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;;;i:' 'J: t,.I):!~.L.. 1!:?',1::5"!"i::11. THE: :i.:,"¢!:.:;'TEH .T.N F!C::E:OP;:I3'F:tJ",!CE: l,.lZ"l"l'"l 'i"HE
Well Owner .
Well Location ~ jr . :'~
Size Casing
Static Water Level
Date of Completion
feet
W.W.D.
Water Well Drilling
Phone 349-3809
Anchorage, AK,
Depth of Hole ;'?'~"?' Cased to ' ,, feet
Well Test ' ''~ Gal per Minute for Hours
WELL LOG
AUTHORIZATION TO DRILL
hereby authorize W.W.D. Drilling to proceed with the above work. Payment shall be made in the following manner:
Rig up Minimum (50% of anticipated depth), feet. @ per foot
Balance due upon completion.
in the event it is necessary to institute legal proceedings to collect any amounts due on this contract, I agree to pay an additional
sum of Ten percent (10%) of the original contract price as attorney's fees, plus costs, for legal proceedings.
Name
Date Address
INsPEcTION APPOINTMENT?
DATE DATE DATE
NSPECTOR INSPECTOR I NSPECTOR/~
~P~BTMEBTOFHE~LTH~VI~O~M~T~L~O~EC~IO~ '~h~. c.q)lECl'lON
825 L Street - Anchoraoe, Alaska 99501
ENVIRONMENTAL SANITATION DIVISION
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 (!0) days for processing.
1. PR~ERT~OWNE~ . PHONE
MAILING A DDR~8
PROPE~TY RESIDENT (If~ifferent from
3, LENJlNG I~STiTUTION --
/.,
4.--R~A ~TO R/AG ENT PHONE
REET LOCATI(~N.
6. 'J'VPE OF RESIDENCE NUMBER OF~BEDROOMS
[] One [] Four
J~ SINGLE FAMILY [] Two [] Five
[] MULTIPLE FAMILY [] Tl~ree [] Six
[] Other
7, WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
* ATTACH WELL LOG. A well Icg is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach Icg if available.)
SEWAGE DISPOSAL SYSTEM
~ INDIVIDUAL/ON-SITE** YEAR ON-SITE SYSTEM WAS INSTALLED,
PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
[~SI'NG LE FAMILY
[] MULTIPLE FAMILY
2.~ER SUPPLY
~J INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTILITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
?~INDIVI DUAL/ON -SIT~) ~
~-JPUBLIC UTILITY ~/
Connection Verified /0 '"~ ~.~t
[~]Septic Tank or [] Holding Tank
Size: .If Tank is homemad(
give dimensions:
NUMBER OF BEDROOMS
[] ONE [] THREE [] FIVE
[] TWO [] FOUR [] SIX
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATEINSTALLED
INSTALLER
SOILS RATING
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES
WELL TO:
Septic/Holding Tank
Absorption Area
Sewer Line
[] OTHER
INearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
DATE
E~APPROVED FOR ~' BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
72-010 (Rev. 6/79)
TELEPNONE (~07)-279,4014 ANCHORAGE INDUSTRIAL CENTER
274-3364 5633 B Street
g Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
WATER SYSTEM: I"
I.D. NO.
Water System Name Phoee No.
Mei~ing Address
City State Zip Cede
Mo. Day Year
SAMPLE TYPE:
[] Routine
[3 Check Sample (for routine sample
with lab ref. no.
F~ Special Purpose
[] Treated Water
[] Untreated Water
SAMPLE
NO,
LOCATION
Time Collected
Collected By
TO BE COMPLETED BY LABORATORY
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 Received
Analytical Method:
[] Fermentation Tube
[] Membrane Filter
Lab Ref. No. Result* Analyst
I I
I
*No of colomes/lOOml ocNo of POSltlVeportlons
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220 (b)
Rev, 1978
eACTERIOLOGICAL WATER ANALYSIS RECORD
Date Collected Source
Date Received Time Received __ p,rn, Lab. No.
Presumptive 1Omi 10mi 10mi 10mi l(Iml 1.Omi 0.1mi
24 Hours
_ 4fl H~oprJ
EMB
Multiple Tube Report:
Membrane Filter= Direct Count__
Verification: LTB
Final Membrane Filter Results
Reported By
Broth 24 hours:
__Broth 48 hours.,_
10mi Tubas Positive/Total 10mi Portions
Collform/lOOml
Date
Collform/lOOml