HomeMy WebLinkAboutROMIG PARK BLK 6 LT 23001
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DATE RECEIVED
INSPECTION APPOINTMENTS
TIME !TIME TIME
DATE DATE DATE 0~'
,NSPECTOR ,NSPEOTOR ,NSPECTOR
MUNICIPALITY OF ANCHORAGE
MUNICIPALITY OF ANCHORAGE DEPT. OF i-'
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEC[~ONM[.NTAL ;:. ;~:.CTiON
825 L Street - Anchorage, Alaska 99501
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ENVIRONMENTAL SANITATION DIVISION
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SE~ ~A~LYT~
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be proceed. Please allow ten (10) days for processing.
1. PROPERTY OWNER PHONE
MAILING ADDRESS
PROPERTY RESIDENT (If different from above) PHONE
2. BUYER PHONE
MAi LING A DDR ESS
MAILING ADDRESS
MAILING ADDRESS
5. LEGAL DESCRIPTION
STREET LOCATION
6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS
[] One [] Four
~ SINGLE FAMILY ~. Two [] Five
[] MULTIPLE FAMILY [] Three [] Six
[] Other
7. WATER SUPPLY
[] INDIVIDUAL* * ATTACH WELL LOG. A well Icg is required for all wells drilled
~ COMMUNITY since June 1975, For wells drilled prior to that date, give well
[] PUBLIC UTI LITY depth (attach Icg if available,)
8. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE** .YEAR ON-SITE SYSTEM WAS INSTALLED.
~;~ PUBLIC UTI LITY
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 OE 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 UTI LITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[]INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified INSTALLER
E~Septic Tank or [] Holdin§ 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
WELL TO:
Absorption Area to nearest Lot Line
5. COMMENTS
I~]'~APPROV ED FOR % BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED ,,
/
DATE BY
72-010 (Rev. 6/79)