HomeMy WebLinkAboutLot 01A, 02A
~ .,~/~ D : RECEIVED
· 6 NSPECTION APPOINT?~IENTS ~. /~__./ J
TIM[~ TIME I~C~.C-%(~,~¢L~ f,~/Lt~ L~
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTO~%~ ~
MUNICIPALITY OF ANCHORAGE DEPT. OP HEALTH &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTI~VIRONMENTAL PROTECTION
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL SANITATION BIVlSIO~
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 probessin9.
1. PROPERTY OWNER /PHONE
MAILI~
PRO~TY RESIDENT (If different from above) PHONE
2. BUYE~ ~ PHONE
MAILING ADD~ESS t
3. ~ENDIN6 INSTITUTI~ PHONE
MAILING ADDRESS
4. REA~OR/AGENT I PHONE
MAILING ADDRESS
5. LEGAL DESCRIPTION
6. TYPE OF RESIDENCE
[] SINGLE FAMILY
. NUMB~ER OF BEDROOMS
¢~ ~ One ~ Four
~ Two ~ Five
MU LTIPLE FAMI LY ~/¢~¢ ~ Three ~ Six
[] Other~
WATER
~ 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**
' PUBLIC UTILITY
YEAR ON-SITE SYS'i'EM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
THIS SIDE F()R OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] S~I NG LE FAMILY [] ONE [] THREE [] FIVE [] OTHER
~"~ MU LTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2, WATER SUPPLY
b~J/' INDIVIDUAL DEPTH OF WELL
[] COMMUNITY -DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDIVI DUAL/ON -SITE DATE I NST~LLED
,[~PUBLIC UTILITY .~ -~Z¢ '
Connection Verified ?~J_' ~"--'(~ ~ INSTALLER
E~]Septic Tank or []Holding Tank
Size: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES Septic/Holding Tank IAbsorption Area Sewer Line I Nearest Lot Line
I
I
WELL TO: __
Absorption Area to nearest Lot Line
5, COMMENTS
//~ APP R 0 V E D FO R"~.~/-/,~ B E D R O0 MS
CONDITIONAL APPROVAL (letter must accompany certificate}
[] DISAPPROVED
Drinking Water Analysis Report for Total Coiifor~
TO BE COMPLETED BY WATER SUPPLIER
WATER SYSTEM:
I.D. NO.
Water System Name Phone No.
Mailing Address
Citv 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.
I
2 I
I
4 1
I
LOCATION
Time Collected
Collected By
TO BE COMPLETED BY LABORATORY
Analys~s shows ~nis Water SAMPLE to be:.
[]- Satisfactory
[] Unsatisfactory
[] Sampm 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
U]. Membrane Filter
Lab Ref. No. Result* Analyst
I ~
I ~-I
*No of colomes/100 mi. or No. of Pos~twe portions·
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-3.220
Rev. 3.978
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Collected Source
Lab. NO.
Presumptive leml 10mi 10mi /0mi ]Omi 1,0mi 0.1mi
24 Hours
48 Hours
Confirmatory
24 Hours
48 HOURS
EMB Broth 24 hours: Broth 48 hours:
Multiple Tube Report: 1Omi Tubes Positlverrotal 3.0mi portions
Membrane Filter: Direct Count Collform/100ml
verification: LTB
Final Membrane Filter Resu. lts :::'j ~ '::i I ;:i , Collform//O0~l
! i Date
Printer's Inc. DBA
/ ,
Service
3,49-7602 Quality
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:
Water System Namei
I.D. NO.
· ' i: :i'
Phone No.
Mailing Address
City . . ,: ~Zip (~ode
SAMPLE DATE: ~
MO,
~. State
Day Year
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref, no.
[] Special Purpose
[] Treated Water
[] Untreated Water
SAMPLE
NO.
1
2
4
, ? i\ .. :',
LOCATION
~,: ,,...':, ~; ,; :.':: :; .... ,
Time Collected
Collected By
I
06-1220 (b)
Rev, 1978
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
[] Satisfactory
[]:'U~satisf~ctgry '~
[] 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
*No. ot colonies/100 mi. or NO. of Positive porlions.
BACTER IOLOG ICAL WATER ANALYSIS RECORD
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Date Collect e(l Source.
No.
3re~umptlve :10mi /0mi 10mi 10mi 10mi 1,Omi 0,1mi
24 Hours
48 Hours
:onfirmatory
24 Hours
48 Hours
EMB Broth 24 hours:
Verification: LTB
Final Membrane Filter ResuJts
Reported By
Broth 48 hours:
1Omi Tubes positive/Total 1Omi Portions
Collform/lOOml
BGB _