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GREATER ANCHORAGE HEALTH DISTRICT
217 E Street P.O. Box 968
Anchorage, Alaska BR 6-3351
VA LOAN %N~PEGTION FORM
Priority:
DIL /Ji
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Phone number where ~aZ- can be ,ontacted: F~ ~' / ~ ~
Mailin~ Address of Buyer:
INDIVIDUAL WATER SUPPLY
/ /~ / ALASKA DEP3~I. TMENT OF
Section of Sanitation and l~ngineerlng
ACTION ON REQUEST FOR BACTERIOLOGIC.&L WATER ~M~I'~LYSIS
Your recent request for an analysis of a sample
from the In~ividu,a~ Private Water Supply
~',05 0nu~,~aeh ~3rivo
serving 5~,v,U~n~ rd was
received 1/3 ~/6~ and
ex~ination has been completed.
3205 Spenard Road
~o'utheent ~'al I(e,qic~nal
Records in this office indicate this Individual Private Water Supply to be o{ ,~" Satisfactory Questionable Unsatisfactory
sanitary status.
Analysis shows this SAMPLE to be !~ / Satisfactory. .Questionable Unsatisfactory.
If an "Unsatisfactory" or "Questionable" status 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 HSE-15
8. Bottle broken in transit, please send new s,wnple.
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 [] Local Health Departmeut 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
A DH---I-].SE-6-RI (e)
This Form Mast Be Filled
LOut Completely.
INDIVIDUAL WATER SUPPLY
ALASKA DEPARTMENT OF HEALTH
Section of Sanitation and Engineering
Request for Bacteriological Analysis
Please Look on Reverse'of
Sheet for Sample Collection
Instructions.
l~,b. No ............
Water sample collected by ._P~4c~ ~ r_-~ L., /)4 w-'
(Name of person collecting sample) (Date) (Time)
Water sample collected from ~ Kitchen tap; ~athr~m tap; ~ Basement tap;
(Mr.)
(/
(Name) (Box No. or street address) (City)
Please place ~n "X" In the b~. before items which b~t describe your water supply:
SOURCE:
Well
Bored
~ Spring, ~ Cistern, ~ Other (list) ...............................................................................................................
~ Creeg, ~ R~ver, ~ Lake, ~ Pond ................................................................................................................
DUG ~LL
OR OISTERN 0ONST~UOTION: ~lls ~ ~ ~ood, ~ 0onoreSe, ~ ~1, ~ ~le, ~ BrOok or Ooncre~e Blook
Top -- ~ ~ood, ~ 0oncre~e, ~ ~1, ~Open Top
LOOATION: ~ In b~se~ent. ~ B~semen$ offss~, ~ Under Ho~e, ~n y~rd O~he~
DISTANOE TO: Bu~tding se~er or oSher dr~n~g~ pipe .............. feeS, Sep$~c ~nk .............. f~e~, THe field
fee~, Seepage p~$ .............. fee~, 0esspool .............. fee~, Privy ..............fee~. OSher possible sources
~TERI~: Building sewer -- ~/O~s~ ~ron ~ ~ood, ~THe, ~ ~bre pipe, ~ Asbestos eemen%
Joint material ~ ~pe.. ~'.C, '~ ,
GENER~ I~OR~ON: Does water become muddy or discolored? ~ yes, ~ no When? ......................................................................................................................................................
Diameter of well ............. ~.""' ................................ depth ....... ~:.~t. ..................................... feet
Well easing marcia1 ......... .~:c~::~ ................. diameter .................... depth ..................................
feet
Pump location: ~In well, ~ Offset ~ basement,~'~ -~ In basement
In uti~ty r~m, ~ On,or of well ./ . ¢
PURPOSE OF EXAMINATION: Illness suspected? ~ yes, ~ no New source of supply? ~ yes, ~ no
Repairs to existing system? ~ yes, ~ no
PLEASE DRAW A SKETCH ~ '~ SPACE BELOW. ~ SKETCH SHOULD SHOW ~CATION OF HOUSE, WA~
SUPPLY SOURCE, SE~IC TANK, SE~R, DRAIN LI~S OR O~ SOURCES OF POLLU~ON ~D DIST~CES
BE~EEN WAT~ SUPPLY SOURCE AND ~ OF ~OVE FACtiOn.
SAMPLES MUST BE S~3BMITTED IN CONTAINEI%S PROVIDED nY THE~LASKA DEPARTMENT OF HF~TI!
DIRECTIONS FOR COLLECTING SAMPLES OF WATEI% FOR BACTERIOLOGICAL EXAMINATION
Read Carefully and Follow Instructions Exactly
DO NOT COLLECT SAMPLES FROM FIRE HYDRANTS,
YA_~D HYD~S, DRINKING FOUNTAINS OR SIIVI1LAR
OUTLETS WHICH ARE DIFFICULT TO D IS I N F E C T
PROPERLY
Bear in mind that water analysis deals with materials present in very minute quantities. The least
carelessness in collecting and handling may give rise to results which are misleading.
Arrangements should be made to have water samples reach the laboratory as quickly as po~sible. After
48 hours the significance of the bacteriological analysis is impaired. For obvious reasons the laboratory
prefers to receive samples in the early part of the week, but is willing to accept samples at any time.
In collecting samples from 'lAPS or PUMI'*S proceed-as follows:
(a) Thoroughly flush tap or pump by allowing water to run freely for five minutes.
(b) Shut off water and flame the outlet with torch or burning paper. The flame should not be merely
passed over the outlet, but should be applied until fixture shows indication of being hot. Flame
should be directed against inside edge.
(c) Open fixture so that a small stream flows.
(d) Remove bottle from mailing tube. Hold bottle by the lower half in one hand and with the other
remove the screw cap with the fingers, leaving paper protecting cover in place. Fill the bottle to
the shoulder. Replace cap with paper cover, screwing firmly into place but do not apply pressure
which will split cap.
(e) Pack bottle carefully in mailing tube enclosing this completed information sheet, being sure that
a simple sketch is included,
In collecting samples from STREAMS and RESERVOIRS proceed as follows:
(a) Remove cap and hold bottle as described under (d) above.
(b) Collect sample by holding bottle in a slanting position and sweeping it below the surface in such
a manner $~hat water that has been in contact with the hand is not introduced into the bottle. Avoid
collecting surface scum and bottom r, ediment.
SAMPLES MUST BE SUB1VII~TED IN CONTAINERS PRoviDED BY THE ALASKA DEPARTMENT OF