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INSPECTION APPOINTMENTS .
DATE RECEIVED
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INSPECTOR
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MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEbf.y"NMENTAL PPOTECTION
825 Street 99501
L - Anchorage, Alaska
ENVIRONMENTAL SANITATION DIVISION
Telephone 264-4720
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REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OWNER
PHONE
MAILING ADDRESS
27(p_ �j10 W
PROPERTY RESIDENT (If different from above)
PHONE
,A-M S
2. BUYER
PHONE
MAILING,APORESS
3. LENDING INSTITUTION
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PHONE
MAILING ADDRESS
[ � p
/L.
4. REACTAO'R/A NT
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ri NE
MAILING ADDRVS
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5. LEGAL DESCRIPTION
LOT
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F- `JCI �S -
STREET LOCATION
07 - 07 - 1�
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�- 57 �=- AL/0
6. TYPE OF RESIDENCE
NUMBER OF,BEDROOMS
❑ SINGLE FAMILY
❑ One ❑ Four ❑ Other
MULTIPLE FAMILY
❑ Two 'Zf��Five
❑ Three ❑ Six-
7. WATER SUPPLY
tF!5o 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.
X?9-, PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79) /j
cam- % J✓LC,, g cl i,t -
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
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 S BEDROOMS
❑ CONDITIONAL APPROVAL (letter mustZan certificate)
/❑ DISAPPROVED' V
DATE (
BY
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72-010 (Rev. 6/79)
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