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HomeMy WebLinkAboutWENTWORTH BLK 2 LT 3e,41+ VVO r * pbg-023 -2� Sit) d h Y ei 0 21 e 14 t t i s ± 0 pp1 ppt qp� q i L = � S i Y � i 3Y F 1 V w � 3 (y a � J4 W e ! Z � W F c� F a H d h Y ei 0 21 e 14 t W I.1 S O t i ± � pp1 ppt qp� q i L = � S i i F 1 V w [ W 3 (y 3 1y J4 W e ! � W I.1 S O t i ± t i L 3 i i F 1 V w [ W 3 (y 3 1y J4 W e ! � F c� F [+ H 3 E i K ji H • ! ! ' i y ; r 1 , i � a ti w w w w w 0 W GCit fwt• '�, p x W I.1 S O C w i h h i FILE (, ,5' � WATEk WELL INVENYORY CHANGE CUSTOMLK—ID N. WILLIAM P QQQQ SW QQQ NE QQ SW Q SE S 28 TWN 013N RN6 003W M S LAT N14 LON W*?H W ALT —,rt. 11LTH DRIF_LER PENN JERSEY COMP DATE 09 27 1962 FIN DEPTH 00045.00 USE [3A00 SINGI r nIJFI I TNr rf)Mr Mt:Tu r nnterrur .�.W1 t i i F e ! � F c� F [+ H t 1 , i � a '+• W GCit fwt• '�, C w i h h i FILE (, ,5' � WATEk WELL INVENYORY CHANGE CUSTOMLK—ID N. WILLIAM P QQQQ SW QQQ NE QQ SW Q SE S 28 TWN 013N RN6 003W M S LAT N14 LON W*?H W ALT —,rt. 11LTH DRIF_LER PENN JERSEY COMP DATE 09 27 1962 FIN DEPTH 00045.00 USE [3A00 SINGI r nIJFI I TNr rf)Mr Mt:Tu r nnterrur .�.W1 N, Cev�(opm nt Services pepar`ment O Suilding safer'/ Divisian -•. !.. iC C elf. aSS..wuTa r 4.1 GG Gragaw SSCeat _inn P.C.Sax 196-54 ,lzrka_zarch - - Anchorage, Al" 99519-6650 i4layof !vwmuni.or�!nn�ira (?Q7-) 24-4-7904 Pump Installation Log 71 Dj''yrOn.n Permit Number: SW_ Date of Issue: I1-Lu++.� ' ,cel Identification Number:_ al Description ' L PTO erty Owner Name & Address: ap InstZEation Date: 29 ap Intake Depth Below Top of Well Casing: �� feet np Njanufacturer's Name: , / . �� ° c T>®rJ A-LI3 np Model. { ILP,99ye.hp..,- ess dapter Burial Depth: feet .ess Adapter Manufactm-er s Mame: _so _dapterinemiler- ®� i� :Il iC.li_ 1Q :J iC mp 1115 taller Ci ane: tenti,on: The PumP iustelier shall provide a pump installation lag to the DSD within 30 days of pump installation- V14 r REQUEST FOR APPROVAL OF INDIVIDUAL SEWACE AND MATER FACILITIES (Fill out in Triplicate) _ Idame.of person requesting approval Q_ -- 2. Na"p of property owner S� 3. Legal description �= =L2 4. Number of bedrooms in house 3 5. Water Analysis: a. Bacterial I -ILA— b. Detergent 6. Well data: W6Kk-tW®Y2.i`H Svcj , a. Type Ad/e/3 b. Depth -w c. Casing Size d. Distance from well to closest existing or proposed: 1. Sewer line 2. Septic tank 001 3. Seepage Area 4. Cesspool' 5. Property Line -1O� 6. Other sources of possible contamination, i.e., creeks, lakes, houses, barn, drainage ditch, etc. 7. Sewage disposal system. a. Age of system I ies b. Septic tank capacity in gallons QQ . 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 ?Xy X 8> - 1. Distance to property line 301 to house foundation -to / . 0 e, Percolation'Test"results f. Percolation Test performed by A- Use the reverse side of this form to show diagram. Diagram should include the following information: property lines;.well location, house location, ��ptic tank location, disposal area location, location of percolation test, and direction of ground slope. 9. The iilformit ion on this form is true and correct to the best of my knowledge.` SSignn�atur o te Sign Applicant aed a^%' TO BE FILLED OUT BY HEALTH DEPARTMENT PERSONNEL The above described sanitary facilities are hereby approved, subject to the =ollowing cond'it'ions: Conditions: The above described sanitary facilities are disapproved for the following reasons: _r -Signh<bre of Of,ieal; _ Date t:, Approval is valid for one year following the date of approval. CPJ:cw Diameter oI Well Depth ADHW - LAB 2W �YPARTMENT OF HEALTH AND WARE Lab. No. "u`' ' o` DIVISION OF.PUBLIC HEALTH (. BACTERIOLOGICAL. WATER ANALYSIS Len th of Length OFFICE r 'DATE ' From B.H.— I t r I t_ Records in this office indicate this WATER SUPPLY to be of: F-1. F-1 INDIVIDUAL O OTHER PUBLIC SEMI-PUBLIC ❑ Satisfactory El Questionable ❑Unsatisfactory Sanitary Status. REPORT RESULTS TO -1- "'� '•rl /- Analysis shows this Wafer SAMPLE to be: NAME - r'- O'Sulisfactory ❑ Questionable ❑ Unsatisfactory. ADDRESS If an -Unsatisfactory- or "Questionable" status is indicated above /1111 2C / ✓ - you should take immediate action as recommended below. CITY - - 1. Notify consumers water is polluted. Boil or chemically - ADDRESS - - treat this water as outlined in the enclosed leaflet OF SOURCE - - - "Drink It Pure." - SAMPLE COLLECTED BY _2.. Increase chlorination sufficiently to meet recommendedresi l standards. - 'Om ry - Determine source of canlaminalion and lake actionnecessaryto maintain ...rc - - -' � DATE COLLECTED - -� -- 'TIME COLLECTED pm - - a sae wafer supply al all limes. ff -- . Sample Collected From El b6en Tap - .l] Bathroom Tap Q Bosement Tap _ 3. Check chlorination and ether mechanical equipment. Make certain it is _ O Other 00 functioning properly. 4. If after checking equipment a disinfecting residual is not obtained, please COMPLETE THIS SECTION UNLESS OTHERWISE INSTRUCTED wire this office for emergency assistance or advisory services. - Well - ❑ Dug ❑ Driven O Drilled 0 Bored —5. This is o surface water source and subject to pollution by man and animals. SOURCE: O Spring O Cistern - O Other An approved water supply source should be developed. - - Dug Well or Cistern Construction: - = r - Bi Brick o 1] spring - —�. Improve your p 9 ❑dug well ❑driven well Walls" O Wood - O Concrete - -❑ Metal O Tile O Concrete - - Top' O Wood [IConcrete- O Metal O. Open Top - - El drilled well ❑cistern. - LOCATION: - O In Basement - O Basement Offset O Under House - _7. Relocate your. well to a safe location in relationship to your sewage _ O In Yard OOther disposal system. ❑ see enclosure or titheing Sewer TenFeel DISTANCE TO: or Other Drainage Pipe Feet. Tank _ 8. Sample too Ion in transit; sample should not be over 48 hours old at p 9 P Tile Seepage Co.. - ezaminalion to indicate reliable results, please send new sample. - - Field Feel. Pit Feet. Pool Feet. Privy Feet. - - O Bottle Broken in transit, please send new sample. Other Possible Sources of Contamination Cost Asbestos MATERIAL: Building Sewer - ❑Iron O Wood O Tile O Fibre_ ❑ Cement - - ._9. Contact your nearest '❑ Local Health Department or O Alaska - Division of Public Health, sanitation office for bulletins, consullalion and _ ❑ Plastic Joint Material -- Type assistance. - - - GENERAL: Does Wafer Become Muddy or Discolored?- O Yes ❑ No SANITARIAN'S REMARKS - - Diameter oI Well Depth Wall -- Materlalsln9 Diameter— iameter Len th of Length - Water Depth Drop Pipe From B.H.— PUMP LOCATION: O In Well El Offset In O In Basement - O ReIn am O OI Well O Other PURPOSE OF EXAMINATION: Illness Suspected? O Yes ❑ No New Scarce al Supply? O Yes O No Repairs to System? O Yes ❑ No READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE ©L 1 BACTERIOLOGICAL WATER ANALYSIS RECORD Date Received i ' '� Time Received /Pn' i Lab. Lactose, Broth loco IOcc 10cc IOcc 1Occ 1.0cc 0.1 cc 24 hours 48 hours --- Brilliant -Brilliant Green 24 hours 48 hours Lactose Broth, 24 firs. Coelorm Density— MF results Reported by This analysis indicates Organisms to be: 48 probable No. per 100cc.) 17 June, 1964 Buyer: Stephen Early RE: Lot 3, Block 2, Wentworth Sub. i This residence has had a 1250 gallon Septic Tank installed with the existing cess- pool. This was in pursuit with an agreement reached last January. Sparkman and i McLane are financing. Installed by Allied Services. Seller: RS:cw Bobby Lee Jeuks Box 4-868 Spenard, Alaska