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Home My WebLink AboutBIRCHWOOD PARK BLK C LT 3010- Z'Z -O ~# &vaauo & OA~e ~iy YbLw properGy ha~ au mpproved %52-looK, d~%%md veL%, A va~er ~awp%e l~redertel~ ]~. bdeF Sdmtcart~ GREATER ANCHORAGE BEALTH DISTRICT 217 E Street P.O. Box 968 Anchorage, Alaska BR 6-3351 VA LOAN INSPECTION ,FORM File Reference: ~ Na~ of Buyer: N~me of Seller: Priority: D/L '4' ProPerty Address: Le§al DescriPtion of Property: ~i~"~ ,~' ~,, PhOne number where buyer can be contacted: / Ma'illng Address of Buyer:_ : , ~~ (Sanitarian) ·" ACTION ON No. ~ , , INDIVIDUAL WATER SUPPLY $m.tt. hoen+..rai Red. I: ALASKA DEPARTMI~NT OF H~ALTH Sectlon.,of ~anttation and ]]ngineerlng o~tc~ REQUEST~OR(BACTERiOLOGICAL WATER ANALYSIS Your recent request for an analysis of a sample from the Individual Private Water Supply examination has been completed. Records in this office indicate this Individual Private Water Supply to be of .. sanitary status. Analysis shows this SAMPLE to be !~/' Satisfactory t~tlsfactory Questionable Questionable Unsatisfactory Unsatisfactory. If an "Unsatisfactory" or "Questionable" stares is indicated above, you should take immediate action as recommended below. 1. Boil or chemically treat your water supply to protect your family from water-borne diseases as outlined in en- closed leaflet, "Drink It Pure." 2. Improve your spring--See bulletin HSE-6-2 3. Improve your cistern--See bulletin HSE-6-3 4. Improve your dug well --See bulletin HSE-6-4 5. Improve your driven well--See bulletin HSE-6-5 6. Improve your drilled well--See bulletin HSE-6-6 7. Relocate your well to a safe location in relationship to your sewage disposal system--See bulletin HSB-15 8. Bottle broken in transit, please send new sample. 9. Sample too long in transit; sample should not be over 48 hours old at examination to indicate reliable results. Please send new sample. 10. Contact your nearest 'U1 Local Health Department or ~[-1 Alaska Health Department, Sanitation office for bulletins, consultation, and assistance. 11. This is a surface water source and subject to pollution by man and animals. An approved water supply source should be developed. SANITAKIAN'S REMARKS. ADI,I--itSE-6-FI tel TAKE WAq'ER SAMPLE TO: Laboratory, 945 Sixth Ave. 1' FOra Mnst Be F~ed [ Mort&y, T~,esday, Wednesday Out Completely. ] ~DU~ ~ATER SUPPLY Section of Sanitat/on and ~n_*ineertug Sheet for Sample Colleotion Instructions. Request for Bacteriological Analysis Lab,"so .......... Water sample collected by ............... ~~_.~d~-<~.. ....................... ._~.~...~,/~.._~. .......... (Name of person collectFng sample) / ~Date) ...... }'~i~;~ ............. Water sample collected Irom ~Ki~hen {ap; ~'Bathr~m tap; ~ Basement tap; ~ Other (l~t) ...................................... ~....~ ....... ~ .................. , ....................... ~ ................. Addr~s premMe where source ~ l~a~d .............. ~..~.~ .......... ~....~f....%.....~ (Mr.) , .. (Box ~. or street address) Please place an "X" in the box before Items which b~t describe your water supply: SOURCE: Well -- ~ Dug, ~ Drlven,~Hed, ~ Bored ~ Sprig, ~ Oistem, ~ O~her (lis~) ....................................................................................................... ~ Creek, ~ River, ~ Lake, ~ Pond .................................................................................................................. DUG ~LL ORC~T~HCONS~UCTION: Walls~ ~ Wood, ~ Concrete, ~tal, ~le, ~ Brick or Concrete Block Top ~ ~ Wood, ~ Concrete,~etal, ~ ~en Top LOCA~ON: ~ In basement, ~ Basement offset, ~ Under ~o~e, ~n yard Other ........................................ ~ ..........................~ .................................................................................................... DISTICH TO: Building sewer or other drainage ~tpe ..... '~.~et, Septic ~nk ...~...feet, ~le field .............. feet, Seepage pit ..~feet, Cesspool .............. feet, Prl~ .............. feet. Other ~sible sources of contamination (l~t) .................................................................................................................... ~R~: Building sewer ~ ~Cast ~on, ~ Wood, ~ Tile, ~ ~bre pipe, ~ Asbestos cement Joint material ~ ~pe ....................................................................................................................................... GENER~ I~OR~ON: Does water become muddy or d~colored? ~ yes, ~ no ~en? ........................................................................... Diameter of well..' ............. ~....~..~....z7 ......... depth .~. ~/'"'"~"'~"~ .......................... Well easing material .......... ~ .......... diameter ....... ~ ......... depth .................................. Length of drop pipe ............................................................................................................................... Water depth from bot~m ............................................................................................................ feet ~ location: ~ well, ~ Offset ~ basement, ~ In b~emen~ ~ ~ uti~ty r~m, ~ On top of well ~ Other (~t) ........................................................................................................ PURPOSE OF EXAMINATION: Illness sus~cted? ~ yes,~o New source of supply? ~ yes, ~ Repairs to existi~ syste~ ~ yes, ~ PLEASE DRAW A S~H ~ ~ SPACE BELOW. ~IS SK~CH SHOULD SHOW ~CATION OF HOUSE, WA'z'~ SUPPLY SO,CE, SE~IC TANK, SE~R, DRA~ LI~S OR O~R SOURCES OF POLLU~ON ~D DISTICHS BE~N WAT~ SUPPLY SO,CE AND ~ OF ~OVE SAMPLES MUST BE SUI~MITTliD IN CONTAINERS PROVIDED BY THE ALASKA DEPARTMENT OF HE/~LTH