HomeMy WebLinkAboutRIFLEMAN BLK 1 LT 10O'7
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
, NSPECTOR I "SPECTOR I NSPEOTO~AU~
OF ANCHo~GE
MUNICIPALITY OF ANCHORAGE ENVIRONMENT,,kL
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 b Street . Anchorage, Alaska 99501 /t ;) J~ ")
ENVIRONMENTAL SANITATION DIVISION
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts ou page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing,
1. PRO~RTY OWNER
MAILING A D~'ESS
PROPERTY RESIDENT (If different from above) PHONE
2, BUYER
MAILING ADD~ESS
3, LE~DING INSTITUT~ '~ "
MAI LINd AbbR ESS
4. REALTOR/AGEnT
MAILING ADDRESS
5. LEGAL DESCRIPTION
STREET LOCATION
6. TYPE OF RESIDENCE
~[]~'SINGLE FAMILY
[] MULTIPLE FAMILY
W . ER SUP,LV
NUMBER OF~BEDROOMS
[] One [] Four
,~[:~ Two [] Five
[] Three [] Six
[] Other
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
8. SEWAGE DISPOSAL SYSTEM
*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.)
INDIVIDUAL/ON-SITE**
._,J~PUB LIC UTI LITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
:~ERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY )ATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
~ERMIT NUMBER
3, SEWAGE DISPOSAL SYSTEM
[]INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified iNSTALLER
[]Septic Tank or [] Holding Tank
Size:_ If Tank is homemade 8OIL$ RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSOFIPTION AREA MATERIAL
4. DISTANCES Septic/H°lding Tank IAbs°rpti°n Area Isewer Line INearest L°t Line
WELL TO:
Absorption Area to nearest Lot Line
5. COMMENTS
E~ APPROVED FOR BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
~ DISAPPROVED .~~
DATE BY
72-010 (Rev. 6/79)