HomeMy WebLinkAboutPALOS VERDES BLK 7 LT 1
MUNICIPALITY OF ANCHORAGE~ur~ ~' ' I IPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIO~EPT OF 14EALTH &
825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL P~OTECTION
ENVIRONMENTAL ENGINEERING DIVISION
Telephone 264-4720 MAR 2 6 1981
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SE~I~I(~/~C]I ~E~
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OWNER -- ~ .PHONE
MAILING ADDRESS ~
~ROPERTY RESIDENT (If different from above) PRONE
2. BUY~
MAILING ADDRESS
3. LENDING INSTITUTION PHONE
MA~NG ADD ~ESS
~. REALTOR/AGENT ~ I PHONE
MAIL~G ADDRESS
5. LEGAL DESCRIPTION
6. TYPE OF RESIDENCE NUMBER OF BEDROOMS
One ~ Four
~ ~ Two ~ Five
SINGLE
FAMILY
~ 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
**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)
~ THIS SIDE FOR OFFICIAL USE ONLY
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
E~PUBLIC UTILITY
Connection Verified ~ NSTALLER
[]Septic Tank or []Holding Tank
Size: If Tank is homemade SOILS RATING
give dimens'ions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES Septic/Holding Tank IAbsorption Area ISewer Line I Nearest Lot Line
WELL TO:
I
I
I
Absorption Area to nearest Lot Line
5. COMMENTS
[~"APPROVED FOR _~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[~ DISAPPROVED -
DATE BY (Title) /~
LEGAL DESCRIPTION
72-010 (Rev. 3/78)