HomeMy WebLinkAboutLAKE SPENARD PARK BLK 4 LT 2 OF RESUB
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMSNTAL PROTECTION
APPLICATICIN FOR HEALTH ~ETHORITY APPROVAL CERTIFICATE
1 o C~r. eral Information
Application Date
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (add,ess or directions)
(b) Applicants Nares._ ~ok~, Ii). ~l¢~-~g
Applicants Address ~.O. %~X ~ )
(c) Appliqant~is (cb~ck one) lending Institution ~--~; fX~ner/builder ~ ;
Buyer ~--~; Other ~-~ (explain);
(d)
Telephcr~
2..Type of Nesidence
Single-Family
Lending Institution
(e) ~al Estate ~. & Agent
Nun~e~ of Bedrooms ~
O~er (~s~i~)
Telephone~(~ ! - 1 7 ~
3. $~ter Supply_
Individual Well ~--T Co~m]nity [~ Public ~
Note: If c~aunity w~tl system, must have w~itten confirmation from the State
Department of Environn~ntal Conservation attesting to tbs_ legality, and status.
Is the well adequate fo= the number of bedrocks specified in this HAA (Y./N)
4. Sewage Disposal
Onsite nit, ank
Is the wastewater disposal system adequate for the ~r of b~drocms (Y/N)
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5. 5~gineering Firm Providin9 Inspections, Tests, Data and Information
I c~rtify that I have checked, verified, or conformed to all MOA HAA Guidelines in
effect on the date of this inspection.
Signed Date
Nam~ of Firm
Telephone
Signed by
Date ~
(ENGINEER SEAL)
Approved for ~ bedrooms By. Date
Approved ~-~ Disapproved ~ Conditional ~
Te~ms of Conditional Approval_ ~~ ~ ? ~~ ~-~ ~-,
/he Municipality of ~cho~a~ ~p~nt of ~alth and Envi~o~ntal ~otection d~s
not ~arantee t~ continued satisfactory ~rf~n~ of t~ wate~ supply a~./or the
was~watez, dis~sal system. ~is approval indicates that, as of ~ ~lidation ~te
sh~ ~, ~d on t~ ~ta and infor~tion f~nished ~ ~ e~gir~er registe~d in
the State of ~aska, ~e ~ter supply ~d wastewater dis~sal system is safe and fun~
'tional fo~ ~e ~r of ~ ~d t~ of s~uct~e indicated.
(~EP S~) ~ ~
7. ~il the ~ to the foll~ing ~ess:
KB2/d5/s
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