HomeMy WebLinkAboutSHADY LANE BLK 2 LT 4sKAdY
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DATE RECEIVED
INSPECTION APPOINTMENTS
TIME -
TIME
TIME
DATE
DATE
DATE
INSPECTOR
INSPECTOR
INSPECTOR
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❑ INDIVIDUAL*
*ATTACH WELL LOG. Awell log is required for all wells drilled
❑ COMMUNITY
since June 1975. For wells drilled prior to that date, give well
OF ANCHORAGE
MUNICIPALDEPT.
MUNICIPALITY OF ANCHORAGE . O
DOf- I"ACTH £,
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEC1B"RONMENT,AL r :iJT7O
825 L Street - Anchorage, Alaska 99501 f f �a 173
MAY 22198&3J3Y'2—
' ENVIRONMENTAL SANITATION DIVISION
' Telephone 264-4720 R 41L
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWERfTYE9'
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days f r processing.
1. PROPERTYOWNER �1j��e (� Q /j�
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PHONE.
MAILING ADDRESS
X5333 �resvie2cce i}�7��
PROPERTY RESIDENT (ifdifferent from above) y A ..{':n/ /j
PHONE
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2. BUYER
PHONE
MAILING ADDRESS
3. LENDING INSTITUTION
PHONE
MAILING ADDRESS
4. REALTOR/AGENTPHONE
/ la r f A:F etsax,
MAILING ADDRESS
5. LEGALDESCRIPTIO
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EOON
STREET LOCATION
6. TYPE OF RESIDENCE
NUMBER OF,BEDROOMS
❑ One ❑ Four ❑ Other
❑ SINGLE FAMILY
❑ Two ❑ Five
MULTIPLE FAMILY
❑ Three Six
7. WATER SUPPLY
-
❑ INDIVIDUAL*
*ATTACH WELL LOG. Awell 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**
\O\I n 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)
0
72010 (Rev. 6/79)
0
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
❑ SINGLE FAMILY
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS
Cl ONE b THREE ❑ FIVE
❑ TWO ❑ FOUR ❑ SIX
❑ OTHER
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
DATEINSTALLED
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
earest L
Not Line
Absorption Area to nearest Lot Line
5. COMMENTS
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'
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❑ AP�PR_OVED FOR BEDROOMS
L4--CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE
'47-
BYlwam
0
72010 (Rev. 6/79)
0