HomeMy WebLinkAboutBROOKWOOD BLK 2 LT 9
APPLll' NT FILLS OUT UPPER HA' ONLY
Property Owner
Phone
Mailing Address
Buyer
Address
Lending Institution ~.~. ~ ~ ~.~ ~} ~ ~ ~ ~ ~ ~ ~ ~ Phone
Address ~ ~ ~ ~ ~ ~ ~ ~ C.. ~ ~/~ ~ h f' t 5 Zip Code
Realty Co. & A~nt -~.~ /t~.z:c~ ~ '~/, ~ ~Z~ 3L %~_O~ ~ '+ Phone
LegalDescrlpl~n ~ ~ ~ ~" ~0~ ~ ~0~ '
Street Locatim
Type of Resl~nce
~ingle Family
~ Multiple Family No. of Bedroo~
~ Other
Water Supply
~ Individual A~ACH WELL LOG. A w~l Icg is required for all wells drilled since June 1975.
~ Community For wells drilled prior to that date, give well depth (attach Icg if available).
~Publtc Utility
Sewer Disposal
~ndlvldual Year IndlvMual Installed:
~ Public Utility When Connected to Public Utility:
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESStNG CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
Field Notes: MUNICIPALITY OF ANCHORAGE
DFPT 0r:
ENVIROi ,Ih':~l',; A ....
6 1982
.RECEIVED
( ) APPROVED BEDROOMS *CONDITIONS OF APPROVAL
( ) DISAPPROVED
( L--'F'CONDITIONAL APPROVAL* '~ ~- , "'
Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received
Well to Tank Septic Tank Size
72-023 (3182)
_ /~[~~'~;--', ~ D'EPARTHEN: iF-HEALTH AND 'ENV/RONMEN~ PROTECTION
~-~~:_':~fl ~ '"~ 825 ~- Street, Anchorages. Alaska ~-' 99501.-
~,.' ~ ~ ~ - - 2~-~o -
. ~~ ~$~'~'~. _ - Date Received:
_- 91: Ti~e ~_~O/a.~._ _ 92: Time ,~/~;~~ ~: Time
- - Date 9~77 Friday Date _1~-~ ~2~ Date
-.
-- 1. ~ding ~stitution ~Request: CoaSt Mortgage Company ~ _ .
',. ~ ,'~" .... ,,~ ~ ' ~ ,-'-- ,.. :--.,.- · ....... . · , . ......
- 2.. Phone: .....
_-. ~ '-MelVing ~dress: 'Star~. ~ ~ ~.
~ 4: Sidle F~ily ResidenCe: (~ -Number of Bedrooms: Three
-- M~itipl~Family ReSidence: ( ) Numbe~ of Bedroo~s:
5. Well : Individu 'Co~unity/Publ ' 'lC SYst'em ~
- Permit ~ -. 1 _ Well Log on File
' ~nstruc~ion ~' '.. . Bacterial Analysis
6. Sewage D~sposal System: On-site System ~x) Public Utility (
DJ to Absorption Area
~:~' ' ' -' ' ' ' a
-- to Sewe~ne - Nearest Lot line Absorption Are,
;~-'~'~ _ _
to Near~_ Lot -Line -
~ J Department of Health and Environmental Protection
~~/ 825 L Street, Anchorage, Alaska 99'501, i "
~uest for Approval of Individual Sewer and Water Pac'ili~k's
Property Owner: l. ~
Mailing Address: -~/; ,/'W~/ /-~-~ / ~
e
Name of Buyer:
Mailing Address:
Lending Institution:
Mailing Address:
Realtor/Agent:
Mailing Address:
Legal Description:
Street Location:
Phone: /~~
Phone:
Single Family Residence:
Multiple Family Residence:
Number of Bedrooms:
Number of Bedrooms:
Water Supply: *Individual Well ~ Public/Community System
If Individual Well, well depth ~~
If Community System, name of system
Sewage Disposal System: On-site System
If On-site System, date of installation:
( )
Public System
( )
*NOTE: A well log is required on ALL wells drilled since 6/75.
3/77
-~ ' -- ~ Department of Health-and Environmental Protection
· Req~st f~r ApprovaI Of Individual Sewer and Water Facilities
- Legal Descr~-tion: Lot 9 Block 2 BrOokwood Su~bd~iSion .. '
Commen~s :. ~ ~ ......
.... ..- · ~- ..... ~ ~ .... .w~ ' -' n
~ ~ , ,~ ~ .... ~¢~ ....... .....
::, / ...... ,
,_.~ ...... ~,~ ....... . .....................
~ ) Let%er Attached: ( ) .
Approv ed:
D isapproved~ ~· Date: -
-- ~partment ~rksheet: - _ -
· o6-~2o~o1.- ,e,;.~-'~? ~' : "''¢ ' ALAb,a DEPARTMENT'OF H~ALTH AND SOCIAL SERVI~S
~ .,~.~ ~
' DIVISION. OF '~BLIC HEALTH
q. [...~ ~:~t.~n ~ INDIVIDUAL A~ SEMI-PUBLIC
I~DtVlDU*'~ ~' SE~ PUBLE .
;¢~:~ ~ CHLORINE RESIDUA~
: - ~' j REPORT RESULTS TO
ADDRESS ::...
o ou,c
ONLY IF ~A-TER IS AN INDIVIDUA[ SUPPEY"~-~q ..... .
, .,. :., ,;~ ....... ..... . , -
~,' ~d'~¢[0 ~om' [ ~K?tchen Tap g ,Bathroom.Tap
r /,:. ~,Oth~rILi~t)~''-' ,~[~ ', ._,. = ...j~-' .. · ...~_
_ . ~' nYard ~ Other . , .,~,-
Bu[Idir~¢ Sewer
DISTANCE TO: " 6r ~)t~r draihage Piae,, '
Tile Seepage - Cess-
Field ,Feet. Pit Feet Pool
Other PoFs~lpte ' ,
Sources of Contominbt~on
MATERIAL: Building Sewer - [] Cast ~ron [] Wood
[] Plastic Jo nt Material - Type
GENERA~ Does Water Become Mud~ty or Discolored?
· When?
Diameter of Well
Well Casing
~atenal Diameter.
Length of
Drop Pipe
Offset in
PU,MP LOCATION: [] In Well [] Basement
On Too
[] Of Well [] Othre~
PURPOSE OF EXAMINATION: Illness_Suspected?
New $~af Supply? ' [] Yes [] No
Septic
Feet. Tank .,,. . . Feet,
' Feet.- Privy'- ..~ [eel.
READ INSTRUCTIONS
ON
REVERSE SIDE
BEFORE
COLLECTINQ, ,SAMPLE
-
.ab No.
ANALYSIS OFF,CE
Analysis shows this '~ter SAMPLE to be: - ' ~
'~1~ Satisfactory
? [~%Unsatisfactory
~ El Quesnonable
[] Sample too long Jn transit: somme should not be over 48
hours old or examination to ndicate reliable results. Please
['-) Bottle broken in transit mease send new samaJe,
SANITARIAN'S REMARKS
[] Fibre [] Asbestos
Cement,
[] Yes [~ 'No
_Feet. I
Depm
.Depth /~ ~et. "
Fram Bottom
I n ,L-i't itil,/ I
[] In Basement [] R~5om "I
Repairs to System,'? ~ Yes.:C~,~°'.~/~ Si. gnatu¢ .. _ ,_. .
064 220 ,~Rev. m73 :"B~%~I~IOLOGIC,~L WATER ANALYSIS REORD' '.~..*' '~*'~" '. "' ~)
Date Received ~ ~ ~ ~ Time Received ~ a~ Lab, No. t~7
Lactose Broth ' j''//~'~' ' ~' ~ . . lOcc' ~ qOcc lOcc lOcc"~'"~"lO~L¢ ' "' ' 1.Occ 1.Occ
24 Hours .. /~ ~:
48 Hours c: ~ .? -- .~ · ~
Brilliant Green / ~ /
24 Hours j' , '.,' '
48 Hours ! ~
EMB
Lactose Broth; ~;4 hrs.
Coliform Density
MF Results
48 hrs
Reportea Dy
This anolys~s indicates Coliform Organisms' to De:
· .~
AGAR
Gram's stain
IMost orobable No. per 100cc]
Date ~;~/ /,)'~ /'-~r'~ ~ / ~_~m.
GAAB-HD-I
GP~:e. TER ANCHORAGE AREA BOROI~H
HEALTH DEPARTMENT
327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
ADDRESS ,PHONE
SEPTIC TANK:
DISTANCE FROM WELL
LIQUID CAPACITY /&~?
GALLONS.
MATERIAL ~~- NUMBER OF /
COMPARTMENTS
~ J~70 LIQUID
INSIDE LENGTH INSIDE WIDTH .DEPTH
SEEPAGE SYSTEM: SEEPAGE PiT:
NUMBER OF PITS l
LINING MATERIAL ~-4/~"/~'
NEAREST LOT LINE. ~J~
OUTSIDE DIAMETER OR WIDTH. I ~
/"~1/"/~ DISTANCE FROM WELL t/'J'J~t~' '
TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA)
LENGTH I ~)"'- , DEPTH ~ ~'
BUILDING FOUNDATION '~7~'
SQ. FT.
TILE DRAIN FIELD:
DISTANCE FROM,)~/ELI ~ ~ ~ TOTAL LENGTH
'~ //~FOTDATION //~q1~TST LOT LINE // ,OF LINES / ,
T / /
ABSORPTION A R'Fr~,~;.,...,,.~ LEN
DEPTH: TOP OF TILE TO FINISH GRADE DEPTH OF FILTER MATERIAL BENEATH TILE IN. ABOVE TILE
~ lf~El DISTANCE FROM WATER
WELL: TYPE PTH ,BUILDING FOUNDATION SAMPLE , NEAREST
NEAREST SEPTIC SEEPAGE OTHER
LOT LINE SEWER LINE ., TANK SYSTEM , CESSPOOL , SOURCES__
DISTANCES:
DIAGRAM OF SYSTEM
[]
HEALTH AUTHORITY