HomeMy WebLinkAboutZODIAK MANOR ALASKA BLK 5 LT 22
~'q) ~ MUNICIP/\LII'Y OF ANCHORAGE
//~"'~i~ I)[~I:'ARTMEI OF HEALTH AND ENVIRONMEN'I PFOTECTiON
........
]., Lendlnq instihuti~on Request: Alaska Mutual F;avings Bank % Linda
Mai.:l. Jng Address: Post Office Box 1120 99510 Phona: 274--3561
Property Owner:
Mail~ng Address:
Gary Conrad Phone:
% Gar Wau¢ h Jack White Realty
Lc~ga.] Descri. p'L:.IOD: LOt 22 Block 5 zodiak Manor Subdivision
4: ~ngle l~am]._,.y I{e.,ldc. nce. ( Number of 6~drooms. six
Mu1%iple Fami].y Resideace: (
Nllm]-)o~ ot! Bedroorl/s:
5. Well System: Indivi. dual. well (x}~ CommunLty/Publ:ic Sysnen, (
PermiL ~ ..~.~_7~ .... Depkh of Wel.l.._~5-- ............ Well. L,)q on
FJ
(
)
oy. t.-fll [ ) ??? Public Uti]iLy
6,Sewage Disposal System: Om-site ~'
Permit Installed Installe['
Sept].c '£ank Size
Absorption Area Soils
Rate
Material
7. ]}istances: We].1 to Septic Tank
to Sewer Line Nearesn
to Nearest Lot
to Abso~;pt.~on Ar~a
Al)sor~tion A'cc~a
Page Two
] J ep ar'~.]a ewl:. of
Request for Approval
Legal Descrzpt :Lon:
I-Ileal ah a~nd Environn,enta 1. P r'ot ec'tion
of Ind-JvJJ lal Sewer and Wat~.n' Fae.i. lit[e,;
Lot 22 Block 5 Zodiak Manor Subdovosion
Affadavit Attached.
Disapproved '
Depa~tlaenw Worksheet
I,etter At. tached: ( )
Date
Date
MUNICIPALITY OF ANCHORAGE
DEPARTMENT O1-- HEALTH AND ENVIRONMENTAL PROTECTION
825 L Shreet, Anchorage, Alaska 9950].
279-2511, ext. 224, 225
REQUEST FOR APPROVAL OF:
INDIVIDUAL SEWER and WATER FACILITIES
1. Type of Inspection:
2. ProperW Owner:_
Mailing Address:__
3, Name of Buyer:___~b 6:~(~
Mailing Address:=.~J~J~_
VA
FHA_ CONY X
Day Phone:_
- Day Phone:_ ;~ /~q~(~
_ II__
4. Name of Lending Institution:__ A
Mailing Addross:..~
Mailing Address:_%~ L ~
6, Legal Description ~-'~¢
7, Type of Facility to bo Inspected:
No, Bdrms.__ (¢~
Water Supply
Type of Supply: Public Utility
If Individual, number of dwellings presently served
If Indiviclual, depth of well_
Individual__.
9. Sewage Disposal System
Type of System:
Public Utility__
Individual (on-site)
If Individual, date of installation
72 003(3/76)
ADHW- LAB · 2~
)ATE
D'OARTMENT OF HEALTH AND WE~ ~.RE
DIVISION C)F'OUBLIC HEALTH
BACTERIOLOGICAL WATER ANALYSIS
- ~ :pOInT RESULTS TC
NAME
ADORESS
CITY
SAMPLE COLLECTED BY-
DATE COLLECTED. . TIME COLLECTED '
When?
PURPOSE OF EXAMINATiON:Illness Suspecled? E] Yes [~] No
SANITARIAN'S REMARKS
READ INSTRUCTIONS
ON
REVERSE SIDE
BEFORE
COLLECTING SAMPLE
BACTERIOLOGICAL WATER ANALYSIS RECORD
om
./