HomeMy WebLinkAboutT13N R3W SEC 13 Lot 74
MUNICIPALITY OF ANCHORAGE
MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTI(~flVIRONMENTAL P[,OTECTION
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL ENGINEERING DIVISION JAN :1. 5 1979
Telephone 264-4720 Ri~CEtT~i:)
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND 8EWER FACIL T
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROP~,~TY OWN E R PHONE
MAILING ADDRESS
PROPERTY RESIDENT (If different from above)
2, BUYER
PHONE
PHONE
MAI LING ADDR ESS
MAILING ADDRESS
4. REALTOR/AGENT I PHONE
MAILING ADDRESS
5. LEGAL DESCRIPTION
STREET LOCATION
6. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] One [~'"'~ou r
[] SINGLE FAMILY [] Two [] Five
~ MULTIPLE FAMILY [] Three [] Six
[~] Other
7. WATER SUPPLY
~ IND(VIDUAL*' I~D J~--~ * ATTACH WELL LOG. A well log is required for all wells drilled
[] COMMUNITY since June 1975. For wells drilled~ to that date, give well
[] PUBLIC UTI LITY ciepth (attach log if available.)
8.
SEWAGE
DISPOSAL
SYSTEM
· *if individual/on-site, give installation date ~'/'L~//~ .
[] INDIVIDUAL/ON-SITE**
If system is over two (2) years old an adequacy test is required
[~"~PUBLIC UTI LITY by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72~1o(3/78}
THIS SIDE FOR OFFICIAL USE ONLY
CATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR
DIRECTIONS:
1, TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [~) OTHER
[] MULTIPLE FAMILY [] TWO E3 FOUR [] SiX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTI LITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDIVIDUAL/ON -SITE DATE INSTALLED
[]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
4. DISTANCESwELL TO: Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line
~.Ab'°rpti°nAr"at°near'$t LotLine /V01~ ' ' ~'~ ~' ~ ~ ~COMMENTS
~ APPROVED FOR BEDROOMS [),~-
~CONDITIONAL~ DISAPPROVED APPROVAL (letter must accompany certificate)
DATE '
BY (Tit[e} / /.
72-010 (Rev. 3/78)