HomeMy WebLinkAboutMOOREHAND #2 LT 9
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" INSPECTION APPOINTMENTS
TIME TIME TIME
, DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL SANITATION DIVISION
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts ca page 1. Incomplete requests will not be processed. PJease allow ten (10) days for processing.
1. PROPERTY OWNER I PHONE
I
MAILING ADDRESS
PROPERTY RESIDENT (If different from above) PHONE
2. BUYER PHONE
MAI LI N~ADDR ES'S~
3. LENDING INSTITUTION I PHONE
M~,I LiNG ADDRbSS
4. REALTOR/AGEN'I~' PHONE
M~,I~LING ADDRESS * z -
5. LEGAL DESCRIPTION
~TR LET LOCATION --
¢¢¢¢
6. TYPE OF RESIDENCE
/~ SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OF BEDROOMS
[] One [] Four
Two [] Five
Three [] Six
[] Other
7. WATER SUPPLY
[] INDIVIDUAL*
COMMUNITY
PUBLIC UTILITY
* ATTACH WELL LOG. A well Icg is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach Icg if available.)
8. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE**
r~ PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
' 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[~ SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY ,~ TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
~;~ COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
-S I T'E~J ~.M~,~- BATE INSTALLED
E~]INDIVIDUAL/ON
~PUBLIC 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 IAbsorption Area Sewer Line Nearest Lot Line
WELL TO:
Absorption Area to nearest Lot Line
5. COMMENTS
E]~/~APPROVED FOR '~- BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
72-010 (Rev. 6/79)