HomeMy WebLinkAboutWALTER G PIPPEL ADDITION BLK 7 LT 6I..o%
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m~_.~_ /~ama .of person requesting approval
2. '~Name- of property.- owner
REQUEST FOR APPROVA
INDIVIDUAL SEWAGE AND WATE
(Fill our in Triplicate)
Legal
Nu~-~.~bedrooms in house.
5. ~a~e~x.J~alys is:
a. Bacteriai
b, Detergent
We~L1 data:
h. / ·
c. Casing Size
Distance from well to closest existing or proposed:
2. Septic tank
3, Seepage Area //~ !
5, Property Lzne /~ ~. /
5. Other sources of ~osstble contamination,/e., creeks, lakes,
houses, barn~ drainage ditch, etc.~'/.
Sew~g~ disposal system. I/
a. Age of system /~Y . //~/
b. Septic tank capacity in gallons ./~'--~
c, Name of septic tank manufacturer .
1. If "home made" show diagram on reverse side of this form.
Disposal field or seepage pit size and type ~~
_ ~>tC~'~':~,~'' ~m,~.b_.
Dist.ance to property~]~ine~/~'~/ to house foundation~ ' %
PePco/~tioz~ Te~t ~e.sults
.~.~he foilowzng information: ~roperty llnes;.w~ll locatzon, house locatzon,
'~l~pTic tanR location! disposa~ area location~ location of percolation test,
a~..direction of ground slope,
9. The ~f~mmation on this form is True and correct to the best of my knowledge.
'Signature of Applicant
TO BE FILLED OUT BY HEALTH DEPAET!~ENT PERSONNEL
Date Si~ned
~e above described sanitary, facilities are hereby approved, sub.je, cy zo the
......... ~l~owing con~ons:
Conditions:
The above described sanitary facilities are disapproved for the following
reasons:
Date :'~' . ~,
Approval is valid for one year following the date of approval.
~- CPJ:cw
AOHW- [AB 2w
DJ ~RTMENT OF. HEALTH AND WEL' ~E
~-~ DIVISION OF ~PUBLIC HEALTH '~,~
BACTERIOLOGICAL WATER ANALYSIS
Lab. No.
OFFICE
NAME
CITY
[~ Olher (List)
~ecords in thls office indicate this WATER SUPPLY to be of:
[] Satisfaclory [] Questionable [] Unsatisfactory Sanitary Status
Analysis shows this Water SAMPLE to be:
~]' Salisfactor¥ [] Questionable [] Unsatisfactory.
am
lIME COLLECTED Pm
Well - [] Dug C~ Driven [] Drilled [] Bored
SOURCE: [] Spring [] Cistern 3 Other '
Dug WeU or Cistern Construction: Brick or
Walls - [] Wood ~ Concrete [~ ~Aelal [] Tile ~] Concrete
Top- 0 Wo°d [] Co~rete [] Melal [] Open TOp
LOCATION: [] In Basemenl [~ Basement Ogsel [] dnder House
When?
Diameter of We Depth Feet
Well Casing
f an "Unsatisfactory" or "Ouesfionable" status is indicated above
you should take immediale aclion as recommended below.
1. Nolffy consumers waler is polluled. Boil or chemically
treat leis water as outEned in Ihe enclosed leaflel
"Drink g Pure."
2. Increase chlorination sufficiently lo meet recommended residual standards.
Determine source of contomlnation and fake actlon necessary 1o malnfain
a safe waler supply at all limes.
3 Check cblorinatian and olher mechanical equipment. Make cerlain it is
functionins proper~y.
4. ff after checking ec~uipmenl a disinfecting residual is not obtained, olease
wLre this office for emergency asslstance or advisory services
5. This is a surface water source and subjecl to pollution by man and animals.
An approved water supply source should be developed.
6. Improve your ~] spring [] dug well [] driven well
[] drilled well [] cistern.
7. Relocate your wel to a sale ocatlon in relalionshTp to your sewage
disposal system, [] see enclosure
8. Sample fao long in transih sample should not be over 48 hours Did at
examinalion to indicate reliable results, please send new sample.
3 Boltle Broken in lransih please send new sampleL
9. Contad your nearesl [] Local Health Departmen~ or E Alaska
Division of Public Heaflb, sanitallon office tar buUetins, consullaUon and
assislance,
SANITARIAN'S REMARKS
Signature ? -
READ INSTRUCTIONS
ON
REVERSE SIDE
BEFORE
COLLECTING SAMPLE
BACTERIOLOGICAL WATER ANALYSIS RECORD
~aclose Broth . IOcc IOcc tOcc fOcc 1Oct t.Occ O.lcc
24 hours
Briiliant Green
24 hours :--
48 hours
EMB
Lactose Broth, 24 hrs.
Coliform Densily
MF results
48 hrs.
Reporled by /~?~'~ .Date
This analysis indicoles Colilorm Organisms lo be:
AGAR
.Gram's stain
(Mast probable No. per 1BOot.)
AbSent