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HomeMy WebLinkAboutParcel 20 / INDIVIDUAL SEWAGE AND WATER FACILITIES [ ~ / (Fill out in Triplicate) ,~ ~'~ %~ama .of person requesting approval ~n-, ~Z c. Casing Size ~ ~ .......... ~ d. Distance f~om well to closest existt'ng_9~...~dse~: 3. Seepage A~ea /~0 t Cesspool~ ~0 5. PropeP~y Line... ~-- ~. 6. O~heP soumces of possible contamination~ i.e.~ c~eks~ lakes, houses, barn, drainage ditch~ etc. Sewage disposal system. c. Name of septic tank ~anufaetu~.~ Q.. 1. If "home made" show dias~am on ~eve~se side of this fo~m. d.' Disposal field o~ seepage pit size and t~e 1, 'Distance to p.ope~y llne ~.~/ to house fo~dation e. Parcolati~ T~st ~sults f. Percolation Test performed by Use the reverse .side of this form to show diagram. Diagra~ should include -The fo~owing ~nformation: p~operty lines~well location, house location, ~ptlc tank location, disposal area location, location of percolation test~ m~ direction of ground slope. The l~£o~ion on this for~v~4-s-.tru~ ~ to the best of my knowledge. , S$~natu~e of ~p~ic~nt ~ Date Si~ned ~0 BE FILLED OUT BY HEALTH DEPART~,~ENT PERSONNEL --The above described sanitary facilities are hereby approved, subject tO the ......... ~llowin~ con~o~s: Conditions:. /~.~7/~ The above described sanitary facilities are disapproved for the following Approval is valid for one year following the date of approval. CPJ:cw ADHW - LAB ' ~W DATE STATE OF ALASKA DE/"'-'~fMENT OF HEALTH AND WEL~-~;"-~ DIVISION OF PUBLIC HEALTH BACTERIOLOGICAL WATER ANALYSIS OFFICE PUBLICI~ SEMI PUBLIC [~ INDIVIDUAL ~] OTHER_ · REPORT RESULTS TO Records in lhis office indicate lhis WATER SUPPLY to be of: [] Satisfactory ~] Queslionable [] Unsatisfactory Sangary Stalus NAME CITY SAMPLE COLLECTED BY DATE COLLECTED am TIME COLLECTED om [] Balhroom Tap [] Basement To~ Well- [] Dug E] Driven ~] Drilled [] Bored SOURCE: [] Spring [~ C slern [] OIher Dug Well or Cislern Conslrucflon: Brick or When? Diameler of Well Depth Feet, Well Caslng Materlal Diameter Deplh Lenglh al Waler Deplh Drop Pipe From BoSom Feet. Analysis shows Ibis Water SAMPLE lo be: [] Satislactor¥ [] Questionable [] Unsatisfactory. I~ an "Unsatidadory" or "Queslionable" slalus is indicaled above you should fohe immediate action as recommended below. I. NotJty consumers water is ~olluled. Boil or chemically treat ~his waler os outlined in the enclosed leaRel "Drink II Pure." 2. Increase chlorlnaBon sufficiently to meel recommended residual standards a safe waler supply at all times 3. Check chlorination and other mechanical equipmenl. Make certain il is funclioning properly 4. If after checking equipment a disin[ecllng resldual is nol obtained, please S. This is a surface waler source and subjecl Io pollution by man and animals. An approved water supply source should be developed. 6. Improve your ~] spring [] dug well [] driven weU [] dr~Bed well [] cistern. 7. Relocale your well Io a safe Ioca~ion in relationshlp to your sewage disposal system [] see enclosure B. Sample lDO long in Iranslt; sample should not be over 48 hours old at examlnatlon to indicale refiable results, p~ease send new sample. [] Bottle Broken in Iransit, please send new sample. 9. Conlact your nearest D Local Health Deparlmenl or ~ Alaska D[vislon of Public'Healfh, sanilaflon office for bulletins, consultation and SANITARIAN'S REMARKS READ INSTRUCTIONS Date Received. BACTERIOLOGICAL WATER ANALYSIS RECORD am ~'/. //" ,/~ Time Received / © ~ "Lab. No. ON REVERSE SIDE BEFORE COLLECTING SAMPLE Laclose Broth 24 hours 48 hours EMB Lactose Broth, 24 hrs. Colitorm Densgy 48 hrs.. BGS. .Gram's slain_ (Mod probable No. per 100cc.) Pre~enf