The URL can be used to link to this page

Home My WebLink AboutWALTER G PIPPEL Block 6 Lots 1 & 2 ~ - ~.j.~ REQUEuT FOR APPROVAL OF INDIVIDUAL SEWAGE AND WATER FACILITIES ~ ' '"' (Fill out in T~iplicate) %~ ~ .~. ~:ame of pePson Peques~ing appPoval ~.~.:~ 5. Water. Analysis: a, b, DetePgent data: d, D~stance fr. om well to closest exzs ~ng or proposeo~ / 1. Bewer line m · r ./, 5, PPopemty Line 6. Othe~ sou~c~s of possible contamlna~t · houses~ ba~n~ d~ainage ditch, 7, Sewage disposal system, a, Age of system .... b. Septic tank capacity in gallons ~) /,_4~z~ . c. Name of septic tank manufactu~ .... 1, If "home made" show diagram on reverse side of this fol-m, d.' Disposal field om seepage pit size and type 1, Distance to proper~cy line to house foundation e, Pereo2atiock T~st f, Percolation Test performed by '~ Use the reverse.side of this form to show diagram, Diagram should include -.~.%he following information: p~operty lines~.well location, house location, ~.[,tJe tank location, disposal area location~ location of percolation test, a~ dJr.ection of ground slope~ 9. The ~r~>~n~on .on this form is true and correct to the best of my knowledge, ~ Signature of Applicant Date Signed ~.p_BE FILLED OUT BY HEALTH DEPART!.~ENT PERSONNEL he~ T above escr~.bed anltary ae:tl~t~_es are hereby approved~ subject to the ......... d ' s ' f ' ' ' ~6'llowing eon~f,lons i Conditions: The above described sanitary facilities are disapproved for the following Approval is valid for one year following the date of approval. CPJ:cw AOHW - LA8 - 2W DATE : D~' %RTMENT OF HEALTH AND WELt 'RE v DIVISION OF PUBLIC HEALTH BACTERIOLOGICAL WATER ANALYSIS NAME ADDRESS ' " ' CITY ADDRESS OF SOURCE SAMPLE COLLECTED BY. DATE COLLECTED - Sample Collecled From [] Kitchen Tap TIME COLLECTED pm [~ Bathroom Tau O Basemenl Tap When? Well Casing Lenglh o; Water Depth Lab. No. Records in this office indicate this WATER SUPPLY ~o be of: Salisfaclory [~ Quesfionabte [] Unsatisfaclory Sanitary Status. Anolys~s,shows this Water SAMPLE to be: [] Safisfaclory [] Questionable [~ UnsatJsfaclory. If on "UnsaSsfactory" or "Queslionable" status is indicated above you should take immediate action as recommended below. 1. ~'4otlfy consumers water is polluled. Boil or chemlcalky treal this water os outlined in ~he enclosed leal[et "Drink II Pure." 2. Increase chlorination sufficiently Ia meel recommended residual s~andards. Determine source of contamination and tahe action necessary to malntaJn a sa~e water suoply al all Braes 3. Chec~ cblori~afinn and other mechanlcal equipmenl. Mal~e certain it is functionlng properly. 4 ii after checking equipmenl a dlslnlecling residual is not obloined, please wire this office for ~rnergency assistance or advisory services. 5. This is a surface water source and subjecl lo pollution by man and animals. An approved waler suppw source should be developea. S. Improve your [] sprig O dug well [] driven we! -1 drilled web [] cistern. 7. Relocate your well Io a sale location in relationship to your sewage disposal system [] see enclosure 8. Sample loo long in transih sample should no~ be over 48 hours old at examlnatJon to indJcale reliable resulls, please send new sample. ~] I~oltle Broken in IransiE please send new sample. - 9. Contacl your nearest [] Local Health Deparlment or [] Alaska Division of Publlc Health, sanilaliom olfice for bulletlns consultation and SANITARIAN'S REMARKS S~gnature READ INSTRUCTIONS. . ON REVERSE SIDE BEFORE COLLECTING SAMPLE BACTERIOLOGICAL WATER ANALYSIS RECORD am r Date Received ' Time Received ~ pM Lab ~o LadoseBrofh )0cc - 10cc ' 10cc t0ccI )oct t.occ 24 hours 48 hours '" Brillionl Green 24 hours 48 hours EM9 AGAR Lactose Broth. 24 hrs. 48 nrs Orom's slain Coliform Densgy 'Most probable No per 100cc.) MF results Reported by This analysis indicates Coliform Organisms to be: am Absent Presenl REQUEST FOR, APPROVAL OF INDIVIDUAL SEWAGE AND WATE. R FACILITIES (Fill out in Triplicate) / ,/ d. Distance fmom well ~O closes~ existing om pmoposed{d "' 1. Sewe~ lzne ' i 3. Seepage A~ea fi? ', .... '~ ~ 5. P~operty Line ' 6. sources of possible contamination, Other houses, baPn, drainage ditch, etc. Nk 7. Sewage disposal system. ~b. ~ Septic tank capacity in gallons c. Name of septic tank manufaetu~e..r. 1. If "home made" show diagram on reverse side of this form. d.' Disposal field or seepage pit size and type 1. 'Distance to proper~cy line .... to housefoundatzon' e, P erccd at ionx?~st ~z~ mults f. Percolation Test performed by Dia~ra~ should include Use the reverse .side of this form to show diafram. · ~he foilowlng information: ~Foperty lines;.well location, house location, ~.~tlc tank location, disposal area location~ location of percolation test~ a~ dlmection of ground slope~ The l~£o~tioe on this form is true and corpect to the best of my knowledge. ,,, ..... \ S~nature of ApPlicant Da~ Signed FILLED OUT BY HEALTH DEPART~.~ENT PERSONNEL ~T~e above described sanitary facilities are hereby approved, subject to the _ ql!owlng con~ions Conditions: The above described sanitary aczlztzes are disapproved for the following reasons: Approval is valid for one year following the date of approval. CPJ:cw DER ~ITMENT OF HEALTH AND WELF\ ~E ~' DIVISION OF PUBLIC HEALTH BACTERIOLOGICAL WATER ANALYSIS SAMPLE COLLECTED BY DATE COLLECTED TIME COLLECTED pm Sample Collected From [J Kitchen Too ~] Bathroom Too [] Basemenl Tap When? READ INSTRUCTIONS Lab. No. OFFICE Records in this office indicate this WATER SUPPLY to be of: Analysis .shows this Water SAMPLE to'be: [] Satisfactory 0 Questionable 0 Unsatisfactory. II an "Unsatlsfac~ory" or "Quasi[enable" sialus [s indicated above you should take immediate action as recomm.nded below. 1. Notify consumers waler is polluled. Boil or chemically treat thls water as outlined in the enclosed leaflet "Drink It Pure." 2. Increase chlorination sufficiently ~o meet recommended residual s~andards. Determine source of contamination and take action necessary lo malnlaln a sale water supply at all times. g. Check chlorination and olher mechanical equlpmen . Make certain il is Iunclioning properly 4Il after checking equ'oment a disinfecling residual is not obtained, please wire Ibis office lot emergency assistance or advisory services, S.This is a surface waler source and subject to pollution by man and animals, An approved water supply source should be developed. 6 Improve your [] spring r~ dug well ~] driven weE~ 7. Relocate your well lo a sa~e Iocolion in relationship lo your sewage disposa~ syslem [] see enclosure 8. Sample too long in Iransit: sample should not be over 48 hours old al examination to indicate tellable results, please send new sample. O Baffle Broken in transit, please send new sample. 9. Conlact your nearest [~ Local Health Department or O Alaska Division of Public'Health, sanitalion office for bu[letlns, consullation and SANITARIAN'S REMARKS Signature Date Received BACI~ERIOLOGICAL WATER ANALYSIS RECORD~;~.j ~ ON REVERSE SIDE BEFORE COLLECTING SAMPLE Lactose ltroth 24 hours 48 hours 48 hfs BGB (Mosl probable No. per 100c¢.) EMB Laclose Broth, 24 hrs. Coliform Density