HomeMy WebLinkAboutELLEN COURT LT 11
APPLI', 'NT FILLS OUT uPPER HA?' NLY
~=Property OWner ~,.,O,/~./y ./~/,,//~ ;~,,.~.~ Phone
Address Zip Oode
Realty Co, & Agent (~O/[~ ~,t,4U)l~l (,~j~m//? Z~/ ~j~/r~.~'//~'~ Phone
Streot Location
Type of~es~dence
J~Slngle Family
[] Multiple Family No, of Bedrooms
[] Other
Water Supply
~'q'~dividual ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
[] Community For wells drilled prior to that date, give well depth (attach log if available).
[] Public Utility ,
Sewer Disposal
[] Individual Year Individual Installed:
when Connected to Public Utility;
Public Utility
Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
Field Notes: }!, ~UNICIPALITY OF ANCHORAGE
..i ! .)~ ~ DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
AUG 8 1983
RECEIVED
(4'~) APPROVED BEDROOMS 'CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) COnDITIONaL APP~VAL*
DATE
BY:
Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received
Well to Tank Septic Tank Size
72.023 (31~2)
, 5633 B Stree't
~ Drinking W~iter Analysis Report for Total Coliform Bacteria
TO BE COMPLETED'I~Y WATER
WATER SYSTEM:
Water System Name
Mailing Address
NO.
City
SAMPLE DATE:
SAMPLE TYPE:
E:] Routine
[] Check Sample (for
with lab ref,
[] Special Purpose
SAMPLE
NO. LOCATION
I
3 I
4 I
5 I
Day
Year
T~E COMPLETED BY LABORATORY
A~alvsis shows this Water SAMPLE to be:
[~atisfactory
[] Unsatisfactory
[] Samole too long in transit; sample should
· ~ot be over 48 hours old at examination
to indicate reliable results. Please send
new sam Die
Date Received
Tir~e Received
ytical Method:
[] Fermentation Tube
lembrane Filter
Result* Analyst
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Rev. 1978
I~'~mJmptlve 10mi 10mi 10mi 10mi 10mi 1.Omi 0.1mi
24 Hours
48 Hours
Confirmatory
24 Hours
48 Hours
EMB Broth 24 heUrs:
, Multiple Tube Report=
Membrane Filter= Direct Count
VorlflGetlon: LTB
Final Membrane Filter R~ulI~ ~
Broth 41~ hours:
~ ~ lOml Tubes poMtlve/Totll 1Omi portions
Collform/lOOml
BGB
Collform/100ml
Time, ./~ ~--~'":~"'~') a.m.
/L,?
2/
,5'
P/AT