HomeMy WebLinkAboutSMITHWAY Block D Lot 4-Dis
Mt
Time
APPLIC NT FILLS OUT UPPER HAL_,_, ONLY
Time
Property owner
!1 Vf,
Phone ry
Date
.,
s0-�ip Code
Ma7ing Address .
_
uyer
Inspector
Address
Zip Code
Lending Institution
Inspector
Phone
Address
Zip Code
( -APPROVED BEDROOMS
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL'
DATE
BY:
Realty Co. & Agent
-
Phone
Address
Zip Code
Septic Tank Size
Legal Description
Lot 4D Block D Smithway_ Subdivision
Street Location
1006 West 39th Avenue 99503
Type of Residence
❑ Single Family
-
Multiple Family
No. of Bedrooms - - -
❑ Other
Water Supply
Individual
ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
/�
❑ Community
For wells drilled prior to that date, give well depth (attach log if available).
❑ Public Utility
Sewer Disposal
❑ Individual
Year Individual Installed:
Public Utility
When Connected to Public Utility:�.�'
Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. -
Time
Time
Time
Time -
Date
Date
Date
Date
Inspector
Inspector
Inspector
Inspector
Field Notes: 7 /� .. I/
— G,d/
( -APPROVED BEDROOMS
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL'
DATE
BY:
'CONDITIONS OF APPROVAL
Soils Rating
Date Sewer Installed
-
Well To Absorption Area
Well to Tank
Well Log Received
Septic Tank Size
72-023 (3182)
+MUNICIPALITY
OF ANCHORAGE -
STREET LOCATIONq
1 b � w, ( rl
MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH 8
6. TYPE OF RESIDENCE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECT[CMVIRONMENTAL PROTECTI N
825 L Street - Anchorage, Alaska 99501 l�
•
q
OCT 1 2 19
❑ SINGLE FAMILY
ENVIRONMENTAL ENGINEERING DIVISION
MULTIPLE FAMILY
Telephone 264-4720 R E C E �% P
CIL�I`II
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FAIg
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. -
1. PROPERTYOWNER
L iO 01)
;S c(�acto2 �@
PHONE
�'7��or �
MAI LING ADDRESS
7 I
W
c3
PROPERTY RESIDENT (If
different from above)
PHONE.
2. BUYER
by this Department.
PHONE
7 ey
M ILING ADDRESS
S /
3. LENDING INSTITUTION
&t A 5'" w-' S• A - Q4tf-Dj - (Wrok)
PHONE
0'V-91:5
MAILING ADDRESS
4. REALTOR/AGENT
PHONE
MAILING ADDRESS
5. LEGAL DESCRIPTION
�o t6cr, D.
` e r
15w) ��� 15vwl olslaz
STREET LOCATIONq
1 b � w, ( rl
6. TYPE OF RESIDENCE
NUMBER OF EDROOMS
ED One %X Four ❑ Other
❑ SINGLE FAMILY
ED Two c«c 0000 ❑ Five
MULTIPLE FAMILY
Three ❑ Six
7. WATER SUPPLY
°`i'y`(:' INDIVIDUAL*
*ATTACH WELL LOG. A well log is required for all wells drilled
❑ COMMUNITY
since June 1975. For wells drilled-orior 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.
PUBLIC UTILITY
If system is over two (2) years old an adequacy test is required
by this Department.
NOTE: THE INSPECTION FEE MUST ACC
PANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010(3/78)
1471-V
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
El 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 T0:
Septic/Holding Tank
Absorption Area
Sewer Line
Nearest Lot Line
Absorption Area to nearest Lot Line -
5. COMMENTS
APPROVED FOR BE RO S
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE
//r • AQ r1 IV
BY (Title)
[LEGAL DESCRIPTION
72-010 (Rev. 3/78)