HomeMy WebLinkAboutLENA HANSEN LT 7Len
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~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION L.t~.-L~
//'m ;,~.'N'~ 825 I. Street - Anchorage, Alaska 99501
/~.r~/ ENVIRONMENTAL ENGINEERING IVISION '
D
~ Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1, Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OWNER PHONE
William A/Betta D. Borchardt . 277-3527<a~
MAILING ADDRESS
2310 Lincoln Street 99503
PROPERTY RESIDENT (If different from cbovs) -- PHONE
2. BUYER PHONE
MAILING ADDRESS
3, LENDING INSTITUTION I PHONE
National Bank of Anchorage % Ruth La BarI 276-1132
MAILING ADDRESS
Pouch 7-025 99510
4, REALTOR/AGENT I PHONE'
MAILING ADDRESS
5. LEGAL DESCRIPTION
Lot ~ and Lot 7 Lena Hansen Addition Subdivision
STREET LOCATION
6. TYPE OF RESIDENCE NUMBER OF BEDROOMS
I-q One [] Four [] Other
~ SINGLE FAMILY ~ Two [] Five
[] MULTIPLE FAMILY [] Three [] Six
7, WATER SUPPLY
~ INDIVIDUAL~ 'ATTACH WELL LOG. A well log is required for all wells drilled
[] COMMUNITY since June 1975. For wells drilled prior to that date, give well
[] PUBLIC UTILITY depth (attach log if available.}
8. SEWAGE DISPOSAL SYSTEM
~] INDIVI DUAL/ON-SITE*' *~ f individual/on-site, give installation date .
f system is over [wo (2) years old an adequacy test is required
[~ PUBLIC UTILITY by this Department,
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING (,AN 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
[] I N DI VI DUAL/ON -SITE DATE INSTALLED
E~PUBLIC UTILITY
Connection Verified INSTALLER
[]Septic Tank or [~] Holding Tank
Size: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4, DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
[] APPROVED FOR ' BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany .certificate)
[~'~'~ISAPPROV ED
LEGAL DESCRIPTION
72-010 (Rev, 3/78)
.... ~ MUNICIPALITY OF ANCHORA~- /
~b Department of Health and Environr0en~l Protection
//~ 825 L Street, Anchorage, Alaska 99501
" '~equest for Approval of Individual Sewer and Water Facilities
2. Na~e of Suyer:
Mailing Address: Phone:
Mailing Address: 3
Realtor/Agent: /~ ~__~ ~
Mailing Address: Phone:
Street Location:
o
Single Family Residence: (~ Number of Bedrooms:
Multiple Family Residence: ( ) Number of Bedrooms:
WaterIf Individual*~'n--~'Supply:Well,*Individual Well we~l~..~ .... (~---~Pu lic/Community..
If Community System, name of system
Syste~n ( )
Sewage Disposal System: *~Dn-site System ( ) Public System
If On-site System, date of installation:
*NOTE:
3/77
A well log is required on ALL wells drillec'l since 6/75.
** If on-site sewer system .is over two(2) years old, an adequacy
test is required by this department.
A fee of $25.00 mt]sC accompany each request before processing
can be initiated.
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