HomeMy WebLinkAboutKWIK LOG BLK 4 LT 6
APPLI ,NT FILL, S OUT UPPER HA . ONLY
Lending Institution, )/¢¢/';¢ _;'X-/If' ,,:bU ~,: ¢ ~ Phone
Phone
Realty Co. & A~nt .....
Address / ~ L Zip Code
Legal Description ~ * " (~
Type of Residence
~ S~le Family
~ultiple Pamily No. of Bedrooms ~2
~ Other
Water S~pply
~dividual ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
~ Community For wells drilled prior to that date, give well depth (altech log if available).
~ Public Utilily
Sewer Disposal
~ Individual Year Individual Installed:
~lic Utility When Connecled to Public Utility: (o- /'' '7 '~ ¢%/
~ Holding Tank (~,¢~ ,
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN SE INITIATED.
Time
Time Time Time
Date Date Date \ 4k' %('~'~ D
Inspector Inspector Inspector~, Inspector
Field Notes: MUNICIPALITY OF
'; , ~:"),.', :'(:" / ' -f:.
[ F CEiVEi)
( ~.&PPROVED BEDROOMS ~ ~, 'COHDITIONS OF APPROVAL
Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received
Well to Tank Septic Tank Size
72-023
CHEMICAL & Gi~.LOGICAL LABORATORIES ,~.~ ALASKA, INC.
TELEPHONE (907)-279,4014 ANCHORAGE INDUSTRIAL CENTER
274-3364 5633 B Street
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
WATER SYSTEM:
I.D. NO.
Water System Name
Phone No.
Mailing Address
City State Zip Code
Mo. Day Year
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab reft no.
[] Special Purpose
[] Treated Water
[] Untreated Water
SAMPLE
NO. LOCATION
Time Collected
Collected Ry
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 i
Analytical Method:
[] Fermentation Tube
~ Membrane Filter
Lab Ref. No, Result* Analyst
I
*No olcolonms/lO0 ml. or No of Positive portions.
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220 (b)
Rev, 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date CoJlecte~ Source
a.m.
Date Recelved Time Received __ p.m. I-al). No.
24 Hours
48 Hours
Confirmatory
24 Hours
48 Hours
EMB. Broth 24 hours: Broth 48 hours~
Multiple Tube Report: ).0mi Tubes Positive/Total ).Omi Portions
Membrane FIIter~ Direct Count Collform/lO0ml
Verification= LTB BGB
Final Membrane Filter Results ~ Collform/100~111
Reporte~ By : : = Date
Tlme~ --a.m.