HomeMy WebLinkAboutSPERSTAD BLK A LT 18
re.- '~N ~' DATE RECEIVED
INSPECTION APPOINTMENTS
DATE DATE~ DATE
INSPECTOR INSPECTOR INSPECTOR/%
MUNICIPALITY OF ANCHORAGE J~UNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENV RONMENTAL PROTECTION,, ~ ~ ON
825 L Street - Anchorage, Alaska 99501 ~NV~K '
ENVIRONMENTAL SANITATION DIVISION
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND S;WE~ ~A~YE~~
DIRECTIONS: Complete all parts on page 1. Incomplete reques~ will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OWNER ~/~/ PH~E
MAILING ADDRESS ~[~ ~
PROPERTY RESIDENT (If different from above) PHONE
. .HON
MAILING ADDRESS
3, LE~ING INSTITUTION P~ONE
4, REALTOR/AGENT ~ /~[~ I PHONE
MAILING ADDRESS
_ST 5. LEG.,AL DESCRIPTION
R~~
6. TYP~E OF RESIDENCE NUMBER OF~BEDROOMS
[] One [] Four
[] SINGLE FAMILY [] Two J~. Five
'5~'~ MULTIPLE FAMILY [] Three [] Six
[] Other
7. WATER SUPPLY
[] INDIVIDUAL*
'J~__ 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** YEAR ON-SITE SYSTEM WAS INSTALLED.
~ PUBLIC UTILITY
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
[] SINGLE FAMILY
[] MULTIPLE FAMILY
2. WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTILITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
[~ INDIVIDUAL/ON -SITE
[]PUBLIC UTILITY
Connection Verified
[~Septic Tank or []Holding Tank
Size: If Tank is homemade
give dimensions:
NUMBER OFBEDROOMS
[] ONE [] THREE [] FIVE
[] TWO [] FOUR [] SiX
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATEINSTALLED
INSTALLER
SOILS RATING
OTHER
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES Septic/Holding Tank Absorption Area Sawer Line I Nearest Lot Line
I
WELL TO:
Absorption Area to nearest Lot Line
5. COMMENTS
I~]-~PR OV ED FOR ---~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE
72-010 (Rev. 6/79)