HomeMy WebLinkAboutWENTWORTH BLK 3 LT 22LoT
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND yATER FACILITIES (Fill out in
a. Bacte~isJ~
h. Detergent, "'
6, Well data:
b. Depth ~
c. Casing Size
Distance from well to closest existing or proposed:
Sewer, line
2. Septic tank ~3 .
3. Seepage Area /~i~ '" ·
4, Cesspool'
5. Property Line
6. Other sources of possible contamination~ i.e.~ creeks, lakes,
houses, barn~ drainage ditch, etc.
Sewage disposal system.
a. Age of system
b. Septic tank capacity in gallon
c. Name Of septic tank manufactu~e.~
1. If "home made" show diagram on reverse side of this form.
d.' Disposal fie~d or seepage pit size and type.
1. Distance to proper~cy line
to housefoundation'
h
Percolation.,T~st ~sults
f, Percolation Test performed by .............. ,
Use t?~ reverse .side of this form to show diagram. Diagram should include
"-~he fo]]o.,~ing information: ~operty lines~well location, house location,
~-~m~]c tank location, disposal area location, location of percolation test,
al~ d~reetion of ground slope.
9. T~e ~n[.~.~on on tkls form is true and correct to the best of my knowledge,
Signature 'of Applicant : Dale Signed
T__O_BE FILLED OUT BY HEALTH DEPART{.~ENT PERSONNEL
......... ~...~ . described sanitary facilities are hereby approved, subject to. the
following cond~fons3, '
The above described sanitary facilities are disapproved for the following
Approval is valid for one year ollowzng the date of approval.
f .
CPJ: cw
DATE
.RTMENT OF ·HEALTH AND WEI ~E
DIVISION OFr PUBLIC HEALTH
BACTERIOLOGICALWATER ANALYSIS
CITY
SAMPLE COLLECTED BY
am
Dm
DATE COLLECTED TiME COLLECTED
Walls - [] Wood O Concrete ~] Metal E] Tile ~] Concrele
Top O Wood [] Concrete [] Metal [] Open Top
When?
Lab. No.
Records in this office indlcale this WATER SU >PLY Io be of:
Analysis shows this Water SAMPLE to be:
Satisfactory [] Questlonable [] Unsalisfadory.
ff on "UnsollsJaclory" or "Questionable" status is indicated above
you should lake immediate action as recommended below·
I. Notify consumers water is aolluled. Boll or chemically
Ireal this water as outlined in the enclosed leallet
"Drink'll Pure."
2. Increase chlorination suU[clently lo meet recommended residual standards
Determine source of contamination and take actlon necessary to mainlain
a sale water supply at all times
3. Check chlorinatinn and other mechanical equipment. Make cerlaln il is
funcEoning properly.
4. ff affer~'~cking equipmenta dlsinfecling residual is not'obfainea, please
wire thi~1ce for emergen~ass~slance or.ad,,~sory serv,ces~ ~
5. This is a surface waler source and sub'ect to ooUution by man and animals.
An approved water supply source should be developed.
6. Improve your [] spring [] dug well [] driven well
[] drilled weU [] cistern.
8. Sample too long in transit; samara should not be over 48 hours old al
examination to indlcote reliable resulls, please send new samole
[] Boflle ffroken ~n transit, please send new sample.
9, Conlacl your nearesl E Local Health Depar~mentor [] Alaska
Divlsion of Public HeaRh. sanlfallon office for bulleffns, consullalion and
SANITARIAN'S REMARKS
READ INSTRUCTIONS
ON
REVERSE SIDE
BEFORE
COLLECTING SAMPLE
Date Received
Lactose Broth
48 hours
3rillia nt Green
24 hours
48 hours
EMB
Laclose Broth, 24 hrs
Coliform Density
MF results
BACTERIOLOGICAL WATER ANALYSIS RECORD
OCT 1 0'196 .....
AGAR
48 hrs.
IMost probable No. per f00cc.
Reported by Date
This ana[ysls indicates Coliform Organisms to be:
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