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Home My WebLink AboutBIRCHWOOD PARK BLK C LT 12010- 7e REQUEST FOR APPROVAL INDIVIDUAL SEWAGE AND WATER (Fill out in T~iplicate) a,,,~ of person requesting approval / Nm~b~. ~,~ ~,k,ooms in house- / W~ll data: c. Casin~ Size d. Sewer line Distance from well to closest existing or proposed: Seepage Area ~ Other sources o~ Poss ~le cont~m~n~tio,, i.e.. c~e~,~. ~. houses, barn, d~ainage ditch, etc. Sewage disposal system. ~~~ '~. ' ' a. Age of system b. Septic tank capacity in gallons c. Name of septic tank manufactu~m,,, 1. If "home made" show diagram on reverse side of this form. Disposal field om seepage pit size and type Distance to property llne to house foundation ~., Pefco] atlon Test f. ~ercolation Test performed by Use the reverse side of this f'orm to show dlaEram. Diaeram should include t~he foCI.owing information: p?operty llnes~.well location, house location, ~'~!~{c tank location, disposal area location, location of percolation test, a~,d dJr~ection of ground slope. The ~n~',r.a*~on on this form is true an~rrec~ Si~na~e of Applicant to the best of my knowledge. Date Si?ned t__O_BE FILLED OUT BY HEALTlt DEPART~.~ENT PERSONNEL above described sanitary facilities are hereby appr. oved, subject to the following conditions: . The above described sanitary facilities are disapproved for the followin~ reasons: _ Approval is valid for one year following the date of approval. CPJ: cw Form Approved HA FOr~L~ 2573 FEDERAL Hal)SING ADMINISTRATION Budget Bureau No. 63-R296.8 ~e~ July 1958 HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM INSURING OFFICE PART I.--TO BE COMPLETED BY FHA MORTGAGEE ?ZONAL SERIAL MORTGAGOR OR SPONSOR UBDIVISION NAME TOTAL NUMBERt WATER SUPPLY BY: Public system SEWAGE DISPOSAL BY: ['-']'Public system BASEMENT [~] Yes ~'1 No -']New installation U Community system il Community system PROPERTY ADDRESS BLOCK NO. LOT NO. g tCan afl.lc or other area be made into additional bedrooms? (If Yes, how man¥~) Ho. SYSTEM DESIGNED FOR r-~ Individual or Gl)RMS. GARBAGE l)ISPOSAL [] Individual 2 [] Yes [~ No PART fl.--TO BE COMPLETED BY HEALTH DEPARTMENT HEALTH DEPARTMENT INSPECTOR'S SKETCH It is the opinion of the ['-] State N County [~ Local Department of Health that this individual water-supply system [] is [] is not satisfactory as a domestic water supply for the subject property. It is the opinion of the [--] State [-] County tem with proper maintenance: --]Can be expected to function satisfactorily, and ' {snot likely to create an igsanitary condition Local Department of Health that this individual sewage-disposal sys- [-~ Cannot be expected to function satisfactorily SIGNATURE TITLE NOTE: The health authority should complete the appropriate opinion statement above and affix date, signature and title in the spaces provided. Usa of the above grid for Health Denartment In;p~.¢tor's sketch a; well ~s use o.~ Iii,, bulk uf this farm is at the option of the health authority. 'PART Ill.--FOR USE OF FHA OFFICE TO THE CHIEF UNDERWRITER: I have reviewed the foregoing and the pertinent FHA Compliance-Inspection Report, an& recofiamend that'the Individual water-supply system be considered [--] Acceptable [] .Not Acceptable Sewage disposal be considered ~ Acceptable [--'] Not Acceptable. DATE SIGNATURE HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM ] CHIEF ARCHITECT ~I DEPUTY FOR CHIEF ARCHITECT FHA Form 257~ Rev. July 1958 'uopnllod alq!ssod jo saamos aaqlo plag I~sods!p '.:~aaj ~.,~td~.~}l~ ~lUgl apdas ':gas [] 'ap~s [] 'auo~j [] ag auq loI ;sa~gau 'loodssa~ :laaj ~t .,_~,~ 'l!d ali'~daas alp '.~aaj- 'Jataas uo.~! ~s~ 'uop~punoj ~'u!pl!n~t :LUOJ~ ile~ Jo 'lla~ pa:o~ [] 'flOra ~n(l [] 'Ila~ ua^!~(I [] 'llata PallP(I/]~ :tuo!{ Xlddns :a;~ [~np!tqpuI '~aaj ~ -5" 'au![ /aaadoJd ~uoJj tuoJj >p~q los g'u}ila~(l 'daap laay 'ap.~ laaj :az~s ~cr1 'smalsts l*sodsip-a~'~axas ....... pu~ Alddns-Jaleta l~np a p.tlu loqq.ll~ padolaaap ~uia. qaou aJu [] a;~ pooq~oqqfi'tau, ul. sapJadosd 'pooqJoqqS}au u! /oemolsn> lou a~u [] aaet~.Slla~ i~npD}pui W:IISAS AlddNS'U31V/V~ 1YNGIAICINI--NOI13:IdSNI JO 1UOdaU 'aaa.,: 'sUOlle~ ':aa./' 'q:dap p!nb!'I '~aaj- huatu:u~dtuoo lalU! ,ilp~edeD 'SUOll~ 'loodssaD[-] sluatu~z~dtuov jo jaqtunN W'-J.LSAS 1VSOdSIO-aE)VM:IS 1VflOIAIONI~NOII:){dSNI :lO 1UOd:lU 1307 h6tL~ Ave., Anchorage, Alaska Septic Tank; Concrete 600 gal. capacity Well: 231 ft. deep drilled 6 3/h in. casing pump located under back step in basement offset 61 ft. from. back lot line 8~ fro from cesspool 6~ ft. from septic tank To the best of my knowledge the above is true arid correc~. ADH-HSE-6-FI (f) , ~10-55- 5M Lab. No._ INDIVIDU.AL W~ATER SUPPLY 7~/~/~-/~ ALASKA DEPARTMENT or HEALTH / /D~TE Section of Sanitation and l~ngineering O~FICE ACTION ON REQUEST FOR BACTERIOLOGICAL WATER ANALYSIS Your recent request for an analysis of a sample ~e J~ ~ trom the Individual Private Water Supply ~,~O7 We A~ 307 th. serving~ was S~, ~ ~eceived and examination has been completed. ~Satisfa Records in this office indicate this Indivl~ Water Supply to be of. ctory .Questionable , ,,Unsatisfactory sanitary status. Unsatisfactory. Analysis shows t~ls SAMPLE to be Satisfactory ,_Questionable If an "Unsatisfactory" or "Questionable" status is indicated above, you should take immediate action as recommended below. 1. Boll 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-$ 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 ~n relationship to your sewage disposal system ~ See bulletin HSE-15 8. Bottle broken in transit, please send new sample. 9. Sample too long in transib sample should not be over 48 hours old at examination to indicate reliable results. Please send new sample. 10. Contact your nearest [] Local Health Department or [] 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. SANITARIAN'S REMARKS_ {~hts ~Form Must Be Fffied { Out Completely. INDIVIDUAL WATI~R SUPPLY ALASKA DEPABTMENT OF ~m.~L,i-h Section of hnlt~iton and ~n_-ineering Please Look on Reverse of Sheet for S~mple Collection Request for Bacteriological Analysis _ Lab. No .......................................... .(Name o£ person collecting sample) ......... F('~ ........ ' ......... ~'~i~i ............. Water sample collected from ]~Kitchen tap; [] Bathroom tap; [] Basement tap; '[] Other (list) ............................................ ~ .................................................................................. Address premise where source is located ........... ,/.~.....~.....~..._.~ ........... __--~'---~-.~- ......... ~4~.~...~... ...... .r. ....... ~.~....e:..~...~.....~.. (Mr.) Mail rel~or~ to (Miss) ..... (l~lame}{ ................................ ............... Please place an "X" i~ the box before items which be,st describe your water supply: SOURCE: Well -- [] Dug, [] Driven, J~ Drilled, [] Bored [] Spring, [] Cistgrn, [] Other (list) ............................................................................................................... [] Creek, [] River, [] Lake, [] Pond .................................................................................................................. .DUG WELL OR CISTERN CONSTRUCTION: Walls ~ [] Wood, [] Concrete, [] Metal, [] Tile, [] Brick or Concrete Block Top ~ [] Wood, [] Concrete, [] Metal, [] O~en Top LOCATION: [] In basement, j~ Basement offset, [] Under Aouse, [] In yard Other ......................................................................................~ DISTANCE TO: Building sewer or other drainage pipe .............. feet, Septic tank .............. feet, Til~ field .............. feet, Seepage pit .............. feet, Cesspool .............. feet, Privy .............. feet. Other possible sources of contamination (list) ............................................................................................................................................... IVIATERIAL: Building sewer -- [] Cast iron, [] Wood, [] Tile, [] Fibre pipe, [] Asbestos cement Joint material ~ 2'ype ................................................................................................................................. OENERAL INFORMATION: Does water become muddy or discolored? [] yes, ~no 'When? ............................................. ~; ................................. ./.~-~ .............................................................. Diameter of well .................... ~..;; ........................... depth .......... ~...~.../. ................................ feet Well casing material ............. ~. ........................ diameter .................... dept~h .......... ~...~.../.. ......... Length of drop pipe ....................................................................................... Water depth from bottom ............................................................................................................ feet Pump location: [] In well, [] Offset..~in basement, [] In basement utility room, J~ On top of well [] Other (list) ...£~-' ...................................................................................... Do you suspect illness from this supply? [] yes, ~no .~emarks: .PLEASE DRAW A SKETCH IN THE SPACE BELOW. THIS SKETCH SHOULD SHOW LOCATION OF HOUSE, ~UPPLY SOURCE, SEPTIC TANK, SEWER, DRAIN LINES OR OTHER SOURCES OF POLLUTION AND DISTANCES ~;BETWEEN WATER SUPPLY SOURCE AND ANY OF ABOVE FACILITIES, SAMPLES MUST BE SUB~X~i-A'EU IN CONTAINERS PROVIDED' BY THE ALASKA DEPARTMF,_~I? ~)F ~A~,,m.'u