HomeMy WebLinkAboutLot 01
DATE RECEIVED
'~ INSPECTION APPOINTMENTS /'*'~. / !~ ;:'" . '? ~/ .r,
TI'ME TIME TIME
.t ~ Y~ ~::0 i,! ,.
DATE DATE
INSPECTOR ./% , ) INSPECTOR ..,~ ' INSPECTOR
MUNiO~P~rV OF ANCHO~AG~
MUNICIPALITY OF ANCHORAGE D~P'r, OF H~,',LrN &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTE~i~ONM~Ni,,,~ V:OVCTION
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL SANITATION DIVISIO~
Telephone 264-4720
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
MA~ L~ NG ADCR E~¢
,¢-f~:.:;//
PROPERTY RESIDENT (If different from above) PRONE
'i'/ ' - . ',r'~ / PHONE
2. BUYER ., /
MAILING ADDRESS
3. LENDING INSTITUTIO~ ~ . ~ PHONE
MAILING ADDRESS - ,,
4. REALTOR/AGENT ~ - / PHONE
MAILING ADDRESS - ~
//s/ f'//' ,,./,,:
5. LEGAL DESCRIPTION
STREET LOCATION
6, TYPE OF RESIDENCE
SINGLE FAMILY
[~] MULTIPLE FAMILY
NUMBER OF,BEDROOMS
[] One [] Four
/¢~ [] Five
Two
[] Three [] Six
[] Other
7. WATER SUPPLY
INDIVIDUAL*
COMMUNITY
PUBLIC UTI LITY
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~*
'?~x PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
L] SINGLE FAMILY ~ ONE ~ THREE I~ FIVE FJ OTHER
El MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
LN COMMUNITY DATE DR I L ~-~D 'i
~3 PUBLIC UTILITY
ConnecLion Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
F-IINDIVIDUAL/ON -SITE(~,,. ~ (~( DATE INSTALLED
LLFPLFB LIC UTI LITY
Connection Verified ~' ~()~v',-e. -
INSTALLER
LJSeptic Tank or [~HoldingTank
Size:__ _ If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAl_ ABSORPIlON AREA MATERIAL
' 'Nearest --'"
4. DISTANCES Septic/Holding Tank IAbsorption Area Sewer Line Lot Line
WELL TO:
Absorption Area to nearest Lot Line
[51 COMMENTS
~ APPROVED FOR 2'~ BEDROOMS
[~[~-- ~ONDITIONAL. APPROVAL (letter must accompany certificate)
r~q DISAPPROVED
72 010 (Rev. 6/79)
CHEMICAL & GEc~£OGICAL LABORATORIES C~' ALASKA, INC,
TELEPHONE (907)-279,4014
274-3364
ANCHORAGE INDUSTRIAL CENTER
5633 B Street
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
WATER SYSTEM: [---T'-~ I 1 ~
I.D. NO,
Water System Name Phone No.
Mailing Address
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. LOCATION
t I
2 I
Time Collected
Collected By
J
TO BE COMPLETED BY LABORATORY
Analvs s snows 13~s Water SAMPLE to be:
[] Satisfactory
[] Unsatisfactorv
[] Samom too ong in transit; sampe Should
no! De over 48 hours o~o au examination
to ~nd~cate rel~aDm resu~s. Please send
new
Date Received
Time Received
Analytical Method:
[] Fermentation Tube
[] Membrane Filter
Lab Ref, No. Result* Analyst
I I
I
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220 (b)
Rev. 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Collected Source
Lab. NO.
24 Hours
Confirmatory
24 Hours
Broth 24 hours:
Multiple Tube Report=
Membrane Filter= Direct Count
Verification= LTB
Final Membrane Filter Results
Reported By
Broth 48 hours:
Z0rnl Tubes Positive/Total lOml Portions
.Collform/100ml
BGB__
Date
Collform/lOOml