HomeMy WebLinkAboutNEWLAND Block L Lots 8 & 9
MUNICIPALITY_~'oF~CHORAGE MUNICIPALITY OF
DEPARTMENT OF HEALTH &~IRONMENTAL PROTECTION DEPT OF
~ 825LStreet-~horage, Aaska99501/ ENVIRONMENT, '::-' ,~
' '~ ...... ~-" ' - ~ ~.C:~c~HON
ENVIRONMENTAL ENGINEERING DIVISION ~
T~phone 264-4720 I~
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DIRECTIONS: Complete all parts on page 1. Incomplete req~ ests will not be processed. Please allow ten (10) davs for processing.
1. PROP~TYOWNER ~ C~ ~ -- PHONE
MAILJ'~Q ADD~ESS - ~ ~/ .
PHOPE~ZY ~ESI~E~T (14~iffe~n~ from above) ~ PHONE
,
MAILINGADDRESSI ~ --[ / ~ t~ ~
6. TYPE OF RESIDENCE
[] SINGLE FAMILY
MULTIPLE FAMILY
NUMBER OF BEDROOMS
[~] One ~ Four
[] Two [] Five
[] Three [] Six
[] Other
7. WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
8. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE**
'I~. PUBLIC UTILITY
*ATTACH WELL LOG. A welt log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.) zf:~;~ ~'
**If individual/on-site, give installation date
If system is over two (2) years old an adequacy test is required
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010(3/78)
· CH~.,AL a GEOLOGICAL LABOI~TOI~F-~ OF AI.A~KA~ lNG.
P.O. BOX 4-1276 ANCHORAGE. ALASKA gcJS09 ~.649 BUSINESS PARK BLVD.
Ddnking Water Analysis Report for Total Coliform Bacteria
TELEPHONE
(907) 279-4014
TO BE COMPLETED BY WATER SUPPLIER
~ ~ ~ ~ I.D. NO.
Public Water Syste~ Name ~ ;.,
Mailing Address ;~ ~ ~
Mo. Day Year
Zip Code
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref. no. )
[] Special Purpose
SAMPLE
NO.
2 I
4 I
[] Treated Water
[] Untreated Water
Time Collected
Collected By
TO BE COMPLETED BY LABORATORY
LABORATORY:
NAME
?.: · .
ADDRESS
Date Received
Time Received
CITY
/
Analytical Method:
[] Fermentation Tube
/~Membrane Filter
Lab Ref. No. Result* A~aly,~-~
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Form No. 18-310 (3-78)
06-1220 (b)
Rev. 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Collected Source
I-ab. No,
24 Hours
48 HOURS
EMB Broth 24 hours:
Multiple Tube Report:
Membrane Filter: Direct Count
Broth 48 hours:
1Omi Tubes Positive/Total 1Omi Portions
Time: a.m.