HomeMy WebLinkAboutLot 06
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate)
~ ~- ~la~m of person requesting approval
~1 II ~ 3. s~dp~g~ A~ k / U~'
~ h(~T ba~n~d~ainage ditch, etc. .
.7. Sewage disposal sy~m. /
~] Nam~ of sept~ tank manufac~u~ - I ', (
1. If "home made" show dlag~am on reverse side of this fo~m.
d.' Disposal field or seepage pit size and type
1. Distance to property line to house foundation
e, Percolatio~ Test h~esults
~ ¥ f. Percolation Test performed by
~'~x Use the ~eve~se ,side of th~s form to show dia~am.
~_~he f~gw~ipfo~mat~on: ~ope~ty lines; ,well location~ house location,
~pti~:'~ank iG~i;oB, disposal area locatlon~ location of percolation test~
g,
Diagram should include
The tnfo~mation on ~h'~s~-'~brm is true and correct to the best of my knowledge.
S~gnature 'of Applicant
Signed
TO BE FILLED OUT BY HEALTH DEPART!.IENT PERSONNEL
~e above described sanitary facilities are hereby approved, sqbject to'the
.......... ~l~owing ' ' ....
, conditions:
Conditions:
The above described sanitary facilities are disapproved for the following
reasons:
Approval is valid for one year following the date of approval.
~- CPJ:cw
ADHV,,~ LAB - 2W
/
DATE
STATE OF ALASKA
DEPARTMENT OF HEALTH AND WELFARE
DIVISION OF PUBLIC HEALTH
BACTERIOLOGICAL WATER ANALYSIS
tab. No.
OFFICE
REPORT RESULTS
CITY
ADDRESS
Wails - D Wood El Concrete J~ Metal D Tile [~ Concrete_
Records in Ibis oHice indicate this WATSR SUPPLY 1o be of:
SalJsfaclory [] Questionable [] Unsagsfaclory SanlJary
/Analysis shows thls Water SAMPLE Io be:
2. Increase chlorination sufficiently to meet recommended residual standards.
Determine source of confaminal[on and take action necessary to mabltaJn
a sale water supply al all times
3. Check chlorin~l;an and other mechanical equipment. Make certain it is
functioning properly.
4. if biter check'no equipment a disinfecting residual ;s not obtained, please
- · wire Jhls office for emergency assislance or advisory services.
5. This is a surface water source and sobjecl to poJlulion by man and animals.
An approved water supply source should be developed.
6. Improve your [] spring [] dug well [] driven well
[] ·drilled well [] cistern.
7. Relocate your well to a sale location in relationship to your sewage
-- disposal system. D see enclosure
g. Sample too long in lrans~l; sample Should not be over 48 bouts old at
-- examination to indicate reliable resulls, please send new sample.
[~ BofJle Broken in transit, please send new sample.
9. Conlacl your nearest [] Local Health Departmenl or [] Alaska
Division of Public Heahh, sanilagon olfice for bullelins, consultal;on and
assislance.
SANITARIAN'S REMARKS
Feel,
READ INSTRUCTIONS
ON
REVERSE SIDE
BEFORE
COLLECTING SAMPLE
Signature
Laclose Broth 10cc J I 0cc I 0cc 10cc 10cc 1.0cc 0.1 cc
I
24 hours
48 hours
Brilliont Green
24 hours
48 hours
EMB AGAR
Laclose Broth, 24 hrs. 48 hrs.- Groin's slain
Coliform Density .(Most probable No. per lOOcc.)
BACTERIOLOGICAL WATER ANALYSIS RECORD
, ~ ( q/ ,:~' ~
Date Received c J/ Time Received C pr~ ~ob. No.
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate)
Number'of bedrooms in house
Water Analysis:
ao Bacterial ~.
b. Detergent ~
a. Type ~
b, Depth
c. Casing Size
Distance from well to closest existing or proposed:
1. Sewer line
2. Sept--..
4. Cesspool'
5. Property Line
6. Other sources of possible contamination~ i.e., creeks~ lakes,
houses, barn, drainage ditch, etc. ~
Sewage disposal system.
a, Age of system ~) -i/~,~,
b, Septic tank capacity in gallons.
c, Name of septic tank manufactu~e.r
1. If "home made" show diagram on reverse side of this form.
Disposal field or seepage pit size ~nd type
e. Percolatiop. Test '~esults ....
f. P~rcolati~n Test performed by
Use the ~ve~e side of this form to show diaHram. Diagram sh~ld include
~h~ following znfo~ation ppoperty lines~.well location, house location,
~6ptic tank location, disposal area location, location of percolation test,
an~ direction of ground slope..
The tnfoEna~ion on ~his form is true and correct to the best of my knowledge.
~$SnatUre of Applicant .... Date SiKned
~ ,~3~ '
,T,O BE ,FILLED O,,UT BY_~EA~T~H ~EP~ART~,~ENT PERSON,NEL
above described sanitary facilities are hereby approved, subject to. the.
~611owin~ con~¢oms~
Conditions
The above described sanitary facilities are disapproved for the following
"~ l~Z~S gna ~re- of M~i¢~_g c, -.~ ~v. i~. ' ,' 'Date
CPJ: cw
June 2~, 1968
180 Grand Larry Street
Anchorage, Alaska 9950~
Se,-vtng Lot 6, Stuand Subdivision
This letter is to confirm our conversation on June 2i, 1968. The
¢ondltlonal approval on your ~ntal unit expir~ c~ July l, 1988,
if the following condition has not been met:
{1) connoctlon to community sewer or
(2) proper installation of a 750 gallon Septic tank and
adequate seepage area.
If you wish approval after July 1, 1968, please contact th~s office
to schedule final inspection of the required modifications prior
tO backfilling.
DAVID R, L, DUNCAN~ M, D.
Medical Director
BY:
Sanitarian
RRg/srr
GREATER ANCHORAGE AREA BOROUGH
HEALTH DEPARTMENT
327 Eagle Street
Anchorage, Alaska 99501
Phone 272-6~67
June 19, 1968
SUBJECT~ Sewage DJspo~:al System
Serving Lot 6, Stz,m~d Subd.
Dear Mr. Willfamson:
This notice is to ~emind you of the conditional approval of
~he subject system by this office. The conditional approval
expires on July ~
Please contact this office to schedule final inspection of
the required modifications prior to backfilling.
If we have not heard from you prior to the above expiration
date, the system will automatically be disapproved.
Sincerely,
DAVID R. b. DUNCAN, M. D.
Medical Director
BY:
S~uni'~arian
Civilian Military Referral
REQUEST FOR APPROVAL OF
.. INDIVIDUAL SEWAGE AND
(Fill out in Triplicate)
Name .of' person requestlBg approval~,~~
Number of bedrooms in house 2
Water Analysis:
a. Bacterial... .:
b. Detergent,
Well data:
c. Casing Size
de
Distance from well to closest existing or proposed:
1. Sewer line
2. Septic tank
3, Seepage Area
Cesspool' ~2g~'
5. Property Line ~
6. Other sources of possible contamination, i.e., creeks, lakes,
houses~ barn, drainage ditch, etc. .,.,..
7. Sewage disposal system.
a. Age of system
b. Septic tank capacity in gallons,
c. Name of septic tank manufactu~or
1. If "home made" show diagram on reverse side of this form.
Disposal field or seepage pit size and type
1, Distance to property line I~~' to house foundation
Percolation Test re~ult~
f. Percolation Test performed by
e. Use the reverse side of this form to show diagram. Diagra~ should include
the following infoz~aation: p~operty lines~.well location, house location,
~eptic tank location, 4isposal area location, location of percolation test,
and direction of ground slope.
9. The information on this form is true and correct to the best of my knowledge.
Signature of Applicant "' Date Signed
TO BE FILLED OUT BY HEALTH DEPART~.~ENT PERSONNEL
~The above described sanitary facilities are hereby approved, subje, ct to the
,. ....
The above descmibed sanitary facilities are disapproved for the following