HomeMy WebLinkAboutPARKWAY ESTATES BLK 2 LT 2
GREATER ANCHORAGE ARF~A BOROUGH
Department of Environmental Quality
_ 3500 Tudor Road. Anchorage· Alaska 99507 279-8686
Date Received ~/x//A>~
Time of Inspection
Date of Inspection
R~QUSST FOR APPROVAL OF
INDIVIDUAL S~ER & WATER FACILITIES
FOR
Aoproval Requested By: >2 . ~:: ~>'.' ~'::;'
Address: Phone:
Pro,,ert~, O~,er.- , ::~.~ :.,.,:_.,~_~ ~.,-,~ ~ ~ '~ Phone..
Type of Facility to be Inspectefl:
Number of Bedrooms:
C,: Construction ~/"~(%.., .~.:,,:' D. Bacterial Analysis
7. -Sewage Disbosal Sys~em~ ~<~-:'-, ...... ,"~::,:~'.--~,~J~t.X>~q~.
A, Installed ' 8, Installer
C. --Septic Tank: 1. ~' '2. Manufscturer-
~lZe
D. Seepage Pit: 1, Size 2. Material
E. Disposal Field: Total Length of Lines
8, Distances:
Well To: Septic Tank
, Nearest Lot Line
Foundation to Septic Tank
, Absorption Area
Absorption Area to Nearest Lot Line
· Other Con'tamination
AbSorption Area
· Sewer Lines
Request for Approval of Irt yidual Sewer & Water Factlitte,.~.
Page Two
Approval Valid for One Year From Date Signed
Greater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
I certify that the information contained in this request for approval to be a true
and accurate representation of the subject sewer and water facilities located at:
Signed Date
DAT~
PURMC [---1 SEMI-PUBMC J~ INDIVIDUAL ~-] OTHER
REPORT B~SULT$ TO
CITY
ADDRESS
OF SOURCE
Records in this. office indicate this WAT]~ SUPPLY to be of:
[] S~isincto~.,' i'-] Questionable [] Unsatisfactory Sanitary Status.
Analysis shows th~s Water.SAMPLE to ~e:
['"1 ~dlsfactory [] Questionable [] Unsatisfactory.
H an "Unsa~fastory' or '*Questionable" status ~s/ndicated above
you should take immediate act/on as recommended below.
1. Noilly consumers water is polluted. Boil or chemically
treat th~ water as outlined in the enclosed lea/let
"Drink It Pure."
SAMPLE COLLECTED BY ~ '
DATE COLLECTED . ' ~ COI,LEGTED '~ ~) ' - J (' pm
Sample Collected From ]~[ Kitchen Tap [] ])athrc~m Tcq:~ [] Basement Tap
~ Other (list)
Well [] ~ug [] ~dven [] mmect [] So,ed
SOURCE: r- spring [] cistern [] Other
Dug Well or C/slem Construction:
Brick or
Walls - [] W~d [] Concrete [] Meted i'-] Tile [] C. onc~ete
Top- [] ".Vocal [] ~ncrete [] Metal. [] OpenTop
LOCATION: [] rn Basement [] B'~sernent Offset [] Under Hou~
['~ In Yard [] Other . , ,
DLSTANCE TO: or Other Dra~n*qe Plpo Feel .. Feet.
MATERIAL: Building Sewer- [] Cc~t [] Woc~
GENERAL: Docs Water Become Muddy or Discolored?
When? .........
Lenqth of
PUMP LOCATION: [] In Well
[] Oi Well [] Other, ,,
PURPOSE OF EXAMIi,~ATION: lllne~ Suspected?
NewSeurceotSupl~T [~ Yea ~ F,o
Cement
[] Ye~ [] No
Depth ...... Fee~,
D~eter Depth _.
Waist Depth
[] Off,~et I~ [] In B~ement [] Room
2..Tnc~ease chlorin~on sufficiently to meet recommended residual standards.
Determine source of contandnation and tnke action secessm~' to maintain
a safe water supply ~ alt l~nes.
3. Check chlor~natlon and other mechanical equipment. Make ce~tc~ it is
functioning properly.
4; If after check~ng equipment a disinfecting residual ~ not obis/ned, please
wke this office for emergency ~istcmce or advisory services.
5. This'is a surface water source and subject to pollution by man and animals.
Au approved water supply source should be developed.
8. Imp]:ove your [] spring [] dug well [] driven well
[] drilled well [] cistern
7. Relocate your well to a safe l~cafion in relationship to your sewage disposal
s~stem. [] ssa enclosure
8..~nnple too long in t~assit~ sample should not bo over 48 hom'~ old at
exomi-~ion to indicate reliable results, please send new sample.
[] Bottle Brokea in t~cmsit, please send new sample,
9. C~ntact your neares~ [] Local Health Dep~tment or [] Alaska
Div~on of P~lle Health, scmitation office for bulletins, consultation and
e~ssistance.
SAN[TAR[AN'S REMARKS
Signaiure --
READ INSTRUCTIONS
ON
BEFORE:
COLLECT/NG, SAMPLE'
~]5-t220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Received, - , - , T/me Received ' - pm l~b. No,