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Home My WebLink AboutLITTLE BEAR BLK 1 LT 8 DEPRRTMENT UF t4ERL. TH RN[)ENVIRONMENTRL i--RCI]"ECTION c. .... ~.9 _ 9L'95~7 ~._,.L~ E. TU[)OR RI:'.., RNE:t4EF.'R'~E., ;.--.'.76- 222'1. ~-,.~ E L_ b. F' E.-"E. F.;: ~-.li Z 'T PERMIT NO. ( 76Z.'.0~ ) RI='PL l C:RNT LOCRT I ON L. EGRL ED RZNNER BRBT BERR F'LRCE L8 E:l LITTLE BE.RR -,,-[- :3~i0 WELL. SLE~" c'r LOT '_--;IZE 84()~3 SCiUFtRE F:EET MINIMUM DISTRNCE BETWEEN R WELL RND ANY ON-SITE SENBGE DISPO~]RL. SYSTF.'[t9 iOE~ FEET FOR R PRIVRTE WELL OR 28~ FEET FOR R PUBLIC NELL NELL LOGS RRE REQUIRE[:, RN[:, MUST BE RETURNED TO THE DEPRRTMENT 1.4ITHIN OF THE WELL COMPLETION. ,-,Fi '--' SPECIFIC:RTIONS RN[:, CONSTRLCTION DIAUR~fl=, FIRE RVRILRE:LE TO INSURE FR_FE.P~ I NSTRLLRT I ON. I C:ERTIFV THaT :~: I 8M FRMILIFIR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND NELL. S RS [SET F'ORTH Bb' THE MUNICIPRLIT~' OF RNCHORRGE. ~: I WILL INS;TRLL THE =,hz rEr] IN RCCORDRNCE ~4ITH THE CODES. RPPLICRNT ED RINNER < 0 0 0 0 0 0 0 0 0 0 0 0 i 0 0 0 0 0 0 ~D 0 0 0 0 : :: : i : MUNICIPALIT~ OFANCHORAGE · : DEPARTMENT OF HEALTH & HUMANSERVICES_ ~' Division of Environmental Services · On-Site Services Section P.O. Box 196650 Anchorage,Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # 01~-'0~}"~-- ~' - HAA# GENERAL INFORMATION 1. Complete legal description Lot 8; 'B10¢~ :r'j~ '~'B~:Subd~vx~ion 6651 Baby Bear Anchorage, AK Day phone 563-9910 Anchorage, AK 99523-0145 Location (site?ddress or directions) g':: ~:' ....'; ..... ? ;:.."~ ~Prope~t~wner ; RZ~z,td ~ Ed, Cdt ¢~zz~p ~Lending agency--... ~. L~ address . ,. ,. .,. ,~., 5~ - . Address 3333 D~ -S~ 110 ':'~'A~orag~ ' AK Day phone Day phone 99503 277-4372 ' Unless otherWise"~e'~l'~te~, HAA'will'be i~eid for-pickup. ' 2.. NUMBER'OF BEDROOMS~." :' ~ · TYPE OF WATER SUPPLY:":; .~ ..' _ ,,, ~ ~ ~ :..: " z ' Individual well ,, ~ ~ ~,,,~._ ~ ~ -. ..... ... . · ,. . -..- . . . ,,?' ~ " / ~'~ ~ ~ ~."-~; ..... Commumty well .,, NOTE: If communt~ well syscom, provtde wrtRen confirmatton from State A~E~ a~est-' ' lng to the legali~ and status of system. '. , , I' Z , ~'2 : . 4. TYPE OF WASTEw~TER DISPOSAL: ' Individual on-site Holding tank NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA~21 5. STATEMENT OF INSPECTION' BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows ~hat the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verifythat based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance .with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. A.. 17034 Eagle River Loop Road No. ~ ooress ............. ./ Engineer's signature 7~,r~y__, ~r/~?"~r'~,---- Date "7/1 T/*5-- DHHS SIGNATURE /~' '" Approved:~r"' _~ bedrooms. Disapproved .... .. Conditional approval for bedrooms, with the following stipulations: I~.11111 [I]~ The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska, The DH HS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Re~,1/91) Back MOA#21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: /-oF' c~/ CL~ // Z/)')-z:*L r~.4,e ~ParcelI.D. ~)/~z -~)£/-,~ $~ A. Well Data Well type P~, Jr4 7/__ If A, B, or C, attach ADEC letter. ADEC water system number Log present (~N) YE ~ Date completed ! /'J~?7~.? Driller'/~(~A$~ ? Total depth ~ '7 / Cased to ~0 y- Casing height / Sanitary seal (t~/N) ~'E J- Wires properly protected (~/N') y£ .,r' FROM WELL LOG AT INSPECTION Date of test Static water level Well flow ! '~' .g.p.m. Pump level1 SEPARATION DISTANOES FROM WELL TO: Septic/holding tank on lot /v//4 Absorption field on lot ~/4- Public sewer main 7.C' -/- Sewer service line ~ 5'- /"~ RECEIVED JUL. 1 $1995 g.p.m. Municipality ot Anchorage Dept. Health & Human Services ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform O Date of sample: S. SEPTIC/HOLDING TANK DATA O Nitrate co,3' ~ Other bacteria Collected by: S & $ ENGINEERING 17034 Eagle River Loop Roi,d No. 204 Eagle River, Alaska 99577 · Cleanouts ~ i. . Foundation cleanout (WN) __Depression (Y/N) High water alarm'S,' ~':" -' Alarm tested (Y/N)__ Date of'pumping ..... ""~ "~ //~imper ______ SEPAR~:FJ ON. DI.sTANcEs, FR~M-';EPTIO/H~ Well(s) on lot ~ , .., _On adjacent I~ __-- - To property line __ Absorption field Water main/se '~ _ Surface water/drainage ~ CONTINUED ON BACK GE 72-026 (3/93)* Front C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) "Pump on" level at / "Purr~-eff'%-'~ at High water alarm level Meets MOA electrical codes (Y/N) SEPARATION DISTANC.~FA~~TION TO: ~ On adjacent lots D. ABSORPTION FIELD DATA Soil rating (GPD/F¢) Date installed Surface water Length Width Total absorption area Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) ~'"'/ SEPARATION DISTANCE FROM ABSORPTI~LD TO: Well on lot ~ adjacent lots To building foundation ~ On adjacent lots / Surface wa..te/ Cu~ '~drain Gravel thickness Cleanout present (Y/N) Results (pass/fail) System type .ep er~'ssion over field (Y/N) for After test If yes, give date Property line To existing or abandoned system on lot Cutbank Water main/service line Driveway, parking/vehicle storage area Bedrooms E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in eff~.¢~ &of this inspection. Signature HAA Fee $ ~. ~ Waiver Fee $ 07/13~1~5 06:51 9078~41211 S AND S ENGINESRING O7/11/95 15:11 COmMERCIaL T~$TIN~ ~ -c~76941~11 ~u. zlF. CT&E Enrichment! Servioel~ Leborator? Analysis Report " 2~ W. Potter Drip,, A~h~, AK ~95~8,1605 -- T~: (907) 56~-23~3 FSx; (~07) 501-5301 ......... ~NV~RONMENTAL F~CILITIE5 IN AL~, ~LWORNIA, ~0RIDA, ILLINOIS, MARYLAND, M;C~tGAm, MiSSOUri. N~W jERSEY, OHIO. WES~ ViRGINiA 87,'tt/95 15~11 COK/~ERCIDL TE~T]NG ~ 90759~121! P~G£ 82 Drinking Water Analysis Report for Total Coliform Bacteria 2~ w. Po,,, >~vo A.,zho,age_ AK g~518-1605 RE.4D INST~UCTION~ ON ~FE~E 5tDE ~EFO~ COZLECT(A~ S4MPLE Tel: (~07} 562-2343 SAMPLE DATE: S AMYbg TYPE: ,~ Routia¢ R~peat Sample (for routine sample ~'ith lab ref, no, __ SAMPLE LOCATfON Month Day Yeae la Treate$ Water ~ Untreated Watar Time CoHect,d MMO-MI.;rJ. Result: Toro[ Coliform Verifi~a{ion: LTB F¢~al Coliform Confirmation Fox: (gO7) 561-5501 Analy~;~ sho,~ :hi, Wa~*r sA~L~ ~" 5atisthcto~ be unreli~b[~ Sample wo long in tr~D$i~; S~ple :hould not be over a8 hO~f$ old at ~:ew ~ample via special deliveey mail Date R,celved Ar, aiyticni M~thod: .,~" Merab/an; Time Coliformlt0o mi /c-3 Parcel I.D. # MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING HAA # ~ {;~ ~ ~% (~d'J-~ c~ 1. GENERAL INFORMATION Complete legal description Lot 8; Block 1 L,CC~e Bear Subdivision Location (site address or directions) 6651 Baby Bear An~horaqe, ALASKA Property owner Mailing address Waggon~r! ~'~ Day phone 349-8939 Lending agency Mailing address Day phone ordered Agent :Janet Hayes, Oentury 21 Pacific North Address 1120 Huffman Anchorage, AK 99515 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 '~ TYPE OF WATER SUPPLY: Individual well XXX Community well Public water NOTE: Day phone 278-8968 If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site NOTE: Public sewer XXX If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 5.. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below; I verify that my investigation of this Health Authority Approval application shows that the on-site water supl~ly and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address Engineer's signature 17034 Eagle River Loop Road No, 204 Phone Date ~-'- I '~-4 '~ DHHS S~JGNATURE Approved for --~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72~25 (Rev. 1/91) Back MOA #21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L. o1' r~ ~d_o~.l< I LITTLE ,,~r~/L ,5/P Parcel I.D. A. WELL DATA Well type pr~l~,~T~' Log present ON) Total depth Sanitary seal If A, B, or C, attach ADEC letter. Date completed Cased to ~ ~ FROM WELL LOG Date of test Static water level 25 Well flow / Pump level /JOT' ~uO~, ADEC water system number I/ ~"/ /-/ ? Driller pg'/Jtl g,p.m. SEPARATION DISTANCES FROM WELL TO: ~ Septic/holding tank on lot .,t)/~, Absorption field on lot /z.//~ Public sewer main Sewer service line ~. ~'-~ Casing height Wires properly protected(~N) AT INSPECTION ; On adiacent lots ; On adiacent lots ///4 Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform (~.~,//00 Date of sample: B. SEPTIC/HOLDING TANK DATA ~?-~'-~&/c ~'~""-,J~-~---~ Date installed Cleanouts (Y/N) High water alarm (Y/N) Date of pumping Nitrate (---)'~"~ /'//~//'"~- Other bacteria C~'//~'/~ IUI?'c'~T~'''r) Collected by:-~''¥' '~' ~"/J(~(/tJ~" . Tank size Foundation cleanout (Y/N) Compartments Depression (Y/N) Alarm tested (Y/N) Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot To property line Surface water/drainage 0,, adjacent lots Absorp',on field Foundation Water main/service line .......... ~,~, ~,~., CONTINUED ON BACK PAGE Date i n st a I ~e-8~-'~----~ Size in gallons Vent (Y/N) High water alarm level ~ Meets MOA eiec~ SEP~ISTANCE FROM LIFT STATION TO: jWell on lot On adjacent lots D. ABSORPTION FIELD DATA Manufacturer ~~ ~Manh°le/Access ~ "Pump on" level at ~"Pump off" level at Surfaco water Length ~Width Total absorption area ~ Depression over field (Y/N) ~-~ Soil rating Gravel thickness Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) System type Total ( Cleanouts present (Y/N) Date of ade¢ test yes, give date bedrooms SEPARATION DISTANCE FROM ABSORPT~ FIELD TO: Wellon lot ~.....~ ~acent lots Pr To building foundation _ To existing or abandoned system on lot On adjacent lots._ ~'"' Cutbank Water main/service line .~rtain drain Driveway, parking/vehicle storage area E, ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect, o.o,~b,C~c~a_te of this inspection. Signature 17034 Eagle River Loop Rood N~. 9~4 Eagle River, Alaska 99577 Engineer's Name Date "Z-- - / '~ - ~ ¢P HAA Fee $ / 7 47 Date of Payment Waiver Fee: $ Date of Payment Receipt Number CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO, 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301 Chemlab Re£.S :93.0541-1 REPORT of ANALYSIS Client Sample ID :L$ Bi LITTLE BEAR Matrix : WATER Client Name :S & S ENGINEERING Ordered By Project Name : Projects : PWSID :UA Collected :02/09/93 ~ 11:14 ks. Received :02/10/93 @ 15:00 hms. WORK Order :63076 Report Completed :02/11/93 Technical Director ~S~ EDE Released By :' ~ '' ' "~~ Sample Remarks: ROUTINE SAMPLE COLLECTED BY: QC Allowable Extract Analysis Parameter Results Qual. Units Method Limits Date Date Init NITRATE-N 0.39 ~/1 EPA 353.2/300.0 10 02/11/93 02/11/93 LLH · See Special Instructions Above UA = Unavailable " See Sample Remarks Above NA = Not Analyzed U = Undetected, Reported value is the practical quantification limit. LT = Less Than D = Secondary dilution. GT = Greater Than co. CI EMICAL & GEOLOGICAL LABORATORY TELEPHONE (907) 562-2343 5633 B Street Anchorage. Alaska 99518. Drinking Water Analysis Report for Total Coliform Bacteria' . TO BE COMPLETED BY WATER SUPPLIER PRIVATE WATER SYSTEM Name Ph(me No, 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 995~' Ma~ling Address Ck'y State Zip Code Mo. Day Year SAMPLE TYPE: .~ Routine [] Check Sample (for routine sample with lab ref. no. [] Special Purpose ) [] Treated Water [] Untreated Water 'SAMPLE No. LOCATION ~ I LoT ¢:,~z. I; Z.'~ Time Collected Collected By TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: [] Satisfactory [] Sample too long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Date Received ~//~ Time Received ~ Analytical Method:. Membrane Filter * No. of colonies/100 mi. Lab Ref. No. Result* Analyst READ INSTRUCTIONS BEFORE COLLECTING SAMPLE BACTERIOLOGICAL WATER ANALYSIS RECORD Membrane Filter: Direct Count Verification: LSB BGB Fecal Coliform Confirmation ~.J ef ~"~f ~ Final Membrane F~sfl~__~ // , Reported By '~ Date ~ '~'~J ~/~ ' C).'_~ .~:a:ma~¢lO0 mi TNTC = Too Numerous To Count Time: OB = Other Bacteria Held For Confirmation PART ONE OF TWO ~s~S Mem~;, REMAINDER TO FOLLOW (~ Coliform/lO0 mi ~, -/2 ~?~ a.m. p.m. GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3330 "C" Street, Anchorage, Alaska 99503 274-4561 Date Received March 3, 1977 Time of Inspection 9:30 a.m. Date of Inspection 3-8-77 Tuesday REQUEST FOR APPROVAL OF Buchholz INDIVIDUAL SEWER & WATER FACILITIES FOR Cony. l. Approval requested by: ~fac Mortgage Mailing Address: 705 West 6th Avenue 2. Property Owner: Lawrence Sebring Mailing Address: % Marion Phone: 277-8588 Phone: 344-3069 3. Legal DescriPtion: Lot 8 Block 1 Little Bear Subdivision 4. Location: B~by Bear Place o Well Data: A. Type C. Construction A. Installed C. Septic Tank: D. Seepage Pit: E. Disposal Field: Distances: Type of facility to be inspected Single Family Permit # 76309 Individual Sewage Disposal System: Public Utility B. Installer 1. Size 1. Absorption Area Total length of lines No. of bedrooms B. Depth 87' D. Bacterial Analysis 2. Manufacturer 2. Material A. Well to: Septic tank Nearest lot line B. Foundation to septic tank , Absorption area ,Other contamination , Absorption area , Sewer Lines __ C. Absorption area to nearest lot line__ E0-034 (1/74) Paae 1 of two Daees Page 2 of two pages - Re ~st for Approval of Individual , er & Water Facilities Legal D~scripti0n Lot 8 Block 1 Little Bear Subdivision Comments ApProved ~ ?_._,~-, Disapproved Date Approval,Valid for one year from date signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM certify that the information contained in this request for approval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating satisfactorily. SIGNED Date EQ-034 (1/74) MUNICIPALITY OF ANCHORAGE ~UNIClP^UTt OF ^NCHOR^G~ DF. PT, OF tI:!AI.Ti'I DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ENVIRONMFHI'AL I~OTI:.CTION 2510 East Tudor Road, Anchorage, Alaska 99504 276-2221 REQUEST FOR APPROVAL OF . INDIVIDUAL SEWER and WATER FACILITIES 1. Type of Inspection: CMRO VA FHA 2. Property Owner: ~-~'~ ~;~'~ ~- ~ '~-~- ~ ~" ~ ~ Mailing Address:. Name of Buyer: ~ Mailing Address: Name of Lending Institution: MAP, 3 - 19Y7 CONV Day Phone: Day Phone: Mailing Address: Phone: Name of Realtor or Agent: , Sailing Address'. ~¢).~/0 ~'~'/'(5"/~? ~-- Phone: Legal Description: L ~ Location: ~-~t~/'~ ~ /"~'~-/' ' / 7. Type of Facility to be Inspected: go No. Bdrms. ~-~ 8. Water Supply Type of Supply: Public Utility If Individual, number of dwellings presently served If Individual, depth of well 9. Sewage Disposal System Type of System: Public Utility Individual Individual (on-site). If Individual, date of installation 72-003(3/76) 06-1220(a) Rev. 1973 DATE ALA,~ DEPARTMENT OF HEALTH AND SOCIAL SE[ ;ES ' DIVISION OF PUBLIC HEALTH Lab No. INDIVIDUAL AND SEMI-PUBLIC BACTERIOLOGICAL WATER ANALYSIS OEP,CE INDIVIDUAL [] NAME SEMI-PUBLIC [] CHLORINE RESIDUAl PPM REPORT RESULTS TO ADDRESS ;ITY - '~ - ' ' ZiP CODE ADDRESS OF SOURCE " : ~[ /: "' ;?. ~ _~' COMPLETE THIS SECTION ONLY IF WATER IS AN INDIVIDUAL SUPPLY Analysis shows this Water SAMPLE to be: [] Satisfactory [] Unsatisfactory [] Questionable [] Sample too long i~ transit; sample should not be over 48 hours old at examination to indicate reliable results. Please send new sarr pie. [] Bottle broken in transit, please send new sample. SANITARIAN'S REMARKS SAMPLE COLLECTED BY DATE COLLECTED ' TIME COLLECTED ~' ' Sample Collected From [] Kitchen Tap [] Bathroom TaB [] BasemenJ Tap [] Other (List) Well -- [] Dug [] Driven [] Drilled SOURCE: [] Spring [] Cistern [] Othei Dug Well or Cistern Construclion: Walls--[] Wood [] Concrete [] Metal Top -- [~ Wood [] Concrete [] Metal LOCATION: [] In Basement [] Basement Offset []In Yard [] Other Building Sewer DISTANCE TO: or Other Drainage P~pe_ Feet Tile Seepage Cass- Field Feet. Pit Feet. Pool _- Other Possible Sources of Contamination MATERIAL: Building Sewer - ~ Cast Iron [] Woad [] Plaslic Joint Maleria] - Type GENERAL: Does Water Become Muddy or Discolored? When? [] Tile Brick or [] Open Top [] Concrete ~- Under House Feet. Privy__ Feet. [] Tile [] Fibre [] Asbestos [] Yes [] No Diameter of Well Depth Feet. Well Casing Materlal DJameter _ Depth . Length of Water Depth Drop Pipe __ From Bottom Feet. PUMP LOCATION: [] in Well [] Basement [] In Bas~ment [] Room ~ On Top [] Of Well [] Other PURPOSE OF EXAMINATION: Illness Suspected? [] Yes [] No New Source of Supply? [] Yes [] No Repairs to System? [] Yes [] No Signature READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE 06 1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD Rev. t973 Date Received !;! i~' i : : Time Received i'~:' · pm Lab. No. Lactose Broth 10cc 10cc 10cc 10cc 10c¢ 1.0cc 1.0cc 24 Hours 48 Hours ' Brilliant Green 24 Hours 48 Hours EMB AGAR Laclose Broth, 24 hrs. 48 hrs. Gram's stain Coliform Densffy (Most probable No. per 100cc) MF Results Reported by This analysis indicates Coliform Organisms to be: Absent Present L,,. TE RECEIVED ~-~' ~ INSPECTION APPOINTMENTS TIME ' TIME ~./~~.--~ ' TIME INSPECTOR INSPECTOR / INSPECTOR ~ , Nc~O~AOE MUNICIPALITY OF ANCHORAGE , ~NvI~ON~,EN~AL ' "'"'~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION " 82. LStreet-Anchorage, Alaska 99501 S~}? 1. 0 't~1 (~) ENVIRONMENTAL SANITATION DIVlSIONTelephone 264-4720 ~c~[v ~D REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete aH parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER PHONE MAILING ADDRESS / ~ROPERTY RESIDENT (If different fr~ above} / PHONE 2, ~YER PRONE MAILING ADDRESS 3, LEND~B INSTITUTION PHONE MAILING ADDRESS MAILING A~RESS /5_~~_ ] 6. TYPE OF RESlDI~NCE NUMBER OF BEDROOMS [] One [] Four [] [] SINGLE FAMILY [] Two [] Five [] MULTIPLE FAMILY [] Three [] Six Other 7. WATER SUPPLY INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON-SITE** 76- 7? [] PUBLIC UTILITY YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS .~-~INGLE FAMILY E~] 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 ~U BtVIDUAL/ON -SITE DATE INSTALLED LIC UTILITY Connection Verified INSTALLER []Septic Tank or []HoldingTank Size: If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4, DISTANCESwELL TO: Septic/Holding Tank Absorption Area Sewe~ Lin~ N~arest Lot Line Absorption Area to nearest Lot Line 5, COMMENTS (.~PPROV ED FOR [] CONDITIONAL APPROVAL (letter mu. st accompany certificate) [] D.~SAPr~ROVED ~ . · CHEMICAL & C )LOGICAL L~.,~ORATORIE$ JF ALASKA, INC.~ ,*,/~· TELEPHONE (907)-279-4014 ANCHORAGE INDUSTRIAL CENTER /~.~ 274-3364 5633 B St re et ~ ....... ~-~ Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER WATER SYSTEM: Water System Name Phone No. Mailing Address City State Mo. Day Year Zip Code SAMPLE TYPE: [] Routine [] Check Sample (for routine sample with lab ref. no [] Special Purpose ) [3 Treated Water [] Untreated Water SAMPLE NO. t 2 LOCATION Time Collected Collected By TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: '[~]~.Satisfactory [] Unsatisfactory --] Samole too long in transit; sample should not be over 48 hours old au examination to indicatereliame results. Please send new sample, Date Received " Time Received Analytical Method: [] Fermentation Tube ~' Membrane Filter Lab Ref. No. Result* Analyst I · No. of co onies/100 mi. 3r No. of POSlbVe porbons. READ INSTRUCTIONS BEFORE COLLECTING SAMPLE 06-1220 (b) Rev. 1978 BACTERIOLOGICAL WATER ANALYSIS RECORD Date Collected Source Date Received Time ReCelvea __ ).m, Lab. NO. 24 Hours 48 Hours Confirmatory 24 Hours 48 Hours EMB. Broth 24 hours: Broth 48 I~ours~ Membrane Filter: Direct Count Collform/100ml Verification: LTB. BGB Final Membrane Filter Results ! ~ ~ CollformJlO0~Ol ~ , ,,:' . ! ~'t Time, ;? ~'~. -17~i'~ e.m.