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GPI:ATER ANCHORAGE AREA BORC' "~H
~ HEALTH DEPARTMENT
327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
~ j ,/, ' (:./~ MAILING
(~ L) ~ V ~ ~ ~)~)~ LEGAL DESCRIPTION
LOCATION
/
SEPTIC TANK:
DISTANCE FROM WELl ~,"'~ F)~3 MATERIAL
LIQUID CAPACITY //('") ~/~'~) GALLONS· INSIDE LENGTH
PHON
NUMBER OF ~
COMPARTMENTS
,/ ~'& ~' LIQUID
INSIDE WIDTH DEPTH___
SEEPAGE SYSTEM:
/
NUMBER OF PITS /
LINING MATERIAl
NEAREST LOT L NF
SEEPAGE PIT:
OUTSIDE DIAMETER
ORW,DT. / m .LENGT. / DEPT. 4
DISTANCE FROM WELl ~'~ ~'~2 {~
· . , BUILDING FOUNDATION
· TOTAL EFFECTIVE ABSORPTION AREA WALL AREA Z~'"~ <''';~) SQ. FT.
TiLE DRAIN FIELD:
DISTANCE FROM WELL.
NUMBER OF LINES
ABSORPTION AREA
DEPTH: TOP OF TILE TO F 'qlSH GRADE
WELL: TYPE ('~/~')/('')
NEAREST
LOT LINE
. NEAREST LOT LINE
TRENCH WIDTH
=OUNDATION_
DISTANCE BETWEEN LINES
SQ. FT. LENGTH OF EACH LINE
DEPTH OF FILTER MATERIAL BENEATH TILE
TOTAL LENGTH
OF LINES
IN. TOTAL EFFECTIVE
~N. ABOVE TILE
~) L~ ([') '~)(g '~ DISTANCE FROM
DEPTH . BUILD NG FOUNDATION
SEPTIC SEEPAGE
· SEWER LINE TANK SYSTEM
WATER
SAMPLE NEAREST
OTHER
· CESSPOOL . SOURCES
DISTANCES:
DIAGRAM OF SYSTEM
DATE
APPROVED
G^a.-.D-2 GREATEL ANCHORAGE AREA OROUGH
, ., Case No.
f
HEALTH DEPARTMENT
327 Eagle St. Anchorage, Alaska 99501 279-2511
SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT
NAME OF APPLICANT'~c ~./ ~'~,,...~'/, ~., MAILING ADDRESS ~ V~ PRONE NO.~ V-~.~/A
RESIDENCE ADDRESS LOCATION OF INSTALLATION~ ~ ~/~ ~ .~' ~,
APPLICATION TO INSTALL: SEPTIC TANK
TO SERVE THE FOLLOWING FACILITY
FINANCED THROUGH f,///~
PERCOLATION TEST RESULTS
, SEEPAGE PIT )(' , DRAIN FIELD ,OTHER
TO BE INSTALLED BY'~'J~,.-- ...................~ L(O,~.~-"/ 0,,
ANTICIPATED DATE OF COMPLETION ~" / 0 ~.~
BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT
THIS IS TO SERVE AS "~'~ ~.~ ~'~.~.'7~, ('~o. , PERMIT TO INSTALL A ~& ~..,/,~ ,
AS DESCRIBED BELOW. SIZE OFUNITTO DESERVED ~ ,~ro~
. SEPTIC TANK SIZE / oeo~T~PE ~/'-/ SEEPAGE AREA TYPE
/ OF SYSTm
DISTANCES:
Health Authority
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 APPLICANTS SIGNATURE
HEALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
PART I.--TO BE COMPLETED BY FHA
INSURING OEFICE
MORTGAGOR OR SPONSOR
MORTGAGEE
PROPERTY ADDRESS
UBDIVISION NAME
i ~ i [~¥es []No
~_ New installation
SERIAL NO.
NO. LOT NO.
ELOCK ?
Can attic or other area be made into
additional bedrooms?
(If Yes, how mony~)
WATER SUPPLY DY:
[] PUblic system [] Community system
SEWAGE DISPOSAL DY:
[] Public system [] Community system [] Individual
~ SYSTEM DESIGNED FOR
[-~ Individual No. OF DORMS GARBAOE~DIEPOEAL
I-I Yes IZl~o
PART IL--TO BE COMPLKTED BY HEALTH DEPARTMENT
HEALTH DEPARTMENT INSPECTOR'S SKETCH
It is the opinion of the [] State [] County I~ Local Department of Health that this individual water-supply system
1~] is [] is not satisfactory as a domestic water supply for the subject property.
It is the opinion of the [] State [] County ~r-1 Local Department of Health that this individual sewage-disposal sys-
tem with proper maintenance:
~J--J Can be expected to function satisfactorily, and [] Cannot be expected to function satisfactorily
is not likely to create an insanitary condition
~ATE SIGNATURE t , , /fI TITLE
J ..-.. / ~~: ·
NOTE: The health authority )%J(ould compiete the appropriate opinion statement above and affix date, signature =nd title in the
Use of the above gdd 'for Health Department Inspector's sketch as well as use of the back of this farm Is at the optian of the
health authority.
PART III.~FOR USE OF FHA OFFICE
I'O THE CHIEF UNDERWRITER:
I have reviewed the foregoing and the pertinent FHA Compliance Inspection Report, and recommend that the
Individual water-supply system be considered [] Acceptable [] Not Acceptable
Sewage disposal be considered [] Acceptable [] Not Acceptable.
DATE
~i.~_i CHIEF ARCHITECT
DEPUTY FOR CHIEF ARCHITECT
SIGNATURE
HEALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
FHA Form 2573
REPORT OF INSPECTIONMINDIVIDUAL SEWAGE-DISPOSAL SYSTEM
__.feet. Material
feet. Inside width,
.gallons. Capacity inlet compartment,
feet. Liquid depth, .feet.
Total liquid capacity,
Inside length,
Cesspooh
Total length of tile lines,.
Trench width,
Length of each line,
Number of compartments
gallons.
feet; nearest lot line at [] front, [] side, [] rear,
feet. Liquid capacity, gallons. Lining material
Date of inspection
Other
feet.
square feet.
inches.
feet; foundation, feet; nearest lot line at [] front, [] side, [] rear,
feet. Number of lines, Distance between lines,
inches. Total effective absorption area in bottom of trenches,
.feet. Depth, top of tile to finish grade,
Depth of filter material over tile,
Type of filter material: [] Gravel. [] Broken stone. Other
Depth of filter material beneath tile,~ .inches.
Number of pits .... Outside diameter, feet. Depth, .feet. Lining material
Distance frnm: Well, feet; building foundation, feet; nearest lot line at [] front, [] side, [] rear,.
fn~lon m,ad~ by: [] State. [] County. [] Local Health Authority.
Inspected by-
REPORT OF INSPECTION--INDIVIDUAL WATER-SUPPLY SYSTEM
Dislance to nearest public water main, feet. Size of main, inches.
Individual wells [] are [] are not custo~naty in neighborhood.
Give most recent record of failure of wells in immediate vicimty to furnish adequate supply of water
Properties fil neighhorb~×~d [] are [] are not being developed with both individual water-supply and sewage-disposal systems.
Lot size: feet wide,_ feet deep. Dwelling set hack from front property line, feet.
Individual water supply t¥om: [] Drilled weft. [] Driven well. [] Dug well. [] Bored well.
Building foundation,
cast iron sewer, feet; tile sewer,
seepage pit. feet; cesspool,.
Diameter, inches. Total depth, __.feet. Type of casing,
Approximate depth to pumping level of water in well,_ feet. Approximate yield,
Sealed watertight to depth of .feet.
Exterior space around casing sealed with: [] Cement grout. [] Puddled clay. [] Ordinary' backfill,
Well cover: [] Concrete. [] Wood. [] Metal. Openings in well cover watertight: [] Yes. [] No.
Pump: [] Shallow well. [] Deep well. Length of drop pipe~ feet. Pump capacity,
Located in: [] Basement. [] Pumproom off basement. [] Pumphouse above ground, [] Pump pit.
pumproom properly drained: [] Yes. [] No. pump mounting watertight: [] Yes. [] No.
Type of storage: [] Pressure. [] Gravity. Capacity, .gallons.
Has bacteriological examination of water been made? [] Yes. [] No. If answer is "yes," give date
Quality of water [] is [] is not satisfactory for human consumption.
Installation [] does [] does not comply with approved exhibits, if any.
Inspection made by: [] State. [] County. [] Lotal Health Authority.
Inspected by
Date of inspection , 19
.feet; nearest lot line at [] front, [] side, [] rear,
feet; septic tank,_ feet; disposal field,
feet; other sources of possible pollution, ~'eet.
Depth of casing,
gallons per minute.
gallons per minute.
feet;
feet.
19