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5. LEGAL DESCRIPTION
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DATE RECEIVED
INSPECTION
APPOINTMENTS
TIME
TYLPP�
TIME
TIME
DATE -
-
DATE
DATE
1 �
Three ❑ Six
7. WATER SUPPLY
INSPECTPR
* ATTACH WELL LOG. A well log is required for all wells drilled
INSPECTOR
INSPECTOR
X PUBLIC UTILITY
MUNICIPALITY OF ANCHORAGE DEPT. OF 1'=ALTH &
PROTECTION:
8. SEWAGE DISPOSAL SYSTEM
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROfli&�WIMENTAL
825 L Street - Anchorage, Alaska 99501
•
DEC 1979,
❑. PUBLICUTILITY
ENVIRONMENTAL SANITATION DIVISION -
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Telephone 264-4720 RECEIVED ECEI\/CD .
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. PROPERTYOWNER
-
PHONE
/ 3
MAILING ADDRESS
f
PRO ER Y RESIDENT (If different from above)
PHO E
2. BUYER
PHONE
MAILING ADDRESS
3. LENDING INSTITUTION
PHONE
MAILING ADDRESS
4. REALTOR/AGENT
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PHONE
.974-a33
MAILING ADDRESS
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5. LEGAL DESCRIPTION
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L=A CLL.)L,
STREET LOCATION
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6. TYPE OF RESIDENCE
NUMBER OFBEDROOMS
❑ One ❑ Four ❑ Other
SINGLE FAMILY
❑ Two ❑ Five
❑ MULTIPLE FAMILY
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
X PUBLIC UTILITY
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
bt INDIVIDUAL/ON-SITE**
YEAR ON-SITE SYSTEM WAS INSTALLED.
❑. PUBLICUTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
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72-010 (Rev. 6/79)
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
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
Nearest Lot Line
Absorption Area to nearest Lot Line
6. COMMENTS
C3y...
❑ APPROVED FOR BEDROOMS
FC,CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE
BY
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72-010 (Rev. 6/79)