HomeMy WebLinkAboutALYESKA BASIN #5 BLK 5 LT 12
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME ~ TIME TIME
\
DATE A DATE DATE
I NSPECT(;~c{ INSPECTOR I NSP ECTOR
m~ ~ ~ MUNICIPALITY OF ANCHORAGE
DEPT. OF ltI:ALIH ~
MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL PROTECTION
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 LStreet-Anchorage, Alaska 99501 NOV 4 1979
ENVIRONMENTAL SANITATION DIVISION
Telephone 264-4720 RECEiV ED
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACl LITI ES
DIRECTIONS: Complete all parts ~ll page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OWNER I PHONE
Ed SheltonJ 243-0258
MAI LING ADDRESS
9541 Arlene Street 99502
PROPERTY RESIDENT (If different from above) PHONE
2. BUYER PHONE
MAI LING ADDR ESS
3. LENDING INSTITUTION ~ PHONE
National Bank of Alaska % ShirleyI 276-1132
MAI LING ADDRESS
Pouch 7-025 99510
4. REALTOR/AGENT J PHONE'
I
MAI LING ADDR ESS
5. LEGAL DESCRIPTION
Lot 12 Block 5 Alyeska Basin Subdivision Unit 95
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 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
[]PUBLIC UTILITY
Connection Verified
[]Septic Tank or [] Holding Tank
Size: If Tank is homemade
give dimensions:
NUMBER OF BEDROOMS
[] ONE [] THREE [] FIVE
[] TWO [] FOUR [] SiX
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
SOl LS RATING
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AR EA MATERIAL
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
OTHER
Septic/Holding Tank
Absorption Area JSewer Line
Nearest Lot Line
5. COMMENTS
DATE
[~;~PPROVED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
72-010 (Rev. 6/79)
MUNICIPALITY OF ANCHORAG~
.__~~ Department of Health and Environmental Protection
825 L Street, Anchorage, Alaska 99501
~~q 264-4720
i~ uest for Approval of Individual Sewer and Water Facilities
Property Owner: Ed Shin1
Mailing Address: ~_ Strmmt
Phone: 2A~-O25g ___
o
Name of Buyer: sam__~
Mailing Address:
Phone:
o
Lending Institution:
Mailing Address: __
National Bank ~f Alaska
Pouc~h 7025 Aneh~r~g~ q~] Q
Phone: _ 276-11 ~2
Realtor/Agent:
Mailing Address:
Phone:
o
Legal Description:
Street Location:
Lot 12, Block,5~ Alyeska Basin Subd. Unit V
9541 Arlene Street
Single Family Residence: (x) Number of Bedrooms:
Multiple Family Residence: ( ) Number of Bedrooms:
o
Water Supply: *Individual Well ( )
If Individual Well, well depth
If Con~nunity System, name of system
Public/Community System (x)
o
Sewage Disposal System: *~Dn-site System
If On-site System, date of installation:
( )
Public System x)
*NOTE:
A well log is required on ALL wells drilled since 6/75.
** If on-site sewer system is over two(2) years old, an adequacy
test is required by this department.
A fee of $25.00 must accompany each request before processing
can be initiated.
3/77
~e~tor Ad~,,:Ln~LstL'at~.ve O~£Xoer