HomeMy WebLinkAboutTHOMAS W SPERSTAD #1 BLK 1 LT 10
INSPECTION APPOINTMENTS
DATE / r__J / ~ / ~ DATE DATE
~SPECTOR , ~) ,o~ ~ INSPECT~ INSPECTOR
- t~ ~ ~,~ L ~ ~ ~ MUNICIPALITY OF ANCHORAGE
%~ ~/ ENVIRON~ENTALSANITATION DIVISION r~0V :[ ~ ]g80
~ Telephone
DIRECTIONS: Complete all parts on page 1, Incomplete requests will not be processed, Please allow ten (10) days for processing.
MAiLiNG ADDRESS¢ ....
PROPERTY RESIDENT (If clifferent from above)
~BUYER' ~ ' PHONE ' ~ '
~AI LI N6 ADDR ESS
~AI LING ADDRESS
~AI LING ADDR ESS
5. LEGAL DESCRIPTION
STREET LOCATION
6~ TYPE OF RE~ID~NC~ NUMBER OF~BEDROOMS
~ One ~ Four ~ Other _
~ SINGLE FAMILY ~ Two ~ Five
~ MULTIPLE FAMILY ~ Three ~ Six ~-~ ~'
WELL LO~ A wel~g
' is reqdiredffor all wells drilled
.~ IND VIDUAL* ATTACH
~ COMMUNITY since June 1975. For wells drilled grJo~ to,at, date. give wel'
~ PUBLIC UTILITY depth (attach log f available.,
E. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE'*
,~' PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PBOCESSING CAN BE INITIATED
72-010 (Rev. 6/79) //
THIS SIDE FOR OFFICIAL USE ONLY -
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 UTI LITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] I NDIVI DUAL/ON -SITE DATE INSTALLED
[~]PU BLIC UTILITY
Connection Verified
INSTALLER
[]Septic Tank or []HoldingTank
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
[~/APPROVED FOR _c~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE
72-010 (Rev, 6/79)
/~ CItEMICAL & Gi'..~,LOGICAL LABORATORIES ~/ ALASKA, INC,
'~ -"--'""-'"" "~ Drinking Water Analysis Report for Total Coliform Bacteria
~~ TEL E PH O2N7~'(393(~ '279'4 0 t 4 A N C H O R A~31~ [~U~tTreReltA L C E NTE R
TO BE COMPLF. TED BY WATER SUPPLIER
I.D, NO,
Water System Name Phone No.
Mailing Address
City State
Mo, Day Year
Zip Code
SAMPLE 'tYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref, no,
['~ Special Purpose
[] Treated Water
[] Untreated Water
SAMPLE
NO,
LOCATION
Time Collected
Collected By
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
[] Sat sfactory
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 48 hours old at examination
to indicate reliable results. Please send
new sample.
Date Received
Time Received
Analytical Method:
[] Fermentation Tube
[] Membrane Filter
Lab Ref. No. Result* Aris!yet
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220 (b)
Rev, 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
[;)ate Collected
Multiple Tube ReportL
Membrane Filter: Direct Count
VeHficat Ion= LTO~
Final Membrane ~!lter:Results
:)
d)
' · ~ .~ o'[ th-~ h~b fom~ whmh i.~; indicated "TO
~) [~)t:l~ bOfti:J¢~ a.'.;Fa)'Hll¥ i~ m~ ing tube N t,'l lab form.