HomeMy WebLinkAboutROOSEVELT PARK BLK 14 LT 15C
MUNICIPALITY OF ANCHORAGE '
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 L Street - Anchorage, Alaska 99501 ~
ENVIRONMENTAL ENGINEERING DIVISION ~~
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DI RECTION~: Complete aH pa~s on pa~e 1, Incomplete requests will not be preceded. Please allow ten (10) days for processlng,
4, REAL~OR/AGENT [ PHONE
MAI LING ADDR ESS
6. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] One [] Four
~ SINGLE FAMILY /~ Two [] Five
[] MULTIPLE FAMILY Three [] Six
[] Other
7. WATER SUPPLY
INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled
COMMUNITY since June 1975. For wells drilled prior tothat date, give well
[] PUBLIC UTI LITY depth (attach log if available.) ~'~------------------~' ~'/~ /
8. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE**
~ PUBLIC UTILITY
If individual/on-site, give installation date
If system is over two (2) years old an adequacy test is required
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
, 72~010(~ --
THIS SIDE FOR OFFICIAL USE ONLY
~ DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified INSTALLER
[]Septic Tank or E~]Holding Tank
Size; If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
5, COMMENTS
[~'~APPROV ED FOR 3 BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany c~te)
o DISAFPROVEO
DATE BY (Title) /-~
LEGAL DESCRIPTION
72-010 (Rev. 3/78)
P.O. BOX 4-1276 ANCHORAGE, ALASKA 99509 4649 BUSINESS PARK BLVD.
TELEPHONE
(907) 2794014
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
City
SAMPLE DATE:
PUBLIC WATER SYSTEM:
State
Mo. Day Year
SAMPLE TYPE:
Zip Code
[] Routine
[] Check Sample (for routine sample
E~peith lab ref. no.
cial Purpose
SAMPLE
NO.
1
2
3
4
5
[] T..ceated Water
E,~"~LI n t re at ed Water
LOCATION
Time
Collected
TO BE COMPLETED BY LABORATORY
LABORATORY:
CHEM & GEO LABS OF AK., INC.
NAME
4649 BUSINESS PARK BLVD.
ADDRESS
ANCHORAGE, ALASKA
CITY
Date Received 9 - ~'
Analytical Method:
[] Fermentation lube
r~Membrane Filter
Lab Ref. No. Result*
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Form No. 18-310 (3-78)
06-]220 {b)
Rev. 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Collected 9-6--78-
Date Received 9--6--78 Time Re~eiv,~,~ gQ0 ....L~b. No. _8638-7
Presumptive 1Omi lOml ]0mi 1Omi 10mi 1.0mi 0.1mi
24 Hours
~4ultipl~ Tube Report'~L
Membrar~e Filter: Direct Coullt ____
