HomeMy WebLinkAboutMORTON ESTATES BLK 2 LT 14s
i.
"~-ff '. ~ DATE RECEIVED
~.
INSPECTION APPOINTMENTS,~ ~'--~'"~2x0 .-~
DATE DATE ~// DATE,~_ ~-~ '~
MUNICIPALITY OF ANCHORAGE ~NVIRONMENTAL F, .:~,?~CTION'
DEPARTMENT OF HEALTH & ENVIRONMENTAL PBOTECTION
825 L Street- Anchorage, Alaska 99501 g"--~'r, U 2 2 ~Oml[i~0
(''~') ENVIRONMENTAL SANITATION DIVISION
Telephone 264-4720 RECEIV[D
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be proce~ed. Please allow ten (10) da~s for processing.
1. PROPERTY OWNER IPHONE
~AILING ADD~ESS
PROPERTY RESIDEN~ (if different from above)
2. BUYER PHONE
3, LENDIN~ INSTITUTION [ PNONE
MAI~I~ ADDRESS ~ ~ . __
4. REALTOR/AGENT PHONE
5. LEGAL DESCRIPTION
;TR E ET LOCATI ON
6. TYPE OF RESIDENCE NUMBER (~F~BEDROOMS
[] One [] Four
~ SINGLE FAMILY ~ Two E~ Five
[] MULTIPLE FAMILY [] Three [] Six
[] Other
7. WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
*ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE**
~'~ PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
THIS SIDE FOR OFFICIAL USE ONLY
I. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[~1 SINGLE FAMILY r-~ ONE [~ THREE C-I 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 PERMIT NUMBER
[] INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified
INSTALLER
[]Septic Tank or F~Holding Tank
Size: If Tank is homemad~
SOILS
RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4, DISTANCES Septic/Ho]ding Tank Absorption Area Sewer Line I Nearest Lot Line
WELL TO:
Absorption Area to nearest Lot Line
5, COMMENTS
~""~PPROV ED FOR ~--- BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED ~~
DATE BY
72-010 (Rev. 6/79)
CHEMIC~AL & GJ...~LOGICAL LABORATORIES ,--~ ALASKA, INC.
TELEPHONE (907)-279-4014 ANCHORAGE INDUSTR AL CENTER
274-3364 5633 B Street
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
WATER SYSTEM:
I,D, NO,
Water System Name Phone No.
Mailing Address
...g..- V\ .~
City State Zip Code
Mo. Day Year
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
[] Treated Water
[] Untreated Water
SAMPLE
NO.
I
2 I
I
LOCATION
Time Collected
Collected By
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
~ Satisfactory
[] Unsatisfactory
'~ SamDle too long ~n transit; sample should
not be over 48 hours old at examination
to indicate reliable res~ ts. Please send
new sample.
Date Received
Time
Received
Analytical Method:
[] Fermentation Tube
~' Membrane Filter
Lab Ref. No. Result* Analyst
*No Of colonies/100 mi. or No. of Positive portions.
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220
Rev. Z978
BACTERIOLOGICALWATER ANALYSIS RECORD
Date Collected_ Source
aDB,
P~esumptlve
48 HOURS
48 Hours
EMB. Broth 24 hours: Broth 48 hours:
Multiple Tube Report,*
Membrane Filter: Direct Count
Verification: LTB
Final Membrane Filter ReSults
10mi Tubes ~osltlve/'rotal 1Omi Po~tlonl
Collform/[OOml
BGB.
Date
Collform/lO0~l