HomeMy WebLinkAboutSPENARD ACRES BLK A LT 1
MUNICIPALITY OF ANCHORAGE
MUNICIPALITY OF ANCHORAGE DEPT. OF H~AL'[H
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTI~IVIRONMENTAL P,~OTECTION
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL ENGINEERING DIVISION JUL 5 '1 1979
Telephone 264-4720
DIRECTIONS: Complete all parts on page 1, Incomplete requests will not be processed, Please allow ten (10) days for processing,
1, PROPERT~ OWNER PHONE
MAILING ADDR~S
PROPERTY RESIDENT(If different from above) ¢ ~ ~PHONE
PHONE
MAILING ADDRESS
3, "LENDING INSTITUTION
MAILING ADDRESS
PHONE
MAILING ADDRESS
STREET LOCATION
B. TYPE OF RESIDENCE
S
INGLE FAMILY
[] MULTIPLE FAMILY
7, WATER S/UPPLY ~ INDIVIDUAL*
[J" COMMUNITY
[] PUBLIC UTILITY
SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE**
PUBLIC UTILITY
NUMBER OF BEDROOMS
[] One [] Four [] Other
[] Two [] Five
.,,~ Three [] Six
*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.)
**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
INSPECTOR INSPECTOR INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] 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
[] INDIVIDUAL/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 MANUFAC'rURER
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 DESCRIPTION
72-010 (Rev. 3/78)
C?~MICAL ~ {~£OLOalCAL LABORATORJF.8 OF' AI.A~KA~ ,NC=.
P.O. BOX 4-1276 ANUMUI~tJ~---"--"A----~'. ALASKA 99509 4849 BUSINES~ PARK BLVD.
Drinking Water Analysis Report for Total Coliform Bacteria
TELEPHONE
(907) 279-4014
TO BE COMPLETED BY WATER SUPPLIER
,ub..f~,,.r Sy,%.eme
'H
Mailing Addreas
City State Zip Code
Mo~ ~ay ~oar
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
~} Treated Water
DJ Untreated Water
SAMPLE
NO.
1
2
3
4
5
LOCATION
Time ~ Collected
Collected : By
TO BE COMPLETED BY LABORATORY
LABORATORY:
~AME ,
ADDRESS
CITY
Time Receive'8 :~ / '" ~
Analytical Method:
',;. [] Fermentation Tube
~embrane Filter
~ ~Lab Bef. No. Result*
Analyst
READ '1 N STRU CTIO N S
-' BEFORE
COLLECTING SAMPLE
Form No. 18.310 (3-78)
06-1220 (b)
Rev. 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Collected Source
a.m.
Date Received Time Received :~,rn. Lab.
Presumptive ]0mi 10mi 10mi 1Omi 10mi 1,0mi 0,1mi
Confirmatory
24 Hours
48 Hours
EMB Broth 24 hours:
Multiple Tube Report:
Membrane Filter: Direct Count
Verification: LTB
l.al .embrane
Broth 48 hours:
10mi Tubes Positive/Total 1Omi Portlon~
Coil form/J, e0ml
BGB
Date
Time=