HomeMy WebLinkAboutLINCOLN PARK BLK 3 LT 16Lincoln Pk.
/,2-7
~ " DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECT_Q~
INSPECTOR INSPECTOR
MUJ~ICIPALITY OF ANCHORAGE
MUNICIPALITY OF ANCHORAGE DEPT. CE HEALTH &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIJ~MJRONMENTAL PROTECTION
825 L Street - Anchorage, Alaska 99501
jbN 6 I981
ENVIRONMENTAL SANITATION DIVISION
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FAC LI
DIRECTIONS: Complete all parts ou page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
PROPERTY RESIDENT (If different from above) PHONE
2. BUYER PHONE · ,
MAI LII~G AD~}~ ESS
3. LENDING INSTITUTION ~-~ · I PHONE
MAI
LING
A D Dd.~R.~!~S S .
4. REALTOR/AGENT PHONE
MAI LING ADD ~R~SS
STREETLOCAT:ON /::.:_
6. TYPE OF RESIDENCE ~ SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OFtBEDROOMS
[] One [] Four
[] Two [] Five
'~ Three [] Six
[] Other
7. WATER SUPPLY
~ INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
*ATTACH WELL LOG. A well Icg is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach Icg if available.)
8. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE**
~-~ PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE IV]UST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
~-oto mev. ~/~/_,],_.~ ?)
THIS SIDE FOR OFFICIAL USE ONLY
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
[]INDIVIDUAL/ON -SITE DATE INSTALLED
E~]PUBLIC UTILITY
Connection Verified. INSTALLER
[]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 Absorption Area Sewer Line I Nearest Lot Line
WELL TO:
1
Absorption Area to nearest Lot Line
5, COMMENTS
[~fAPPROV ED FOR ....--
BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE
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:
I.D. NO.
Water System Name Phone No. ~,
Mailing Address
State Zip Code-
City -
Mo. Day Year
SAMPLE TYPE:
[] Routine
[3 Check Sample (for routine sample
with lab ref. no.
[3 Special Purpose
[] Treated Water
[] Untreated Water
SAMPLE
NO.
2 [
3 l
LOCATION
Time Collected
Collected By
J
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
[] Satisfactory
[] bnsatisfactory
[] Sample too long in transiT; samole should
not De 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
*No. of colonms/100 mi. or No. of Posilive DOt[iOnS
READ INSTRUCTIONS
BEFORE
COLLECTING SAM PLE
06-1220 (b)
Rev. 3978
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Collected Source
PresumPtive 10mi 10mi 10mi 10mi 10mi 1,0mi 0,1mi
24 Hours
48 Hours
Confirmatory
24 Hours
48 Hours
EMB Broth 24 hours.'
Multiple Tube Report:
Membrane Filter: Direct Count
Verification: LTB
Final Membrane FIter Result~ ,~ -'
Reported By '~ :' "' '~ !"
Broth 48 hours:
10mi Tubes Posltlve~Total 10mi Portions
Collform/3.00ml
BGB __
/ : Collform/100ml