HomeMy WebLinkAboutWALTER G PIPPEL ADDITION BLK 5 LT 2 (2)
~t~ l and I{, Bl~k t{$ Walt~l~ O, l~ipp~l t{~b~ivit~iou,
~i~ty of ~.ehor~, ~5~ ~t ~d~ Ro~. l[ you h~ve ~y quo~i~
the abov~, plm~ do not ~t~te to ~t th~ p~r~t Of~ g
FT~tIw
· ~" .~,~ / INDIVIDUAL SEWAGE AND WATER FACILITIES ~
' k ~/"' (Fill out in Triplicate) ~ .~,_
% a'~ of person requesting approval ~ ~'~. '~.
4. Nu~,~oe. ~e~'ooms in house
5, Water. Analy~sls:
a. Bactem{al
b. Detergent
Well data:
b. Depth_..,- ,,-
c. Casing Size ~
de
Distance from well to closest existing or proposed:
1. Sewer line
Septic tank..~
2.
~. Saepa~e Area I~)~ .
4, Cesspool'.
5. Property Line
houses, barn, drainage ditch, etc.
Sewage disposal system.
Other sources of possible contamination~ i.e., creeks, lakes,
a. Age of system ~k~.~
b. Septic tank capacity in gallons ~0~) ~D ,
c, Name of septic tank manufacturer '~_~ ~
1. If "home made" show diagram on reverse side of this form,
d.' Disposal field or seepage pit size and type
1. Distance to property line
to house foundation
Percolatic~l Test ~resuD_ts .
f. Percolation Test performed by
Use the reverse .side of this form to show diagram. Dia[ra~ should include
.~'~he foilowlng information: ~operty llnes~well location, house loeaticn~
~Utle tank location, disposal area location, location of percolation test,
an~ direction of ~round slope.
The~[mfor~tion on this form is true and correct to the best of my knowledge.
$lgnature of Applicant
Date Signed
TO BE FILLED OUT BY HEALTH DEPART~-~ENT PERSONNEL
~e above described sanitary facilities are hereby approved, subject to the
~l~owing cond,i.'~ons i ' --
Conditions: /~X~
The above described sanitary facilities are disspproved for the following
reasons:
"' Signature of ~i~'R~ ~ ..... ~.~'--~i ' 'Date /f ,
Approval is valid for one year following the date of approval.
CPJ:cw
DATE
D ARTMENT OF HEALTH AND WE[ RE
DIVISION OF PUBLIC HEALTH ~"
BACTERIOLOGICAL WATER ANALYSIS
REPORT RESULTS TO
CITY
~DD RESS
OF SOURCE
SAMPLE COLLECTED BY
DATE COLLECTED TIME COLLECTED_
Sample Col ecled From E '(lichen Ta~* [] ~olhroom Top [] J~asement Tap
[] Olher (List)
OFFICE
Records in this office indicate lhis WATER SUPPLY 1o be of:
SaBsfactor¥ [] Questionable [] Unsatidactory Sanilary Status.
Analysis shows thls Waler SAMPLE to be:
J~J'~allsfactor¥ [] Questionable [] UnsaHsfacfory.
1. Notlf~ consumers waler is polluted. Boil or chemically
treal this wgl~r as outlined in lhe enclosed
"OrinJ~ B Pure."
2. Increase chlorination sufflcleatty to meet recommended residual standards.
$. This is a surface water source and subiect fo pollution by man and animo[s.
6. Improve your [] spring [] dug well [] driven well
[] grilled well [] cistern.
disposal system ~ see enclosure
8. Sample too long in lransih sample should
examination Io tad;cole reliable results, please send new sample.
[] 3oltle Broken in transit, mease send new sample.
9. Conlact your nearesi J~ Local Health Deparlmenl or [] Alaska
Division of Public Heollh sonilation olfice for bulletins, consullation and
SANITARIAN'S REMARKS
Offset In [] In Basement [] Roam
PUMP LOCATION: [] In Well [~ Basement
[] of Well [] Other
READ INSTRUCTIONS
ON
REVERSE SIDE
BEFORE
COLLECTING SAMPLE
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Received. .Time Received . .
Lactose Broth 10cc J 10CC 10CC 1Oct 10CC J 1.0CC 0.1CC
I
I
24 hours
Brilliant Green
24 hours
48 hours
EMB
AGAR
Laclose Bro~h, 24 hrs. 48 hrs Groin's stain
Coliform Densily _ . (Most probable No. per !OOcc.)
-' ..... - 5' {
(, p~¥
Reported by (~") '/ Dote ...... . - .
®L