HomeMy WebLinkAboutCAMPBELL HEIGHTS BLK 4 LT 18 MUNICIPALITY OF ANCHORAGE DEPT. OF I :Z%TH &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTI~"VjRONMFNTAL ~;*,OTECTION
ENVIRONMENTAL ENGINEERING DIVISION AUG 2 1 1979
~EQUE~T FO~ APPROVAL OF INDIVIDUAL WATE~ AND ~E~Efl FAOILITIES
PHONE
PHONE
PHONE.
PHONE
PHONE
t. PRO, P/E, RTY OWNER
MAI'LI~NG ADDRESS ' '
PROPERTY RESIDENT (if different from above)
2. BUYER
3. LE~NG I~}ITm~N
4. REALTOR/AGENT I
MAILIN~ ADDRESS
5. LEGAL DE~RI~ION
6. TYPE OF RESIDENCE I NUMBER OF eEOROO~
~ One ~ Four
~ SINGLE FAMILY ~Two ~ Five
~ MULTIPLE FAMILY ~ Thr~ ~ Six
[] Other
7. WATER SU~LY
· ~ INDIVIDUAL* * ATTACH WEL.L 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.)
~/'~INDIVI DUA~L/ON-SITE** **If individual/on-site, give installation date _
~ If system is over two (2) years old an adequacy test~ required
[] PUBLIC UTI LITY by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED · :.
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR [ INSPECTOR INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE NUM~tER OF BEDROOMS
I-'1 SINGLE FAMILY I-'1 ONE [--I THREE [] FIVE I-'1 OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
2. WATER SUPPLY PERMIT NUMBER
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTI LITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDIVIDUAL/ON -SITE DATE INSTALLED
I-'IPUBLIC UTILITY
Connection Verified
INSTALLER
[]Septic Tank or [] Holding Tank
Size: If Tank is homemade SOILS RATING ~
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES Septic/Holding Tank Absorption Area JSewer Line J Nearest Lot Line
I
WELLTO:
Absorption Area to nearest Lot Line
RDVEOFOR m EDROO S
~ CONDITIONAL APPROVAL (letter must accompany certiflcate).~ [::).~.,~(~-~ ~ /7.; (.~
[:~'"DISAPPR OVED
LEGAL DESCRIPTION
72-010 (Rev. 3/78)