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Home My WebLink AboutNEWTON LT 3 HEALTH DEPARTMENT 327 EAGLE ST. ANCHORAGE, ALASKA 99501 ~)-2511 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM SEPTIC TANK: ADDRESS PHONE DISTANCE FROM WELL '7 7 / ~_~.~:~__~ NUMBER OF / MATERIAL COMPARTMENTS. LIQUID CAPACITY 7 ~""~ GALLONS. INSIDE LENGTH INSIDE WIDTH. DEPTH __ SEEPAGE SYSTEM: SEEPAGE PIT: NUMBER OF pITS / OUTSIDE DIAMETER '-- OR WIDTH / ~ / LINING MATERIAL ~.~'~4~'~..o ~",'//L~ ~ DISTANCE FROM WELL /~'~/ NEAREST LOT LINE ~ TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) ., DEPTH BUILDING FOUNDATION , sQ. FT. TILE DRAIN FIELD: DISTANCE FROM WELL. FOUNDATION j, NEARESTLOT LINE . NUMBER OF LINES DISTANCE BETWEEN~,,/' TRENCH WIDI~H ABSORPTION AREA SQ.~TH OF EACH LINE DEPTH: TOP OF TiLE TO FINISH GRADE TOTAL LENGTH , OF LINES DEPTH OF FILTER MATERIAL BENEATH TILE IN. TOTAL EFFECTIVE IN. ABOVE TILE ,,,//~¢ ~ DISTANCE FROM WELL: TYPE 4~/"/ , DEPTH * , BUILDING FOUNDATION. ~ NEAREST ~ 7 / SEPTIC 7 / SEEPAGE LOT LINE * , SEWER LINE , TANK '~ , SYSTEM ~-~ ~.~ WATER : SAMPLE /x/~ ., NEAREST /~/~./ ' OTHER ~' , CESSPOOL ~ , SOURCES DISTANCES: DIAGRAM OF SYSTEM DATE APPROVED HEALTH AUTHORITY GREATE1,.,.ANCHORAGE AREA . :)ROUGH C. No. HEALTH DEPARTMENT 327, .. Eagle St. Anchorage, Alaska 99501 279-2511 /[[ ~ SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT NAME OF APPLICANT f/'u////~;t~ !./~/~)-~tD/~L~,.,. 'MAILING ADDRESS ~,~× 6Z PHONE NO RESIDENCE ADDRESS ',." ' r ' LOCATION OF INSTALLATION .~c~.~;¢>~,~ / h/~? · ' , - .-. Z ~ ~ ~(~ ~ -~u ~zd~ APPLICATION TO INSTALL: SEPTIC. TANK , OTHER TO SERVE THE FOLLOWING FACILITY" FINANCED TH ROUGH ~ ~ ~ ~ ~z~iUA '/~ ~o~ ~ ~~-TEST RESULTS · ANTICIPATED DATE OF COMPLETION` ~z~ kv~ ~?~6~-_ ' BELOW TO BE FILLED ~UT BY HEALTH DEPARTMENT THIS IS TO SERVE AS ~)?, k)a[/) '~ :' , PERMIT TO INSTALL A ~<~: ,' , ~'/, SEEPAGE PIT ~ .,"DRAIN. FIELD . . '"'"'"" TO BE'INSTALLED.BY AS DESCRIBED BELOW. : SIZE OF UNIT TO BE SERVED . SEPTIC TANK SIZE '~'?.) 'TYPE(?~;/C'~fU /SEEPAGE AREA /~ ~./L TYPE DIAGRAM OF SYSTEM DISTANCES: -IOo/ ~, / Jthority I I am familiar with the requirements of Greater Anchorage Area Borough Ordinance No. 28-68 and that the above described system is in accordance with said code. '~ APPLICANTS SIGNATURE DATE · / ¢/ 7- 7& ' DATE D'-'ARTMENT OF HEALTH AND WEI~ 'rRE DIVISION OF PUBLIC HEALTH '- ' BACTERIOLOGICAL WATER ANALYSIS Lab. No. OFFICE PUBLIC [] NAME ADDRESS CITY ADDRESS OF SOURCE SEMI-PUBLIC ~I INDIVIDUAL [~ OTHER v~ Ft[-PORT RESULTS TO' SAMPLE COLLECTED 8Y -- DATE COLLECTED d? - ? -- -7,&: T,MECOLLEC,ED Sample Colleded From [~K~tchen Tap [] Bathroom Tap [] Basement Tap [] Other Well- [] Dug [] Driven [] Drilled [] Bored SOURCE: [] Spring [] Cistern [] Other Dug Well or Cistern Constructiom Brick or Wails - [] Wood [] Concrete [] Metal [] Tile [] Concrete Top - [] Wood [] Concrete [] Melor [] Open Top LOCATION: [] In Basemenl [] Basement Offset [] Under House [] In Yard [] Other Building Sewer Septic DISTANCE TO: or Olher Drainage Pipe Feet. Tank Feet. File Seepage Cess- Field Feet. Pit Feet. Pool Feet. Privy Feet Other Possible Sources oF Contominallon Asbestos MATERIAL: Building Sewer - []IronCaSt {~ Wood [] Tile [] Fibre [] Cement [] Plaslic Jolnt Material -- Type Records in this office indicate this WATER SUPPLY to be of: Satisfaclory [] Questionable [] UnsatisFactory Sanitary Status. ~Jnal~,sls shows this Water SAMPLE to be: Satisfactory [] Questionable [] Unsatisfactory. If an "UnsatisFactory" or "Questionable" status is indlcated above you should take immediate action as recommended below. __1. Notify consumers water is polluted. Boil or chemically treat this water as outlined in the enclosed leaflet "Drin~ It Pure." .2. Increase chlorination sufficiently to meet recommended residual standards. Determine source of contamination and take action necessary to malntain a safe water supply at all times. 3. Check chlorination and other mechanical equipment. Make certain it is functioning properly. 4. If after checking equipment a disinfecting residual is not obtained, please wire this office for emergency assistance or advisory services. 5. This is a surface water source and subject to pollution by man and animals. An approved water supply source should be developed. 6. Improve your [] spring [] dug well [] driven well [] drilled well [] cistern. __7. Relocate your well to a safe location in relationship to your sewage disposal system. [] see enclosure __8. Sample too long in transit; sample should not be over 48 hours old at examination to indicate reliable results, please send new sample. [] Baffle Broken in transit, please send new sample. 9. Contact your nearest [] Local HealthDepartmentor [] Alaska DJvlsion of Public Health, sanitation office for bulletins, consultation and assistance. GENERAL: Does Water Become Muddy or Discolored? [] Yes [] No When? Diameter of Well Depth. Feet. Well Casing Materlal Diameter .Depth Lenglh of Water Deplh Drop Pipe From Boffom Feet. PUMP LOCATION: [] In Well []BasementOlfset In [] In Basement [] Roomln Utility On Top [] Of Well [] Other PURPOSE OF EXAMINATION: Illness Suspected? [] Yes [] No New Source of Supply? [] Yes ~ No Repairs to System? [] Yes [] No SANITARIAN'S REMARKS DATE D?'ARTMENT OF HEALTH AND WEt,~ 'RE DIVISION OF PUBLIC HEALTH BACTERIOLOGICAL!. WATER :ANALYSIS Lab. No. OFF[CE PUBLIC [~ SEMIPUBLIC ~] INOIVIDUAL [~ OTHER REPORT RESULTS TO NAME ADDRESS CITY ADDRESS OF SOURCE SAMPLE COLLECTED BY DATE COLLECTED Sample Collected From [] Other Lisl] rIME COLLECTED [] Kitchen To~ [] B~throom Tap am orr Well- [] Dug [] Driven [] Drilled SOURCE: [] Spring [] Cislern [] Other Dug Well or Cistern Construdion: Walls- [] Wood [] Concrele [] Mefa Top- [] Woad [] Concrete ~ Metal LOCATION: [] n Basemenl C Basement Offset [] In Yard [] Olher Building Sewer DISTANCE TO: or Other Drainage Pipe Feel Tile Seepage Cass- Field Fee' Pil Feel Pool__ Other Possib~e Sources al ConlaminaHon MATERIAL: Building Sewer - ~ Cosl ~] Wood Iron GENERAL: Does Water Become Muddy or Discolored? Brick or [] [tie [] Concrete [] Ooen [~ Under House [] Tile E Fibre ~] Asbeslos Cement [] Yes [] No When? Diameter of WeB Depth Feet. Well Casing ~UMF LOCAIIOF, [] In Well []BasemenlOgsel In [] [n Basement [] Room [] Of Well [] Olher PURPOSE OF EXAMINATION: Illness Suspected') [] Yes ~ No Records in thls office indicate this WATER SUPPLY fo be of: [] Satisfactory [] Questionable [] Unsatisfactory Sanitary Status. Analysis shows this Water SAMPLE to be: [] Satisfactory [] Questionable [] Unsatisfactory. if an 'Unsatisfactory" or "Questionable" status is indicated above you should take immediate action as recommended below. 1. Notify consumers water is polluted. Boll or chemically treat this water as outlined in the enclosed leaflet "Drink It Pure." 2 Increase chlorination sufficiently to meet recommended residual standards. Determine source of contamination and take action necessary to maintain a safe water supply at all limes. 3. Check chlorination and other mechanical equlpment. Make certaln it is fundion~ng properly. 4. Il after checking equipment a disinfecting residual is not obtained, please wire this office for emergency assistance or advisory services. 5 This is a surlace water source and subjectto pollution by man and animals. An approved water supply source should be developed. §. Improve your [] spring [] dug well [] driven well [] drilled well [] cistern. 7. Relocate your well to a safe location in relationship to your sewage disposal system. [] see enclosure 8. Sample too long in transit; sample should not be over 48 hours old at examination to indicate reliable results, please send new sample. [] BaHia Broken in transit, please send new sample. 9. Contact your nearest [] Local Health Department or [] Alaska Division of Public Heallh, sanitation office for bulletins, consullation and asslstance. SANITARIAN'S REMARKS Signature READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE BACTERIOLOGICAL WATER ANALYSIS RECORD Dale Received Lactose Broth 24 hours 45 hours griJJiont Green 24 hours 48 hours EMB om Time Received pm Lab. No. Lactose Broth, 24 hrs. Coliform Density. MF results Reported by This analysis indicates Coli!orm Organisms to be: AGAR 48 hrs.- (Mosl probable No. per 100cc.) Date am , Absent~ Present