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INSPECTION REPdR'T ON-SITE SEWAGE DISPOSAL SYSTEM
NAME
LOCATION
SEPTIC TANK:
MAILING
ADDRESS ~-~'~--"'/gz' /-~J~-~'.. ~'~'-~ -'~' PHONE_
LEGAL D ES C RI P TI 0 N .,/~,7"' -L~ .~4~.
C~ -~:/~. ~) MATERIAL ..~. ~_~_~:~,~/ NUMBER OF
COMPARTMENTS
DISTANCE FROM WELL 4 ~,/.~/~. ~"~.<' ~'7~.. /=-.~"~:~, ~".~..~...,)
LIQUID CAPACITY ...,~ ~ L') ~ GALLONS. INSIDE LENGTH -- INSIDE WIDTH ~
LIQUID
DEPTH
SEEPAGE SYSTEM:
NUMBER OF PII'S_
LINING MATERIAL
NEAREST LOT LINE
SEEPAGE PIT:
OUTSIDE DIAMETER
OR WIDTH ./,/' /, LENGTH .,/./~- X , DEPTH
DISTANCE FROM' WELL~'~.'?'''~''d'''''''''''''''~`/~'//~ '~ ~ BUILDING FOUNDATION~--)
TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) ~ ~ ~ SQ. FT.
TILE DRAIN FIELD:
TOTAL LENGTH
DISTANCE FROM WELl , FOUNDATION , NEAREST LOT LINE . OF LINES .
ABSO~ON AREA ~, ~,~O. FT. LENGTH OF EACH LINE
/
DEPTH~ TOP OF TILE TO FINISH GRADE DEPTH OF FILTER MATER AL BENEATH TILE IN. ABOVE TILE
DISTANCE FROM WATER
WELL: TYPE .~.~'x..~,x'~ /~.~-~ ~ DEPTH ~ , BUILDING FOUNDATION -~' SAMPLE NEAREST
NEAREST SEPTIC SEEPAGE ~ .. OTHER
LOT LINE ~ SEWER LINE. ' . TANK , SYSTEM CESSPOOl SOURCES
DISTANCES:
DIAGRAM OF SYSTEM
DATE
HEALTH AUTHORITY
Ga*.-.D-2 G'REATE '~--NCHORAGE AREA i )ROUGH
-HEALTH DEPARTMENT "-'
j 0 327 Eagle St. Anchorage, Alaska 99501 279-2511
Case NO. ~ ~ ~'
NAME OF APPLICANT
RESIDENCE ADDRESS.
SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT
,,~..,/// ~_~'..7-C~(/,2~ MAILING ADDRESS ~'~?[{~ '~' "' ¢' -/' P PHONE NO, .
LOCATION OF INSTALLATION
LEGAL DESCRIPTION
APPLICATION TO INSTALL: SEPTIC TANK
TO SERVE THE FOLLOWING FACILITY
FINANCED THROUGH
PERCOLATION TEST RESULTS
SEEPAGE PIT. t'**'~ , DRAIN FIELD.
'~'/¢~ ~¢~ TO BE INSTAkkED BY
/0(2 '~/.//'~.~,~.fY~ ANTICIPATED DATE OF COMPLETION
BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT
,OTHER
THIS ISTO SERVE AS
AS DESCRIBED BELOW. SIZE OF UNIT TO BE SERVED
, SEPTIC TANK S~ZE
DIAGRAM OF EM
DISTANCES:
I certify that I am familiar with the requirements of Greater Anchorag
above descdbed system is in accordance with said code.
~ Ordinance No. 28-68 and that the
'~ /65 J, /')
.~ '~'~' ¥.. ~' ',,~l n ..... ~,.,~
HEALTH AUTHORITY APPROVAL
· INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
PART I.--TO BE COMPLETED BY FHA
INSURING OFFICE
Anchorages Alaska
MORTGAGEE
Box 600s Anchorages Alaska
SERIAL NO.
111-010553-203
MORTGAGOR OR SPONSOR PROPERTY ADDRESS
Don Straub NH~ Sunny Circle
SUBDIVISION NAME BLOCK NO. LOT NO.24
Sunny Slopes S/D
TOTAL NUMBER:
BATHS
LIVING UNITS BEDROOMS
i 2
WATER SUPPLY BY:
[Ti Public system
1
] BASEMENT
Yes []No
[-~] New installation
~] Community system
additional bedrooms?
(If Yes, how many~)
SYSTEM DESIGNED FOR
[] Individual .o. oF ~Z>RMS. OA.B^OE ~,,S.OS^L
[] Individual [] Yes [] No
SEWAGE DISPOSAL BY:
']Public system
[]Community system
PART II.--TO BE COMPLETED BY HEALTH DEPARTMENT
HEALTH DEPARTMENT INSPECTOR'S SKETCH
If is the opinion of the [] State [] County [] Local Department of Health that this individual water-supply system
[] is [] is not satisfactory as a domestic water supply for the subject property.
It is the opinion of the [] State [] County
tern with proper maintenance:
[~] Can be expected to function satisfactorily, and
s not likely tQ ~create an insanitary conditi~n_
DATE SIGNATURE
July 15, 1970
] Local Department of Health that this individual sewage-disposal sys-
]Cannot be expected to function satisfactorily
~ ~ ,,. / liealth Su[~rvisor
NOTEs The hca th author ty should complete the appropriate opinion statement above and affix date, signature and title in the
spaces provided, ,' /
Use of the above grid for Health Department Inspector's sketch as well as use of the back of this form is at the option of the
health authority,
PART Ill.--FOR USE OF FHA OFFICE
TO 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.
SIGNATURE
CHIEF ARCHITECT
DEPUTY FOR CHIEF ARCHITECT
DATE
HEALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
FHA Form 25/.s
Rev. July 1958