HomeMy WebLinkAboutFREEMAN LT 9
GP~ .~,TER ANCHORAGE AREA BOROU-~H
i ~ HEALTH DEPARTMENT f\ A~TO.
327 EA~.,~.E ST. ANCHORAGE. ALASKA 99S01 27'/-2511
250
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
/ MAILING
NAME ~, ~, ~~ - ADDRESS ./~-~ ~ Z~/' /~ PHONE
LOCATION ~'~' ~ ~~ /~ LEGAL DESCRIPIION ~ ~ ~ ~~///~
SEPTIC TANK:
DISTANCE FROM WELL ~ ~'~ ~f~
LIQUID CAPACITY /'~'~ ~ ~') GALLONS·
NUMBER OF ~ ,
MATERIAl. ~.,~Z~ COMPARTMENTS.
INSIDE LENGTH ~"~NSIDE WIDTH DEPlH
SEEPAGE SYSTEM: SEEPAGE PIT:
NUMBER OP P,TS / OUTS,DE D,AMETER OR W,DT.
. · BUILDING FOUNDAtIOI~-~
LINING MATERIAl C-~')~/C.~___r~ ~/~Z~-~J' DISTANCE FROM WELL /~~
TILE DRAIN FIELD:
DISTANCE FROM WELL ~'~'~N, FOUNDATION~ , NEAREST LOT LINE
NUMBER OF [l~.]~/~ DISTANCE BETWEEN LINES ! TRENCH WIDTH
DEPTH: TOP OF TILE TO FINISH GRADE DEPTH OF FILTER MATERIAL BENEATH TILE
TOTAL LENGTH
, OF LINES
IN. ABOVE TILE
WELL:
LOT LINE
~P~/~ ~' ~ DEPTH
~EWER LINE
~ DISTANCE FROM /WATER
j BUILDING FOUNDATION.~SAMPLE
~ ,~T, TEPTIC . ~..SEEPAGE
ANK ~ , SYSTEM ~' ,-~"'"~'~ESSPOOL
~'"~-'-~ NEAR EST
~O, soTHER L~
URCES
DISTANCES:
DIAGRAM OF SYSTEM
GREATE?~,ANCHORAGE AREA r'~OROUGH
~ tlEALTI! DEPARTMENT
327 Eagle St. Anchorage, Alaska 99501 279-2511
SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT
NA~E OF APPL,CANT'~ £--~ /~-
RESIDENCE ADDRESS
LEGAL DESCRIPTION
MAILINGADDRESS./ .~..~ ~ (-~'~ PHONENO.
APPLICATION TO INSTALL: SEFTIC TANK ~ ,SEEPAGE PIT. /~ ,DRAIN FIELD ,OTHER
BELO~TO BE FILLED OUT BY HEALTH DEPARTMENT
THIS IS TO SERVE AS
. SEPTIC TANK SIZE
AS DESCR,,ED ,ELOW. S,ZE OF UN,T', ,E SERVED ~
DIAGRAM OF 'EM
DISTANCES:
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.//-/t~}/~ ? X~ ~~ /~~
DATE '~? APPLICANTS SIGNATURE
~..REATER ANCHORACE AREA BOROUGH
'' · ~ ~ ItEALTH DEPART!.~ENT ~
327 EAGLE STREET
ANCHORAGE, ALASKA 99501
Performed For ~.O....~/q~_/~. Date Performed ~U~, !~; 1770
Legal Description: ~ot__.~._Block, --,,,Subdzvisjoh ~ ~ .....
This Fc~ Reports a. Soils Log . -, ~f'ercolation Test
Depth
Feet
Sol1 Characteris'~ics
Location Sketch
Was Ground Water Encountered? ~ ~W~e &*~ L;~g
If Yes, At What Depth --
Readlng I Date Groas Ti~,e Net Time Depth ~9 H20 Net Drop
-*rco£a~on rate 'l"/ ~znute _
Yrcposed Installation: Seepage Pit q Dratn Field
· Depth Of Inlet ? Depth To ~ottom Of Pit Or Trench
COMMENTS. ~¥$~ C~-~_t-} ~ ,~;o.~'~ ~?~'_ ~,~t~ ./:p~r" ~~
Test Performed
Date:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APP. ROVAL FOR A SINGLE FAMILY DWELLING
016-112~16~
HAA #
1. GENERAL INFORMATION
Complete legal descript~n
Lot 9, Freeman S/D
Location (site address or directions) 11500 Reader Road
· Property OW'her ~'Donald, Far let
Mailing address '~' '
Day p~one
Lending agency
Mailin. g address
Agent Janet Gort'on/Jack White
(Prudential)
Address3ZO! C Street, AnchoraGE, AT 99503
Day phone
Day phone 762-3148
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
NOTE:
Individual well XXX
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
XXX
Individual on-site
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
D. UFT STATION
Manhole/Access (Y/N~
High water alarm level at*
Cycles tested
SEPARATION DISTANCES
Size in gallons
'Pump on' level at*
"Pump off level et*
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot //~/?
Public sewer main
Sewer/septic service line ~' ~' "~
On adjacent lots /~)/4-
On adjacent lots /',~
Public sewer manhole/cleanout
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation ~z~'~' Properly line .2 .~'~' Abso~ptlon field //~
Water maln/sen~ice line ~'~' .Surface water/drainage //~0'+ Wells on adjacent lots /~_
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line ~ Building foundation
Surface water
Driveway, parking/vehicle storage area Wells on adjacent lots //~0 /
F. ENGINEER'S CERTIFICATION
Engineer's Name
Date
I certify that I have determined thru field inspecfio.~ am
Signaturein conformance .'~_Z ~ ~Z~wffil MOA ~ guidelines in e~ffect on this date.
HAA Fee $
R ipt.um.r 0
72-026 (Rev.
Waiver Fee $
Date of Payment
R~coipt Number
J~l-li-gg 12:4g FROff-CTE E~VIRO~L~IJTAL
ZT~__ CT&E Env;,onment,, Se,wc,$ Inc.
5615301
T-BH P.02/03 F-HO
CT&E R¢f.#
Client N~me
ProJecs Name/#
Client Sample l~
Ordered By
PTVS~
Sample Rema~l~:
Client
Printed D.~te/Time 06/15199 11:17
Collated Llate/Th~e 06114199 16:45
Received Date/Time 06114199 16:50
Technlc~l Directo~ Stephen C.
o
0.616