HomeMy WebLinkAboutBROOKWOOD BLK 1 LT 1701 - I'11- 06
DATE RECEIVED
· ' INSPECTION APPOINTMENTS ~--<;L~ j~_./~
TIME TIME ' TIME '
DATE DATE DATE
INSPECTOR INSPECTOR
· INSPECTOR
MUNIC AL ANCHOR .......
IP ITY OF AGE I=klVIBC3NMENTAL
~ DEPARTMENT OF HEALTH&ENVIRONMENTAL PRO'I'EC~""-i-'~,8
825 L Street-Anchorage. Alaska 99501 1980
U
ENVIRONMENTAL SANITATION DIVISION
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACl LITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPER~.,yOWNER ' , ' ' I PHONE~.,5'lCJ .'~'~
PROPERTY RESIDENT (If different from ~bove) ' " PHONE
2. BUYE~ ' ~ ' PHONE
~AIEING ADDRESS
3. LENDING INSTITUTION~ ~ , I PHONE
4. REALTOR/AGENT
I5.LI~3AI. DESCRIPTION
_ 12, I , Lo/'
J STREE~OCATION ~ I
J 6. TYPEOF~RESIDENCE
.~ SINGLE FAMILY
[] MULTIPLE FAMILY
7, WATER suPPLY
[] INDIVIDUAL*
COMMUNITY
[] PUBLIC UTILITY
8. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE**
PUBLIC UTILITY
NUMBER OF~BEDROOMS
[] One ~ Four [] Other
[] Two [] Five
[] Three [] Six
* ATTACH WELL LOG. A well log is required for all wells drilled
since. June 1975. For wells drilled prior to that date, give well
depth .(attach log if available.)
%~,(~.- ~°t~ 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
[] SINGLE FAMILY
[] MULTIPLE FAMILY
2. WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTILITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON -SITE
[]PUBLIC UTILITY
Connection Verified
[]Septic Tank or [] Holding Tank
Size: If Tank is homemade
give dimensions:
[] ONE
[] TWO
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
SOl LS RATING
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES
WELL TO:
NUMBER OF BEDROOMS
[] THREE [] FIVE
[] FOUR [] SlX
[] OTHER
Absorption Area to nearest Lot Line
Septic/Holding Tank [Absorption Area
Sewer Line
Nearest Lot Line
5. COMMENTS
DATE
[~-"'APPROVED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
72-010 (Rev, 6/79)
FHA Form 2573 '; Form Approved
Rev. July 1958 FEDERAL HOusING ADMINISTRATION Budget Bureau No. 63-R296.8
HEALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
PART I.--TO BE COMPLETED BY FHA
INSURING OFFICE MORTGAGEE SERIAL NO.
MORTGAGOR OR SPONSOR PROPERTY ADDRESS J ~
SUBDIVISION NAME ~-~ BLOCK NO. LOT NO.
TOTAL
NUMBER:
Can attic or other area be made into
J~J New installation additional bedrooms?
BASEMENT
LIVING UNITS BEDROOMS BATHS
(If Yes, how many~)
WATER SUPPLY BY: SYSTEM DESIGNED FOR
~ Public system ~ Communi, system ~ Individual ~o. o~
SEWAGE DISPOSAL BY:
~ ~blic system ~ Community system ~ Individual ~ ~ Yes ~ No
PART II.~TO BE COMPLETED BY HEALTH DEPARTMENT
HEALTH DEPARTMENT INSPECTOR'S SKETCH
~':-~--~, .... . ~---
. ~ ~---~-~--
I
___~ ...... ~___~ , . .......
~- 4 ~ .......
/
....... ~.~ ~
~ o~o~ o~ ~e ~ ~a~ ~ ~ou~. ~a~ ~a~ o~.~h ~h~ ~h~ ~a~ w~-~ ~m
~ is ~ is not satishctory as a domestic water supply for the subject properS.
It is the opinion of the ~ State ~ County ~ocal Department of Health that this individual sewage-disposal sys-
tem with proper maintenance:
~h be expected to hnction satishctorily, and ~ Cannot be expected to function satishctorily
is not likely to create an insanit~ condition
SIGNATURE
f
Ute of the above grid for Health Department Inspector's sketch as Well as use of the bae~ of ii~J~ f~'~
health authority.
PART III.~FOR USE OF FHA OFFICE
TO THE CHIEF UNDERWRITERJ
~ h~ve reviewed c~e (o~e~oin~ ~nd the pe~inenc ~HA Compli~ce ins~ion Kepo~, ~nd ~ecommend
Individual water-supply system be considered ~ Acceptable ~ Not Accep~ble
~wage dis~sal ~ considered ~ Acceptable ~ Not Acceptable.
DATE SIGNATURE ~ C~IEF ~RC~T~CT
DEPUTY FOR CHIEF ARCHITECT
HEALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
FHA Form 2573
Rev, July 1958
61
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