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DATE RECEIVED
INSPECTION APPOINTMENTS
TIME
TIME
TIME �n
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DATE
DATE
DATE
❑ Two ❑ Five
❑ MULTIPLE FAMILY
4-\_ -
INSPECTOR
INSPECTOR
INSPECTOR
MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH 8, ENVIRONMENTAL PROTECTIOVEPT. OF HEALTH &
825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL PI:OTECTION
ENVIRONMENTAL SANITATION DIVISION MAR J 1 1981
Telephone 264-4720
®®
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SERfiGid1,, LLilD
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY WNER
Po
PHONE
MAILING ADDRESS
PROPER 7RESIQENT (If different from above) PHONE
�F/! S 3 y y
- - - - - PHONE - - - - - -
2. P� i ^ to 5 / //�
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MAILING ADDRESS
32- 30 `' C_ Sir z l S 5 3
PHONE
MAILING ADDRESS /� G�
40 /0 —37� IT��� GT`l / l�� l
PHONE
4. REALTORIAGEN/T
P E
_ O
MAILING ADDRESS
Piz" S. , L f, --,C--
72-010 (Rev. 6/79)
5. LEGAL DESCRIPTION
L ok) /A 1,14
31-1
STREET LOCATION
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6. TYPE OF RESIDENCE
NUMBER OF,BEDRO MS
5.4-1 ► ❑ One ❑ Four ❑ Other
❑ SINGLE FAMILY
❑ Two ❑ Five
❑ MULTIPLE FAMILY
❑ Three ❑ Six
7. WATERSUPPLY
INDIVIDUAL*
* ATTACH WELL LOG. A well log is required for all wells drilled
El COMMUNITY
since June 1975. For wells drilled prior to that date, give well
❑ PUBLIC UTILITY
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
INDIVIDUAL/ON-SITE**
YEAR ON-SITE SYSTEM WAS INSTALLED.
❑ PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
i
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
❑ SINGLE FAMILY
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS
❑ ONE ❑ THREE ❑ FIVE ❑ OTHER
❑ TWO ❑ FOUR ❑ SIX
2. WATER SUPPLY
❑ INDIVIDUAL
❑ COMMUNITY
❑ PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
❑INDIVIDUAL/ON -SITE
❑PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATE INSTALLED
INSTALLER
❑Septic Tank or ❑ Holding Tank
Size: If Tank is homemade
give dimensions:
SOILS RATING
TYPE OF TANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL
4. DISTANCES
WELL TO:
Septic/Holding Tank
Absorption Area
Sewer Line
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
M_—APPROVED FOR �A BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE 4 `
BY
72-010 (Rev. 6/79)