HomeMy WebLinkAboutNEWLAND BLK A LT 10lO
DEPT. 07 I 2~1'. &
MUNICIPALITY OF ANCHORAGE - ENVIRONh:: qT.~L
DEPA.TMENT OF HEA'TH & ENWRONMENTA' PROTECTrON ....
ENVIRONMENTAL ENGINEERIN8 DIVISION
BEQUEST FOB APPROVAL OF INDIVIDUAL WATER AND 8EWER FA01LITIE8
BIREOTIONS: Complete ~ll parts on psge 1. Incomplete request~ will not be pro~es[e~, PLease allow ten (J0) d~ys for processing,
PHONE
1. PROPERTY OWNER
MAILING ADDRESS ~C( ~ - ~ ~ ~,
~ ~WO~ PHONE
~OPE~TY ~ES~BENT ~ dff~e[ent f[om above)
PHONE
~, BUYE~
~A~L~NG A~ESS
PHONE
~. LEN~N~ ~NST~TUT~ON
MAILING AD~ES8
~. REALTOR/AGENT
MAILING ADDRESS
5, LEGAL DESCRIPTION
BTREET LOCATION
NUMBER OF BEDROOMS
TYPE OF RESIDENCE
[~"xSi N G L E FAMILY
[] MULTIPLE FAMILY
[] One [Z~ 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.)
S. SEWAGE DISPOSAL SYSTEM
[~ INDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
**If individual/on-site, give installation date
,r,~ , ,,I I .... ~C:;L:.-C, '--~'. .... :"-~
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 NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
2, WATER SUPPLY PERMIT NUMBER
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[~]INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified
INSTALLER
[]Septic Tank or []Holding Tank
Size: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTIQN AREA MATERIAL
4, DISTANCES Septic/Holding Tank IAbsorption Area ISewer Line J Nearest Lot Line
WELL TO:
Absorption Area to nearest Lot Line
[] APPROVED FOR BEDROOMS
[] CONDITIONAL APPROVAL (Petter must accompany certificate)
~ DISAPPROVED
DATE BY (Title)
LEGAL DESCRIPTION