HomeMy WebLinkAboutLINCOLN PARK BLK 5 LT 1Linc. oln PK.
MUNICIPAfLIT¥ OF ANCHORAGE
MUNICIPALITY OF ANCHORAGE DEPT. OF ;::.:/',LT;!
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIOI~hi'VIRONiY. F~NTAL ~:.~:::i ECTION
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL ENGINEERING DIVISION APR !
Telephone 264-4720
REC sED
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FAOIL
DIRECTIONS: Oomplete all parts on page 1, Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPE. I~T-)Y OWNER PHONE
MAILI'NG ADDRESS /
PROPERTY RESIDE~-T (T~ different from above) PHONE
~ ~ PHONE
2. BUYER
MAILING ADDRESS
3. LEN~G INSTITU, TION ~ , / ~ , ~ ~HON~ .
M~LTN~ ADDRESS / '
5. LEGAl_ DESCRIPTION ',
STREET LOCATION ~ -- -- /
6, =I'YI~E OF RESI~I~ENCE-
~ SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OF BEDROOMS
[] One ~ Four
[] Two [] Five
[] Three [] Six
[] Other
7. WATER SUPPLY
NmW UAL*
[] 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 log if available.)
8. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE**
~ PUBLIC UTI LITY
**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
I NSP ECTOR ~NSPECTOR INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTNER
E~] 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
EZ~] I NDI VI DUAL/ON -SITE DATE INSTALLED
[]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:
Absorption Area to nearest Lot Line
5. COMMENTS
~ APPROVED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY (Title) / '~
LEGAL DESCRIP'rION
72-010 (Rev. 3/78)
ABOI T0
4649 BUSINESS PARK BLVD.
· P.O. BOX 4-1276 ANCHORAGE, ALASKA 99509
Drinking Water Analysis Repbrt for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
PUBLIC WATER SYSTEM:
Public Water System I~a~me
Mailing Address
City- State " Zip Code
Mo. Day Year
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref. no. ) [] Treated Water
[] Special Purpose [] Untreated Water
SAMPLE
NO.
1
2
3
4
5
LOCATION
Time Collected
Collected By
TELEPHONE
(~07) 27g-4014
TO BE COMPLETED BY LABORATORY
LABORATORY:
f CITY
Date Received ~?/'~
Time Received //4~/~) .~
Analytical Method:
[] Fermentation Tube
~f~ Membrane Filter
Lab Ref. No. Result* Analyst
I I--:
::
NO. of colonies 1100 mi. or No. ol Poeltlve p~rllone.
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Form No. 18-310(3-78)
06-1220 (b)
Rev. 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date C ollectect ' ': Source
: a.m.
Lab. No.
24 Hours
48 Hours
3onflrmatory
48 Hours
EMB Broth 24 hours:
Multiple Tube Report:
Membrane Filter: Direct Count
Report. By ~.., L~ .....
Broth 48 hours:
1Omi Tubes Positive/Total lOml Portions
Date (f'° "~/~ '~Tf°rm/100m;