HomeMy WebLinkAboutCOLLEGE PARK BLK 2 LT 3LO'I:
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APPLIC ~NT FILLS OUT upPER HA' ' ONLY
Property Owner /~:~f-~/~;~,,,~...~ ~,. /~.,.-,,,,,,~0~:~/~ j,.~'~,~ Phone
Buyer
Address j~ ~ / / /~j..~{ ~ ~ Zip Code
Lending Institution~/~2 ~ ~. ~~[~4 ~ ~ ~/,l ¢~'1 Phone
Realty Co, & A~nt Phone
Address Zip Code
Street Looatl~ , "~ 6 2 Z I?~o ~ (~
Type of Resl~nce
Single Family
~ Multiple Family No. of Bedroo~
~ Other
Water Supply
~ Individual A~ACH ~LL LOG. A w~l 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 IndlvMual Installed:
Public Utility When Connected to Public Utility:
Holding Tank ~
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
Field Notes:
~ow'u~' ~ w-,4 ~ ~.~¥~.~ ~.~ ~xe_~L~Cb , -5 9 t983
RECEIVED
( ~ APPROVED BEDROOMS *CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL'
DATE ~"--('~ ~' '~
Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received
Well to Tank Septic Tank Size
72-023 (3182)
CHEMICAL & G£ LOGICAL LABORATORIES oF ALASKA, INC.
TELEPHONE (907)-279,4014 ' ANCHO"~GE INDUSTRIAL CENTER
274-3364 5633 B Street
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED' BY WATER SUPPLIER
TO BE COMPLETED BY LABORATORY
WATER SYSTEM:
Water System Name
I.D. NO.
Mailing Address
~,.
City
SAMPLE DATE:
MO.
Day Year
SAMPLE TYPE:
,J3' Routine '
/O.~Check Sample (for routineaample
with lab ref. no. ~,, )
[] Special Purpose
SAMPLE
NO.
3
4
.
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Zip Code
[], Unti,~ed~Water':
Analysis shows this Water SAMPLE to be:
~.~ Satisfactory
[] Unsatisfactory
[] Sample too long in.transit; sample should
not be over 48. hours old at examination
to indicate reliable results. Please send
new sample.
Date
Received
~!me Received
An~ytlcal Method:
D~,,Fermentatlon Tube embrane Filter
Result*
I ~
I
A~l~et
; *No. of colonies/lOO'ml, or I~, of Positive 13orUons
Rev. 1978
Date Collected Source
Date Received Time ReCeived ),m. Lib. No.
Presumptive 1omi 1Omi 1Omi 1Omi 1Omi 1.0mi o.lml ,
24. Hours '. .
4e Hpurs
Confirmatory
24 Hour;
4~ Hours I'
EMB Broth 24 hours: , Broth 48 hourlr , ,
Multiple Tube ReDort:
Memhrlne Filter; Direct Count
Verification: LTB
Final Membrane Filter R ~el~lts
1Omi Tubes Poiitlvl/Total 1Omi PMtlofll
COllform/lOOml
BGB,
Date
Tlma~
r OF ANCHORAGE
MUNICIPALITY
MUNICIPALITY OF ANCHORAGE DEPT. OF i':-ALTi/ &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION~,,,RONMENT,
825 L Street - Anchorage, Alaska 99501[~vl ,' ,~ ,, · ; £CTION
ENVIRONMENTAL ENGINEERING DIVISION FEB
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWN --
DIRE~TION~: Complete all part~ on page 1. In~ompl~t~ r~q~t~ will ~ot b~ pro~d. Please allow ten (10) days for processing.
MAI LING ADDR ES~
PROPERTY RESIDENT (l{ different fr~m ~e) - ~' (] ~ PHONE
2. BUYER PHONE
MAILING ADDRESS
3. LENDING INSTITUTION ~ PHONE
I
MAILING ADDRESS
4. REA~R/AGENT -' ' I PHONE'
MAILING ADDRESS
5. LEGAL~DESCRIPTION ,//~-~'~--~ --~
STREET LOCATION ~
6. TYPE OF RESIDENCE U~/
'[~ SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OF BEDROOMS
[] One [] Four
[] Two [] Five
'~ Three [] Six
[] Other
7. WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTI LITY
8. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE**
PUBLIC UTILITY
* ATTACH WELL LOG. A well log is required for all wells drilled
since June lg75. For wells drilled,,~p, ri°r to that date, give well
depth (attach log if available.) ~/~../~T'~j~4,., _.~
**If individual/on-site, give installation date
If system is over ~wo (2) years old an adequacy test is required
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-01 O(3/78)
THIS SIDE FOR OFFICIAL USE ONLY ',
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE
[] SINGLE FAMILY
[] MULTIPLE FAMILY
2. WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTILITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
[] INDIVI DUAL/ON -SITE
[]PUBLIC UTILITY
Connection Verified
[]Septic Tank or [] Holding Tank
Size: If Tank is homemade
give dimensions:
NUMBER OF BEDROOMS
[] ONE [] THREE [] FIVE
[] TWO [] FOUR [] SIX
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
SOl LS RATING
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4i DISTANCES
WELLTO:
Absorption Area to nearest Lot Line
[] OTHER
Septic/Holding Tank IAbsorption Area
lSewer Line
Nearest Lot Line
5. COMMENTS
[~APPROVED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE
LEGAL DESCRIPTION
BY (Title)
72-010 (Rev. 3/78)
P.O. 6Ox 4-1276 ANCHORAGE, ALASKA 99509 4649 BUSINESS PARK BLVD.
D~nking Water Analysis Report for Total Coliform Bacteria
TELEPHONE
(907) 279-4014
TO BE COMPLETED BY WATER SUPPLIER
PUBLIC WATER SYSTEM:
Public__ __Water System .anl. e.~ ~_~
City State
Mo, Day Year
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
SAMPLE
NO, LOCATION
4 I
Zip Code
[] Treated Water
[] Untreated Water
Time Collected
Collected By
TO BE COMPLETED BY LABORATORY
LABORATORY:
NAME
"ADDRESS
CITY
Date Received .~. -//.C/.- :7.~?
Time Received /' ..~ ~'~ ..~
Analytical Method:
[] Fermentation Tube
Membrane Filter
Lab Ref. No. Result* Analyst
* No. of colonlel 1100 mi. or NO. Ol:Po.lllve pertlon,,.
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Form No. 18.310 (3-78)
06-1220 (b)
Rev. 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Collected Source
Date Received Time Received p.m. Lab. No.
Presumptive 1Omi 10mi 10mi 10mi 10mi 1.0mi 0.1mi
24 Hours
48 Hours
Confirmatory
24 Hours
48 Hours
EMB Broth 24 hours:
Multiple Tube Report:
Membrane Filter: Direct Count
Verification: LTB ~s~~~
Final Membrane Filter ul
Reported By ~
~_y~ /~
Broth 48 hours:
.].Omi Tubes Positive/Total 1Omi Portions
Collform/100ml
BG~
' Collform/lOOml
Da,e:
Time, / ~/"'~'~ a.m.
p.m.