HomeMy WebLinkAboutEDEN PARK #3 LT 2
DATE RECEIVED
INSPECTION APPOI NTM ENTS
TIME TIME ~...,,~,.~ TIME
DATE __~', , DATE
ENVI~ONM~Nh~,L :.Ori%T~NiCiPALiTY OF ANCHORAGE
~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
~ I~~ ~/~ [~ ~ ~t;"i 825 LStreet-Anchorage, Alaska 99501
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will ~ot be processed. Please allow t~n (10} days for processing.
PHONE
1, PROPERTY OWNER ~
MAILING ADDRESS /
PROPERTY RESIDENT (If different from abov~ PHONE
' PHONE
3. LENDINGINST~TION . f ~', .~ . PHONE
MAILING ADDRESS ,~
6. TYPE OF RESIDENCE
~ SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OF~BEDROOMS
- One E~ Four
Two [] Five
[] Three [] Six
Other
7. WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
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 UTILITY
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 NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [~ THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
~] INDIVIDUAL/ON -SITE DATE INSTALLED
~]PUBLIC UTILITY
Connection Verified INSTALLER
C~]Septic Tank or []HoldingTank
Size: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCESwELL TO: Septic/Ho]ding Tank Absorption Area Sewer Line .... Nearest Lot Line
Absorption Area to nearest Lot Line
'~, COMMENTS
[]/'APPROVED FO. '[ BEDROOMS
[] CONDITIONAL APPROVAL (letter r~ t~t accompany certificate)
72-010 (Rev. 6/79)
REQUEST FOP, APPROVAL OF
'/ZZI~D~VIDUAL SEWAGE AN~ WATER FACILITIES
b. Deter~ent
data:
c. Casin: Si. zq ~ ':
d. Distance from well to closest existing or proposed:
2. Septic tank I,~(('
3. Seepage Az.aa
4. CesSpool'
5. Property Line__
Other sources of possible contamination, J.e., creeks, lakes,
houses, barn, drainage dltch, etc._, ~!~,'~
7. Sewage d:[sposal system.
a. Age of system , ~/, '
b. Septic tank capacity in gallons
c. Name of septic tank manufac-tum~m ~ 'i;7'1~.~w.>~-2
1.
If
"home made" show dlaFram on reverse siae of this form.
d.' Disposal field o~ seepage pit size and t~e
1, Distance to propar~ty line
to house fo~mdation
e. Peree.l~ti{~n TestPemuLts
f. Percolation Test performed by
Use the reverse .side of this form to show diagram. Dia,}ram should include
']~he foJ].o',lim~ information,: Property lines~ .well location, house location,
~,~'~c tank !ocation, disposal aPea location~ location of percolation test
a~'d d]t.ection of ground slope,
9. TLe ~,~t.~,.,,..z~;o~ on this form is true and correct to the best of my knowledge.
S{gn at ure'-of Applicant
Date Signed
.z. BE FILLED OUT BY HEALTH DEPARTS,lENT PERSONNEL
above
described sanitary facilities are hereby approved, subject to the
~lP~9~i_n.f eond,i~ions:
The above described sanitary facilities are disepproved for the following
re asollS t '
Appr-oval is valid for one year --- ~s~°]].°w';n~ the date of dpp 0 l---r~va~.
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