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MUNICIPALITY OF ANCHORAGE '~I~UNICIPALITY OF ANCHORAGE/
U DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION E DEPT, OF HEALTH &
~ 825 L Street - Anchorage, Alaska 99501 N~IRONMENTAL PROTECTIO/~
/
ENVIRONMENTAL ENGINEERING DIVISION SEP
Telephone 264-4720 '
EST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER~I~ ~~
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1, PROPERTY OWNER ] PHONE
MAILING ADDRESS
PROPERTY RESIDENT(Ifdifferentfromabove) ~/ PHONE
2. BUYER PHONE
MAILING ADDRESS
3, LENDING INSTITUTION ~'Pb~~' ~ ~.~ ] PHONE
MAILING ADDRESS
4. ~/AGENT ~ PHONE
MAI LING ADDRESS
TR EET LOCATION
6. TYPE OF RESIDENCE
SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OF BEDROOMS
[] One ~ Four
[] Two [] Five
[] Three [] Six
[] Other
7. WATER SUPPLY [] 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.) (~ o p~)c/~
8. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE**
PUBLIC 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.
72q310(3/78)
THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
'~ NSPECTOR INSPECTOR INSPECTOR
-DIRECTIONS:
1, TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SlX
PERMIT NUMBER
2, WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
L~ COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connectioll Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC 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. DI-STANCES Septic/Holding Tank Absorption Area Sewer Line I-Nearest Lot Line
1
WELL TO:
Absorption Area to nearest Lot Line
5, COMMENTS
~'~- APPROV ED FOR I~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY ('ride)
LEGAL DESCRIPTION
72-010 (Rev. 3/78)
MUNICIPALITY OF ANCHORAGE
Department of Health and Environmental Protection
264-~4720
INFO~IATtON SHEET
Health Authority Approval of Water and Sewage Facilities
Lending institutions request the Municipality to approve the
water supply and sewage facilities on specific lots.
The Municipality will inspect the well construction, sewer
design(required components and bedroom rating) and protective
diskances between each.
Items that must be provided to the Municipality at the
applicant's expense prior te .final processing are.as follows:
The water supply will be analyzed for bacteriological quality.
An inspector will collect and deliver a water sample to a private
laboratory. Four(4) days after inspection-, the homeowner or
agent must make payment to the laboratory and deliver or mail
the analysis report to this department. The lab's address is:
Chem Lab, 4649 Business Park Boulevard, Building L 99503,
274-3364.
The septic 'tank must be pumped if in use over two(2)' years
and a receipt provided to this department° Aerobic package
treatment plants are exempt.
The sewer system must be'tested for adequacy(septic system)
if in use over four(4) years. Private engineering firms
conduct the test. A listing is available from this department.
If there are any questions, please contact this office
at 264-4720.
7/78
4~40 BUSINESS PARK BLVD.
P.O. BOX 4-1276 ANCHORAGE, ALASKA ggS09
TELEPHONE
(G97) 279-4014
TO DE COF, qPLETED BY WATER SUPPLIER
dA1 ~:h SYSTEi'dh
PUBLtCV '-~
I.D. NO.
City Slate
Mo. Day Year
SAB~PLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
Zip Code
[] Treated Water
[] Untreated Water
SAMPLE
NO.
4
§
LOCATION
L. I ~' s-O .~//,,o
Time Collected
Collected By
TO BE COBqPLETED BY I~GORATORY
LABORATORY:
CHEM & GE0 LABS OF AK., INC.
NAME
4649 BUSINESS PARK BLVD.
ADDRESS
ANCHORAGE, ALASKA
Date Received
Time Received
Analytical Method:
CITY
[] Fermentation Tube ·
~Membrane Filter
Lab Ref. No. Result* Analyst
I I
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Form No. 18-310(3-78)
06-1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD
Rev, 1978
Date Collected 1 0-4-78 Sour~
10-4-78 9:45. ~(~L~b. No. 8837-9
Presumptive 1Omi /Omi lOml lOml lOml 1.Omi O,lml
Confirmatory
24 Hours
48 Hours
EMB Broth 24 hours:
Multiple Tube Report.-
Membrane Filter= Olrect Count
Verification= LTB
,r-~
Final Membrane FI tar Results {~
10mi Tubes Positive/Total 1Omi Portions