HomeMy WebLinkAboutHULSE #2 LT 673'
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYS'~EM AND/OR WELL INSPECTION REPORT
NAME
PHONE [~I~W
[] UPGRADE
MAI LING ADDRESS
LEGAL DESCRIPTION
NO. OF BEDROO~
PERMIT NO.,~ ~-) ~L~-- -~ ~ ~-
Well
I DISTANCE TO: I
I- ;~ ] Manufacturer ~'
u~ I Liq. cap~ci.ty in gallons [ ,c U.~.C~.~A r~c
I I ..............
~, ~ v I DISTANCE TO' I Well
-J ;~ I ' I
=D~--~ Manufacturer
Q I ] Well
m-r i DISTANCE TO: I //00
J"-z I No. of Unes ! I Length °f ea~ J~e
-~ Top of tile to finish grade
u~ I Length Width
~ ~- / Type of crib Crib diameter
~' I Well
" DISTANCE TO:
~ I C]~,~_~,O Depth
-~ /"DISTANCE TO' Building foundation
OTHER
PIPE MATERIALS
SOl L TEST RATING
NSTALLER
REMARKS
Absorption area
Dwelling
Mat~
Width
Inside length
No. of compartments
Liquid depth
Dwelling PERMIT NO.
Liquid capacity in gallons
Foundation PERMIT NO.
Total length o,~,es¢
Material
Nearest lot lin~
Trench width
.:.~ inches
Material beneath tile
Depth
Total effective absorption area
PERMIT NO.
Crib depth
Building foundation
Driller
Sewer line
Total effective absorption area
Nearest lot line
Distance to lot line
PERMIT NO.
Absorpt on area(s)
Septic tank
DATE LEGAL
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erfo~ned for
egal Description:
his Fo~ reports:
3NSTRUCTION TEST LAB
"One Test is worth a Thousand Opinions"
2204 Cleveland Anchorage, Alaska 99503 277-0231
~~O~q~'~ ~~-. ~-~° Date Performed
Lot _~ ~Block -- Subdivision I~U/S ~' -~- ~'
SOILS TEST y~ PERCOLATION TEST
Depth
Feet
Soil Characteristics
as ~round Water Encountered
f .YES, What depth?
!
~_ading Date Gross TLme .Net TLme Depth to H20 Net Drainage
-=rcolation Rate }4inure
Proposed Installation: SEEPAGE PIT D_~AIN FIELD
Depth of Inlet De.oth to Bottom of Pit or Trench
. - ~ % ~ ~ _ ~
~st Performed by ~j~ · Data Certified By: ~~-
'~' - - ~ Date :' ' ' ~ ~/~//~
, ~ DATE RECEIVED
, ,NSPECT,ONAPPO'NTME TS C 4.
TIME TIME TIME
INSPECTOR INSPECTOR I NS P EC;fl~O R !
MUNICIPALITY OF ANCHORAGE MUNICIPALI~ OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION DEPT. OF ~;D¢,LT~I &
825 L Street * Anchorage, Alaska 99501 ENVIRONMEN]'AL i: ~:,OTECTION
ENVIRONMENTAL SANITATION DIVISION ~JN 9 1980
Telephone 264-4720
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be proce~ed, Please allow ten (10) days for processing.
PHONE
1. PROPERTY OWNER ~
MAI LING ADDRESS
PROPERTY RESIDENT (If different from above) PHONE
2. BUYER PHONE
MAILING ADDRESS
3. LENDING INSTITUTION ~ PHONE
I
MAILING ADDRESS
4. REALTOR/AGENT ~ PHONE
MAILING ADDRESS
5, LEGAL DESCRIPTION
STREET LOCATION
6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS
[] One [] Four [] Other
j~ SINGLE FAMILY [] Two [] Five
[] MULTIPLE FAMILY J~] Three [] Six
[ 7. WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
*ATTACH WELL LOG. A well Icg is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach Icg if available.)
8. SEWAGE DISPOSAL SYSTEM
[~ INDIVIDUAL/ON-SITE** / ~' '7 ?
[] PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72~010 (Rev. 6/79) ~['
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2, WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[]INDIVIDUAL/ON -SITE DATE INSTALLED
E~PUBLIC UTILITY
Connection Verified
INSTALLER
I--ISeptic Tank or [] Holding Tank
Size: !(.~(~(~) If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER ~ ..
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot L~ne
I
WELL TO:
Absorption Area to nearest Lot Line
5. COMMENTS
APPROVED FOR BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY