HomeMy WebLinkAboutVANS BLK 5 LT 8E (2)
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C" Street, Anchorage, Alaska 99503 274-4561
Date Received ~/*-
Time of Inspection
Date of Inspection
1. Approval requested by:
Mailing Address:
2. Property Owner: '
Mailing Address:
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
FOR
,~ j Phone:
3. Legal Descriotion: ~m~>Y Pc~ WJ;'~ ~c~ ~<~
4. Location: ~/(9 0 '~ ~
5. Type of facility to be inspected
6. Well Data: ~'
C. Construction 4~), "~ D. Bacterial Analysis
7. Sewage Disposal Sy§tem: ./,~c~.~/~,4~
A. Installed B. Installer
C. Septic Tank: ';X1. Size 2. Manufacturer
No. of bedrooms
D. Seepage Pit: l. Absorption Area
2. Material
E. Disposal Field: Total length of lines
8. Distances:
A. Well to: Septic tank , Absorption area , Sewer Lines ,
Nearest lot line
Other contamination
B. Foundation to septic tank
, Absorption area
C. Absorption area to nearest lot line
EQ-034 (1/74) Page I of two pages
Page 2 of two pages - R .st for ~pproval.~of. Individual _ er & Water Facilities
~egal Descriptiom
Comments
Approved ~ ./~JJA42 Disapproved Date ~-
Appeal Valid for one year from date signed
Greater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
certify that the information contained in this request for approval to be a true and
accurate representation of the subject sewer and water facilities and these facilities
are operating satisfactorily.
SIGNED Date
EQ-034 (1/74)
3330
GREATER ANCHORAGE AREA BOROUGH_.
Department of Environmental Quality
"C" St., Anchorage, Alaska 99503 - 274-4561
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
Type of Inspection: CMRO VA
Mai-ling Address:
Name of Buyer:
Mailing Address:
Name of Lending Institution:
Mailing Address: ~.
Name of Realtor or Agent:
Mailing Address:
FHA CONV
Day Phone-~,~ ~,.~ O~/Tdo
Day Phone "Z72'~.~.5-~'~- v~T~.
C~,,~'~b, ~Pe]) .~eb/T ~/~ ~ -
Phone
Phone
6. Legal Description:
Location: "~/C)~)(~'E--,~=-A.)&c-)~o~3
7. Type
8. Water Supply
Type of Supply:
If Individual,
If Individual,
9. Sewage Disposal System
Type of System:
If Individual,
of Facility to be inspected: No. Bdrms.
Public Utility Individual
number of dwellings presently served
depth of well //~
Public Utility ~fl~. Individual
date of installation
on-site)
Eq-037 (~/74)
O6.1220(al Rev 1973
DATE
ALASKA DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF PUBLIC HEALTH
INDIVIDUAL AND SEMI-PUBLIC
BACTERIOLOG I CAL WATER
INDIVIDUAL SEMI PUBLIC [] CHLORINE RESIDUALP~M
REPORT RESULTS TO
3J.68
Lab No
A NA LYSI S OFF,C
[] Unsatisfoclory
[] Questionable
[] Sample too long in lransil; sample should not be over 48
hours old at examination 1o indicate reliable results Please
send new sample.
[] Boule broken in transit, please send new sample.
SANITARIAN'S REMARKS
COMPLETE THIS SECTION
ONLY IF WATER IS AN INDIVIDUAL SUPPLY
BAMPLECOLLECTEDBY ./~
Well --[] Dug [] Driven [] Drilled [] Bored
SOURCE: [] Spring [] Cistern [] Other
Dug Well or Cistern Corlslr uction~
WaRs [~ Wood [] Concrete [] Metal [~] Tile Brick or
Top [] Wood [] Concrete [~ Metal [] ?pen Top [] Concrete
LOCATION:
[] In Basement [] BasementOffset [] Under House
[] InYard [] Olher
Building Sewer Septic
DISTANCE TO: or Other Drainage Pipe, Feet. Tank Feet
Tile Seepage Cass-
Field Feet Pit Feet. Pool Feet. Privy_ Feet.
Other Possible
Sources of Contamination
MATERIAL: Building Sewer [] Cast Iron [] Wood [] Tile ~] Fibre [] Asbestos
Cement
[] Plastic Joint Material Type
GENERAL= Does Woler Become Muddy or Discolored? [~ Yes [] No
When?
Diameter of Well Depth Feet
Well Casing
Material .Diameter Deplh
Length of Woler Deplh
Drop Pipe. From Bobom Feet.
PUMPLOCATION: [] InWell [] Basement [] InBasement [] Room
On Top
[] Of Well [] Other
PURPOSE aP EXAMINATION: Illness Suspected? J~ Yes
DATE
ALASKA DEPARTMENT OF HiEALtH AND SOCIAL SERVICES
DIVISION OF~pUBLIC HEALTH
'INDIVIDUAL. .(~b ~EMI:PUBLIC
BACTERIOLO:GI ca[ WA'TER
INDIVIDUAL
ADDRESS
CITY
ADDRESS
OFSOURCE
SEMI-PUBLIC [] CHLORINE RESIDUAL PPM
REPORT RESULTS TO
Lab No.
ANALYSIS OFF,CE
A//~r alysis shows lhis Water SAMPLE to be:
factory
[] Unsahsfactory
[] Questionable
[] Somole too long in lransil; sample should not be over 48
hours o[o at exominotlor to mdicote rehoble results Please
senn new sample.
[] Bonlebrokenmtroos ,pleosesend newsomple
SANITARIAN'S REMARKS
COMPLETE THIS SECTION
ONLY IF WATER IS AN INDIVIDUAL SUPPLY
SAMPLE COLLECTED BY ~.~.~
DATECOLLECTED ~- ~' 7~' TIMECOLL[CTEB /r'~~') /~/~ '-"
Somple Collected Fro~ ' ~itchen Too ~ Bothroo~ Toe ~ Bosemenl TOO
~ Olher (Dsl}
LOCATION
[~ [~ Bosemenl [~] Basement Offset E Under House
Building Sewer SeotJc
DISTANCE TO or Other Drainage Pio~ Feel Tank Feet
Tile See/~age Cess-
Field Feet Pn Feet Pool Feet Pnw ~' Feet
Other Possible
Sc Jrces of Contamlnahon
MATERIAL: Building Sewer [] Cost Iron [] Wood [] Tde (~ F~bre [] Asbeslos
Cemenl
[] Plastic Jo~rJt Maleaal Tvoe
GENERAL. DoesWaterBecomeMudd orDiseolored? [] Yes [] No
Diameter of
Well Casing
Length of
Drop P~pe
Offset in
PUMP LOCATION [] n Wel [] Basement
On Top
[] Of Well [] Olher
PURPOSE OF EXAMINATION: IIIne'*~ B
[] Ye!
ALASKA DEPARTMENT'OF H'E~L~'.I'I~AND SOCIAL,SERVICES ' DIVISION ~J'P4J~UBI~IC~flEALTH
' IND!V D'UAL' ~O ~EMI~?OBLIC
BACTERIOL.O G I CA' wATER ANALYSIS
OFFICE
nalvsis shows this Water SAMPLE lo be
~ Sg jlSEaclor v
[] Questionoble
SANITARIAN'S REMARKS
COMPLETE THIS SECTION
ONLY IF WATER IS AN INDIVIDUAL
SAMPLE COLLECT ED BY ~.~.~
DATE COLLECTED ~' ~ ' 2 ~ EIME COLLECTED
Well Casing
Lenglh of d Wolff DepTh
~' m No S,gnature
READ INSTRUCTIONS
OF,
REVERSE SIDE
BEFORE
COLLECTING SAMPLE
O No
06 1220 [bi -'>' "~'BACTERIOLOGICAL WATER ANALYSIS RECORD
LocloseBroth , '' 1Oct lOcc lOcc ' IOcc IOcc 1.Occ I.~)cc
I
EMB - AGAR
ColiEor m Densd.
MF Results