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Home My WebLink AboutS E POTTER LT 31� -) x 1,,ak2 0 t S GARB -HDI GRf-ASTER ANCHORAGE AREA BOROUGH HEALTH DEPARTMENT 327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NUMBER OF PITS OUTSIDE DIAMETER OR WIDTH , LENGTH , DEPTH , o LINING MATERIAL /J( % . DISTANCE FROM WELL T1 , BUILDING FOUNDATION , NEAREST LOT LINE �-O j TOTAL EFFECTIVE. ABSORPTION AREA (WALL AREA) I C ate' Z) SQ. FT. E DRAIN FIELD: DISTANCE FROM WELL NUMBER OF DEPTH: TOP OF. TILE TO FINISH G TOTAL LENGTH FOUNDATION - , NEAREST LOT LINE , OF LINES , E B TWEEN LINES TR IDTH IN: TOTAL EFFECTIVE FT. ENGTH OF EACH DEPTH OF FILTER MATERIAL BENEATH TILE _ IN. ABOVE TILE DISTANCE FROM 11 WATER WELL° �->�� DEPTH BUILDING FOUNDATION. Z'a SAMPLE -/�� NEAREST LOT LINE DISTANCES: TYPE - NEAREST .✓ SEPTIC //U/ % SEEPAGE` - `j OTHER ZZ SEWER LINE—, TANK—SYSTEM—, CESSPOOL SOURCES_ DIAGRAM OF SYSTEM APPROVED �. 'ell DATE �� // HEALTH ALAHORHY MAILING PHONE NAME Tom/ %�!� Zia" ADDRESS �%�/ 4'_;--OS LEGAL DESCRIPTION.G/1% LOCATION SEPTIC TANK: DISTANCE FROM WELL r7 ' _ / MATERIAL G'�-d.'�i1/T NUMBER OF COMPARTMENTS C"�g' f, 7,— �/�'r%O� LIQUID /7 LIQUID CAPACITY /T GALLONS. INSIDE LENGTH_INSIDE WIDTH DEPTH SEEPAGE SYSTEM: SEEPAGE PIT: C� 1 �S%/UG NUMBER OF PITS OUTSIDE DIAMETER OR WIDTH , LENGTH , DEPTH , o LINING MATERIAL /J( % . DISTANCE FROM WELL T1 , BUILDING FOUNDATION , NEAREST LOT LINE �-O j TOTAL EFFECTIVE. ABSORPTION AREA (WALL AREA) I C ate' Z) SQ. FT. E DRAIN FIELD: DISTANCE FROM WELL NUMBER OF DEPTH: TOP OF. TILE TO FINISH G TOTAL LENGTH FOUNDATION - , NEAREST LOT LINE , OF LINES , E B TWEEN LINES TR IDTH IN: TOTAL EFFECTIVE FT. ENGTH OF EACH DEPTH OF FILTER MATERIAL BENEATH TILE _ IN. ABOVE TILE DISTANCE FROM 11 WATER WELL° �->�� DEPTH BUILDING FOUNDATION. Z'a SAMPLE -/�� NEAREST LOT LINE DISTANCES: TYPE - NEAREST .✓ SEPTIC //U/ % SEEPAGE` - `j OTHER ZZ SEWER LINE—, TANK—SYSTEM—, CESSPOOL SOURCES_ DIAGRAM OF SYSTEM APPROVED �. 'ell DATE �� // HEALTH ALAHORHY GAAB-HD-2 GREATEF�ANCHORAGE AREA ?'`IROUGH Case No.� HEALTH DEPARTMENT �S 327 Eagle St. Anchorage, Alaska 99501 279-2511 R SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT NAME OF APPLICANT ' 44 MAILING ADDRESS 0/7 1 clft4 PHONE N0:_ Z�1Y6% LL `% RESIDENCE ADDRESS LOCATION OF INSTALLATION LEGAL DESCRIPTION �` S'6- /�� e APPLICATION TO INSTALL: SEPTIC TANK, SEEPAGE PIT , DRAIN FIELD , OTHER t ,i , TO SERVE THE FOLLOWING FACILITY o%' 'rJyzztizs e /'11< VIAX_ FINANCED THROUGH TO BE INSTALLED BY— PERCOLATION TEST RESULTS �`- ANTICIPATED DATE OF CO BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT THIS IS TO SERVE AS ' ` '' AS SEPTIC TANK SIZE DISTANCES: ✓�} PERMIT TO INSTALL ED BELOW. SIZE OF UNIT TO BE SERVED TYPE SEEPAGE AREA TYPE DIAGRAM OF SYSTEM /HEALTH AUTHORITY I I I I I I 1 1 OR I LICENSED DESIGNER I rtify that I am familiar with the requirements of Greater Anchorage above described system is in accordance with said code. DATE A/ /�' APPLICANTS SIGNATURE Borough Ordinance No. 28-68 and that the 1 b. Depth,_ C. Casing Size , .1 d. Distance from well to closest existing or proposed: F �3 1: -Sewer line 1 2. Septic tank 7�F/ 3. Seepage Area / 4, Cesspool' 5. Property Line__X 6. Other sources of possible contamination, i.e., creeks, lakes, houses, barn, drainage ditch, etc. 7, Sewage disposal system. a. Age of system a a eeef- 440-1 *9 b. Septic tank capacity in gallons Iry c. Name of septic tank manufacturer 1. If "home made" show diagram on rerse side of this form. d: Disposal field or seepage pit size and e {�(i (' 1. Distance to property, line U k to house foundation e. Percolation^ Test "results f. Percolation Test performed by Use the reverse side of this form to show diagram. Diagram should include he following information: property lines; -well location, house location, -aoptic tank location, disposal area location, location of percolation test, anj direction of ground slope. ti I 9. The Information on this form is true and correct to the best of my knowledge. Signature of Applicant Date Signed TO BE FILLED OUT BY HEALTH DEPARTMENT PERSONNEL *he above described sanitary facilities are hereby approved, subject to the #ollowing conditions: Conditions: The above described sanitary facilities are disapproved for the following reasons: or 44 %,iyLtv S nature of Af£leYd7,; Date yj. : ' ;" Approval is valid for one year following the date of approval. CPJ:cw STATE OF ALASKA ADHW LAB -4W _ •ARTMENT OF. H EALTH AND. WEI'—RE .Lae:. -No. - " DIVISION OF -PUBLIC HEALTH zBACTERIOLOGICAL _WATER ANALYSIS DATE' OFFICE Records in this office indicate this WATER SUPPLY to be of: - PUBLIC SEMI-PUBLIC INDIVIDUAL [_1- OTHER - REPORT RESULTS TO ❑ Satisfactory ❑ Questionable- ❑ Unsatisfactory Sanitary Status. NAME ADDRESS CITY ADDRESS OF SOURCE SAMPLE. COLLECTED. BY DATE .COLLECTED Sample Collected From ❑ Other (Ust). TIME COLLECTE C] Kitchen Top ❑-Bothrao Analysis shows this Water SAMPLE to be: El, Satisfactory ❑ Questionable ❑ Unsatisfactory. IL oa "Unsatisfactory. or "Questionable" status is indicated above you should fake immediate action as recommended below. - .. I. Notify consumers water is polluted_ Boil or chemically treat this wafer as outlined- in .the enclosed leaflet - "Drink 1f Pure." - _- '- _2. Increase chlorination sufficiently to meet recommended residual standards. °m Determine source of contamination and take action necessary to maintain D - - Pee a sale, wafer supply at all times. - m Tap ❑ Boxemem Top _3. Check thlorinalfnn and other methodical. equipment. 'Make certain it is functioning properly. -4 If aftrileft king equipment al disinfecting residual is not obtained, please --- wire thii+YiNice for emergenLTas3istmce or-adeisory, servicee� -- 7- - - well - ❑ Dug ❑ Driven. '❑ Drilled, ❑ Bored - - -5. This is a surface water source and subject to pollution bymanand animals. - SOURCE: ❑ Spring- ❑ Cistern , - ❑ Other An approved water supply source should be developed. I - Dug Well or Cistern Construction: - - - - Brick —6. -Improve your ❑spring ❑dug well. .❑ driven well ' wan. - ❑woad. ❑eo Concrete El Metal E) Tile Ele Concrete - - Top - - 4 Wood - ❑ Concrete - ❑ Metal ❑ Open Top - - ❑ drilled well ❑ cistern. LOCATION: 0 I Basement - ❑ gas emsotOffset ❑ Under House 7. Relocate your well to a sale location in relationship to your sewage Cl In Yard ❑ Other - disposal system. ❑ see enclosure - DISTANCE TO: or�O1h a,SDrainage li Feet. or Tark Feer. g pe - 8: Sample too long in transit; sample should not be over 48 hours old of TileSeepage - Cess- - - examination to indicate reliable results, please send new sample. - - Field - Feet Pit Feet. Pool Feet Pi -my Feat - Other Possible - ❑ Bottle Broken in transit, please send new sample. Sources of Comaminotion Cost Asbestos MATERIAL: Building Sewer - ❑ ❑ Wood ❑ Tile. ❑ Fibre ❑ 9.' Contact our nearest ' ❑ Local Health Department or ❑ Alaska.. Iron Cement. ' Y El Plastic Joint Material -r Type Division of Public Health, sanitation office for bulletins, consultation and assistance. GENERAL: Does Wafer Become Muddy or Discolored? ❑ Yes ❑ No SANITARIAN'S REMARKS - - - - Diameter of Well Depth Fee,. Well Casing Material Diameter Depth Length of Water Depth - Drop Pipe From BaMom - Feet PUMP LOCATION: ❑ In Well ❑ Oset BoNemen, ❑ In Basement E] In Raomility On Top ❑ Of Well ❑ Other PURPOSE OF EXAMINATION: Illness Suspected? ❑ Yes ❑ No New Source of Supply? ❑ Yes ❑ No Repairs to System? ❑ yes ❑ No BACTERIOLOGICAL WATER ANALYSIS RECORD READ INSTRUCTIONS am 02O:3.�ri y Date Received ['. r (T Time Received % > `* 'Pm -a Lab. No. ON REVERSE SIDE BEFORE COLLECTING SAMPLE Lactose Broth IOcc IOcc locc IOcc IOcc LOc< 0.7 ec 24 hours 48 hours ------- Brilliant "'_Brilliant Green - - 24 hours 48 hours Lactose Broth, 24 hrs. Coliform Density— MF results _Reported by This analysis indica) Coliform Organisms to be: 48 AGAR :Absent" stain sst probable No. per 100cc.) DIRECHOI!S FOR CCi1. F ING SAMPLES 01: WATER FOR BACTERIOLOGICAL EXAMINATION Read Carefully and Follow Instructions Exactly Bear in mind Ilial wolor analysis hauls with matcrtols present in very mtnuto quantities. The least carelessness in collecting unci hanclIing may give ,iso to results which are mist ending. Arrangements should be made to have water samples reach the luuorakuy as quickly as possible. After 48 hours the signMcmKe of The baderioloyical analysis is impahad. Forohvtous masons Lha oboralory prefers to receive samples in the WHY purl of the, weak but isv,11hrig to accept samples of any Time. In a HoWng samples from TAPS or PUMPS proceed us follows: (a) Thoroughly flush lap or pump by allowing wales to run: h-ucly for five mtnules. (b) Shut off water and fielne the outlet :vith torch or buintng paper. The flame should not be merely passed over the oullel but should he applied until fixture shows h0kalton of bulny hol. Elaine should be directed against inside udgc. (c) Open fixture so Ilial a small stream flows (d) Remove bottle from mailing tube- Hold Eolllo by the lower half in one hand and with the, ether remove the scow rap vvilh the fingers, euvtng paper proleding cover iii place. Fill the Eolllo to the shoulder. Replace cap with paper cover, screwing finely tato place bul ch not apply pressure which will split cap. (e) Pack bottle carefully in moiling lube ondosing this compleled infornwlton sheel. In colluding samples from STREAMS and RESERVOIRS proceed as follows: {a) Remove cap and hold boldo as describod under 0) above. (h) Called sample by holding bolllo in o slanting posilion and sweeping it below the surface in such in mnnrer [licit water &M hos been in canted with the hand is not introduced Into the bolllo. Avold colluding surfnca scum and bottom sediment, d r " p�../�-. R y y u 1 MIAMI I ", ,2�k ��I t' ��xV r�111?1V v,/�� r�L_a� al H �%'�v /T�17,y7 Ill v i a€� e'.`'�� 11y �i j'`� � �9 d-�av dl l,,�d'(A�K 9,Y- j-,Tf ,'�9.n �\�/a ��li.ti Jrl �t7u . II i t -:-r r V d u, 11:T-rr it If err �� V � g '7/ 7� I'r.rLl Cf�. r (r1 [' $� 301:R STERILE WATER SAMPLE BOTTLES ARE LP. AVAIIABUPON RI`GUFS M: GRFr+1` fi?4Cpois rm AREA , 1 { :Ty e Dept. of Fiaalth &Welfare Dept, of Fleo6h R, Welfare Y10RO.f- "D'cpt of Iiealih Rr Welfare SOUTHEASTFRN REGIONAL LABORATORY SOUTIICENTRAL REGIONAL LABORATORY NORIIIERN REGIONAL. 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