HomeMy WebLinkAboutSILAS JACK SPARKS LT 1C5. LEGI�L DESCRIPTION
D; 'RECEIVED
INSPECTION APPOINTMENTS
TIME'
TIME
TIME
6. TYP 'OF RESIDENCE
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DATE
DATE
DATE
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❑ Two ❑ Five
❑ MULTIPLE FAMILY
Three ❑ Six
INSPECTOR
INSPECTOR
INSPECTOR
* ATTACH WELL LOG. A well log is required for all wells drilled
❑ COMMUNITY
since June 1975. For wells drilled prior to that date, give well
PUBLIC UTILITY
MUNICIPALITY OF ANCHOP,AGE
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIOWNVIP.ONMENTAL P 'O T ECTION
825 L Street - Anchorage, Alaska 99501
O`-
ENVIRONMENTAL SANITATION DIVISION
N PUBLIC UTILITY
Telephone 264-4720 r
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FA60- 1 5_U
DI RECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OVVNER
PHONE
AILING'ADDRESS
PROPERTY RESIDENT (If different from above)
PHONE
2. BUYER
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PHONE
MAILING ADDPESS
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3. LENDING INSTITUTION
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'P}HONE
MAILING ADDRESS
4. REALTOR/ /AGENT 1 moi. /jam/
PHONE
MAILING AD R SS 1
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5. LEGI�L DESCRIPTION
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—STREET OCATI N
6. TYP 'OF RESIDENCE
NUMBER OF BEDROOMS
❑ One ❑ Four ❑ Other
92 SINGLE FAMILY
❑ Two ❑ Five
❑ MULTIPLE FAMILY
Three ❑ Six
7. WATER SUPPLY
,'�7` INDIVIDUAL`
* ATTACH WELL LOG. A well log is required for all wells drilled
❑ 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.
N PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
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THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
❑ SINGLE FAMILY
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS
❑ ONE
❑ TWO
THREE ❑ FIVE ❑ OTHER
❑ FOUR ❑ SIX
2. WATER SUPPLY
❑ INDIVIDUAL
❑ COMMUNITY
❑ PUBLIC UTILITY /
Connection Verified r/ 0 r
r
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
❑ " APPROVED FOR BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE
Y /
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