HomeMy WebLinkAboutEAGLE RIVER HEIGHTS NORTH BLK 10 LT 4- lXlor th
Addn.
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR I"SPECTOR INSPECT
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION DEPT. OF HEALTH &
825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL
PSC, TECT
ON
/ ENVIRONMENTAL SANITATION DIVISION APR 1 3 1981
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND
DIRECTIONS: Complete all parts ol~ page 1. Incomplete reques~ will not be proce~ed. Please allow ten (10) days for processing.
1. PROPERTY OWNER PHONE
MAi LING ADDRES~
PROPERTY RESlDEN~ (If different fr~m above) / PHONE
2. BUYER PHONE
MAILING ADDRESS
3. LENDING INSTITUTION PHONE
MAI LIN~ ADDRESS
4. REALTOR/AGENT
MAILING A~DRESS ~
STREET LOCATION
6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS
[] One [~ Four
~ SINGLE FAMILY
[] Two [~ Five
MULTIPLE
FAMILY
~ Three [] Six
[] Other
7. WATER SUPPLY [] INDIVIDUAL*
~ COMMUNITY
PUBLIC UTILITY
* ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
INDIVIDUAL/ON-SITE**
PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE ~ROCESSIN(~CAN BE INITIATED.
72-O10 (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
[] INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified iNSTALLER
[]Septic Tank or []HoldingTank
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:
I
Absorption Area to nearest Lot Line
5. COMMENTS
[~'~ APPROVED FOR -.~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY ~~
72-010 (Rev. 6/79)
