HomeMy WebLinkAboutTract B (19)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
/L~- /./-/-~ HAA#
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Day phone
Day phone
Day phone
m
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
NOTE:
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
NOTE:
Public sewer /X~ ',.~ x/,
If community wastewater system, Provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:-l~-A ~7~ ~/, /~n~ ~ci/;'>.~ ,~';,~L~. Parcel I.D.
A. Well Data
Well type
Log present (Y/N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed LJ~JV~J obOhJ Driller
Cased to ~' ~//-0 / Casing height
V wires properly protected (Y/N)
FROM WELL LOG
Total depth '~
Sanitary seal (Y/N)
Date of test
Static water level
Well flow
Pump level1
g.p.m.
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform Nitrate Other bacteria
Date of sample: Collected by:
LOING TANK DATA C' ~'-'~/
Tank size .... Compartments
Cleanouts (Y/N)~ Foundation cleanout (Y/N) __ Depression (Y/N)
High water alarm (Y/N) ~~ Alarm tested (Y/N)
Date of pumping ~er
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: ~
Foundation
Well(s) on lot On adjacent lots
To property line Absorption field Water main/service line
Sudace water/drainage
72-026 (3/93)° Fro~lt CONTINUED ON BACK PAGE
FROM P. OO~
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CT&E Ref.#
Cliant Sample ID
Matrix
Client Name
Ordered By
Project Nme
Project//
PWSID
Commercial Testing & Engineering Co.
Environmental Laboratory Services
LABORATORY ANALYSIS REPORT
94.3767-1
TRACT B MILE BORNE SUB
WATER
ANDERSON ENGINEERING
ALAN ANDERSON
UA
WORK Order 80738
Printed Date 07/28/94 @ 15:20 hrs.
CollectedDate 07/26/94 @07:30 hrs.
Received Date 07/26/94 ~10:15 hrs.
Technical Director STEPHEN C. EDE
Released By: ~~,o~
Sample Remarks: ROUTINE SAMPLE COLLECTED BY: MEA.
QC
Parameter Results Qual
Units
Allowable Ext. Anal
Method Limits Date Date
Init
Nitrate-N
0.10 U mg/L EPA 353.2/300.0 10
07/28/94 DJS
* Sec Special Instructions Above
** Sec Sample Remarks Ab ove
U = Undetected, Rep orted value is the practical quantification limit.
D = Secondary dilution.
UA=Unavailable
NA=NotAnalyzed
LT=LessThan
GT=C~euterThan
5633 B Street, Anchorage, AK 99518-1600 -- Tel: (907) 562-2343 Fax: (907) 561-5301
ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, OHIO, UTAH, WEST VIRGINIA
Drinking Water Analysis Repor~ for Total Coliform Bacteri~
~ ~vsrsucr:o~vs o~v mrmrvxs smsBs~'ome cozz~cr~r~a s,~m,z~ I
Commercial Testing & Engineering Co.
Environmental Laboratory Services
5633 B Street
Anchorage., AK 99518-1600
Tel: (907) 562-2343
Fax: (907) 561-5301
MUST BE COMPLETED BY WATER SUPPLIER
[] PUBLIC WATER SYSTEM I.D. #
El PRIVATE WATER SYSTEM
[] Sendlnvoice
O S~dR~
0 Send.Re. xultS 0 Sendlnvoice
Month Day Year
SAMPLE TYPE:
El Routine 13 Treated Water
[] Repeat Sample (for routine sample El Untreated Water
with lab ref. no. )
[] Special Purpose TLme Collected
~ Collected By
SAMPLE LOCATION ,
please Prat
TO BE COMPLE'I'ED BY LABORATORY
Analysis shows t. this Water SAMPLE to be:
B/ Satisfactory
[] Unsatisfactory
[] Sample over 30 hours old, results may
be unreliable .!
rn Sample too lon~ in transit; sample should
not be over 48 hours old at examination
to indicate reliable results. Please send
new sample ',(ia special delivery mail.
'JUL 2 6 1994
Date Received
Time Received
Analysis Began
Analytical Methbd: ~ Membrane Filter
[] MMO-MUG
* Number of col6nies/100 mi.
Lab Ret No,! Result*
94.3767
Sent to A.D.E.C. ~ Fb'ks Jun
Analyst~
Dat~: "~J~D~9. Time:.
Client notified of unsatisfactory results:
Phoned Spoke with
Date: _ Time:
Faxed
Faxed
Comments;
BACTERIOLOGICAL WATER ANALYSIS i:LECORD
MMO-MUG Result: Total Coliform
Membrane Filter: Direct Count
Verification: LTB BGB
Fecal Coliform Confirraatiou
Final Membrane Filter Restllts
Reported By .f r Date
E, Coli
Colonies/100 mi
COLIFIRM
ColJ£orra/100 mi
PART ONE OF TWO:
REMAINDER TO FOLLOW
AH, WEST VIRGINIA
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