HomeMy WebLinkAboutT12N R3W SEC 33 LT 125 120'X 135' ~-- ¢IUNICIPALITY OF ANCHORAGE
i~.~ DEPARTMENT OF HEAL'CH & ENVIRONMENTAL
PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
[~ 825 L Street- Anclmrage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME P~NE ~ " EW_
*~ Liq. capacity in gallons Inside length 4/ Width i Liquid depth ~A~ --
m v~ %4} iF HOMEMADE: [ ~ id
DISTANCE TO: Well ~% :oundation X --[ &(} '~ ~)*C) (¢)
~~ ~'. "Ol Of lines ~ L~ngth of ,ecl% line(~(:, Total length of lin~,~ (~,,_ Tre,,oh w~:l;~,,,~ inches Distance between lines
CI ss CX Depth Driller Distance fo lot line PERMIT NO.
OTHER ] ).~c ~-~L
PIPE MATERIALS / X~
~ k
72-013 (Rev. 3/78)
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825 L Street - Anchorage, Alaska 9gE01 . I:l~vmu~,~ ....... 0 I~[
REQUEST FOR P R V LO I L ERA
DIRECTIONS: Comolete aH parts on eago 1, Incomeloto remmsts will not be processed. Please allow ten (10) days for pl'ocesslna,
~'HONE
1. PROPERTY OWNER
MAILING ADDRESS
PR£ ~ERTY RESIDENT uf differonl from
I~HONE
PHONE
[~UYER
MAILING ADDRESS
'~. LENDING INST{TUTION
MAILING ADDRESS
4, REAL'FOR/AGENT
MAI LING ADDRESS
PFIONE
STREET LOCA'FION
6. TYPE DP RESIDENCE
S[NGLE FAMILY
MULTIPLE FAMILY
NUMBER OF BEDROOMS
[] One [] Four
[] Two [] Five
[] Tnree ~} Six
[] Other
7. WATER SUPPLY
INDIVIDUAL'
[] COMMUNITY
[] PUBLIC UTILITY
-~', SEWAGE DISPOSAL SYSTEM
NDIVIDUAL/ON'SITE*"
[] ~UBLIC UTILITY
ATTACFI WELL -OG. A well log is requlree fo~ all wells drilled
since June 1975, :or wells drilled ~ric ' to mat earn, give we
depth {attach log f available.. -~'~.~ e_. /~
~* ~ individual/on-site, give installation dam
f system is ovor two (2) veers old an adequacy test is requlreQ
t)V this Department,
NOTE: THE INSPECTION FEE MUST ACCOMPAN¥~EACH REQUI:ST BEFORE PROCESSING CAN BE INITIATED.
THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME --
DATE DATE
i DATE
INSPECTOR INSPECTOR I NS PECTO R
DIRECTIONS:
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
2. WATER SUPPLY PERMrT NUMBER
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[]INDIVIDUAL/ON -SITE DATE INSTALLED
E~] PUBLIC UTILITY
Connection Verified
INSTALLER
[]Septic Tank or [] Holding Tank
Size; /~ If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
~'~"~p ' /Holdin§ Tan Area Line Line
4. DISTANCES Se tm
k IAbs~rption Sewer Nearest Lot
WELL
TO:
I
Abs~p~tion Area to nearest Lot Line
5, COMMENTS
~-APPROV ED FOR ~"~- BEDROOMS
[~] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY (Title)
LEGAL DESCRIPTION