HomeMy WebLinkAboutCREEKSIDE PARK #1 LT 34
DATE'RECEIVED
INSPECTION APPOINTMENTS
TIME TIME ,,, .t__.~ TIME
~ ~/// DATE
DATE
DATE O~)
INSPECTOR INSPECT
MUNICIPALITY OF ANCHORAGE DEPt.
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEC~~O~E~AL
825 L Street-Anchorage, Alaska 99501 0CT 9 1980
ENVIRONMENTAL SANITATION DIVISION
Telephone 264~720 .RECEI .ED.
REOUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete reques~ will not be proc~d. Please allow ten (10) days for processing.
1. PEOPEETYOW~ ~ / PHONE
~ROP~RTY RESlD~ (If different from above) ~ PHONE
PHONE
3. LENDING INSTITUTION ~ PHONE
4. REALTOr/AGENT ~ · PHONE
~AILING ADDreSS
5. LEGAL.DESCRIPTION /
STF[E ET 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 PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
[] SINGLE FAMILY
[] MULTIPLE FAMILY
2. WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTILITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON -SITE
[--IPUBLIC UTILITY
Connection Verified
[]Septic Tank or [] Holding Tank
Size: If Tank is homemade
give dimensions:
NUMBER OF BEDROOMS
[] ONE [] THREE
[] TWO [] FOUR
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
SOl LS RATING
[] FIVE
[] SiX
OTHER
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCESwELL TO: Septic/H°lding Tank IAbs°rpti°n Area Isewer Line INearest L°t Line
Absorption Area to nearest Lot Line
5. COMMENTS
DATE
~APPROVED FOR ._~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[--~ DISAPPROVED
B Y .' '/~'''~
72-010 (Rev. 6/79)