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~EATER ANCHORAGE AREA BOROUGH
rtment of Environmental Quality
3330 "C" Street, Anchorage, Alaska 99503 274-4561
Date Received February 3, 1977
Time of Inspection ..~.'~ P,~l.
Date of Inspection
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
FOR
1. Approval requested by:
Mailing Address:
2. Property Owner:
Mailing Address:
Legal Description:
e
4.
5.
6.
Theresa J. Miller
pQs~ Office Box 8-666, 99508
Lot 4 Creekside Subdivision
Phone:
Phone: 337-6082 (h)
333-9411 (w)
Location:
Type of facility to be inspected
Well Data: ~.~~
A. Type
7701 Old Harbor Road. t~,~.~
Single Family
B. Depth
C. Construction
7. Sewage Disposal System:
A. Installed
C. Septic Tank:
D. Seepage Pit:
E. Disposal Field:
8. Distances:
A. Well to: Septic tank
Nearest lot line
No. of bedrooms 3
D. Bacterial Analysis
On-site system
B. Installer
1. Size
1. Absorption Area
Total length of lines
2. Manufacturer
2.
Material
, Sewer Lines
, Absorption area
, Other contamination
, Absorption area
B. Foundation to septic tank
C. Absorption area to nearest lot line
EQ-034 (1/74) Page 1 of two pages
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
2510 East Tudor Road, Anchorage, Alaska 99504 276-2221
1. Type of Inspection:
2. Property Owner:
Mailing Address:
3. Name of Buyer:
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTIObl
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER and WATER FACILITIES
FEB 3 1977.
CMRQ VA FHA CONV
Theresa J. Miller
Post. Office Box 8-666
Anchorage, 99508
Day Phone: 337-6082 (h) , 333-9411 (w)
Mailing Address:
Day Phone:
4. Name of Lending Institution:
Mailing Address:
Phone:_
5. Name of Realtor or Agent:
Mailing Address:
Legal Description:
Location:
Phone:
Lot 4 Creekside Subdivision
7701 Old Harbor Road
7. Type of Facility to be Inspected:
8. Water Supply
Type of Supply:
Single Family
Public Utility
No. Bdrms.. 3
Individual
If Individual, number of dwellings presently served
If Individual, depth of well
Sewage Disposal System
Type of System: Public Utility
If Individual, date of installation
Individual (on-site) xx
72-003(3/76)
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C" Street, Anchorage, Alaska 99503 274-4561
Date Received
Time of Inspection
Date of Inspection
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
FOR
--~ ......... ~ ..... ~ ,.:.:.~ ~
1. Approval request y~, .~.~
Mailing Address: /~, ~, ~/..].~, ~b ~F~:/.[' Phone:
...... .~ ,~/-~
2. ~ro,er~ Owner: '":~...~ ~::~ .: , ~o~e: ~::-
~. Typ~ o~ ~ac~]~ty ~o b~ ~nsp~ct~.,... _~~~~' .... ~o. of bedrooms
6. ~ell Data:
A. Type B. Depth
~Pag'e '2 of two pages - Re, .st for Approval of Individual , er & Water Facilities
Legal Description Lot 4 Creekside Subdivision
Approval Valid for one year from date signed
Greater Anchorage Area Borough, Department of Environmenta,~..Quality
DIAGRAM OF SYSTEM
'.
certify that the information contained in this request for approval to be a true and
accurate representation of the subject sewer and water facilities and these facilities
are operating satisfactorily.
SIGNED Date
EQ-034 (]/74)
2.
3.
4,
5.
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate)
.of person requesting aporoval
of property: owner
Number oF bedrooms in house -3 .
Water, Analysis:
a. Bacterial
b. Detergent
Well data:
a. Type .
c. Casing Size
Distance from well to closest existing or proposed:
1. Sewer line
2, Septic tank
3. Seepage Area
4. Cesspool'
5. Property Line
houses, barn, drainage ditch, etc.
Sewage disposal system.
a.
b.
C.
Other sources of possible contamination, i.e., creeks, lakes,
Septic tank capacity in gallons /~.~
Name of septic tank manufactu~e.r 4LLi~'~
1. If "home made" show diagram on reverse side of this form.
Disposal field or seepage pit size and t~e
1. Distance to property line
t-'-~[~., to house foundation
e. Pefco]etlon. Te'st zesu]ts
f. Percolation Test performed by
Use the reverse .side of this form to show diagram. Diagram should include
""~he foil.owing information: p.roperty lines ~ .well location, house location,
~i~'~c tank location, disposal area location, location of percolation test,
a~'d direction of ground slope.
The hr[o~',~.~t~rm on this form is true and correct to the best of my knowledge.
,~ signature Of A~licant ' ~ ' Date Signed'
TO BE FILLED OUT BY HEALTH DEPAP, T~,IENT PERSONNEL
above described sanitary facilities are hereby approved, subject to the
iol!ow~ng conditions:
Conditior, a: /~/~
The above described sanitary facilities are disapproved for the following
re as OTiS:
Approval is valid for one year following the date of approval.
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