HomeMy WebLinkAboutROBINDALE #1 BLK 1 LT 5
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
hftp://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP221395
Work Type: SepticTank Upgrade
Tax Code Number: 05105248000
Site Legal Address: ROBINDALE #1 BLK 1 LT 5 G:1561
Site Mailing Address: 24121 RAMBLER RD, Chugiak
Owner: PAULOSKI FRANCIS T
Design Engineer:
This permit is for the construction of:
Effective Date:
Expiration Date
ent
ti
Department
Lot Size in Sq Ft:
Total Bedrooms:
10/7/2022
10/7/2023
45490
Disposal Field Q Septic Tank Holding Tank Privy Private Well Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Special Provisions:
During construction, verify orientation of septic field and show this accurately on the record drawings.
If the as built survey after installation indicates that the septic field pipes are in the utility easement, letters
of non objection will need to be sought from the utility companies prior to issuance of a COSA.
Received By:
Issued By:
Date:
Date: to Z2-
4
� U v • 1_1
1���I M���C��PAUTV Oo F L HCHOR�AG s�
Development Services Department �` �`J Phone: 907-343-7904
On -Site Water & Wastewater Section -- Fax. 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 051-052-48
Property owner(s) Francis Pauloski
Mailing address 24121 Rambler Rd, Chu
Site address Same
iak, 99567
Day phone 907-688-4018
Legal description (Sub'd., Block & Lot) Robindale #1, Block 1, Lot 5
Legal description (Township, Range & Section)
Lot Size 45,490 Sq. Ft. Number of Bedrooms 4
n
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF) El
(w/wo ADU)
Septic Tank
Q
Upgrade 171
(D) E]❑
Holding Tank
❑
RenewalDuplex
Multiple Dwellings ❑
Privy
❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION
INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permi ush Fees:
a 5 Waiver Fees:
Date of Payment: of La7 Date of Payment:
Receipt Number: oc�TA5 Receipt Number:
Permit No. O5 ra';� 1 �CJ� Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client FormsTermit Application.doc
James “Jay” Crewdson, P.E.
Email: CELLC.1@outlook.com
Cell/Text: (907) 280‐9493
Fax: (907) 688‐2295
PO Box 671389 ● 18368 Amonson Road ● Chugiak, Alaska 99567
October 6, 2022
Onsite Reviewer
Municipality of Anchorage
On‐site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99519‐6650
Reference: Robindale #1, Block 1, Lot 5
Septic Tank Upgrade
Design Narrative
Design Narrative: The existing septic tank is leaking and needs to be upgraded. It will be removed and
disposed in accordance with the code. The proposed septic tank will be located in the same general
location. The installation will also include a BioMicrobics RetroFAST septic treatment system.
Installation of the proposed septic tank is detailed on the design drawing. If constructed as designed, it
will;
Satisfy all code required horizontal and vertical separation distances,
Not cause any probable adverse impacts to adjacent properties,
Not negatively impact existing wells and septic systems on adjacent properties,
Not be adversely affected by potential drainage that could flow onto and off of the subject
property.
Please feel free to contact me if you have any questions.
James “Jay” Crewdson, P.E.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221395, Curtis Townsend, 10/07/22
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221395, Curtis Townsend, 10/07/22
~ MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME PHONE I~NEW
MA,L.N ADDRESS & o o s- P q ¥
LEGAL DESCRIPTION ~ ~-- 'a/~ / ~~
LOCATION NO. OF BEDROOMS
Well . ]~ Absorption area Dwelling PERMITNO.
DISTANCE TO: O O
~ Z Manufacturer~~ Material No, of compartments
~ ~ Liq. capacity in g~llons Inside length Width Liquid depth
~ ~ , IF HOMEMADE:
~ ~ DISTANCE TO: Well Dwelling PERMIT NO.
~z
O ~ ~ Manufacturer Material Liquid capacity in gallons
~ Well Foundation Nearest lot line PERMIT NO.
~ mSTANC~ TO: ~ ~ ~
~ ~ Z No, of lines Length of each line Total length of line~ Trench width Distance between lines
~ ~7~ ~ O inches
~ ~ ~ Top of tile to finish grade ¢ ~¢ Material beneath tile ~ Total effective absorptio~
Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class ~ Depth Driller Distance to lot line PERMIT NO.
~ Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER I
PiPE MATERIALS
SOIL TEST RATING
INSTAULER
0
APPROVED DATE LEGAL
F'E R M I T N 0.
~PPI._ I C~HT NIL. L. IFIH 51',t I TH
L ]CRT ! ON [:,FiF.:L ENE
LEGRL L 5 B i F.:OBINDFILE
DEPFIRTI'"IEN]' HEFILTH F'~N[:, ENVIRONMENTFI[ '~:OTEF:TION
:.325 '"L" STREET., RNCHORRGE., FIK. 9950i
264-4720
< ',B30595 >
6005 E. 22N[:, 99504
F"EE~:It"-I Z T'
'= ~- 20000 SQUFIRE FEET
LAT _,I,=E
[:,F.:R i NFi ELD
T'¢PE OF SOIL RE:SORF'TtON S"r'STEM iS:
MFI'XIMUM NLIMBER OF' BEDROOMS = 4 SO IL RRTING
THF REQUIRED SIZE OF THE SOiL FtBSORF'TiON S"r'STEM iS:
[:. E F' T F-[ == T;' L E p-.il ,] "T ~'4 = '7 C"] ,] F: R '-.'" E 1~ ......
':SQ FT,-"'BR )= i50
[:. E F- ]- H == ]=:
THE LENGTH DIMENSION IS ']'FIE LENGTH (IN FEET.':' OF THE TRENCH OR DRFtINFIEL[:,.'
THE [:,EPTH OF FI TRENCH OR PIT IS THE [:,ISTFtNCE E:ETNEEN THE SURFFtCE OF THE
GROUND FIND ']"HE BOTTOM OF THE E',dE:FtVRTION (IN FEET).
TFtE GRFIVEL [:,EF'TH t:5 THE MINIMUH DEPTH OF GRBVEL BETI.,.iEEN 'THE OUTFRLL PIPE
FIND THE BOTTOM OF THE E',:.::CFP,,'RTIOI'-4 ,::IN FEET).
PEF.:MIT RPF'LICRHT HRS ]'HE RESF'ONSiBiLIT'¢ ]"0 iNFORM THIS [:,EPRRTMEHT DURING THE
INSTFIL. LRTION iHSPECTIONS OF FfN'-r' i.4ELLS RD._TFICENT TO THIS PROPERT'¢ FIND THE
NUMBER OF RESIE.,ENCES THFIT THE NELL N!LL SERVE.
BFICKF'ILLiNG OF RN"r' S'¢STEM NITHOUT F:i'NFIL INSPECTION FIND FIIPPROVFIL B"r' THIS
[:,EPFIRTHENT I,.IiLL BE SUBJECT TO PROSECUTION.
MINIMUM DtSTFiNCE BETNEEN Fl NELL FIN[:' FIN'¢ ON-SiTE SENFIGE [:,ISPOSFIL S'¢STEH IS
i00 FEET FOR FI F'RIVFITE NELL OR 150 TO 200 FEET FF.:OM FI F'UBLIC WELL DEPEN[:'ING
UPON THE T"r'PE OF PUBLIC NELL
MINIMUH DISTFINCE FROM FI F'RIVFtTE NELL TO R PRIVFITE SENER LINE IS '25 FEET FIN[."
'FO FI COMMUNIT'¢ SENEF.: LINE IS 75 FEET.
klELL. LOGS FIRE REQUIRED RN[." MUST BE RE:TURNE[:' TO THE [:,EF'FIRTMEN]' I4ITHIN .'2:0 [:,R"r'S
OF THE NELL COMPLETION.
OTHER REQUIREMENTS i'"tFI"r' FIPPL.'¢. SPECIFtCFITIONS FINE:' C:ONSTRUE:TION DIFIGRRMS FIRE
FIIVFItLFIBLE TO INSURE PROPER INSTRLLFITION.
F' E-.-] ~ I"'1 .'Z T E :="':: F' .'Z F..: El Z.'E;., [:" E C: E ~'-~ E: E F: ]~:: :.!_ .. i 9 :---: ~-'":
! CERT'iF'¢ THFIT
:L: I FIf"i FFtldiLiF4R t.4!"FH TFtE REQUIRENENTS FOR ON-SITE SEIAERS FIND NELLS FIS SET
FORTH B'¢ THE MUNICIPFILIT'¢ OF FINCHORFIGE.
2: I kiILL. INSTFILL THE S'¢STEM IN FICCOR[:'FINCE NITH THE CO[:'ES.
S: I UNDERS-f'FIN[:' THFIT '.THE: ON-SITE SEF.IER S"r'STEM MFI"r' REQUIRE ENLRRGEMENT IF THE
RESiDEHCE IS REMO[:'ELED TO INCLUDE MORE THFIN 4 BE[:'F.:OOMS.
RF'F'L I E:FiNT Pi. i L!U "¢4N~%M I TH
e
PERFORMED FOR:
LEGAL DESCRIPTION:
OL
1
2
3
4
7
8
13
14-
~7-
18-
20-
COMMENTS
PERFORMED BY:
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
[] PERCOLATION
TEST
DATE PERFORMED:
SLOPE · SITE PLAN
ENCOUNTERED? (~) L
O
P
E
IF YES, AT WHAT ~
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
(minutes/inch)
TEST RUN BETWEEN
CERTIFIED BY:
FT AND ~ ET
t~t
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological ~ Geophysical Surveys
Drilling Permit Ne.
LOCATION OF WELL (Please complete either lot lb or lc.) A.D.L. NO.
~o~.JBorough Subdl¥1slo~ : Let Block I~.I I/eqlre. Section No. TownehlPN[::~ Range E~ Meridian
~of~of~of ~ S~
~ JDISTANCE AND DIRECTION FROM ROAD INTER~ECTIONS ~. OWNER OF WELL:
Street Address and Area of Well Location
2. WELL LOG Fief Below 4. WELL DEPTH: (final)
5. DATE OF C~PLETI~
Malarial Type Top Bottom
...... ~ ~ Recharg, ~ Commerical
~. FINISH OF WELL:
Type: Dlametl~:
~ Above o~ ~Belo~ land lurfece Dali
II.PUMPING LEVEL below land lurf~e and YIELD
. ft. ofte~, ~r~. pumping g.p.m.
: ft. aff~~ hrs. pumping g.p.m.
IZ.~ROUTING Well Grouted: ~ Yel ~ No
Malarial: ~Neet Cement ~ Other:
I~. PUMP= [if available) HP.
Length ef Drop Pipe fl. capocily
14. REMARKS:
16. WATER WELL CONTEACTOR'~ CERTIFICATION:
Authorized Repr esPn(oliVe /
Parcel I.D. #
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
'::!~V~IONDN¥ ~10 A.LIIYdlDINflW"
1. GENERAL INFORMATION
Complete legal description
Lot 5; Bloc~' I; Robindale #I Subdivision;
Location (site address or directions)
Property owner Francis T. Paulos/zi Day phone 688-4018
wk: 552-2175
L~end~ng a-~e/-icy -- Ma~y-SdsS-~_rd'- C ITY~ MORTGAGE Day phone
Mailing address 121 'W~t Fi~66d Lane Anchorage, A~zgz~ 99503
Agent Day phone
Ad dress
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
4
NOTE:
×X
Individual well
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site XX
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm
Address
Engineer's signature
a & :~ ENGINEERING
17034 Eaqie River Loop Road No. 204
Eagle River, AJaska 99577
Phone
DHHS SIGNATURE
./'/..~ Approved for
Disapproved.
Conditional approval for
Date ~"Z-~E::~/_
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA #21
Municipality of Anchorage ~i~
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~c~'1"~" ~'~t.&/.- ~ ~-ic)[~, ,..~C~/k-b.~tO~J~ Parcel I.D.
A. WELL DATA
Well type '~CrJ~'~r~;...
Log present (~N) ~
Total depth ~ Lz)~ ~
Sanitary seal ~)'N)
If A, B, or C, attach ADEC letter.
Date completed
Casedto ~[.~'c>~
Date of test
Static water level
Well flow
Pump level
ADEC water system number
~J~ ~ ~ ~"~ Driller ~¢~-~
Casing height ~,
Wires properly protected ~'N)
AT INSPECTION
.,-,- ~
g.p.m. (.~ D~' mc
g.p.m-'
; On adjacent lots \ ~
; On adjacent lots \ c)~ ~ ~--
Public sewer manhole/cleanout
Petroleum tank '~'
FROM WELL LOG
SEPARATION DISTANCES FROM WELL TO: ,..
Septic/holding tank on lot
Absorption field on lot
Public seWer main
Sewer service line
WATER SAMPLE RESULTS:
Coliform (~) c'~'"'~/ ~ oo~., Nitrate
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Date installed "~
Cleanouts ~'N)
High water alarm (Y~)
Date of pumping
Collected by:
Other bacteria
S & S ENGINEERING
Eagle River, Alaska 9~577
Tank size ~'7~¢o /.~,d.~ Compartments
Foundation cleanout (~)/N) ~ ~ Depression (Y~
Alarm tested (Y/N)
Pumper ...~,, ~. ~__~..~&POO
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot /~0 I+'
To propertyline /¢ r-/-
Surface water/drainage
On adjacent lots
Absorption field
/Do ~'~
Foundation /O I 4-
Water main/service line ! ~
14-
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIF'r STATION
Date installed
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level s~
Meets MOA e~___
SE~.~.TJ~rR DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
Manufacturer
Manhole~
"Pump off" level at
Cycles tested
Surface water
D. ABSORPTION FIELD DATA
Soil rating
Date installed
Length ~ Width ~ ~
Total absorption area (.¢"~-~ ~
Depression over field (Y/(~ /~/
Results~fail)
Peroxide treatment (past 12 months) (Y~
System type
Gravel thickness '~ ~ Total depth
Cleanouts present(~N)
Date of adequacy test
for ,;¢::::~ o ~
~JE. 1'//,~/~ ~/,~ If yes, give date
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots ~'~
Surface water
Curtain drain
On adjacent lots I0O ~ '~ Property line
To existing or abandoned system on lot
Cutbank 'd/A'' Water main/service line
Driveway, parking/vehicle storage area
E. EN(~INEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection,
Signature
Engineer's Name
Date
5' ~ S ENGINEERING
,~ngle ~iYer, Alaska 99577
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET
ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343
ANALYSIS RESULTS fo~ INVOICE t 40997
Chemlab Ref.% 91.6574 .~a~ple ! 3 Matrix: WATER
FAX: (907) 561-5301
Client Sample ID : L5 B1 ROBINDALE 3/D
PWBID : UA
Collected : DEC 10 91 ~ 10:15 h~s.
Received : DEC 11 91 ~ 14:30
P~ese~ved with : AS RSOUIRED
Client Name :S & S ENGINEERING
Client Acct =$NSENOP
BPO~ :
Req{ :
O~de~eB By :R. SHAPER
PO{ =NONE RECEIVED
Analysis Completed : DEC 13 91 Send Reports to:
Laboratory Supe~viso~ : STEPHEN C. EDE 1)S & S ENOINgERINO
Raleaeed By :
Pa~amete~ Results Units Method Allowable Limits
NITRATE-N 4.0 ~/1 EPA 353.2 10
Sample ROUTINg SAMPLE COLLECTED BY: RAY.
Remarks:
I Tests Performed ' See Special Instructions Above UA-Unavailable
ND~ None Detected "See Sample Re~arks Above
NA- Not Analyzed LT-Less Than, GT-Ozeatoz Than
~'~-C~G-~ Member of the SGS Group (Soci6t6 G~n6rale de Surveillance>
-CHEMICAL & GEOLOGICAL ' ABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
TELEPHONE (907) 562-2343 ,5633 B Street
FJ~ED ~-{ 5- t~ /~C_..~-' Anchorage, Alaska 99518
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
PRIVATE WATER SYSTEM
Mailing Address
C~¥
Mo. Day
SAMPLE TYPE:
~L Routine
[] Check Sample (for routine sample
with lab ref. no. )
[] Special Purpose
Phone No.
Year
0.?77
Tip Code
[] Treated Water
[] Untreated Water
SAMPLE
No. LOCATION
41
Time Collected
Collected ~B_y. ,. ,.~
TO BE COMPLETED BY LABORATORY
Analysis Shows this Water SAMPLE to be:
'~ Satisfactory
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 30 hours old at examination
to indicate reliable results. Please send
new sample via special delivery mail.
Date Received {~//)/~/
Time Received ] ('~ ~---)
Analytical Method: Membrane Filter
' No. of colonies/100 mi.
Lab Ref. No. Result*
J
I
A.D.E.C._ )2--17.-- q{ A~
READ INSTRUCTIONS Membrane Filter: Direct Count
Verification: LSB
BEFORE
Fecal Coliform Confirmation
COLLECTING SAMPLE Final Membrane Filter'cT~'Resultsl ~/,
TNTC = Too Numerous To Count
OB =
BACTERIOLOGICAL wATER ANALYSIS RECORD
Coliform/100 mi
BGB
Other Bacteria
Date
PART ONE OF TWO:
REMAINDER TO F. OLLOW
Coliform/100 mi
APPLIC:' IT FILLS OUT UPPER HAL 3NLY
Property Owner Phone
LOGS Construction
Mailing Address P~0; BOX 279, Chugiak Ak 99567 zip Code 338-3598
Buyer
Francis & Deborah Pauloski
Address P.O. Box 279, Chugiak, Ak 99567 Zip Code
Phone
Lending Institution Nation1 Bank of Alaska 694-5373
Address ]Eagle River, Ak 99577 Zip Code
Realty Co. & Age0t Phone
Todays Real ]Estate Nancy Stahly
Address P.O. Box 279, Chugiak Ak 99567 Zip Code 688-3999
Legal
Description
Robindale #1, Blk 1 Lot
Street Locatio~ Darlene Street, Chugiak, Ak
Type of Residence
~Single Family
[] Multiple Family NO. of Bedrooms
[] Other
Water Supply
~lndividual ATTACH WELL LOG. A we{I Icg is required for all wells drilled since June 1975.
[] Community For wells drilled prior to that date, give well depth (attach Icg if available).
[] Public Utility
Sewer Disposal
.--~lndividual Year individual Installed: 1983
[] Public Utility When Connected to Public Utility:
[] Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
~[JNII( ]PAl ITY OF
Field Notes: DEPT. OF H~ALTit
ENVIRONMENI AL PROT~-C[ION
RECEIVED
-)APPROVED BEDROOM8 'CONDITION8 OF APPROVAL
( ) CON DITJO NA~LAPPROVAL*
/
Soils Rating Date ~wer Installed Well To ~sorption Area / ~11
Log
Received
Well to Tank Septic T~k Size
MICAL &GEO lOGICAL LABORATORIES OF ALA~SKA, INC.
TELEpHot~
Drinking Wat,
(907) 562-2343 ANCHORAGE INDUSTRIAL CEN'i'E~
5633 B Street
Analysis Report for Total Coliform ~act~ria
SAMPLE
NO. _//OCATION~
TO BE COMPLETED BYyATER SUPPLIER_
SYSTE : I ! ] "'s"'°"'"'
Water System/Name / J Phone NO.
Mailing ~re~ J
Ci~ ~ State Zip C~
SAMPLE DATE' ~ ~ ~ '
, .. ~ntroatod Wator
3 I
4 I
READ INSTRUCTIONS
BEFORE
COLLECTING SAM PLE
Time Collected
I
I
1
TO BE COMPLETED BY LABORATORY
Analys's shows this Water SAMPLE to be:
t~Satisf~ctory
[] Unsalj~factory
[] Sample too long in transit; sample should
not be over 48 hours old at examination to
indicate reliable results. Please send new
sample via special delivery mail.
Date Received ~ -'
';rime Received
Analytical Method:
~ Fermentation Tube
.~M embrane Filter
Lab Ref. No.
,i
I ~ I
I-J I
Result* Analyst
o~.~22o (bi BACTERIOLOGICAL WATER AN .YSIS RECORD
Rev, 197e
-F 1.Omi O.lml
p~etu rnptlve }0mi lOml 10~nl! 1Om! 1Omi
24 HOurS
48 Hours
Confirmatory ~
24 Hours
ultlplll Tube Report.*
Membrane Filter= Direct Count
'Jerlflcatlon= LTB
F~nll Membrane Filter ~Jtl