HomeMy WebLinkAboutKIRCHNER LT 57O/0
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825L Street- Anchorage, Alaska 99501
ENVIRONMENTAL ENGINEERING DIVISION
Telephone 264-4720
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 (10) days for processing.
1, P~PERTYOWNER PHONE.
MAIL
~G
A~DR ESSD ~ · .
PROPERTY RESIDENT (If different from above) PHONE
2.~BUY~ ~ ~,HON E
MAILING ADDRESS
3. LENDINGINSTITUTIO~ ~ ~ PHONE
MAILING AD D~SS ~ ,
L¢cx /
MAILING A~RES~. . ~.~ ~ ' 4 ~ - ~ ~
~ 5. .LEGAL DESCRIPTION. .
VP .O__. ENCE .EDROOMS
SINGLE FAMILY --
[] One [] Four [] Other
[] Two [] Five
[] MULTIPLE FAMILY ~ Three [] Six
7. WATER S~IPpLY
'~ INDIVI DUAL* * ATTACH WELL LOG. A werl log is required for all wells drilled
/l_J COMMUNITY since June 1975. For wells drilled prior to that date, give well
[] PUBLIC UTILITY 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(3/78)
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
E~] INDIVIDUAL/ON -SITE DATE INSTALLED
[~] PUBLIC UTILITY
Connection Verified INSTALLER
[~Septic Tank or ~] Holding Tank
; Size:_ If Tank is homemade SOILS RATING
give dimensions:
~-YPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
' Absorption Sewer
4. DISTANCES SepticTHolding Tanl~ Area Line Nearest Lot Line
WELL TO:
Absorption Area to nearest Lot Line
[]~'~PPROVED FOR . BEDROOMS
[~CONDITIONAL APPROVAL (letter must accompany certificate)
LEGAL DESCRIPTION
72-010 (Rev, 3/78)
DATE
DATE SIGNED
R®dJ~prm ® SEND PARTS 1 AND 3 WRH CARBON INTACT -
4S 469
po~yPak(SOse~sJ4P469 PART 3 WILL BE RETURNED WITH REPLY
DETACH AND FILE FOR FOLLOW-UP
Date
ALASv -~EPARTMENT OF HEALTH AND SOCIAL °- VICES
.... DIVISION OF P.UBLIC HEALTH '~ ~
Lab. NO.
BACTERIOLOGICAL WATER ANALYSIS
Office
PLEASE MAIL RESULTS TO:
NAME
ADDRESS
CITY-
ZIP CODE
Sample collected by
Phone No.
Date Collected
Sampling Address
Time
Specific place of collection
REASON FOR SAMPLE SUBMISSION:
[] Illness suspected
[] Health Regulated Establishment
[] Other
WATER SAMPLE SOURCE
[] Well Type of casing
[] Improved (Enclosed, Covered) Spring
[] Surface (Reservoir, stream, lake)
[] Holding Tank
[] Other
Analysis ~hoWs this WATER SAMPLE to be:
~-]'S'ati. s fac tow
[] Unsatisfactory
[] Questionable .'[] submit other sample
[] Sample tOo long in transit to indicate reliable results.
Sample should not be over 48 hours old at time of
examination. ·
[] Bottle broken o1: leaked in transit.
[] Other
: ·
SANITARIAN~S REMARKS
.-Sanitarian's Signature:
BEAD INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD
Rev. 1978
Date Collected /"i / : _ ?'! '~' Source
Date Received.. ///
Presumptive lOml 10mi 1Omi 10mi 10mi 1.0ml 0,1ml
24 Hours
Confirmatory
24 Hours
48 Hours :: , J
EMB, ,-" ~ ~ - Broth 24 hours: Broth 48 hours:
Multiple Tube Report: / '~ 1Omi Tubes Positive/Total 1Omi Portions
Membrane Filter: Direct Count Coliform/100ml
verification: LTB 8GB
Final Membrane Filter. Results. J ~ Coliform/100ml
:! /-,,, /.-/,
Reported By :- Date j/'": £