HomeMy WebLinkAboutPALOS VERDES BLK 6 LT 7
MUN,C PA.,T¥ Or ANCHORAG".ROTEC ON NT^L
DEPARTMENT OF HEALTH & ENVIRONMENTAL PI:~OTECTION
825 L Street - Anchorage, Alaska 99501 JUL ~- 2 19~'9
ENVIRONMENTAL ENGINEERING DIVISION
Te,ep,o.. 264-4 o R[CEIYFD
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
~)1RECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERT¥OWNER I PHONE
Larry White
MAILING ADDRESS
Out of State
PROPERTY RESIDENT (If different from above) PHONE
Danny R. Simmons
2. BUYER PHONE
Danny R. Simmons
MAILING ADDRESS
3, LENDING INSTITUTION I PHONE
Coast MortgageI 279-0665
MAILING ADDRESS
I PHONE
4. REALTOR/AGENT AREA, Inc. Realtors
Myrna Johnston 694-9555
MAILING ADDRESS
P. O. Box 249, Ea.91e River,...AK 995~7 .
5. LEGAL DESCRIPTION
Palos Verdes Subd. Blk 6, Lot 7
~TR E ET LOOAT~ ON
Baronoff Avenue
6. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] One [] Four [] Other~
[] SINGLE FAMILY [] Two [] Five
[] MULTIPLE FAMILY ~ Three [] Six
7. WATER SUPPLY [] INDIVIDUAL*
COMMUNITY
[] PUBLIC UTILITY
* ATTACH WELL LOG. A well Icg is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach Icg if available.)
8. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
**If individual/on-site, give installation date
If system is over two (2) years old an adequacy test is required
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010(3/78)
L,,...~, THIS SIDE FOR OFFICIAL USE ONI'Y
DATE 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 [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL 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 F-IHolding Tank
Size: If Tank is homemade ! SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES Septic/Holding Tank IAbsorption Area Sewer Line I Nearest Lot Line
WELL TO:
I
Absorption Area to nearest Lot Line
5. COMMENTS
[/~APPROV ED FOR ~.~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
LEGAL DESCRIPTION
72-010 (Rev. 3/78)
