HomeMy WebLinkAboutFAIRVIEW BLK 10 LT 22
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME ' ~ TIME TIME
DATE DATE DATE
MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE
.EPA.TME.T OP .ALT.. E.V,.O.ME.TAL P.OTEOT,ON DEP'. OF
825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL FKU
ENVIRONMENTAL SANITATION DIVISION SEP 1 6 1980
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEW~ ~ITYE~~
DIRECTIONS: Complete all parts on page 1. Incomplete reques~ will not be proceed, Please allow ten (10) days for processing.
~HON
E
T~ o
MAILING ADDRESS I -
PROPERTY RESIDENT (If different from above) PHONE
L ~O~ PHONE
MAILING ADDRESS
3. LENDING INSTITUTION ~ ~ PHONE
MAILING ADDRESS
4. REALTOR/AGENT ~ PHONE
MAILING ADDRE88
5. LE'GAL DESCRIPTION
STREET LOCATION
6, TYPE OF RESIDENCE NUMBER OF~BEDROOMS
[] One [] Four
~ SINGLE FAMILY [~ Two [] Five
[] MULTIPLE FAMILY [] Three [] Six
[] Other
7. WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTI LITY
* ATTACH WELL LOG. A well Icg is required for all wells drilled
since June 1975, For wells drilled prior to that date, give well
depth (attach Icg if available.) ~ ~- 6/ f, ~
8. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE**
PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified INSTALLER
[]Septic Tank or [] Holding Tank
Size: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES Septic/Holding Tank Absorption Area ISewer Line I Nearest Lot Line
WELL TO:
I
Absorption Area to nearest Lot Line
5. COMMENTS
[Z~ APPROVED FOR <-~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accomp~y._c~tificate)
[] DISAPPROVED
72-010 (Rev. 6/79)
CHEMICAL & Gk~,~LOGICAL LABORATORIES ~£ ALASKA, INC.
TELEPHONE (907)-279,4014 ANCHORAGE INDUSTRIAL CENTER
274-3364 5633 B Street
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
WATER SYSTEM: I II I I I I
I.D, NO.
f i,'~ :,t:.'~ i: .', .[//~,; ~ ' ' ~ ~,
Water System Name Phone No.
Mailing Address
City State
MO. Day Year
Zip Code
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
[] Treated Water
[] Untreated Water
SAMPLE Time Collected
NO. LOCATION Collected By
2 ': ~- ~ '"' '': / ,'": J *
, I I
TO BE COMPLETED BY LABORATORY
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
Time Received
Analytical Method:
[] Fermentation Tube
[] Membrane Filter
Lab Ref. No. Result* Analyst
I ~
I CT--J
I
I
*No ot colonies/100 mi or No of Positive portions
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220 (b)
Rev. 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Collected Source
Date Re~:llvecl Time ReCelv~ p.m, Lab, No,
~resumptlve 10mi 10mi 10mi 1Omi 10mi 1.0mi 0.1mi
24 Hours
/,8 Hours
"onflrm.itory
24 Hours
48 Hours
EMB
Multiple Tube Report;
Membrane Filter: Direct Count
Verification: LTe
Final Membrane Filter Relultl
Reported By
Broth 24 hours: ,
Broth 46 hours:
10mi Tubes Positive/Total 1Omi Portlonl
Collform/100ml
BGB
Oeta
Collform/lO0ml