HomeMy WebLinkAboutFYFE BLK F LT 26DATE RECEIVED
INSPECTION
APPOINTMENTS
TIME
TIME
TIME
DATE
DATE
DATE
INSPECT11N
INSPEC R
INSPECTOR
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-EY OF MUNICIPALI ANCHORAGE
DEPT. OF HEALTH &
MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL PROTECTION
DEPARTMENT
OF HEALTH & ENVIRONMENTAL PROTECTION
825 L Street - Anchorage, Alaska 99501
®
NOV 51979
ENVIRONMENTAL SANITATION DIVISION
Telephone 264-4720 RECEIVED
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete re pests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OWNE !/KPHONE
J v�
MAILING ADDRESS
PROPERTY RESIDENT (If different from above)
PHONE
2. BUYER
PHONE
MAILING ADDRESS
3. LENDING INSTITUTION
\`
PHONE
•.y
MAILING ADDRESS
4. REALTOR/AGENT
i\`
PHONE
MAILING ADDRESS
5. LEGAL DESCRIPTION
STREET LOCATIONI
al
6. TYPE OF RESIDENCE
NUMBER OF,BEDROOMS
j SINGLE FAMILY
❑ One ❑ Four ❑ Other
/�
Two ❑ Five
❑ MULTIPLE FAMILY
0 Three ❑ Six
7. WATER SUPPLY
*
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.
❑ PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 ( Rev. 6/79) Lok'o'� C„"� Q Vca'-- ,a
`tJ'z) �
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
EP<UBLIC 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
VA PROVED FOR ��—� BEDROOMS
❑� CONDITIONAL APPROVAL (letter must accomp y certificate)
EL DISAPPROVED
DATE l 1 \
I! f
BY
�j
72-010 (Rev. 6/79)
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