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Home My WebLink AboutSAND WILLHOLTH BLK 2 LT 9Lob GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY 3500 TUDOR ROAD ANCHORAGE, ALASKA 99507 279-8686 DATE RECEIVED: INSPECT: TIME: REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES FOR 1 . APPROVAL REQUESTED ADDRESS: BY: PHONE 2. PROPERTY OWNER: X PHONE: 3. LEGAL DESCRIPTION: i (./` .11,"i/ �•,'` �., j ' 1 '. 4. TYPE FACILITY TO BE INSPECTED: ��a)_/,-%<`ij/-`/Ll.� STREET: NUMBER OF BEDROOMS: 5. WELL DATA: A. TYPE B. DEPTH i0 ` C. SIZE D. CONSTRUCTION E. BACTERIAL ANALYSIS 6. SEWAGE DISPOSAL SYSTEM: A. SEPTIC TANK (IF HOMEMADE, SHOW DIAGRAM ON BACK) 1. SIZE 2. AGE 3. MANUFACTURER 4. INSTALLER b APPROVAL REQUEST FOR SEWER & WATER FACILITIES PAGE TWO B. SEEPAGE PIT 1. SIZE 2. LINING C. DISPOSAL FIELD 1. NUMBER OF LINES 2. TOTAL LENGTH 7. REQUIRED MEASUREMENTS A. WELL TO SEPTIC TANK B. WELL TO SEEPAGE PIT C. WELL TO SEWER LINE D. WELL TO PROPERTY LINE E. WELL TO OTHER POSSIBLE CONTAMINATION F. FOUNDATION TO SEPTIC TANK G. FOUNDATION TO SEEPAGE PIT_ H. SEEPAGE PIT TO PROPERTY LINE S. COMMENTS: APPROVED: DISAPPROVED: ll _ DATE: DATE: APPROVAL VALID FOR ONE YEAR FROM DATE SIGNED. GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY L) Alumcm vP 7'ICALIN AI IL) VVLL XL a DIVISION OF PUBLIC HEALTH BACTERIOLOGICAL NATER ANALYSIS DATE PUBLIC El SEMI-PUBLIC D INDIVIDUAL r_1 OTHER REPORT RESULTS TO NAME _ ADDRESS _ CITY ADDRESS OF SOURCE SAMPLE COLLECTED BY DATE COLLECTED_ Sample Collected From ❑ Other (list) _ TIME COLLECTED_ ❑ Kitchen Tap ❑ Bathroom Tap Well - ❑ Dug ❑ Driven ❑ Drilled SOURCE: ❑ Spring ❑ Cistern ❑ Other_ Dug Well or Cistern Construction: Feet. Well Casing Walls - ❑ Wood ❑ Concrete ❑ Metal Top - ❑ Wood ❑ Concrete ❑ Metal LOCATION: ❑ In Basement ❑ Basement Offset ❑ In Yard ❑ Other on) pm ❑ Basement Tap 0 ❑ Bared Brick or ❑ Tile ❑ Concrete ❑ Open Top ❑ Under House Lob. Records in this office indicate this WATER SUPPLY to be of: Satisfactory ❑ Questionable ❑ Unsatisfactory Sanitary Status. Analysis shows this Water SAMPLE to be: Satisfactory ❑ Questionable ❑ Unsatisfactory. 'f an "Unsatisfactory" or "Questionable" status is indicated above you should take immediate action as recommended below. 1. Notify consumers water is polluted. Boil or chemically treat this water as outlined in the enclosed leaflet "Drink It Pure." 2. Increase chlorination sufficiently to meet recommended residual standards. Determine source of contamination and take action necessary to maintain a safe water supply at all times. 3. Check chlorinatinn and other mechanical equipment. Make certain it is functioning properly. 4. If alter checking equipment a disinfecting residual is not obtained, please wire this office for emergency assistance or advisory services. 5. This is a surface water source and subject to pollution by man and animals. An approved water supply source should be developed. b. Improve your ❑ spring ❑ dug well ❑ driven well ❑ drilled well ❑ cistern. _7. Relocate your well to a safe location in relationship to your sewage disposal system. ❑ see enclosure Building Sewer Septic DISTANCE TO: or Other Drainage Pipe Feet. Tank Feef. 8. Sample too long in transit; sample should not be over 48 hours old at Tile 5a epage Cess. examination to indicate reliable results, please send new sample. Field Feet. Pif Feef. Pool Foot. Privy Feet. Other Possible ❑ Bottle Broken in transit, please send new sample. Sources of Contamination MATERIAL: Building Sewer - ❑ Cc" ❑ Woad El Tile ❑ Fi6re ❑ Asbestos Iron Cement 9. Contact your nearest ❑ Local Health Department or ❑ Alaska C.1 Plastic loin) Material Type Division of Public Health, sanitation office for bulletins, consultation and -- assistance. GENERAL: Does Water Become Muddy or Discolored? ❑ Yes ❑ No SANITARIAN'S REMARKS When? IOcc 1Occ IOcc 1Occ Diameter of Well 0.1 cc Depth Feet. Well Casing Material Diameter _ Depth Length of Water Depth Drop Pipe From Bottom Feet. PUMP LOCATION: ❑ In Well ❑ Offset In El to Basement ❑ In Utility On Top ❑ Of Well ❑ Other Basement Room PURPOSE OF EXAMINATION: Illness Suspected? ❑ Yes ❑ No New Source of Supply? ❑ Yes ❑ No Repairs to System? ❑ Yes ❑ No READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE BACTERIOLOGICAL WATER ANALYSIS RECORD am Date Received Time Received Pm Lob. Lactose Broth IOcc 1Occ IOcc 1Occ IOcc l.Occ 0.1 cc 24 hours 48 hours Brilliant Green 24 hours 48 hours EMB AGAR Lactose Broth, 24 hrs. 48 hrs. Gram's stain Coliform Density (Most probable No. per 100cc.) MF results am Reported by Date pm This analysis indicates Coliform Organisms to be: Absent flc,�nber 2fi, 1971 Ray S petal hy se 'runfor fowz. 11 SubjIm t; 1 1 CA 11, 0 1 ock Q Sell tit I no Ch Subtf f ld s I CIO War Ps. Drahnn: An irlsionction off thn suIM-ct lat rayr-Men! that the well ww� huriewl. So -fare our approval fol, tail. 11all :an y qjvy;j ;p-. MAI i:asivg trill tci Liu- extcnded abovin ground lunkmi. A Lwcwrill analysis �,ctober 1, V171 vy-oved to w factory £f f) u a v f, a r" y V, I I �! S t i r;- I -�i i r c. g a 'r d i a !,i it :�,, b o v I L j 1 6 s, t A t a t 0 to C On t a C t t h i S c� f f i C Si nc,,F r` €. I jr , L.v , i n S . C -,} a d Envfromwi"-nital Sp,�,rdjllst VA Adv�iid!jtritinri Tom, 13 rt I cey I ch St Lltr -KIPI ll V11- MItALIM AND WELF" 1E DIVISION OF PUBLIC HEALTH BACTERIOLOGICAL WATER ANALYSIS DATE PUBLIC F1 SEMI-PUBLIC INDIVIDUAL F� OTHER REPORT RESULTS TO NAME _ ADDRESS CITY _ ADDRESS OF SOURCE SAMPLE COLLECTED BY am DATE COLLECTED TIME COLLECTED pm Sample Collected From ❑ Kitchen Tap ❑ Bathroom Tap ❑ Basement Top ❑ Other Ristl Lab. No OFFICE Records in this office indicate this WATER SUPPLY to be of: Satisfactory ❑ Ouestionable ❑ Unsatisfactory Sanitary Status. Analysis shows this Water SAMPLE to be: Satisfactory ❑ Ouestionable ❑ Unsatisfactory. If an "Unsatisfactory" or "Questionable" status is indicated above you should take immediate action as recommended below. 1. Notify consumers water is polluted. Boil or chemically treat this water as outlined in the enclosed leaflet "Drink It Pure." 2. Increase chlorination sufficiently to meet recommended residual standards. Determine source of contamination and take action necessary to maintain a safe water supply at all times. 3. Check chlorination and other mechanical equipment. Make certain it is functioning properly. —4. If after checking equipment a disinfecting residual is not obtained, please wire this office for emergency assistance or advisory services. Well - LlDug C3Driven ❑ Drilled C)Bored —5. This is a surface water source and subject to pollution by man and animals. SOURCE: ❑ Spring ❑ Cistern ❑ Other An approved water supply source should be developed. Dug Well or Cistern Construction: Walls - El Wood El Concrete 11:1 Metal ❑ Tile Brick or, —6, Improve your El spring El dug well ❑ driven well ❑ Convata Top - ❑ Wood ❑ Concrete ❑ Metal ❑ Open Top ❑ drilled well ❑ cistern. LOCATION: ❑ In Basement ❑ Basement Offset ❑ Under House 7. Relocate your well to a safe location in relationship to your sewage ❑ In Yard ❑ Other disposal system. ❑ see enclosure Building Sewer Septic DISTANCE TO: or Other Drainage Pipe Feet. Tank - Feet. 8. Sample too long in transit; sample should not be over 48 hours old at _ Tile Seepage Cess. examination to indicate reliable results, lease send new sample. Field Feet. Pit -Feet. Pool Feet. Privy Feet. P P Other Possible ❑ Bottle Broken in transit, please send new sample. Sources of Contamination MATERIAL: Building Sewer - ❑ Cost ❑ Wood ❑ The IJFibre [] Asbestos Iron Cement 9. Contact your nearest ❑ Local Health Department or ❑ Alaska f.) Plastic Joint Material -- Type Division of Public Health, sanitation office for bulletins, consultation and assistance. GENERAL: Does Water Become Muddy or Discolored? ❑ Yes ❑ No SANITARIAN'S REMARKS When? IOcc IOcc IOcc Diameter of Well IOcc Depth Feel. Well Casing Material Diameler Depth Length of Water Depth Drop Pipe From Bello. Feel. PUMP LOCATION: ❑ In Well ❑ Offset In ❑ In Basement Basement ❑ In Utility Room On Top ❑ Of Well ❑ Other PURPOSE OF EXAMINATION: Illness Suspected? ❑ Yes ❑ No New Source of Supply? ❑ Yes ❑ No Repairs to System? ❑ Yes ❑ No READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE Date Received Signature BACTERIOLOGICAL WATER ANALYSIS RECORD am Time Received pm Lab. No Lactose Brolh IOcc IOcc IOcc IOcc IOcc I.Occ 0.1 cc 24 hours 48 hours Brilliant Green 24 hours 48 hours FMA Lactose Broth, 24 hrs. Coliform Density MF results Reported by This analysis indicates Coliform Organisms to be: 48 Date AGAR Gram's stain —(Most probable No. per 100cc.( Absent Present am -41- yL RE UEST FOR APPROVAL OF INDIVIDUAL SEWAGE AND WATER, FACILITIES ✓�-�� s� s (Fill out in Tri licate) tame .of person requesting approval 2. klanp of property -owner 3. --Eal. de 4. Number of _bedrooms in house 5. Water.,1,nalysis : 6, 7 a, Bacterial, ►f b. Detergent Well data: a. Type I rX b. Depth C. Casing Size 1 d. Distance from well to closest existing or propose d 1. Sewer line "I 2. Septic tank 3, Seepage Area 4, Cesspool' 5. Property Line �)c:;1 6. Other sources of possible contamination, i.e., creeks, lakes, houses, barn, drainage ditch, etc. Sewage disposal system. a. Age of system b. Septic tank capacity in gallons c. Name of septic tank manufacturer 1, If "home made" show diagram on reverse side of this form. d: Disposal field or seepage pit size and type 1. Distance to property line to house foundation e e. Percolation, Test'nesults --- f. Percolation Test performed by a. Use the reverse,side of this form to show diagram. Diagram should include the fols.owing information: property lines; -well location, house location, optic tank location, disposal area location, location of percolation test, and direction of ground slope. 9. The iz,L�r1rati-on .on this form is true and correct to the best of my knowledge. f r l ecs�o t �r .. Ze / Si€nature of Applicant Date Si, 'r0 BE FILLED OUT BY HEALTH DEPAP.TF1ENT PERS014NEL „he above described sanitary facilities are hereby approved, subject to the Conditions: The above described sanitary facilities are disapproved for the following reasons: 9 F Date.5� Approval is valid for one year following the date of approval. CPJ:ew