HomeMy WebLinkAboutT12N R3W SEC 20 N2S2NW4SW4SE4 PARCEL 7A
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improvement* situated thereon a{e within the proper~ I,ne* and do no~
on the proper~ lying adjacent thereto, that no improvement~ on proper~ lying adiacen~ shereto
encroach on the premi~e~ In question and that there' are no roa~way~ ~ran~rnl~ion lin'o*
ather vl,ibie ea~emen~ on ~ald prope~ except as indicated hereon.-
C~ & OEOLOOICAL LABORATORIES OF ALAS~ lNG,.
P.O. BOX 4-1276 ANCHORAGE, ALASKA 99~09 4649 BUSINESS PARK BLVD.
Drinking Water Analysis Report for Total Coliform Bacteria
TELEPHONE
(IK)7) 279-4014
TO BE COMPLETED BY WATER SUPPLIER
PUBLIC w~ER~ysTEM: ~1'
Mailing Add~ess '
TO BE COMPLETED BY LABORATORY
LABORATORY:
City State
Mo. Day Year
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
Zip Code
[] Treated Water
[] Untreated Water
NAME
ADDRESS
Date Received
Time Received
Analytical Method:
CITY
[] Fermentation Tube
XMembraneFilter
SAMPLE
NO.
4 I
' I
:':' 5 :;
Time Collected Lab Ref. No.
Collected By
I
Result* Analyst
READ INSTRUCTIONS
BEFORE
'~LLECTING SAMPLE
/78)
06-1220 (b)
Rev, 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Collected Source
Lab, No.
Presumptive ).0mi 1Omi 10mi 10mi 10mi 1.0mi 0.1mi
48 Hours 'i
Confirmatory
24 Hours ~ .~
EMB
Multiple Tube Report:
Membrane Filter: Direct Count
Verification: ETS
Final Membranee F~ul ~'~Filt ult
Broth 24 hours: Broth 48 hours:
,~ 1Omi Tubes Positive/Total 1Omi Portions
Collform/).O0ml
BGB __
DEPT. OF H:ALTH &
MUNICIPALITY OF ANCHORAGE ENVIRONMENi'AL PROTECTION
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
AUG 6 !979
825 L Street - Anchorage, Alaska 9gS01
I ENVIRONMENTAL ENGINEERING DIVISION
Telepho.e 264-4720 RECEI_ ED
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. PROPERTY OWNER I PHONE
~AILI~
PROPERTY RESIDENT (If different from above) PHONE
2, BUYER PHONE
MAILING ADDRESS
3. LE~DI~GI~STITUTIO~ I PHONE
I
MAILING ADDRESS
I PHONE
4. REALTOR/AGENT G~T~ &l I
MAI LING ADDRESS
5. LEGAL 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* *ATTACH WELL LOG. Awell log is required for ail wells drilled
[] COMMUNITY since June 1975. For wells drilled prior to that date, give well
[] PUBLIC UTILITY depth (attach log if available.) / ~'~-;/~al
~.r~GE DISPOSAL SYSTEM x ,,~::,
~ .... V .... L,~N SiTE.~SE~If individual/on-site, give installation date ~ ~ ~
~ ~ / . /If system is over two (2) years old an adequacy mst is required
q- ~ ~ PUBLIC UTILITY(~,U~'i/-h~/~E~ by this Department.
OTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
THIS SIDE FOR OFFICIAL USE ONLY
DATE R ECEIVE'D
INSPECTION APPOINTMENTS
TiME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR
DIRECTIONS:
1, TYPE OF RESIDENCE NUIV]BER 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
I~ PUBLIC UTILITY
Connection Verified
INSTALLER
F~lSeptic 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 Sewer Line 1 Nearest Lot Line
WELL TO:
Absorption Area to nearest Lot Line
5, COMMENTS
APPROVEDFOR. i BEDROOMS
~ CONDITIONAl APPROVAL {letter must accompany certificate)
[] DISAPPROVED /~ ,
DATE BY (Title)
LEGAL DESCRIPTION
72-010 (Rev. 3/78)