HomeMy WebLinkAboutEARL RAY BLK 3 LT 29L
051
EATER gNOiORgGE gRE^ BOROU~
!~EgL~i DEPgR%~NT
327 EgGLE STP~ET
~NCHORAGE, ALASKA 99501
279-2511
DATE RECEIVED ¢.~/~/~
/ :
REQUEST FOR APPROVAL OF
INDIVIDIIAL SEWAGE AND WATER FACILITIES
FOR
2. Property Owner k~9>L.:(~'~:'~.d~
3. Legal Description
4. Type of Facility to
Number of Bedrooms
Well Data:
^. Type
B. Depth
C. Size
D. Construction
E. Bacterial Analys~s'
6. Sewage Disposal System:
Ao
Septic Tank (If homemade, show diagram on back)
/(~'/ ~
2.
Age
3. ~4anufacturer
4. Installer
Approval Request for Se
Page Two
Water Facilities
Seepage Pit
1. Size
2. Lining
C Disposal Field
1. Number of Lines
2. Total Length
Required Measurements
A. Well to Septic Tank
B. Well to Seepage Pit
C. Well to Sewer Line
D. Well to Property Line
E. ~ell to Other Possible Contamination
F. Foundation to Septic Tank
G. Foundation to Seepage Pit
/:
H. Seepage Pit to Property Line
8. CO~ENTS:
APPROVED: f~ ~.~.~
DATE:
DISAPPROVED:
DATE:
APPROVAL VALID FOR ONE YEAR FR0tI DATE SIGNED.
GREATER ANOtORAGE AREA BOROUGH HEALTH DEPARTMENT
EDll70
DATE
STATE OF ALASKA
tTMENT OF HEALTH AND WE
DIVISION OF PUBLIC HEALTH
BACTERIOLOGICAL WATER ANALYSIS
Lab. No.
OFFICE
PUBLIC r'~ SEMI-PUBLIC [~] INDIVIDUAL ~'J OTHER
REPORT RESULTS TO'
NAME
ADDRESS
CITY
ADDRESS
OF SOURCE
SAMPLE COLLECTED BY
am
DATE COLLECTED TIME COLLECTED pm
Sample Collected From [] Kilchen Tap [] Bathroom Tap [] Basement Tap
[] Other (List)
Well- [] Dug [] Driven [] Drilled [] Bored
SOURCE: [] Spring [] Cistern [] Other
Dug Well or Cistern Construction:
Brick or
Walls- [] Wood [] Concrele [] Metal [] Tile [] Concrete
Top - [] Wood [] Concrele (~ Metal [] Open Top
LOCATION: [] In Basement [] Basement Offset [] Under House
[] In Yard [] Olher
Building Sewer Septic
DISTANCE TO: or Other Drainage Pipe Feel Tanl~ Feet
Tile Seepage Cess-
Field Feet, FU, Feet. Pool Feet, Privy--Feet
Other Possible
Sources of Contamination
Asbestos
MATER~AL: Building Sewer - E] Cast [] Wood [] Tile [] F~bre L~ Cement
Iron --
GENERAL: Does Water Become Muddy or Discolored? [] Yes [] No
When?
Diameter o~ Well. Depth Feet.
Well Casing
Material D~ameter Depth.
Lenglh of Water Depth
Drop Pipe From Bottom Peet.
In Utility
PUMP LOCATION: [] In Well [] Offset rn [] In Basement [] Roam
Bdsement
On Top
[] Of Well [] Other
PURPOSE OF EXAMINATION: B~ness Suspected? [] Yes [] No
New Source of Supply? [~ Yes [] No Repairs to System? [] Yes [] No
Records in this office indicate this WATER SUPPLY to be of:
[] Satisfactory [] Questionable [] Unsatisfactory Sanitary Status.
Analysis shows this Water SAMPLE to be:
[] Satisfactory [] Questionable [] Unsatisfactory.
If on "Unsatisfactory" or "Questionable" status is indicated 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
"Drink It Pure."
2. Increase chlorination sufficienHy to meet recommended residual standards.
Determine source of contamination and take action necessary to maintain
a safe water supply at all times.
--3. Check chlori~atinn and other mechanical equipment. Make certain it is
functioning properly.
4. If after checking equipment o disinfecting residual is not obtained, please
wire Ihls office for emergency assistance or advisory services.
S. This is a surface water source and subject to poltutlon 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 lo 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.
E] Bottle Broken in transit, please send new sample.
9. Contact your nearest [] Local Health Departmentor [] Alaska
Division of Public Health, sanitation office for bulletins, consultation and
assistance.
SANITARIAN'S REMARKS
Signature
READ INSTRUCTIONS
ON
REVERSE SIDE
BEFORE
COLLECTING SAMPLE
BACTERIOLOGICAL WATER ANALYSIS RECORD
Dote Received Time Received pm Lab. No.
Lactose Broth 10cc 10cc 10cc 10cc J IOcc 1.0cc 0.1cc
I
24 hours
48 hours
Brilliant Green
24 hours
48 hours
EMB AGAR
Lactose Broth, 24 hrs. 48 hrs.- Groin's stain
Coliform Density (Most probable No. per 100cc.)
MF results om
pm
Reported by Date ____
This analysis indicates Coliform Organisms to be: Absent
Present