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HomeMy WebLinkAboutMURRAY BLK B LT 22340 APPLIC.NT FILLS OUT UPPER HAL ONLY - ProF rty Owner '-' /~ ~/ //'/L. ~ ~*'/~/'*'¢'~ Phone Address Zip Code Lending ,ns~/~ ~/~ ~ ~,~/~ ~ '~ Phone Type of Residence ~ingle Family ~'/ ~ Multiple Family No. of Bedrooms ~ ~ Other Water Supply ~dividual ATTACH WELL LOG. A w~l Icg is required for all wells drilled since .June 1975. ~ Community For w~lls drilled prior to that date, give well depth (attach Icg if available). ~ Public Utility Sewer Disposal ~ Individual Year Individual Installed: ~oblic Ulility When Connected to Public Utility: ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED1 Time Time Time Time Date Date Date Date Jngpector Inspeotor /~h tot .... i I;~e~t'~l~, Field Notes: ~ ~ ~ ~ IClP~y OF ANQ fORAGE ~ ( ; ~ t~*cONDIT~ F APPROVAL ( ) APPROVED BEDROOMS ( ) DISAPPROVED ( ) CONDITIONALAPPROVAL'By:DATE Soils Rating Date ~wer Installed Well To Absorption Area Well Log Received Well to Tank Septic T~k Size 72-023 (3182) Time ' Time la Date Data Date Inspector Inspector Comments Date Sewer Installed Conditional Approval Inspector Permit No. Holding Tank Size Soils Rating Well To Absorption Area Well Log Received Well to Tank APPLICANT FILLS OUT LOWER HALF ()NLY Buyer Address Lending Institution ~' Address ' ? Real. ty Co. & Agent Addrsss Legal Street Location Phone ~ Phone Phone Type of Residence .L~ Single Family 4'3 Multiple Family No. of Bedrooms id Other ~'] Individual [] Community [] Public Utility Sewage Disposal ~ Individual Public Utility [; Holdin.~ Tank ATTACH WELL LOG. A well log Is required for all wells drilled since June 1975. For ~eJls~;C.~l,C.d0f//'l:)]~''~°'z:h:~' date, give well depth (attach log if available.) ~.,/-r,-'/,¢:-r _ Year Individual Installed: When Connected to Public Utility: NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATE[), CHEMICAL & .'OLOGICAL LABORATORI~. .~F ALASKA, INC.~~ - TELEPHONE (907)-279,4014 ANCHORAGE INDUSTRIAL CENTFR 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: I.D. NO. Water System Name Phone No. Mailing Address City State Zip Code Mo. Day Year SAMPLE TYPE: [Z} Routine [] Check Sample (for routine sample with lab ref. no. L~ Special Purpoee [] Treated Water [] Untreated 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 : Time Recelved Analytical Method: [] Fermentation Tube ©. Membrane Filter SAMPLE NO. LOCATION 3 I 4 I 'rime Collecled Collected By Lab Ref. No, I L J I Result* Analyst *No of colonies/lO0 mi or No; of Positive portions READ INSTRUCTIONS BEFORE COLLECTING SAMPLE 06-1220 (b) Rev. 1978 BACTERIOLOGICAL WATER ANALYSIS RECORD Date Collected Source Date Received Time Received -- p.m, Lab. No, Presumptive ZOml 1Omi 1Omi 1Omi 1Omi 1,0m1 O,Zml 24 Hours 48 Hours Confirmatory 24 Hours 48 Hours EMB Broth 24 houri: _Broth 4B hours,' Multiple Tube Report= 10mi Tubes Positive/Total :l. 0ml Portions Membrane FIIter~ Direct Count Collform/100ml verification= LTB ,BGB Final Membrane Filter Relult$ Coliform/lOOm! Reported By Date : = Time:__ ' = ' _l.m,