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GAAB-HD-t
GP-~TER ANCHORAGE AREA BORO"~H
HEALTH DEPARTMENT
327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME
LOCATION
'(~"~/~ ~ LEGAL DESCRIPTION ~0A,~ .~US,~/ J,..,~)~'"'' .,~'
pe . OF
_ _ COMPARTMENTS
GALLONS. INSIDE LENGTH ~1~" INSIDE WIDTH
SEPTIC TANK:
DISTANCE FROM WELL
LIQUID CAPACITY /
SEEPAGE SYSTEM:
NUMBER OF PITS.
LINING MATERIAl
NEAREST LOT LINE
SEEPAGE PIT:
OUTSIDE DIA/~ETER
TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA)
BUILDING FOUNDATION__
OR WIDTH
DISTANCE FROM WELL
SQ. FT.
TILE DRAIN FIELD:
DISTANCE FROM WELL
NUMBER OF LINES
ABSORPTION AREA
DEPTH: TOP OF TILE TO FINISH GRADE
FOUNDATION.
DISTANCE BETWEEN LINES
SQ. FT. LENGTH OF EACH LINE
NEAREST LOT LINE
TOTAL LENGTH
OF LINES
TRENCH WIDTH
IN. TOTAL EFFECTIVE
DEPTH OF FILTER MATERIAL BENEATH TILE'
IN. ABOVE TILE
WELL: TYPE ~ DEPTH J ~t f/
LOT LINE --I['J""~!
NEAREST
SEPTIC
. , SEWER LINE , TANK
DISTANCE FROM
· BUILDING FOUNDATION
/ SEEPAGE , SYSTEM
WATER
SAMPLE
CESSPOOL
, NEAREST
OTHER
, SOURCES
DISTANCES:
.l~C"' 110~
DIAGRAM OF SYSTEM
DATE
APPROVED
HEALTH AUTHORITY
GAAB-H D-2
GREATE' ,. ANCHORAGE AREA )ROUGH ' eNo.
HEALTH DEPARTMENT
327 Eagle St. Anchorage, Alaska 99501 279-2511
SEWAGE DISPOSAL SYSTEM APPLICATION & PERMIT
NAME OF APPLICANT
RESIDENCE ADDRESS
MAILING ADDRESS ~. ~-~ ~c,,~Z;z7 PHONE
LOCATION OF INSTALLATION .~-,~r~
TO SERVE THE FOLLOWING FACILITY ~ ~.~/~,~c~, ~o~,£ ! ~ - ~ ~/~-~c~-
FINANCED THROUGH TO BE INSTALLED BY
, OTHER.
PERCOLATION TEST RESULTS ANTICIPATED DATE OF COMPLETION
BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT
THIS IS TO SERVE AS
DISTANCES:
, 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
I certify fhat 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 APPLICANTS SIGNATURE