HomeMy WebLinkAboutWONDER PARK TR C LT 2C
~ ~--~ MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME P R O-N-~--- [] NEW
C'.F_..e..,I,c T, Ha~aov~ ._~33-%z/_0 E]UPORADE
MAILING ADDRESS
LEGAL DESCRIPTION
Low
LOCATION NO. OF BEDROOMS
~ ~ Manu[acturor Material ~o. of compartments
~ kiq, capacity in gallons IF HOME.DE: Inside length Width Liquid depth
, ~ Well Oweging PERMIT NO,
~Oz DISTANCE TO:
O ~ < Manufacturer Material Liquid capacit~ in gallons
~ Well Foundation Nearest lot line PERMIT NO,
~ DISTANCE TO:
~ No. of lines Length of each line Total length of lines Trench width Distance between lines
i~mhes
-- ~ ~ Top of til~, to flnish grade Material beneath tile --~ Total effective absorption area
Q inches
Length Wid{h Depth
~ ~ Type of crib C~ib diameter Crib depth Total effective absorption area
m Well Building foundation Nearest lot line
m DISTANCE TO:
~ DISTANCE TO: ~Xh~ ~/O ~ ~O ~¢; .~
PIPE MATERIALS f ~ %~
72-013 (Rev. 3/78)
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Mountain View Area Reference Map-P3
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Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
I.D. NO.
Public Water:System Name
Mail~dres~
City
SAMPLE DATE:
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref, no.
[] Special Purpose
State Zip Code
[] Treated Water
[2Ufit?eated Wate~
SAMPLE
NO.
1
4
5
LOCATION
Time Collected
Collected By
TO BE COMPLETED BY LABORATORY
LABORATORY:
NAME
ADDRESS
CITY
Date Received
Time Received
Ahalytical Method:
lEt/Fermentation Tube
[] Membrane Filter
Lab Ref. No. Result* Analyst
I Iii
I
* NO. OI colonies 1100 mh or ND. of Poslllvo @orllons,
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Form No. 18-310 (3-78)
06-1220 (b)
Rev. 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
Presumptive lOrnl ZOml 1Omi 1Omi 1Omi /.Omi O.Zml
24 Hours
48 Hours ·
Confirmatory
EMB Broth 24 hours:
Multiple Tube Report:
Membrane Filter: Direct Count
Verification: LTB
Broth 48 hours:
10mi Tubes Positive/Total 10mi Portions
Joo Lamon aC.o
101 L'ast Intorn~.t£onal Airport. Road.
Anchorage%, Alaska 99%)02
and, %~at,~.r facilities ak
oxten<iad t%~lw:~(lP) iucht%t~ abov,:~ ground level an~.:~ th~ pit
office) at 264-4720,
First National Bank of An¢.'.horac~o
Post off. ifJc'~ BO;~ 4-2090 99509
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
82~ L Street -Anchorage, Alaska 99501
ENVIRONMENTAL ENGINEERING DIVISION
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Compmte all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PRO,~RTY OWNE~ ,~ o PHONE
MAILING ADDRESS
2.PROPERTYBuYER RESIDEN'¥ (if different from abovel PHoNEPHONE
MAILING ADDRESS
3. L, ENDING J~.$TITUTION
~IAI LING ADDRESS
4. REALTO..~.~.GENT I PHONE
6. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] One ~ tour [] Other
~ [] Two [] Five
SINGLE
FAMILY
[] MULTIPLE FAMILY [] Three [] Six
7, WATEFi SUPPLY
~ NDIVI DUAL* ~ ATTACH WELL LOG. A well log is required for ail wells drilled
[] COMMUNITY since June 1975. F3r wells drilled prior to that date, give wel
[] PUBLIC UTI LITY depth (attach log if available.)
8. SEWAGE DISPOSAl. SYSTEM
[] NDIVI DUAL/ON-SITE** '* f individua /on-site, give [nstalletion date
If system s over ~wo (2) years old an adequacy test is required
[~~ PUBLIC UTILITY by this Department.
NOTE: THE INSPE"CTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED,
72-010(3/78)
· THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
I :,,~E} ~,~
DATE DATE DATE
INSPECTO~.. INSPECTOR INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
~ SINGLE FAMILY ~ ONE ~ THREE ~ FIVE ~ OTHER
~]'~ MULTIPLE FAMILY ~ TWO ~FOUR ~ SIX
/
2, W~TER SUPPLY
PERMIT
NUMBER
~ COMMUNITY
DATE DRILLED
~ PUBLIC UTILITY
Connection Verified LOG RECEIVED
3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
DIVIDUAL/ON DATE INSTALLED
BLIC UTILITY
Connection Verified INSTALLER
~Septic Tank or ~ Holding Tank
Size:~ If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCESwELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line
Absorp[ion Area to nearest Lot Line
~APPROVED FOR ~ BEDROOMS
~ CONDITIONAL APPROVAL (letter must accompany certificate)
~ DISAPPROVED
D ATE~ ~ ~ -- ~ 8Y (Title)
LEGAL DESCRIPTION
72-010 (Rev, 3/78)