HomeMy WebLinkAboutNEWLAND BLK B LT 12
MUNICIPALITY OF ANCHORAC
DEPARTM~fOF HEALTH AND ENVIRONMEN,,._/~ PROTECTION
825 L Street, Anchoraa~. Alaska 99501
264-4720
Date Received: January 11, 1978
#1: Time 11:30 a.m.
#2: Time #3: Time
Date 1-16-78 Monday
Date Date
Insp Pratt insp Insp
REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES
Lending Institution Request: First Federal Savings % Jim Smith
Mailing Address: Post Office Box 4-2200 99509 Phone: 274-6561
Property Owner: William D. Dudley
Mailing Address: Elmendorf AFB
Phone: 752-3964
3. Legal Description: Lot 12 Block B Newland Subdivision
4:
Single Family Residence: ( )
Multiple Family Residence: (xk
Number of Bedrooms:
Number of Bedrooms: Total four
Well System:
Permit #
Construction
Depth of Well
Individual Well (x) Community/Public System ( )
Well Log on File
Sewage Disposal System:
Permit #
Septic Tank Size
Absorption Area
On-site System ( ) Public Utility (x)
Installed Installe~
Manufacturer
Soils Rate Material
Distances: Well to Septic Tank
to Sewer Line Nearest Lot line
to Nearest Lot Line
to Absorption Area
Absorption Area
Paq.e 'Two
Department of Health and Environmental Protection
Request for Approval of Individual Sewer and Water Facilities
Legal Description: Lot 12 Block B Newland Subdivision
Comments:
Af fadavit Attached:
Approved:
Disapproved:
Letter Attached: (
Date:
Department Worksheet:
~ ..> xL~--~- .~_- \C.'--~/ '-~,~UN I C I PA L I TY OF ANCHORAG E"'..~' .'
% "'~~/ Department of Health and Environmental ProtectiOn
[(~r~]] 825 L Street, Anchorage, Alaska 99501
264-4720
' .... uest for Approval of Individual Sewer and water Fa'~ili~i;~~'
, o e.,Owne ,
Mailing .Address: ~ ~'~ (' / ~ ~~-~/~/ Phone:
Mailing Address: ..... Phone:
3. Lending instit.%ion: ~~ ~- ~ ~ '
Mailing Address:
5. Legal Description: ~ [ ~ ~ ~ ~
Street Location: ¢~ ~ ~ ~ ~' ~
Single Family Residence:
Multiple. Family Residence:
( ) Number of Bedrooms:
(~"~Number of Bedrooms:
Water Supply: *Individual Well
If Individual Well, well depth
If Community System, name of system
(/Public/Co~nunity System
Sewage Disposal System: *~n-site System
If On-site System, date of installation:
( ) Public System
*NOTE: A well log is required on ALL wells drilled since 6/75.
** If on-site sewer system is over two(2) years old, an adequacy
.test is required by this department.
A fee of $25.00 must accompany each request before processing
can be initiated.
3/77
06-1220(a) Rev. 1973
DATE
ALA~., DEPARTMENT OF HEALTH AND SOCIAL SE.,.~..,ES
DIVISION OF PUBLIC HEALTH
INDIVIDUAL AND SEMI-PUBLIC
BACTERIOLOGICAL WATER ANALYSIS
INDIVIDUAL El SEMI-PUBLIC .r~ ~ '~HI~ORINE RESIDUAL PPM
NAME
REPORT RESULTS TO
ADDRESS
ADDRESS
OF SOURCE ~ :. ~
ZIP CODE~
COMPLETE THIS SECTION
ONLY IF WATER IS AN INDIVIDUAL SUPPLY
[~ Kitchen Tap [] Bathroom Tap [] Basement Tap
Well -- [] Dug [] Driven [] Drilled
SOURCE: [] Spring [] Cistern [] Other
Dug Well or CJstern Construction:
Walls--[] Wood [] Concrete [] Metal
Top -- [] Wood [] Concrete [] Metal
LOCATION:
[] In Basement [] Basement Offset
OIn Yard [] Other
Building Sewer
DISTANCE TO: or Other Drainage Pipe Feet.
Tile Seepage Cess-
Field Feet, Pit Feet. Pool
Other Possible
Sources of Contamlnatlon
MATERIAL: BuJld~ng Sewer- [] Casl Iron [] Wood [] Tile
[] Plastic Joint Material - Type
GENERAL: Does Water Become Muddy or Discolored?
[] Bored
[] Tile Brick or
[] Open Top ~ Concrete
[] Under House
Feet. Privy .__
[] Fibre [] Asbestos
Cement
[] Yes [] No
Diameter of Well
Well Casing
Material
Length of
Drop Pipe
PUMP LOCATION: [] In Well
On Top
[] Of Well [] Other
Depth Feeh
Diameter . __ Depth .
Water Depth
From Bottom Feet.
Offset in In Utility
[] Basement [] In Basement [] Room
Lab No.
OFFICE
Analysis shows this Water SAMPLE to bei
[] Satisfactory
[] Unsatisfactory
[] Questionable
[] Sample too long in transit; sample should not be over 48
hours old at examinatTon to indicate relTable results. Please
send new sample. -
[] Bottle broken in transit, ptease send new sample.
SANITARIAN'S REMARKS
PURPOSE OF EXAMINATION: Illness Suspected?
New Source of Supply? [] Yes [] No
READ INSTRUCTIONS
ON
REVERSE SIDE
BEFORE
COLLECTING SAMPLE
[] Yes [] No
Repairs to System? [] Yes [] No Signature
064220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD
Rev. 1973
~ J ~" Time ReceTved :. f pm Lpb. No.
Date
Received
Lactose Broth 10cc 10cc 10cc 10cc 10cc 1.0cc 1.0cc
24 Hours
Brilliant Green
24 Hours
48 Hours
EMB AGAR
Lactose Broth, 24 hrs. 4B hrs Gram's stain
Coliform DensHy (Most probable No. per 100cc)
MF Results
Reported by /::// Date / ,'/~C; / ~ a.m.
This analysis indicates Coliform Organisms to be:
~A~sent
Present