt'
STREET: �11-✓+'
YW14 4�
B. DEPTH s
C. SIZE_ 67 —
D. CONSTRUCTION
E. BACTERIAL ANALYSIS -At114
-✓y/@�5���
6. SEWAGE DISPOSAL SYSTEM: 1A5(A%e014&ce. L�, 0(47 pk K-70
A. SEPTIC TANK (IF HOMEMADE, SHOW DIAGRAM ON BACK)
1. SIZE������ _
amp
2. AGE
3. MANUFACTURER
4. INSTALLER
APPROVAL REQUEST FOR SEVIER & WATER FACILITIES
PAGE TWO
B.
SEEPAGE PIT
%:% �., /�
j
1. rl%> (•: C)i�%
1. SIZE
2. L I N I N G_
C.
DISPOSAL FIELD
1. NUMB R OF LINES
2. TOTAL ENGTH
_!
7. REQUIRED
MEASUREMENTS
A.
WELL TO SEPTIC TANK_
B.
WELL TO SEEPAGE PIT
C.
WELL TO SEWER LINE
D.
WELL TO PROPERTY LINE
�<<
E.
WELL TO OTHER POSSIBLE
CONTAMINATION -
F.
FOUNDATION TO SEPTIC
TANK
(i
G.
FOUNDATION TO SEEPAGE
PIT _
H.
SEEPAGE PIT TO PROPERTY
LINE
8. COMMENTS:
APPROVED: ��n (�j� e� DISAPPROVED:
DATE:/, DATE:
APPROVAL. VALID FOR ONE YEAR FROM DATE: SIGNED.
GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY
REPORT OF INSPECTION ---INDIVIDUAL SEWAGE -DISPOSAL SYSTEM
PRIMARY TREATMENT consists of O Septic tank. F-] Cesspool.
Septic Tank:
Distance from well, feet.
Total liquid capacity,
Inside length,_ .___feet.
Cesspool:
Inside w
Number of compartments
gallons. Capacity inlet compartment,
-
-feet. Liquid depth, feet.
Distance from: Well, feet; foundation, _feet; nearest lot line at ❑ front, [_1 side, ❑ rear, feet.
Inside diameter, —feet. Depth, feet. Liquid capacity, gallons. Lining material
SECONDARY TREATMENT consists of Q Tile disposal field. ❑ Seepage pits. Other
- r
additional:an attic or other area be made into
Yes No
-
ividual
SYSTEM- DESIGNED FOR
GARBAGE DISPOSAL
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REPORT OF INSPECTION ---INDIVIDUAL SEWAGE -DISPOSAL SYSTEM
PRIMARY TREATMENT consists of O Septic tank. F-] Cesspool.
Septic Tank:
Distance from well, feet.
Total liquid capacity,
Inside length,_ .___feet.
Cesspool:
Inside w
Number of compartments
gallons. Capacity inlet compartment,
-
-feet. Liquid depth, feet.
Distance from: Well, feet; foundation, _feet; nearest lot line at ❑ front, [_1 side, ❑ rear, feet.
Inside diameter, —feet. Depth, feet. Liquid capacity, gallons. Lining material
SECONDARY TREATMENT consists of Q Tile disposal field. ❑ Seepage pits. Other