HomeMy WebLinkAboutLAKEHURST BLK 7 LT 9B
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL ENGINEERING DIVISION
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITI~
DIRECTIONS: Complete all parts on pege 1. Incomplete requests will not be processed. Please allow ten (10) days for processing,
1../P~PERrTY OW.~R PHONE
MAILING ADDRESS
PROPERTY RESIDENT (If different from above) PHONE
2. BURR_ PHONE
MAILING ADDRESS
3. LENDING INSTITUTION PHONE
MAILING ADDRESS
4. REALTOR/AGENT I PHONE
MAILING ADDRESS
5. LEGAL DESCRIPTION
6. TYPE OF RESIDENCE
[~SII',IG LE FAMILY
[] MULTIPLE FAMILY
NUMBER OF BEDROOMS
[] One
[] Two [] Five
[] Three [] SLx
[] Other
7, WATER SUPPLY [] INDIVIDUAL*
~ COMMUNITY
[] PUBLIC UTILITY
*ATTACH WELL LOG. Awell 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**
[~3--~PU B LIC 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 WL-'LL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
E~.,JUUB~vl DATE INSTALLED
DUAL/ON
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 Sewer Line -- Nearest Lot Line
Absorption Area to nearest Lot Line
5, COMMENTS
> APPROVEDFOR & BEDROOMS
[~'~CONDITIONAL APPROVAL {letter must accompan~/~icate)
[] DISAPPROVED. ~~_~
DATE BY (~/..
LEGAL DESCRIPTION \
72-010 (Rev. 3/78)
Date
ALASK ' ~EPARTMENT OF HEALTH AND SOCIAL S~-'VICES
DIVISION OF PUBLIC 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 shows this WATER SAMPLE to be:
[] Satisfactory
[] 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 or 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 :; ., Source
/ / iJ ~' /'/' :' 'a;m. ~ :,
Date Received Time Received p,m. Lab. No.
24 Hours : ' "
48 Hours
3onfirmatory
24 Hours
Broth 48 hours:
.Z0ml Tubes Positive/Total 10mi Portions
__ BGB
Date