HomeMy WebLinkAboutLAKEHURST BLK 7 LT 13A
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 L Street - Anchorage, Alaska 99501
DEC 1 ~ 1978
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER ~J~I[IJE¥[ D
· MUNICIPALITY OF ANCHORAGE
DEPT. O,: t'L-ALT~-f &
ENVIRONMEN],~.L , ;..:; '!:CTJON
ENVIRONMENTAL ENGINEERING DIVISION
Telephone 264-4720
)IRECTIONS: Complete all parts on page t. Incomplete requests will not be processed. Please allow ten (10) days for processing. f PHONE
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1. PROPERTY OWNER
MAILING ADDRESS
PROPERTY RESIDENT II~ differen[ from above)
2. BUYER
PHONE
PHONE
MAILING ADDRESS
3. LENDING INSTITUTION
bPHON E
¢4-/_5-~ /
MAILING ADDRESS
4. REALTOR/AGENT
.H'ONE'
MAILING ADDRESS
5, LEGAL DESCRIPTION
STREET LOC..A2TI ON
6. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] One [] Four [] Other
[] SINGLE FAMILY F-I Two ,~ Five
~ MULTIPLE FAMILY [] Three [] Six
7. WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
8, SEWAGE DISPOSAL SYSTEM
INDIVIDUAL/ON-SITE*~
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.)'
**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)
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GE(J OelGAL LABORATORIF OF ALAS INC.
P.O. BOX 4-1276 ANCHORAGE, ALASKA 99509 4649 BUSINESS PARK BLVD.
TELEPHONE
(907) 279-4014
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
I.D. NO.
Mailing ,,~dd r~as
City State
Mo. Day Year
Zip Code
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref. no. )
[] Special Purpose
[] Treated Water
[] Untreated Water
SAMPLE
NO.
1
§
LOCATION
Time Collected
Collected By
TO BE COMPLETED BY LABORATORY
LABORATORY:
NAME
ADDRESS
CiTY
Date Received
Time Received /
Analytical Method:
[] Fermentation Tube
, ,~'Membrane Filter
Lab Ref. No. Result* A~n~.yst~,
"'::'- ~I' ~'~
No. o! colonies 1100 mi. or No. of Positive p~rllons.
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Form No. 18-310 (3-78)
06-1220 (b)
Rev. 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Collected Source
24 Hours
EMI3 Broth 24 hours: Broth 48 hours:
Multiple Tube Report:
Membrane Filter: Direct Count
Reported By .~_~./
1Omi Tubes Positlve/Totat 1Omi Portlorls
Collform/lOOmt
BGB
VICINITY MAP
CERTIFICATE O~F OWNERSHIP AND DEDICATION:
NOTAR Y'S ACKNOWLEDGEMENT:
PLAT APPROVAL:
DTI000899 -- '~ "
NYMAN
~HAYES
IAK£HURST SUB,
19 82- 2 693 $-5~z~___