HomeMy WebLinkAboutCALAIS BLK 5 LT 6000
DATE RECEIVED
APPOINTMENTS
INSPECTION ~.~~-
~/~,'~ ~_' DATE
MUNICIPALITY OF ANCHORAGE MUNICIPALITY CF AF.!CHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECT MI "~:F'T. :.
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL SANITATION DIVISION t": ["~
Telephone 264-4720
o. ,..,V,OUA.
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed, Please allow ten (10) days for processing,
1. PROiPERTYOWNER I PHONE
MAI LIN G/ADDR ESS
PROPERTY RESIDENT (if different from above) PHONE
2. BUYER PHONE
MAILING ADDRESS
3. LENDING INSTITUTION ~ PHONE
MAILING ADDRESS
4. REALTOR/AGENT I PHONE
MAILING ADDRESS
5. LEGAL DESCRIPTION
STREET LOCATION
6. TYPE OF RESIDENCE
[] SINGLE FAMILY
[;;~'-MU LTIPLE FAMILY
NUMBER OF~BEDROOMS
[] One _.[~'" Four
[] Two [] Five
[] Three [] Six
[] Other
7. WATER SUPPLY E~ 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
[] ONE
[] TWO
NUMBr~R OF BEDROOMS
[] THREE [] FIVE
[] FOUR [] SlX
[] OTHER
2. WATER SUPPLY
[] INDIVIDUAL
COMMUNITY
[] PUBLIC UTILITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON -SITE
[]PUBLIC UTILITY
Connection Verified
[]Septic Tank or [] Holding Tank
Size: If Tank is homemade
give dimensions:
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
iNSTALLER
SOl LS RATING
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
Septic/Holding Tank
Absorption Area [Sewer Line
Nearest Lot Line
5. COMMENTS
/,.:.)~ ยท ; t
DATE
[~.~/APPROVED FOR /' ~' BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED ....
/
I BY / .
72-010 (Rev. 6/79)
