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HomeMy WebLinkAboutSAND WILLHOLTH BLK 2 LT 13�c�- oilI1 ho I fh fo►�d fU( GREATER ANCHORAGE AREA BOROUGHov { Department of Environmental Quality 3330 "C" Street, Anchorage, Alaska 99503 274-4561 AW REQUEST FOR APPROVAL OF INDIVIDUAL S%EINER & 'NATER FACILITIES FOR o2P� Date Received 9 2 Time of Inspection Date of Inspection 1. Anproval Requested By:'d—,,J�u, `Z� ✓C��r ���C� C�d ( v Address; Phone: A7�Z—ZG/ 2. Pro oerty Owner: �¢iEi �� c/c clef Phones (D / 3. Legal Description: oC / 2.� J —ode ' S' � 4. Location: 5. Type of Facility to be Inspected:_� G� Number of Bedrooms: � 6. Nell Data:.-cr A. Type B. Depth C. Construction 7. Sewage Disposal System: A. Installed D. Bacterial Analysis B. Installer C. Septic Tank: 1. Size 2. Manufacturer D. Seepage Pit: I. Size 2, Material E, Disposal Field: Total Length of Lines 9. Distances: A. 'Alell To: Septic TankAbsorption Area Sewer Lines Nearest Lot Line Other Contamination 3. Foundation to Septic Tank -1, Absorption Area C, Absorption Area to Nearest Lot Line rJ ,Ili"dSL lvi nPYLVVOl ui IUIVIvu ...,....a ..a ..�+��. Jae Two �-_I Approved Disapproved Date Approval Valid for One Year From Date Signed Greater Anchorage Area Borough, Department of Environmental Quality DTAGRAM OF SYSTEM T certify that the information contained in this request for approval to be a true and accurate representation of the subiect sewer and water facilities located at: Signed Date M/ 06-1220 (a) STATE OF ALASKA DEPA` MENT OF HEALTH AND SOCIAL SL ICES Lab. No. DIVISION OF PUBLIC HEALTH F BACTERIOLOGICAL WATER ANALYSIS -. - - �flATE - _ .. - OFFICE... _ Records in this office indicate this WATER SUPPLY to be of: PUBLIC SEMI-PUBLIC SEMI-PUBLIC❑ - - JNDIVIDUAL.❑+ OTHER.. - - --- - 0 Satisfactory 0 Questionable 0 Unsatisfactory Sanitary Status. - REPORT RESULTS TO t Analysis shows this Water SAMPLE.to be: NAME j©`Satisfactory 0 Questionable 0 Unsatisfactory. _ ! n ..: t ) = /1 f- ; f r, I ADDRESS - _ _� -I- ZIP '�j�i jjr�-'l7 5 If an "Unsatisfactory" or "Questionable" status is indicated above below. i�3" -_ C i - CODE l j..�✓�! 1 - you should take immediate action as recommended CITY - r_- 1. Notify consumers water is polluted. Boil or chemically ADDRESS- ?'!'1 ° - - _:-` treat this water as outlined in the enclosed leaflet - "Drink It Pure." SAMPLE COLLECTED BY - C�-1-1 i� 1 ;— %``� -. 2. Increase chlorination sufficiently to meet recommended residual standards. Determine source of contamination and take action necessary to maintain at times. - - I ') TIME COLLECTED a safe water supply all DATE COLLECTED -' Sample Collected From ❑ Kitchen Tap ❑-Bathroom Tap 6 Basement Tap 3. Check chlorination and other mechanical equipment. Make certain it is 0 Other (List) functioning properly. COMPLETE THIS SECTION LINLES%OTHERWISE INSTRUCTED 4. If after checking equipment a disinfecting residual is not obtained,please wire this office for emergency assistance or advisory services. - _ •:� Well . 0 Dug 0 Driven - _ rjp Drilled ❑Bored 5. This is a surface water source and subject to pollution by man and animals SOURCE:- 0 Spring ❑ Cistern 0 Other An approved water supply source should be developed. Dug Well or Cistern Construction: - _ - - '— Wails-- OWood - OConcrete - - ❑Metal. 0Tile - CBrickror - 6. Improveyour Cspring Odugwell Cdrivenwell Cdrilledwell Ccistern - _ Top — ❑ Wood [I concrete Concrete 0 Metal 0 Open Top 7. Relocate your well to a safe location in relationship to your sewage disposal LOCATION`. 0 In Basement - 0 Basement Offset 0 Under House - - system. 0 see enclosure -- - - 0 1n Yard 00ther - Building Sewer - - 8. Sample too long in transit; sample should not be over48hours old at _ - Septic - DISTANCE TO: or Other Drainage Pipe Feet. Tank Feet. - examination to indicate reliable results, please send new sample. - Tile. .Seepage - . Cass- ess-Field Feet. Pit Feet. Pool Feet. Privy. - Feet. Field—Feet.- - 0 Bottle Broken in transit, please send new sample. - Other Possible _ Sources of Contamination Cast - _ - Asbestos-- - —. 9. Contact your nearest 0 Local Health Department or 0 Alaska - MATERIAL: -Building Sewer — ❑ Iron ❑Wood ❑Tile ❑ Fibre ❑Cement Division of Public Health, sanitation office for bulletins, consultation and - assistance. _ C Plastic_ _ Joint Material —Type -SANITARIAN'SREMARKS GENERAL: _Does Water Become Muddy or Discolored? 0Yes - 0 No - - - �__ - When?. - - Diameter -of -Well - Depth - Feet. _ Well Casing - -' `° epth Material- - Diameter Depth— - Length of - Length - Water Depth :. - - - Drop Pipe - - From Bottom - Feet. PUMP LOCATION: ❑ In Well 0 In In Utility - BOffsetasement Basement ❑ In Basement ❑ Room - 0 On Top 0 Other _ Of Well PURPOSE OF EXAMINATION: Illness Suspected? 0Yes 0 No - New Source of Supply? 0 Yes 0 No - Repairs to System? 0 Yes 0 No - _ - - - Signature - I 06-12210 (b) -- BACTERIOLOGICAL WATER ANALYSIS RECORD r'� READ INSTRUCTIONS Date Received Time:ReceivedNLab.No. Lactose Broth - torn 10cc 10cc 10cc 10cc 1tOcc O.Acc 24 hours 48 hours - Brilliant Green -- - - 214 hours - 48 hours BEFORE EMB - - -Lactose Broth, 24 hrs.� - - - .-Coliform Density COLLECTING SAMPLE -MF result, - - -Detergent Test . I—Reported by - This analysis indicates Colife AGAR 48 Gram's stain — (Most probable No. per 100cc.) -r Date - - ' (. P. to be: - - Absent' - `I 0 /Zl �Lb�i[2 4i12G� 5'ip k� fm7p /Yr��'' Oce. ]� e e T, /� n c L 0 &a- Z - Q v/L Go 7 /j /Y/oma y S�vv4, C S Pew rscl) Jar Ice ve 54c-,rr5- ctle �rC�tT sir@w� C12g PI e%cete zE� .