HomeMy WebLinkAboutELLEN COURT LT 2L?-
OIG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 L Street - Anchorage. Alaska 99501
ENVIRONMENTAL ENGINEERING DIVISION
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PRO_~[~TY OWNE ~1~ PHONE
PROP~Rc~T~ESIDENT (~,fferent from above)
2. BUYER PHONE
MAILING ADDRESS
I
MAILING ADDRESS
4. ~EA[?ORIAGENT ~ PHONE
MAILING ADDRESS
5. LEGAI' DESCRIPTION
STREET LOCATION
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**
[~ PUBLIC UTILITY
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.) (~/
**If individual/on-site, give installation date
If system is over two (2) years old an adequacy test is required
bv this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010(3/78)
~ . THIS SIDE FOR OFFICIAL USE ONL ~"~ '
DATE R EC-~I V ED
INSPECTION APPOINTMENTS
TIME TIME TiME
DATE DATE DATE
INSPECTOR. INSPECTOR INSPECTOR
)IRECTIONS:
I
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
2. WATER SUPPLY PERMIT NUMBER
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE'DISPOSAL SYSTEM PERMIT NUMBER
I--IINDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified INSTALLER
I--iSeptic Tank or I-~ Holding Tank
Size; If Tank is homemade SOILS RATING "
give 'dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCESwELL TO: Septic/H°lding Tank IAbs°rpti°n Area Isewer Line INearest L°t Line
Absorption Area to nearest Lot Line
~ APPROVED FOR BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY (Title)
LEGAL DESCRIPTION
72-010 (Rev. 3/78)
ALASK/--"~ARTMENT OF HI~LTH AND .SOCIAL
DIVISION.OF p~BLIC~tEALTH
· ~. Lab. No.
BACT E R I O~LOG I CAL~WAT E R ~ANALYSIS
Phone No.
ZIP CODE
Time
Date Collected
Sampling Address
Specific place of collection
REASON FOR SAMPLE SUBMISSION:
[] mness suspected
[] Health Regulated l~tablishment
[~]~Other ~ ¢3
WATER SAMPLE SOURCE
[] ~][:-....~ Type of casing
[] Ia~proved (Enclosed, Covered) Spring
[] Surface (Reservoir, stream,,]ake)
[] Hold~ng Tank
[] Othe~~''
Office
~EAp INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220 (b)
Rev. 1978
BA(~E: RIOLOG ICAL WATER ANALYSIS RECORD
Date Collected ~' '/~/-~'~' ~ Source ~
- A? a.m. 4459 ?
Date Received ~/'~/'/'~'~ Time Received ~La~, No.
Presumptive ' lOml 10mi 10mi 10mi 10mi 1.0mi 0.1mi
24 Hours
24 Hours
Multiple 3~ube Report:
Membran FIIte[: Direct Coun~t,~,.
Ve r~,a t I o~: L~B,
F~ter Result~
Broth 48 hours:
10mi Tubes Positive/Total lOml Portions
, Collform/lOOml
BGB
Collform/lOOml
Tlme~ ~" x.~ ~ ~
Analysis shows~ this WATER'~MPLE to be:
atisf~tory ?
[] Unsati~facf~y- '
[] Questionable . ',T-] submit other sample
[] S~mpl~ t~,o long ,in transit to indicate reliable results.
Samp!~ should not be ~oveg 48 hours old at time of
exami~{ion, -~: ....
[] Bottle.broken O~'lea~ed in'~ransit.
[] Other
SANITARIAN'S REMARKS
3500 Tudor Road, Anchorage,.Al~sk~ 99507
' ' ' :
REQUEST- - .' , , -
~VIDUAL SEWHR & WA~R FACILIT~S
FOR ,
.-.: 1-:':~_~: Aoproval Requested By:
· Address: .
· .,Phone; ·
4. Location:
'. 5. Type of Facility to be Inspected:
· Number of' Bedrooms: ' . .
6. Well Data:
?'~':~ ,C. Consti'uction ~ D. Bacteria] Analys~.
A. ' ~ns%al~ed ~. Installer
C. Septic Tank: 1, Size 2.
D. Seepage Pit: 1. Size 2.
E. Disposal Field: Total Length.of Lines
8..Distances:
A. Well To: Septic Tank , Absorption Area
· Nearest Lot Line , Other Contamination _-,.. ,__. '
B. Foundation Go Septic Tank '~,, AbSorption'Arena
C. Absorotion. Area to Nearest Lot.Line.
a: Req~Z~ for Approval of Ino~vfdua! Sewer & Water
~':Page TWO
9. Comments:
Approval Valid for One Year From Date S~gned
Greater Anchorage Area Borough, DeFartment of Environmental Quality
DIAGRAM OF SYSTEM
I certify that the tnformat~on contained tn this request for approval to be a true
and accurate representation of the subject sewer and water fac~llt~e$ located at~
"
SXgned
Date