HomeMy WebLinkAboutBEVERLY BLK 1 LT 5/,
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t'~''~ REQUEST FOR APPROVAL
(PiLl. out ,In
%,.: I~a~..of ~erson requesting approval ~)z~F;
2. Ua,,~. Of proper~y,..owner .f~/~?
· -W/si -
. .
b. Dete~en~. ' ' ' . /
".-".:':-'::,.,
c. Casln~ ~iz~ ~ ~
d. Di~ance from well ~o ~loseat existing om p~posed: ~.
Septic ~an~ ~ /
Cesspool'
5. Property Ltn~/ .
6. O~her sources of pom~bl~ con~mmina~ion, ~.e., creeks, lake~,
house~, barn, drainage ditch, e~c.
Sewege dtspocal system,
a, '.ge of syste~ /9~ 7 ·
Septic tank capacity in gallons
C. }lame of septic tank manufacture= /~/
1. If "home made" ~how dlafram on rever~e side of ~his form.
1. D~stance ~o prope~y lin~ to house f~dation
Percolation Test performed by
Use the reverse .side of this form to show dtafram. Diagra~ should include
· ~%he foJlo, dng information: property llnes;.well location, house location,
~.l,~4c tan~ location, disposal area location, location of percolation ~est,
a~ d~ection cf ground slope·
9. Tke'~,j..,~ on tkis form is %rue and cerrect to ~he best of my knowledge.
,~ $,iFnature of Applicant D~te Signed
TO BE FILLED oL~r BY HEALTH BEPART~.~ENT PERSONNEL
...... ~r,~. ab?va described sanitary facilities are hereby approved, subject to the -'~'llowin? conditions:
Condit~orm:
.~e above described sanitary facilltie~ are dls~pp~oved for the following
· . '' '" ' Date - F'.
'-$.p~'oval is valid for one year followinE the date of approval,
.- CPJ!cw
'\
· %~/~ / (Fxll out in Triplicate)
®
Wa~c[. Anal~s~s:
h. DeterEent
Well data:
b. Depth ~/'
c. Casln~ Size
Distance from well to closest existlnE or proposed:
1. Sewer line ~9~
3. Seepage ^~ea
Cesspool'
S. Property Line
Other sources of possible contamination, I.e., creeks, lakes,
houses, ba~n, drainage ditch, etc.
Sewas. e disposal system.
..
b. Septic tank capacity In gallons
c. Name of septic tank manufacturer
d:
1. If "home made" show dlaFram on reverse side of this form.
Disposal field o~ Seepage pit size and type
1. Distance to property line to house foundation
.e. Percolat{o~ Test ~sults
Percolation Test performed by
Use the reverse side of this form to show diaEram. DiaEra~ should ~nclude
.~he foilowln~ information: ~operty l[nes;.Well location, house location,
t~pr~c tank location, disposal area location~ location of percolation test,
ar~ dlreet[on of Fround slope.
9. The l~£oz~t[on on this fo~m is true and correct to the best of my knowled[e.
SiFnature of Applicant
Date $iFned
TO BE FILLED OUT BY HEALTH DEPAP. T~Et~T PERSONNEL
~--~?he-' above described sanitary facilities are hereby approved, subject to the
..... ~llowln~ condlttons~
Conditions:
The above described sanitary facilities are disepproved for the
"Signature of ~ffici%l.¢ .,'.' ~ ;. Date :'l..~7' :'~ ~
Approval is valid for one year following the da~e of approval.
CPJ:cw
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate)
· of person requestlnf approval
2. ~ta,~.. of proper'cy:owner
~. Numb~'~"'~£..bedrooms in house
5. Water, Analysis:
a. Bacterial
b. Deter~ent
Well data:
c. ,~asta~ Size
· d., DistanCe ~rom'~el! to closest existin~ or proposed:
l. Sewer lt~e
2. Septic tank
3, Seepage Area ~.T'' .
q. Cesspool' .
5. Property Line ._~''.
Sewage disposal system.
a.
b.
¢.
Other sources of possible contamination, I.e., creeks, lakes,
houses, barn, dralnaEe ditch, etc.
Age of system /~f.. ~
Septic tank capacity In ~allons
}lame of septic tank manufactu~
1.
If "home made" show dle~rsm on reverse side of this
d; Disposal field or seepage pit size and type
1. Distance to proper~y l~ne
to house foundation.,
-e. Perc~l~t£~ Test 'l~su~ts
m... f. Percolation Test performed by
~. Use the reverse.side of this form to show dlaEmam, Dia~ra~ should include
-3~he foJA~,dng tnfor~.ation: p~operty ltnes;.woll location, house location,
~-4,ti¢ tank location, disposal area location, location of percolation
m~ direction of Fround slope.
9. Tko l,,'r-,.~-ati~n on ~kis form is ~rue and correct Xo the best of my knowledge.
S$fnature of Applicant
Date SiFned
~0 BE FILLED Olf~ BY HEALTH DEPARTtlENT PERSONNEL
~'~?he-' ebove described sanitary facilities are hereby epproved, subject to the
..... ~llowinf cond~ilons}
~?//Conditlon~:
The above described sanitary facilities are dlsepproved for the following
- Appx~val Is valid fop one year following the da~e of approval.
CPJ:cw
O~obez- 30,, 1967
~vllian ~illtary F4fem. al Office
P. O. ~ox 179
Ancho~.age, Al~ka 99501
~ SUB,IECTt Conditional C~RO Approvals
Nlll~ary approval of V. he pr~mlsea listed belo~ hu no~ been fran~ed
by ~hls kpaz'tman~ for me ox. nor~ o~ the ~ollo~ing re~,~msl (l)
Insu~fl~tea~ data m disposal systen. (2) Disposal syn~an ia
inadaqua~ely sAsed. (3} Disposal system lacks septia Zank-a~epage
pit azwaaie,ant.
2. Rose S~ith
~oc 80 Block 1e Dixon Subdivisl~
l)aced iiarah 22e 1967
Sincerely,
DAVID E. L. IMIIICAM, ii. D.
iiedical Dlz~e~