HomeMy WebLinkAboutTURNAGAIN PARK #2 BLK 2 LT 1
.C. NE]JlC4L & e,rOLOGIC~. LA~ORAToRIr~ OF AI.A~I(A, INC.
P.O. BOX 4-1276 4649 BUSINESS PARK BLVD.
ANCHORAGE, ALASKA 99509
Drinkin§ Water Analysis Repo~ for Total Coliform Bacteria
TELEPHONE
(~07) 279-4014
TO BE COMPLETED BY WATER SUPPLIER
PubSc/~/ater System Name /]
MalSng Address
City
SAMPLE DATE:
State
Zip Code
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine
with lab ref. no
[] Special Purpose
sample
[] Treated Water
[] Untreated Water
TO BE COMPLETED BY LABORATORY
LABORATORY:
NAME
~ ' ~ADDRESS ~.'
CITY
Date Received
Time Received
Analytical Method:
[] Fermentation Tube-- -
[] Membrane Filter
SAMPLE
NO. LOCATION
4
Time Collected Analyst
Collected By
Lab Ref. No. Result*
J ~
I
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Form No. 18-310 (3-78)
o6-]`220 (b) ' BACTERIOLOGICAl WATER ANALYSIS RECORD
Rev. ].978
Date Collected Source
Presumptive 1Omi ].Omi lOml lOml 1Omi 1.Omi O.3ml
24 Hours
48 Hours
Confirmatory
24 Hours
48 Hours
Final Membrane FJlter.Rl~ILs - ~'~ Collform/ZO0ml
C~~'~ Timer /~ ~ a.m.
-' MUNICIPALITY OF ANCHORAGE F-NVI2ONMEN[AL P~OTECTION.
~ D E PA R T M E N ~2(~FLH~ 'Ae e~tT-HA~ c~rVa geR OANa~skEaN~T9~ (~ IP R O r E CT I O N S~'~- cZ ~ ~."~
ENV,"O' EN"'ALENG,.E .,NG"'V'S'ON
~ Telephone 264-4720 < CEIVED
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
)IRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed, please allow ten (10) days for processing.
PROPERTY RESIDENT (l'f different from-above)
PHQNE
2. BUYER PHONE
MAI LING ADDR ESS
3. LENDING INSTITUTION
PHONE
MAILING ADDRESS
4, REALTOR/AGENT
MAILING ADDRESS
PHONE
~ One ~ Four
SINGLE FAMILY
Two ~ Five
MULTIPLE FAMILY Three ~ Six
[] Other
~] INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled
[] COMMUNITY since June 1975. For wells drilled prior to that date, glve well
I~ PUBLIC UTI LITY depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
"~ iNDiViDUAL/ON_SiTE~
[] PUBLIC UTILITY
**If individualJon-site, give installation date J-/7'~'~ ~
If system is over two (2) years old an adec~uacy test is required
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED
72~10(3/78)
THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE I DATE DATE
INSPECTOR INSPECTOR I NSPECTO R
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
giveSiZe:'dimensions'.l~}OO If Tank is homemade SOILS RATING
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 .~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY (Title)
LEGAL DESCRIPTION .
72-010 (Rev. 3~78)