HomeMy WebLinkAboutNADINE LT 20B1 CRESCENT HILLS03
MUNICIPALITY OF ANCHORAGE ..........
~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECT O1~':
~ Te ephone 264-4720 ,' ' ' ' '~ ~';~'
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONSI Complete all parts on page 1. Incomplete reques~ will not be processed. Please allow ten (10) days for processing, '
MAIUNGADDRESS ~ ' ~~ /+~
PROPERTY BE~IDENT (If diff~ent from ebove}_ .
4. REALTOR/A~ENT ~ PHONE
MAILING ADDRESS '
i5.
LEGAL
DESCRIPT
ON
STREET LOCATIOi~
S. 'rYPE OF RESIDENCE
XSINGLE FAMILY
[] MULTIPLE FAMILY
7, WATER SUPPLY
~ INDIVIDUAL* [] COMMUNITY
[] PUBLIC UTILITY
SEWAGE DISPOSAL SYSTEM
~ INDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
NUMBER OF BEDROOMS
[] One [] Four [] Other
~Q, Two [] Five
[] Three [] Six
ATTACH WELL LOG A well Icg is required for all wells drilled
since June 1975, For wells drilled prior to that date, give well
depth {attach log if available,)
If md~wduat/on-sKe, give installati -
If system is over [wo (2) years old an adequacy test is required
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR
)IRECTIONS;
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
[] COMMUNITY DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM ~ERMIT NUMBER
[] INDIVIE~UAL/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. DISTANCES Septic/Holding Tank Absorption Area ISewer Line [Nearest Lot Line
WELL TO:
I
I
Absorption Area to nearest Lot Line
5, COMMENTS
[] APPROVED FOR BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
,[~;]/"DIsAPPROV ED
DAT~- BY ITitlel
LEGAL DEscRIPTION
72-010 (Rev, 3/78)
Date
ALAS~
~EPARTMENT OF HEALTH AND SOCIAL ~ /ICES
DIVISION OF PUBLIC HEALTH
Lab. No.
BACTERIOLOGICAL WATER ANALYSIS
Office
PLEASE MAIL RESULTS TO~ ....
ADDRESSJ~]x~ .~,~.~ "~
Phone No,
Date ~llected ~f-')~ Time
ZIP CODE _
Sampling Address
Specific place of collectioo. L ~' c>~..~ ,~
REASON FOR SAMPLE SUBMISSION:
[] lllness suspected
[] He~th Regulated Establishment
WATER SAMPLE SOURCE
Type of casing
[] Improved (Enclosed, Covered) Spring
[] Surface (Reservoir, stream, lake)
[] Holding Tank
[] Other
Analysis shows this WATER SAMPLE to be:
[~atisfactory
[] Unsatisfactory
[2 Questionable [] submit other sample
[] Sample too long in transit to indicate reliable results.
Sample should not be over 48 hours old at time of
examination.
[] Bottle broken or leaked in transit.
[-] Other
SANITARIAN'S REMARKS
Sanitafian's Signature:_
Date_
ALASK hEPARTMENT OF HEALTH AND SOCIAL 2' VICES
DIVISION OF PUBLIC HEALTH
Lab. No.
BACTERIOLOGICAL WATER ANALYSIS
Office
PLEASE MAIL RESULTS TO:
NAME
ADDRESS_
CITY_
ZIP CODE
Sample collected by
Phone No.
Date Collected
Sampling Address_
Time
Specific place of collection
REASON FOR SAMPLE SUBMISSION:
[] Blness suspected
[] Health Regulated Establishment
[] Other
WATER SAMPLE SOURCE
[] Well Type of casing
[] Improved (Enclosed, Covered) Spring
[] Surface (Reservoir, stream, lake)
[] Holding Tank
[] Other
Analysis shows this WATER SAMPLE to be:
[] Satisfactory
[] Unsatisfactory
[] Questionable [] submit other sample
[] Sample too long in transit to indicate reliable results.
Sample should not be over 48 hours old at time of
examination.
[] Bottle broken or leaked in transit.
[] Other
SANITARIAN'S REMARKS
Sanitarian's Signature:
~EAD INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD
Rev. 1978
Date Collected / ' ~ ~ ~ Source__
Date Received_' i ; ' ; i Time Received' ,' ~ '~p.m; Lab. No.
Presumptive 10mi 10mi 10mi 10mi 10mi 1.0mi 0,1mi
24 Hours
48 Flours
Confirmatory
24 Hours
48 Hours
EMB Broth 24 hours: Broth 48 hours:
' ~' . ~ 10mi Tubes Positive/Total 10mi Portlous
Collform/100ml
Coftform/lOOmt
Time: a.m.
Multiple Tube Report:.
Membrane Filter: Direct Count
Verification: LTB
Final Membrane Filter Results
Reported By