HomeMy WebLinkAboutLot 01, 02
APPLI('-NT FILLS OUT UPPER HAl-~ ONLY
& Agent ' ~ ~ '
Type of Resi~nce
~ Single Family
Multiple Family No. of Bedrooms
Other
Water Supply / ,~ .
~ Individual ~ G~?D~ A~ACH WELL LOG. A wall log is requirodfor 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
~'x2 Year Individual Installed:
Holding Tank
NOTE:~E INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
Time Time Time Tim~~,~,~ ~
Date Date Date Date 1 ~f_~ ~
Inspector Inspector Inspector I n spect (~,~
MUNIcIPALITy OF ANCHO~E
Field Notes:
," :.,
RECEIVED
( ) APPROVED BEDROOMS *CONDITIONS OF APPROVAL
( ~PPROVED
( ) OONDITIONAL APPrOVAl*
Soils Rating Date ~wer installed Well To Absorption Area Well Log Received
Well to Tank Septic T~k Size
72-023 (3182)
.* ' MUNICIPALITY OF ANCHORAGE MU ~Cl P_ALIT~'.~O F
~ DEPARTMENT OF HEALTH & ~NVIRO.MENTA~"OTECTI~ , r, SALTH ~
~ 825 L Street- Anchorage. Alaska 995 ENV~O~ ~NTAL pI;OT~ON
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SE~.~I~~
DIRECTIONS: Complete all part p g . p q ' . ~s fc
~ PROPERTYOWNER . ~ ~1 PHON~
PROPERTY RESIDENT (If different from above) PHONE
2, BUYER PHONE
MAILING ADDRESS
3. LENDING INSTITUTION I PHONE
I
MAILING ADDRESS
MAILING ADDRESS
5. LEGAL DESCRIPTION
¢ ' '' '" .~,~Ci
STREET,.OCAT, O,
6. TYPE OF RESIDENCE
[] SINGLE FAMILY
[~ MULTIPLE FAMILY
NUMBER OF BEDROO..~1S
[] One ~ Four
[] Two [] Five
[] 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
t
If system is over two (2) years old an adequacy tes[ is required
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
'i'NSPECTOR ' ~ ""'" INSPECTOR INSPECTOR
DIRECTIONS:
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
{~UUBIVI DATE INSTALLED
DUAL/ON
LIC UTILITY
ConnectiOn Verified q NSTALLER '
['-]Septic Tank or [] HOlding Tank
Size: , If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
Absorption Area to nearest Lot Line
5. COMMENTS
APPROVED FOR , /SEDROOMS
[~f-~ONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE ~ ~3 -- ~lC'~ BY (Title)
LEGAII DESCRIPTION
72~010 (Rev. 3/78)