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Home My WebLink AboutCLYDE M DICKSON BLK 1 LT 19 6] ~ o C CHEMICAL & GEOLOGICAL LABORATORIES ~' ALASKA, INC. TELEPHONE274.3364(907}-279-4014 ANCHORAGE56331NDUSTRIAL CENTERB Street Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER WATER SYSTEM: Water S~stem Name Mailing Address CiW State Mo, Day Year Zio Code SAMPLE TYPE: [] Routine [] Check Sample (for routine sample with lab ref. no. [] Special Puroose [] Treated Water '~ Untreated Water SAMPLE NO. I = r I LOCATION Time Collected Collected By TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: [~ Satisfactory [] Unsatisfactory [] Sample too ong ~transit: sam~leshould not De over 48 hours OlO at examination to ndicate reliable results. Please send n§w sample Date Received ,~ Time Received Analytical Method: [] Fermentation Tube ,~, Membrane Filter Lab Ref. No, Result* Analyst I I F~ *No. of colonies/1 O0 mi. or No of Positive [~O~ZIOnS READ INSTRUCTIONS BEFORE COLLECTING SAMPLE 06-1220 (b) Rev. 1978 BACTERIOLOGICAL WATER ANALYSIS RECORD Date Collected Source INSPECTION APPOINTMENTS ~ . MUNICIPALITY OF A~CHORAGE DEPT. OF H~ALTH & DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTE~I~ONMENTAL PROTECTION OCT 8 1980 ENVl RO~E~TAL SANITATION DIVISIO~ REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete reques~ will not be processed. Please allow ten (10) days for processing. PROPERTY RESIDENT (If different from above) / PHONE 3. LEN lNG INSTITUTIO / PHONE 6, TYPE OF RESIDENCE NUMBER OF~BEDROOMS [] One ~ Four [] Other__ ~ SINGLE FAMILY [] Two F~ Five [] MULTIPLE FAMILY [] Three [] Six 7. WATER SUPPLY ,~ INDIVIDUAL* ATTACH WELL LOG.~A well log is required for all wells drilled [] COMMUNITY since June 1975. For wells drilled prior to that date, give well [] PUBLIC UTI LITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON-SITE** ~1~ PUBLIC UTILITY YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY , NUMBER OF BEDROOMS [] ONE [~3 THREE ~] FIVE [] OTHER [] TWO [] FOUR [] SIX PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 1. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY 2. WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM [] iNDIViDUAL/ON -SITE E~PUBLIC UTILITY Connection Verified []Septic Tank or [] Holding Tank Size: If Tank is homemade give dimensions: PERMIT NUMBER DATEINSTALLED NSTALLER SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCESwELL TO: Septic/Holding Tank Absorption Area S~wer Line Nearest Lot Line Absorption Area to nearest Lot Line 5, COMMENTS []~]/~PPROV ED FOR [] CONDITIONAL APPROVAL BEDROOMS (letter must accompany certificate) [~] DISAPPROVED DATE 72-010 (Rev, 6/79) A® MUNICIPALITY OF ANCHORAG~ DEPT. OF HEAL'Ill & ~NV[RONMENTAL Pi<Gl ~CTiON MUNICIPALITY OF ANCHORAGE (MOA) HEALTM A[YI~ORIT¥ APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Legal Description: NOV g, 'b 1984 RECEIVED Well Classification Well Log P~esent (Y/N) //~ ~ ~te~CQ~pJ~d~~ ~'.~/~"~'~'~ Yield~'~ f/~/ Total Depth ~ l/f~ caSed Static Water Level /~ ~ ~ ~. Casing Height Above G~ound Electrical Wiring in Conduit (Y/N) Separation Distances f~om Well: To Septic/Holding Tank on Lot Sanitary Seal on Casing (Y/N) zFJ ~ Depression A~ound Wellhead (Y/N) ~ ; On Adjoining Lots To Nea~est Edge of Absc~ption Field on Lot To NearestPublicSewe~ Line Cleanont/Manhole ~o ~ Water Sample Collected By Water Sample Test P~sults B. SEPTIC/HOLDING TANK DATA //~,A/'~'~ Date Installed Size No. of C(~,pa~tmsnts Standpipes (Y/N) Air-tight caps (Y/N) Foundation Cleanout (Y/%q) Depression ore= Tank (Y/N) Date Last Pumped Pumping/Maintenance Contract on File (Y/N) ; for Holding Tank High-Water Alarm (Y/N) Tempo~a=y Holding Tank Permit (Y/N) Separation Distances f~om Septic/Holding Tank: To Wate~-SupplyW~ll To P~operty Line To Water Main/Se=vice Line '~Cou~.s~ , ',.' Cerm~nts '"'.'.:,.~i, To Building Foundation TO Disposal Field To Stream, Pond, Lake, c~ Major Drainage [Page i of 2] 2-15-84 C. ABSORPTION FIELD DATA /~/~/~' Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption A~ea Eepression over Field (Y/N) Results of Last AdeqUacy Test Type. of System Eesign Length of Field Depth of Field Gravel Bed Thickness Standpipes P~esent (Y/N) Date of Last Adequacy Test Separation Distance from Absorption Field: To ~ter-Supply Well To Building Foundation Lot To Water Main/Service Line To P~operty Line TO Existing o~' Abandor~d System cn ; On Adjoining Lots To Cutbank(if present) To Stream/Pond/Lake/c~ Major D~ainage Course To D~iveway, Parking A~ea, o~ Vehicle Sto~age A~ea __ Co~nts D. LIFT STATION Date Installed Size in Gallons "P~l~p On" Level at High Water Ala~mLevel at Tested for Electrical Codes(Y/N) Dimensions Manhole/access (Y_/N) "Pump Off" Level at Vent (~Y/N) Pumping Cycles du~ing Adequacy Test. Meets MOA ComTents ** Check Permitted Bedroc~ Rating Against HAA Request I certify that I have checked, verified, o~ conformed to all MOA HAA Guidelines in effect on the date of thi~ %nspec~n. Signed ~-~ Date ~;ompany /~ k~_~.~.~ ~ - /~.~ ~ . MOA No. KB1/d5/s [Pa~e 2 of 2] ENGINEERS ! SE~r. 2-15-84 5. En~ineerin~ Firm Providin~ Inspections~ Tests~ File Search~ Data and Information As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of' this Health Authority Approval shows that the on-site water supply and/or wsstewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein.- I further verify that, based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-si{e water supply and/or wsstewater disposal system is in compliance with ~ll Municipal and State codes, ordinances, and regula- tions in effect on the date of this inspection. · ~ .: ~... Approve-~[or bed rooms"s~.' By ~ Date ' ~i~i(:? 0 '~ :A',,. 'c- , .... Approved ~ Disappr oved~'~ Coaditions-I ~ Terms of Condition~proval ~.~ ~'~ TH~ MUNICIPALITY OF ANCHORAGE DEPARtmENT OF HEALTH AND ENVIRONI~NTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN T~ STATE OF ALASKA. THE DHEP DOES THIS AB A COURTESY TO PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTS. EMPLOTEES OF DHEF DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. THE }fONICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84