HomeMy WebLinkAboutTIMOTHY Block 2 Lot 2
~ .... DATE/~ECEiVED
INSPECTION APPOINTMENTS
TIME TIME I TIME
DATE DATE DATE
NSPECTOR INSPECTOR INSPECTO"i%'
o
MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIO~NviRONMENTAL pr~orECT
825 L Street - Anchorage, Alaska 99501
( ENVIRONMENTAL SANITATION DIVISION
REOUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER
DIRECTIONS~Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
MAILIN ADDR S , '
PROPERTY RESIDENT {If different from above) PHONE
PHONE
3. ~END · STITUTION PHONE
MAILING ADDRESS
4. REALT~/AGENT PHONE
6. TYPE OF RESIDENCE f NUMBER OF~BEDROOMS
[] One ~ Four
[~ SINGLE FAMILY [] Two [] Five
[] MULTIPLE FAMILY [] Three [] Six
[] Other
7. WATER SUPPLY
~ INDIVIDUAL~
[] COMMUNITY
[] PUBLIC UTI LITY
* 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.)
8. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE**
PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] ~'~INGLE FAMILY [] ONE [] THREE [] F~VE [~) OTHER
[] MULTIPLE FAMILY [] TWO [~'F~O U R [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[~]~INDIVIDUAL'" DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTF~VI PERMIT NUMBER
INDIVIDUAL/ON -SITE c~'~~'~- DATE INSTALLED
[]PUBLIC UTILITY /~_ /4~l
Connection Verified
I INSTALLER
[~Septic Tank or [~Holding Tank
Size: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
5, COMMENTS
PPROVED FOR BEDROOMS
~J '~CONDITIONAL APPROVAL (letter must accompany certificate)
72-010 (Rev. 6/79)
-' CHEMICAL & G~-'~LOGICAL LABORATO~RIES F ALASKA, INC.
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
I.D. NO,
Water System Name Phone No.
~ 7
Mailing Address
City _. _ S'~a..t.e ~ip Code
Mo. Day Year
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
[] Treated Water
[] Untreated Water
SAMPLE
NO. ,oc^~p.
~I
~I I
4I I
I I
Time Collected
Collected By
TC BE COMPLETED BY LABORATORY
Aha vs~s snows this Water SAMPLE to be:
~.Satisfactory
r~ Unsatisfactory
[] Sample too long n transit; samole should
not De over 48 hours om al examination
to indicate reliable results. Please send
new sample.
Date Received
Time Received
Analytical Method:
[] Fermentation Tube
.[] Membrane PIIter
Lab Ref. No.
I
I
Result* Analyst
[-~ I ~ .;'_~
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220 Ih)
Rev. 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
~esumpttve 10mi 10mi 10mi /0mi 10mi 1,0mi 0.1mi
24 Hours [