HomeMy WebLinkAboutLAKEHURST BLK 5 LT 10A
D A-T~' RECEIVED
ANNU ,TIE~. p~.S,O~>po~.S TS
-" TIME
INSPECTOR
NEW YORK LIFE INSURANCE COMPANY I 2'~
279-647 I ~LITY Of ANCHORAGE MUNICIPALITY
.LTH & ENVIRONMENTAL PROTECTION DE~T. ~:,:
...... ~et - Anchorage, Alaska 99501 ENVIRCh~', &, ....
ENVIRONMENTAL SANITATION DIVISION ~: i: ~;
Telephone 264-4720
.o.A...OVA. o.
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed, Please allow ten (10) days for processing.
PHONE
I. PROI~ERTY OWNER · , >
MAILING ADDRESS
PROPERTY RESIDENT (If differer{t from above)
MAILING AD DR ES,~./
PHONE
PHONE
3. LENDING INSTITUTION
PHONE
MAILING ADDRESS ~/ .'1 ~ '~'-- 0 ~/
4. REALTOR/AGENT
MAILING ADDR ES~S
PHONE
5. LEGAL DESCRIPTION
;TREET LOCATION
6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS
[] One EZ] Four
~ SINGLE FAMILY ~ Two [] Five
[] MULTIPLE FAMILY [] Three [] Six
[] Other
7. WATER SUPPLY [] INDIVIDUAL*
COMMUNITY
[] PUBLIC UTILITY
* 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.)
8. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE**
)~ PUBLIC UTILITY
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
E] iNDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
E] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] IN DI VI DUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified j0 -'t0 '--) ~ INSTALLER
E~Septic Tank or [~]Holding 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
1
WELL TO:
Absorption Area to nearest Lot Line '
5, COMMENTS
I~]'-'" APPROVED FOR ~-~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[~] DISAPPROVED
DATE BY