HomeMy WebLinkAboutWALTER G PIPPEL ADDITION BLK 9 LT 105o
INDIVIDUAL
!~,~,.~TER ANCHORAGE AREA BOROUk~.~,~
DEPARTMENT OF ENVIRONMENTAL QUALITY
3500 TUDOR ROAD
ANCHORAGE, ALASKA 99507
279-8686
DATE RECEIVED:
INSPECT:
TIME:
REQUEST FOR APPROVAL OF
SEWER AND WATER FACILITIES
FOR
APPROVAL
ADDRESS:
PHONE:
REQUESTED BY:
2. PROPERTY OWNER:
$. LEGAL DESCRIPTION:
4. TYPE FACILITY TO BE
o
NUMBER OF BEDROOMS:
WELL
DATA:
A. TYPE _
B. DEPTH
C. SIZE
co s RUC IO,
E. BACTERIAL ANALYSIS.~',~$~¢~'~ /~'/~'~/
6. SEWAGE DISPOSAL SYSTEM:
A. SEPTIC TANK (IF HOMEMADE, SHOW DIAGRAM ON BACK)
1. SIZE ,:~,~00
2. AGE
3. MANUFACTURER
4. INSTALLER
APPROVAL
PAGE TWO
REQUL~"-~q~ FOR SEWER & WATER FACILt~-~-~S
B. SEEPAGE PIT
1. SIZE
2. LINING
DISPOSAL FIELD
1. NUMBER OF LINES
2. TOTAL LENGTH
REQUIRED MEASUREMENTS
A. WELL TO SEPTIC TANK
B. WELL TO SEEPAGE PIT
C. WELL TO SEWER LINE
E. WELL TO OTHER POSSIBLE CONTAMINATION
F. FOUNDATION TO SEPTIC TANK
G. FOUNDATION TO SEEPAGE PIT
H. SEEPAGE PIT TO PROPERTY LINE
COMMENTS:
DATE: DATE: / ~, '- ~-. 7 ~ ~/
APPROVAL VALID FOR ONE YEAR FROM DATE SIGNED.
GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY
ADHW-~B-2W
~'-"~.RTMENT OF HEALTH AND WE,"" RE
~-0./ DIVISION OF PUBLIC HEALTH ~
BACTERIOLOGICAL WATER ANALYSIS
Lab. No.
OFFICE
PUBLIC [~ SEMI'PUBLIC [~ INDIVIDUAL r~ OTHER
REPORT RESULTS TO
NAME
ADDRESS
CITY
Records in this office indicale this WATER SUPPLY to be of:
[] Safis~adory [] Questlanable ~] Unsa~islaclory Sanitary Status.
Analysis shows this Water SAMPLE iD be:
[] Satisfactory ~] Questionable [] Unsatisfactory.
If an "Unsafisfadory" or 'Quesganab~e" slatus is fndicated above
you should take immediale action as recommended below.
__1. Notify consumers water is polluled. Boil or chemically
treal this woler as oulllned in the enclosed ~eaflet
"Drink B Pure."
SAMPLE COLLECTED BY
DATE cOLLECTED
Sample CaReered From
[~ Other ILislI
am
TIME COLLECTED
[] Ritchen Tap [] Bathroom Tap ~] Basement Tap --
Well- [~ Dug [] Driven [~ DrRled 0 Bored
SOURCE: [~ Spring [] Cislern [] Olher
Dug Well ~r Cistern Construction:
Wails - E~ Wood C~ Concrete [] Metal [] Tile [] Concrele
Top - 0 Wood [] Concrete [] Metal [] Open Top
When?
Diameter al Well. Depth Feet.
Well Casing
2. Increase chlorination sufficieally Io meet recommended residual standards.
Determine source of contamlnafion and fake action necessary Id maintain
a sa~e water supply ot all times.
3. Check chlori~alian and olher mechanical equlpm~nL Make cerlaln J! is
functioning properly.
4. If abet checking equipment a disinfecting residual is not obtained, please
wire lh~s office for emergency assistance or advlsory services.
S. This is a surface water source and Subject to pollution by man and animals.
An approved water supply source should be developed.
6. Improve your [] spring [] dug well [] driven well
[] drille~l well [3 clslern;
7. Relocale your well fo a sa~e location in relationship Io your sewage
-- disposal system. [] see enclosure
8. Sample tad ~ong in lranslb sample should not be over 48 hours old at
examination 1o indicate reliable resulls, please send new sample.
[] Bottle Broken in Iranslt. please send new sample.
.9. Contacl your neared [] Local Heallh Department or [] Alaska
Division of Public Health, sanifation office ~or bulletins, consullation Dad
SANITARIAN'S REMARKS
Signalure
READ INSTRUCTIONS
ON
REVERSE SIDE
BEFORE
COLLECTING SAMPLE
BACTERIOLOGICAL WATER ANALYSIS RECORD
om
Date Received Time Rece]ved pm Lab. No.-
Laclose Broth I 0cc I 0cc 10cc I 0cc 10cc ! .0cc 0.1 cc
24 hours
48 hours
Brilliant Green
24 hours
48 hours
EMLR AGAR.
Lactose Broth. 24 hrs. 48 hrs. .Gram's stain
Coliform Density [Most probable No. per 100cc.)
MF resans. ~
Reporled by
This analysis indicates Coliform Organisms to be:
Absent
Presenl.