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~..REATER &NCHORAGE ARE^ BOROU6Yl
I{E~L?H DEP~RT~ENT ~
327 EAGLE STREET
~NCHORAGE, ALASKA 99501
279-2Sll
DATE RECEIVED
INSPECT:
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND IqATER FACILITIES
FOR
Approval Requested
Address ,~,~ ~
Phone ~ ~ ~ ---
2. Property Ownerf~/~'/~,~'f~/~/~/_~
5. Legal Description,~, f~f~f ~/~,
4. T~e of Facility to be Inspected ~//~ STREET:
Number of Bedrooms ~
S. Well Data:
A. Type
B. Depth
C. Size
D. Construction
E. Bacterial Analysis ,. /
6. Sewage Disposal System:
A. Septic Tank (If homemade, show diagram on back)
1. Size /'~/p//~_~ ~ j~//~
2. Age.
S. ~4anu£acturer
4, Installer
Apprbv'al Request for Se¢~_~ ~ Water Facilities
Page Two
Seepage Fit
2. Lining
C._ Disposal Field
1. Number of Lines ~//~ ,
2. Total Length ~//z~
Required Measurements
A.
C.
D.
E.
F.
G.
H.
Well to Septic Tank
Well to Seepage Pit
Well to Sewer Line
Well to Property Line
Well to Other Possible Contaminat
Foundation to Septic Tank
Fo~dation to ~it
Seepage Pit to Property Line~
CO~4ENTS:
APPROVED:
DATE:
APPROVAL VALID FOR ONE YEAR FROH DATE SIGNED.
GREATER ANCHORAGE AREA BOROUCH HEALTH DEPARTMENT
EDll70