HomeMy WebLinkAboutPALOS VERDES BLK 5 LT 165
--3
"'~ DA~ ~_'~R ECEiVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE f_~(: ~{
INSPECTOR INSPECTOR I NSPECTOF~ ,
MUNICIPALITY OF ANCHORAGE ~UNICIPALI~ OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTE~oF HEALTH
825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL
ENVIRON~ENTAL SANITATION DIVISION OCT ~ ? 1980
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AN~
DIRECTIONS: CompJete all parts on page 1. Incomplete reques~ will not be proce~ed, Please allow ten (10) days for processing.
1. PROPERTY OWNER ~ ~ PHONE
MAI~ADDRESS
PROPERTY RESIDENT (If different from above) PHONE
PHONE
MAiEING ADDRESS /~ .
3. LENDIN~INSTITUTION I PHONE
~AILING ADDRESS
4. REALTOR/AGENT / I PRONE
M~G A D DR ESS
5.
LEGAL
DESCRIPTION
/
TREET LOCATION
6. TYPE OF RESIDENCE NOMBER OF~BEDROOMS
[] One J~ Four
~J~ 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) f~/C
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY I-~ ONE [~ THREE BI FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVI DUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
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. DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line
I
WELL TO:
Absorption Area to nearest Lot Line
5, COMMENTS
APPROVED FOR BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY
72-010 (Rev. 6/79)
GREATER ANCHORAGE AREA BOROUGH
Department of 'Environmental Quality
3330 "C" Street, Anchora§e,:Alaska 99503 274-4561
Date Received ~lj
Time of Inspection
Date of Inspection
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
FOR
Conv.
1. Approval requested by:
Mailing Address:
2. Property Owner:
Mailing Address:
National Bank of Alaska
Post Office Box 3-3859
Phone:
Curt Dahl Phone:
3. Legal Description: Lot 16 Block 5 Palos Verdes
Location:
e
Type of facilityto be inspected Single Family No. of bedrooms
. Well Data: Community System
A. Type B. Depth
C. Construction D. Bacterial Analysis
Sewage Disposal System: Public utility
A. Installed B. Installer
C. Septic Tank: 1. SiZe 2. Manufacturer
D. Seepage Pit: 1. AbSorption Area . 2. Material
E. Disposal Field: Total length of lines
Distances:
A. Well to: Septic tank , Absorption area , Sewer Lines
Nearest lot line , Other contamination
B. Foundation to septic tank , Absorption area
C. ADsorption area to nearest lot line
EQ-034 (1/74) Page 1 of two pages
Page 2 of two pages - R~___~st for Approval~of Individual ~er & Water Facilities
Legal' Description Lot 16 Block 5 Palos Verdes Subdivision
Comments
Approved
~~p~Ap ov Disapproved Date
al ,.Valid for one year from date signed
Greater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
I 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 (1/74)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF ENVIRONMENTAL QUALITY
3330 'C" Street, Anchorage, Alaska 99503 -- 274-4561
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER and WATER FACILITIES
MUNiCiPALiTY OF ANCHOP. AGE.
gEPT. OF HEAL'TH 8~
ENVJRONMJ~NTAt' pROT ~.CT IOJq.
£CEIVED
1. Type of Inspection: CMRO VA
2. Property Owner:
FHA
CONV
Mailing Address:
3. Name of Buyer: ~
/
Mailing Address:
4. Name of Lending Institution:
Mailing Address:
5. Name of Realtor or Agent:
Mailing Address:
Day Phone
Day Phone
Phone
Legal Description:
Location:
7. Type of Facility to be inspected:
8. Water Supply
Type of Supply:
Public Utility
No. Bdrms.
Individual ~
If Individual, number of dwellings presently served
If Individual, depth of well
Sewage Disposal System
Type of System:
Public Utility
Individual (on-site)
If Individual, date of installation
EQ-037 (1/74)