HomeMy WebLinkAboutWICKLUND LT 24DOoS-os¢-'
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~ '- ' ~ .... D,~,TE RECEIVED
-' INSPECTION APPOINTMENTS ~ (~-~-L ~
DATE DATE DATE
INSPECTOR INSPECTOR I NSPECTO~
MUNI~IPALI~ O~O~AGE
MUNICIPALITY OF ANCHORAGE DEP'r. OF HEALTH &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIO~vIRONMENTAL p20~ECTION
JLfiq & 1981
ENVIRONMENTAL SANITATION DIVISION
Telephone 264-4720
RECEIVED
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWE~ FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete reques~ will not b~ processed. Please allow ten (10) days for processing.
PROPERTYRESID~NT(Ifdifferent from~ove) / ' PHONE
MAILING ADDRESS ~ Fr~ ·
4. REALTOR/~GENT ' f / PHONE
MAILING ADDRESS
STREET LOCATION
6. TYPEOF RESIDENCE NUMBER OFtBEDROOMS
[] One [] Four
'~ SINGLE FAMILY [] Two [] Five
[] MULTIPLE FAMILY ~ Three [] Six
[] Other
7. WATER SUPPLY
~ INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled
[] COMMUNITY since June 1975. For wells drilled prior to that date, give well
[] PUBLIC UTI LITY 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.
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
[] COMI~NITY
DATE DRILLED
[] PUBLIC UTi LITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[~] INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified INSTALLER
[]Septic Tank or [] Holding Tank
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
5. COMMENTS
/APPROVEDFOR BEDROOMS
[] CONDITIONAL APPROVAL (letter mustiaccompanv certificate)
DATE
72 010 (Rev. 6/79)
MUNICIPALITY OF ANCHORAGE '
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL ENGINEERING DIVISION
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
31RECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OWNER PHONE
MAILiNG ADDRESS ~ff,,,{C~Z*~ j .~i~.Y-~.~l ~::~t~'O--~
PROPERTY RESIDENT (If different from above}
PHONE
2. BUYER PHONE
MAI LING ADDR ESS
3. LENDING INSTITUTION I PHONE
I
MAILING ADDRESS
4. REALTOR/AGENT PHONE
MARLING ADDRESS
51 LEGAL DESCRIPTION
STREET LOCATION
6. TYPE OF RESIDENCE NUMRER OF BEDROOMS
[] One [] Four
~, SINGLE FAMILY [] Two [] Five
[] MULTIPLE FAMILY [~ Three [] Six
[] Other
7, WATER SUPPLY
[] INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled
[] COMMUNITY since June 1975. For wells drilled prior to that date, give well
[] PUBLIC UTI LITY depth (attach log if available.) ~>p.~- (~t'7~S- ~)c:::P~'~ =- 4~
8, SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE** **If individual/on-site, give installation date
If system is over two (2) years old an adequacy test is required
~ PUBLIC UTI LITY by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72~)10(3/78}
THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TiME TIME
DATE DATE DATE
I NS~ECTOR I NSP ECTOR I NSP ECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE NU~BER OF BEDROOMS
~NGLE FAMILY [] ONE [~TH R E E [] FIVE [] oTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
2. WATER SUPPLY PERMIT NUMBER
~'~INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
E~INDIVIDUAL/ON -SITE DATE INSTALLED
[~P~ LIC UTILITY
Connection Verified
INSTALLER
[]Septic Tank or []Holding Tank
Size: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4, DISTANCESwELL TO: S~ptic/Holdina Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
5, COMMENTS
'~APPROVEDFOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must eccompany certificate)
[] DISAPPROVED
LEG,~L DESCRIPTION v ~ ~- ,~//_/
72-010 {Rev. 3/78)
GREATER ANCHOP~AGE AREA BOROUGH
Department of Environmental Quality
3500 Tudor Road, Anchorage, Alaska 99507 279-8686
Time of nspeotion
REQUEST FOR APPROVAL OF
INDIVIDUAl. SE~ER & WATBR FACILITIES
Prooertv Owner: _~~_
Type of Facility to' be Inspected:
Number of Bedrooms: 5
Phone
Phone
6. Well Data: ,
A. Type ~ ~//~/~ //J B. Depth. /x"~ '~
C ~-~truction ~z~///~z~-~/ D, Bacteria] Analysis
A. %nmt~lled B. Instmller
C. Septic Tank: 1. Size 2. Manufacturer
D. Seepage Pit: 1. Size ... 2. Material
Disposal FAeld: Total Length of Lines
Distances:
^. Well To:
Septic Tank
· Nearest Lot Line
Absorption Area , Sewer Lines
· Other Contamination ·
B. Foundation to Seotic Tank
"e Ab~orntion Area
C. Absorption Area to Nearest Lot Line
Request for Approval of t~_.zvidual Sewer & Water Facilitie~_~
Page Two
Approval Valid for One Year From Date Signed
Greater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSTIT~M
I certify that the information contained in this request for approval to be a true
and accurate representation of the subject sewer and water facilities located at:
Signed Date