HomeMy WebLinkAboutCORONADO BLK 2 LT 1 oro 0
S,D'
II
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
~~ ~. (Fill out in Triplicate)
W~l 1 data: i ~/~b-~ ~
b. Depth ~, .. . .t:~' . ;'":'' i~,.".'
c. Casin~ size" , i,I
d.
Distance from well to closest exlstinE or proposed:
7. Sewage disposal system.
3. Seepage Area . ~
4. Cesspool' . ~~
5. Property Line . ~
6. Other sources of possible cont~ination, i.e., creeks, lakes,
houses, barn, drainage ditch, e~. .
a. Age of system -, ~ '~'~
b. Septic tank capacity in gallon~
Name of septic tank manufactu~9~
1. If "home made" show diagram on reverse side of this form.
Ce
d.' Disposal field or seepage pit size and type~
'~t+ to house f'otmdation /~ ~ . ~
istance to pr~pert7. line
.e. Percolatio~Test'~suLts .
f. Percolation Test performed by .
Use the reverse ,side of this form to show diafram. Diagram should include
.,,,,he following information' p?operty lines, .well location, house location,
r~utic tank location, disposal a~ea location, location of percolation test,
a~d~ di~',ection of ground slope.
9 The ~ .
· ~n'f~at~on .on this form is true and correct to the best of my knowledge.
'S'ign;]ture ~of A~plic~n~ ........... ~'~e $i~'ned~ '
TO BE FILLED OUT BY HEALTH DEPART~4ENT PERSONNEL
The above escr~.bed sanitary facilities are hereby approved, subject, to the
d '
~'l!owing con~ilions:
Conditions:_~7 TH[ 5~~ .
The above described sanitary facilities are disspproved for the followinK
reasons: .-
Approval is valid for one year following the date of approval.
CPJ: cw
(To be,~ip,,.y,,epared only under the supervision of your
SPECIAL POWER. ~F ATTORNEY Legat',~i~i;~FStance Officer or Civilian Attorney.)
, ~ ~ , ,-, ,, ff,,~' ,
~OW ~L MEN BY TtlE~E PRESETS, that 1 (s~ate full n~m~, [i'~,, grade, service n~ber/SS~, as ~p~llc~bl~)
de~irin~ to ~ecute a ¢~I~PO~OF A~Ol~Y have ~ade, constituted and appointed, and ty these pre~ent~ ~'m~e, coCa,tut-
whose address is __ ,-d.' ,~
County (City) of Irk ~ C ~ O~ ~[ ~ -- , State of
( in,aTt a~roortate clause(s)).
my Attorney-in-Fact to act as follows. GIVI~ ~ 6~1~ ~to my said attorney fult ~ower~to* . '' '~ l') ~
To ac.~ in mY beha'Lf to rc:.o:~ov, rent (.p~:(, .P~, ' .... ' .... - ';:
fol. l:owin~ ~mopert'~ loaa~'e'~ m l,ot,~ ~ au ....
A'}asks. One (}) !960 2olu.mbT,.a ~obt~.z,'-: ,.omc Ser~;4 ~a),~o c,' ,-r.'~ ,,: ..
~)~, ~ l?:~ ]e3nto attached ~, eo]].aw-]n~ ?urnisk~rF'~ .'~r'r., ~_n~l.u't,7~ ~"~ the pr'op~r~y
~ '' ~. 1 e~ ~00 6a]_ e~e~tank, O. % ]0C ']_L ~m,,pane tank :~d 'l 2J" J.b ~7opane
riot, ~r:e~'¢¢ ~,~y'¢~n] 'n~(me~tF. T~ the e,:en'b ~,e pro,-ert,'x ':~ sold *~¢ ~'eo~7~r't.y
~em,~t~ Oq ~ho ~'e~'r~hea rea~ [~r oPe" [,',' F, rov'~c'ed !p ocr n,o ..... =: ace r-:-r~t }.s paZd. .
~¢ fhe ~ro~er~ 4s ~o}d ~n,~ 2n'~ hart o'r the sale pr~.ce ':s l"~r~?ed h'/ ,J. ri
~be trM.%e~ Willtremai-n 0~'%o'b I ',-.lqC ,.. boro~tado .... ' ...... ~"~ C.L ~'~e lien has
h~en com, fite'~e~ ach4
F~T~ I do authorize my a[oresald Attorney-in-Fact to perlorm all necessary acts in the execution of the a/oresaid
authoriz~tlo~ with the ~eme validity as I could effect if personally present. Any act or thing lawfully done htrem~der
my said attorney shall be bl~tflg .on myself and my heirs, legal and personal representatives, and assigns.
p~VI~, ho~er, that,all busine~m t*a~sact~d hereunder for me or for my account shall be transacted [n my n~e, and that
a-Il j~dorsewentm ~ instx~e~ts executed b), ~ said attorney roi the purpose pi carrying out the foregoing powers shall
cOnfai~ ~y n~e~ [oJ[~d bF that of my said attorney and the desl~a[~on "Attorne)-~n-Fact".
I FU~ D~E that th~s power shall remain to eFFect even though [ ~ repomted or lxsted, officially ot otherwise, as
Att, ~ney i* revoked ',y my death ar as otberwlse provided here~n.
It~. ~le~ soouer -e~oked pt terminated by me, this Special Power of Attorney sha~ c,.ome ~.1, and ~ID from and
Notwithstanding my insertion of a specific 'expir~tlon date herein, if On the above specified expiration date I shall
or have been, carried in a mLlitary status of "mlssinge~ .missing-in*actionn or apr[so.er-of-war," then this power of attorney
sh'alJ automatleally c0nt[nue to remain valid and in full effect until sixty (60) days after I have returned to United States
military control following termination of such "miaaing,~ "misslng'i~'acti°n~* or "prisoner-of-war* status.
1N WITNESS ~R~F, I have hereunto set my hand and seal this ~ day of ~IFtF: ~19 f)~ ·
WITNESSES: ~ . (
ADDRESS ARD SEEVICE NO./SSAN (If any)
IF ACKNOWLEDGED BEFORE A NOTARY PUBLIC:
st.t,, of ' 'iL, "-i ) ss
County (P-~4'3') '' "'~ ~ ' '
I, }i~T' [?[ I' ,.' '" )':P,"' '¢ ' , n Notary Public in anti for the County (Ca)"~.') and State aforesaid, d0 hereby certify
that on Il ......... '~)2i~_. day {,t ..... ~ .... ~ ....... 19 ~:?. before me personal ly app ........ 1 .......................
, , who is known by m. to be the identi-
~7~I U';s',~ .vi*,. ~'.' ~s~ tLe*l in, wh,,s- n.,~,e is s~i~'hcrihed to, alld who signed and executed the f,,~(.,(oirig instrument, alid having
k~,),~.l ' )i:: t'l, ¢olltPi)t~ therr'~f. I',~ personally acknowledged to me that h,, si~npd and sealed the same on the date
Iff ~itness ~ere~*f, I harp hereuoto s°t ntv h~,qd and official s,' Ithis ray ancl~ear,~h~-e.
Nr~tary P.blic
MY Commission Expires:
AF ,~o,~,, 831
SEP 68
(To. he prepared on~)r under the supervkslon ~f your
SPE~f~L'~POW.~/O, FC,A'TTORNEY,r.,. . . .. . ., Le~l Assistance ,O~f[cer or C[v[lian Atto~e'~.)',1
:~W,~ ~N BY T~E PRES~S. that I (state full n~e, title, If~e, *.~tce: n~ber/SS~, e~ /ppl~l~eble)
and presently stained-or re.idin~ st ~8e~18~ AFB. M~ssi~i~i .... ·
' ' -~ ' - ' ~ "~ .... .~ c t te
Co;daty"(C[~y) bf ......... Rgqh~Ke . ~.t.-of .. Alaska ., .. .~. ,
fo~t~n~ ,ord~r%~ loea~d on ~t.~. % ~tbck 2.~ Coron~o Su~.livzsio ~ :~ze a', ,,,
~' x 40' ].eanto attached. The follo~ng f~n~hin~'.a~e ,incluAed ~ ~Ne ,~ro~r,~y~
a-~ .... + ~ ~ ~--a ~ ~a= n~s-nt- +~nnants. 1. 1 ~ee~;"o~ator~ 2. 1 built
........... . , '~ ~,~' ",'- ~ ..... ' : ~" ........ : ~'. :" " .......... "
~ ~t,~-,~l~ . "i'~ ~2 ~'~6at',.,~el %ask-, 9. 1..t~ ~ ;oropm~s tank. a~ a
~a~': .... ~r-'afld~' ~hl~fe~ h~e 'al~o~ au%~or~.ze~'-~o deduc%-lO% of tl~e ~n%al ~ee as
~r_ co=ntaa1~a.~-~ ~%~ i~_.~~' ~".~ ~.~ p~%ce. The abgve aa'le.a. Oe~
'~e,'t~'"~~ i'~,~e~'.i~ ",n~':~- o~'~'the Sa~e, pr~-.'¢~ i~inanced, ~Y ~'a .~ .h', H~i~'.' .... .
4' ill :" ~t~':~Pt~ ,~:.L,._" X= :~;~:-::- ;~: ........ 7:-::--- -J.u . ' '' ' '~:: ' , , , t " '"-' :
~, I do authoel~ my aforesaid Attorney-in-Flct to perfoM.e~l ..c~Wy,,act~ Aa the elequtiqn qf tM
a~t~s~t~, ~.~ {~ .~ity as I could effect if persOnal'ly preie~; ' ~,a6t ~f"thine l~full~l ~e~er
~,~e.;,~t~l~l ~.t~l'~+~rt~"M~.~* for me~%r ~or my ~cco~nt ab~ll ~
I F~~ that }hA. ~wer shall remain in effect evei,~h '1 I rir~ or Jilted;
A~torBey la revoke~ by my death or Is otherwise provided herein. ~ · ......... *' ' "~ : '
~, .m~ee~ ~:,~d"of..ler~t~-'~ ~eg .~bls ~eclel Power of Attorney shall becoee ~ and ~ID from and
insertion df ~ specific e~lra[~on ~te heYeln, i'f"~n t~ ~dve'apeclfled'~lt~tt~ d~' I 'shall be,
sW~ll'"~h}~}tleaIt~ bSat'tn~e iie:'r~'a'i~ '{ali~lihd'tn!'f~l'"effect until sixty (60) days after I have returned to United States
- .June l~ 6~.
IF lC~OWLEDGED BEFORE A NOTARY
st a~e of l'~I~,~i6,>T} PT
County (~) ~IA"LttISON ~ ss
I,'' KA~4~}~E '~ ~'1W~]";~}I'}~. , s Notary Plibltc in and for the County (~'I~) and State ~fo'resald, a'0 hereby c~rtlfy
that on the' l~h day o f ,T~)~' _ , 19 ~9 . , before me personally appeared
,..~'_~.~Ll ___ who is k .....by me to be the identi-
cal person who t~ ,fescrihed in, whose name is subscribed to, and who signed and executed the foregoing instrument, and having
first made known t him the contents thereof, he personally acknowledged to me that he signed and sealed the s~ne on the date
tt bears as his t~ue, free and voluntary act and deed for the uses, purposes and considerations therein set forth.
Itll'.lit.~h~:l.~llietreof, ! have hereunto set my hand and official seal this day a;~.~ear above.
iF roam 8~1
SEP 68