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f'ARGEl*Oiy-13 I-32-DCO
N°. 711
HEALTH DEPARTMENT
327 EAGLE ST ANCHORAGE, ALASKA 99501 279-251
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
SEPTIC TANK
DISTANCE FROM WELL
LIQUID CAPACITY
ADDRESS
LEGAL DESCRIPTION
GALLONS
NUMBER OF //
MATERIAL _~'~/'~/~--,~J'J ~///?/t,//_-~7~ COMPARTMENTS
/.~,~j/.p-/~/'..~ ~".~'.~.~4~'f ~-~-~.,~----~/~ /~?~..,¢~,~'~.~r'~ LIQUID
INSIDE LENGTH '~"~' INSIDE WIDTH z..--- DEPTH
SEEPAGE SYSTEM SEEPAGE PiT
NUMBER OF PITS ,/ OUTSIDE DIAMETER ~ OR WIDTH J~'
LINING MATERIAL ('Z~/J/f'/~'~,'/~d~ ~ ~Cg~'/'/~-'~ DISTANCE FROM WELL /'~Z~J
NEAREST LOT LINE ~'~(~ TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA)
LENGTH /~ , DEPTH
, BUILDING FOUNDATION
'/-~'~' SQ FT
TILE DRAIN FIELD
DISTANCE FROM WELL
NUMBER OF LINE~'~'~''~'/ DISTANCE BETWEEN LINES
ABSO~PI~REA
DEPTH TOP OF TILE TO FINISH GRADE
TOTAL LENGTH
~/FOUNDATION ~'~NEAREST LOT LINE , OF LINES
~,~RENCH WIDTH~ ~J¢~i~i'~TAL'~'PE~;TIVE
SQ FT LENGTH OF EACH LiNE
DEPTH OF FILTER MATERIAL BENEATH TILE
IN ABOVE TILE__
./...(./,~/~.~..~,~<,~.~ .4~/.~,,~//r,
WELL TYPE ~z/~ DEPTH /'/~ '
NEAREST SEPTIC
LOT LINE //~) /'7~ SEWER LINE Z'~)-'/x'~ ., TANK
DISTANCE FROM
, BUILDING FOUNDATION
/ SEEPAGE
/-//~/' , SYSTEM
WATER
SAMPLE /'&'~C~, NEAREST
OTHER/f/~'~
CESSPOOL ,/~/~.2//~:- , SOURCE$~
DISTANCES
DATE
?
?
DIAGRAM OF SYSTEM
,~. HEALTH DEPARTMENT
327 Eagle St. Anchorage, Alaska 99501 279-2511
.AME OF APP.,CANT/ /
RESIDE.CE ADDRESS
LEGAL DESCR.PT, O.
MAILING ADDRESS.~'~ 0/~., ~ PHONE NO
LOCATION OF INSTALLATION "~.~
., OTHER
APPLICATION TO INSTALL SEPTIC TANK ~ , SEEPAb~PIT X' , DRAIN FIELD
TO SERVE THE FOLLOWING FACILITY ~f-~ ~ ~-~ //-~' ~~
v , TO BE INSTA4_LED BY_/~cCz-¢'"'/'~ bZ'''~' m
FINANCED
THROUGH
PERCOLATION TEST RESULTS //~ ~ ANTICIPATED DATE OF COMPLETION BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT
THIS IS TO SERVE AS /~ [-~ ,PERMIT TO INSTALLA ~ ~
AS DESCRIBED BELOW SIZE OF UNIT TO BE SERVED ~ ~'~---~"'"~""
,,~,~-z,.~ ~.< ,~/~"~/- TYPE
SEPTIC TANK SIZE J~/7~P,.TYPE ~ SEEPAGE AREA
~¥~ .,~ ~,.,'~ ~,~-¢~-~. DIAGRAM OF SYSTEM ~ ~f~'
DISTANCES
I certify that I am familiar w~th the reqmrements of Greater Anchorage Area Borough Ordinance No 28-68 and that the
ab ove described system is in accordance with said code ,~/~ ~/c6/~ /37~~
GREATER ANCHORAGE AREA BOROU6~.~
HEALTH DEPARTb~ENT
327 EAGLE STREET
ANCHORAGE, ALASKA 99S01
279-2511
INSPECT:
TIME:
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
FOR
[/f
1. Approval Requested By ~/~~j~
Number of Bedrooms ~
Well Data'
A. Type,,
B. Depth
C. Size
IllI
D. Construction
E. Bacterial Analysis
6. Sewage Dxsposal System:
A. Septic Tank (If homemade, show diagram on back)
1. Size
2. Age
3. Manufacturer
4. Installer
--%~[pproval Request for g~age ~ ~/ater Facilities
Page
Seepage Pit
1. S~ze
2. Lining
Disposal F~eld
1. Number o£ Lines
2. Total Length
Required Measurements
A. Well to Septic Tank
B. Well to Seepage P~t
C. Well to Sewer Line
D. Well to Property Line
E. Well to Other Possible Contamlnatlon~?OO/
F. Foundatxon to Septic Tank
G. Foundation to Seepage Pit
H. Seepage Pit to Property Line
COMMENTS-
APPROVED:
DATE
APPROVAL VALID FOR ONE YEAR FROH DATE SIGNED.
GREATER ANCHORAGE AREA BOROUGH HEALTH DEPARTMENT
EDll70