HomeMy WebLinkAboutQUICK BLK 3 LT 1Onsite File
Quick
Block 3
Lot 1
PID# 016-203-48
(Formerly Gregg Blk 3 Lt 7A1)
Municipality of Anchorage
Community Development Department
On -Site Water & Wastewater Program
4700 Elmore St. im P.O. Box 196650 m Anchorage, AK 99507-6650 im www.rrturJ, jqqsite . n (907) 343-7904
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Legal Address:
Subdivision(IM.
'6 Block 5 Lot -7
Lot 01
T R Section
On-site Water & Wastewater Program certified contractor performing the well decommissioning:
Name:
Signature
Company:
Well decommissioning date:
Method of decommissioning: AMC 15:55.060LI
a. 7 b. 0 c.
Location: Use the space below to provide a drawing of the property showing the following items;
• North Arrow
• Decommissioned well,
• Other water wells on the property,
•Two separate swing -tie distances for each well shown in the drawing,
A
Note: The swing -tie distances shall be measured from either permanent structures of property corners t
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` MUNICIPALITY OF ANCHORAGE
DEPARTM T OF HEALTH AND ENVIRONMEI L PROTECTION
825 L Street, Anchoraup-, Alaska 99501
\L 264-4720
/ Date Received: \q-12 _
#1: Time�3m
i #2: Time o #3: Time
° _
Date Date-ice-�� Date
J-- _ - - -
Insp _ �� , Insp Insp
REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES
1. Lending Institution Request: National Bank of Alaska % Ruth La Bar -
Mailing Address: Pouch 7-025 9951.0 _ Phone: 265-2883
2. Property Owner: Donald R. Showers
Mailing Address: Box 4-548
Phone: 344-2444
3. Legal Description: Lot 7A Block 3 Gregg Subdivision
4: Single Family Residence: (x) Number of Bedrooms: Five
Multiple Family Residence: ( ) Number of Bedrooms:
5. Well System: Individual Well (x) Community/Public System ( )
Permit it
Construction
6. Sewage Disposal System
Permit #
Septic Tank Size
Depth of Wel]_
Well Log on File ( )
Bacterial,Analysis
txi_m�
On-site System (x) Public Utility ( )
Installed Installer
Manufacturer
Absorption Area _ Soils Rate
7. Distances: Well to Septic Tank
to Sewer Line
to Nearest Lot Line
Nearest Lot line
Material
to Absorption Area
Absorption Area
MUNICIPALI"fy OF ANCHOUr'
Departme,it
of Health and Envi.ronmen_.:l
Protection
825
L Street, Anchorage, Alaska
99501
1
264-9720
iequest
for Approval.
of Individual Sewer and
Water Faci�l.ities
1. Property
Owner:_—
J
Mailing Addr.ess:+
L- Ll- 5�lf p�
Phone: J41'1
3.
4
Name of Buyer:
Mailing Address:
Lending Institution:
Mailing Address:
Realtor/Agent:
Mailing Address:
Y
Phone:
vo_T Phone: -_1 6 .5-
YJ
5
Phone:
5. Legal Description: '�` �� 7 .
—�—_
Street Location- ODD
6. Single Family Residence: (!) Number of Bedrooms:
Multiple Family Residence: ( ) Number of Bedrooms:
7. Water Supply: *Individual Well (✓S Public/Community System ( )
If Indi.vi.dual Well, well depth
If Community System, name of system
8. Sewage Disposal System: "On-site System Public System ( )
If On-site System, date of installation:
*NOTE: A well log is required on ALL wells drilled since 6/75.
**If on-site sewer system is over two(2) years old, an adequacy
Lest is required by this department.
A fee of $25.00 must accompany each request before processing
can be initiated.
3/7 7
Pace Two
Department of Health and Environmental Protection
Request for Approval of Individual Sewer and Water Facilities
Legal Description: Lot 7A Block 3 Gregg Subdivision
Comments:
Affadavit Attached: ( A Letter Attached: ( )
Disapproved:
Date: �-3- 1S _
Date:
Department Worksheet: s
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