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~ MUNICIPALITY OF ANCHORAGE MUNICIPALITY O~ ANCHORAGE
ENVIRONMENTAL ENGINEERING DIVISION
Telephone 264-4720
DIRECTIONS: Complete all pa~s on page 1. Incomplete requests wiB not be processed, Please allow ten (10) days for pr~essing.
PROPERTY RESIDENT (If different fr~m above) PHONE
MAILING ADDRESS
4, REALTOR/AGENT PHONE
STREET LOCATION
6, TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] One [~ Four c~- Other
[] SINGLE FAMILY [] Two [] Five
,~ MULTIPLE FAMILY [] Three [] Six
7, WATER SUPPLY
~ INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTi LITY
* 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.)' ~
8. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE"*
PUBLIC UTI LITY
*"If individual/on-site, give installation date .....
If system is over two (2) years old an adequacy test is required
by this Department,
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010(3/78)
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