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DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 /L' STREET, ANCHORAGE, HK. 99501
279-2511
PERMIT NO. ( 77188 )
APPLICANT EDWIN RINNER 8]10 1,1ELLSLE9,CT 344~4i]1
LOCATION
LEGHL L12 B1 SHANE LEE ESTATES LOT SIZE 8000 SQUHRE FEET
MINIMUM DISTANCE BETWEEN H WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
i00 FEET FOR H PRIVATE WELL OR 200 FEET FOR H PUBLIC WELL.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPHRTMENT WITHIN ]0 DAYS,
OF THE WELL COMPLETION.
'"PE' IFICHTIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER
INSTALLATION.
F-11 E -E iF,;-"' 1-1 1 -1-* -11 Ca F:Co Fe ED Fr --1 E-" �F.;"' Fz* F�--! CJ t"I T. RJ E:-
I CERTIFY THAT
1: I HM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS HS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL I 8LL THE M IN ACCORDANCE WITH THE CODES.
SIGNED�~~.-�=���~~.-�_��..-._'~�~���~~~_~~~'_-��~,`-�
APPLICANT EDWIN RINNER
our i�� INET
.rAP 7/1AAR 1
•
MUNICIPALITY OF ANCHORAGE
E
VV -.
ENVf =ALTF1 &
'ENT/L pr;�„ECTION
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 L Street- Anchorage, Alaska 99501
•
MAR,
NUMBER OF BEDROOMS
�STNGLE FAMILY
19i9
ENVIRONMENTAL ENGINEERING DIVISION
Telephone 264-4720
RECEIVED
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 noePH�
/ �NE
/�
❑ COMMUNITY
` O�
MAI LING ADDRE S
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
PROPERTY RESI DENT0f different from above)
❑ INDIVIDUAL/ON-SITE**
PHONE
2. BUYER
If system is over two (2) years old an adequacy test is required
p�UBLIC UTILITY
PHONE
MAILING ADDRESS -
3. LENDING INSTITU ION
PHONE
441O
Cvta
MAILING ADDRESS
4. REALTOR/AGENT��
PHONE
MAILINGADDRESS
5. LEGAL DESCRI TION/
STREET LOCATION
/
6. TYPE OF RESIDENCE
NUMBER OF BEDROOMS
�STNGLE FAMILY
El One ❑ Four 0 Other
❑ Two ❑ Five
❑ MULTIPLE FAMILY
1 i; ree ❑ Six
7. WATER SUPPLY
tK---+NOIVIDUAL*
* 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**
**If individual/on-site, give installation date
If system is over two (2) years old an adequacy test is required
p�UBLIC UTILITY
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
nG 72-010(3/78)
14'704
THIS SIDE FOR OFFICIAL USE ONLY
INSPECTION APPOINTMENTS
DATE RECEIVED
TIME
TIME
TIME
DATE
DATE
DATE
INSPECTOR
INSPECTOR
INSPECTOR
DIRECTIONS:
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
❑PUBL.IC 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 T0:
Septic/Holding Tank
Absorption Area
Sewer Line
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
CyAPPROVED FOR BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE
BY (Title) 24
LEGAL DESCRIPTION
72-010 (Rev. 3/78)