HomeMy WebLinkAboutZODIAK MANOR ALASKA BLK 4 LT 17ZoDi/ K '
17
i ii!
GREATER ANCHORAGE
-/~,~ )f~ ARIiA BOROUGIt
/
' ' Department of Environm(~ntal Quality
/~/ C,L /~V~L~ -/~500 Tudor Roa~, Anchorage, Alaska 99507 279~.8686
~// Date Received
1. Aoproval Requested
Address:
2. Prooertv Owner:
3. Legal Description:
Location:
'rime of Inspection
Date of Inspection
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
FOR
Phone:
5. Type of Facility to be Inspected:
Number of Bedrooms:
6. Well Data:
C. Construction
7. Sewage Dlsoosal System:
A. %nstalled
D. Bacterial Analysis .:'? t ~__.~
8. Installer
C. Septic Tank: 1. Size
2. Manufacturer
D. Seepage Pit: 1. Size
2. Material
Disposal Field: Total Length of Lines
Distances:
A. Well To:
Septic Tank -----__, Absorption Area__~_,~' ' Sewer Lines
~ , Nearest Lot I.tr, e._~ . , Other Con'tamination
Foundation to Septic Tank ~ '~ Absorption Area
Absorption Area to Nearest Lot Line .."~: ~
~eqJe~:t fo~' Approval of In~ividua] Sewer & Water ?acill~ies
Page Two
Comments
~AP'~vo] VaJ. id for One Year From Date Signed
Greater Anchorage Area Borouqh, Dei-.artment of Environmental Quality
D]iAGRA~J OF SYSTH~M
that the }nformahion contained in this request for approval to be a true
..~esen~at~ ,r of t, he subject sower and watar facilities located
Signed
Date
DATE
NAME
ADDRESS
CiTY
ADDRESS
DEP[ 'MEHT OF HEALTH AND SOCIAL S. qCliS
DIVISION OF PUBLIC HEALTH
BACTliRIOLOGICAL WATER ANALYSIS
INDIVIDUAL [-~ OTHER______
REPORT RESULTS TO
ZIP
CODE
O~_F S_OU R__CE______
SAMPLE COLLECTED BY
Diameter of Well .Depth Feat.
Well Casino
Material Diameter Depth '
READ INSTRUCTIONS
OFFICE
REVERSE SIDE
BEFORE
COLLECTING SAMPLE
Records in this office indicate this WATER SUPPLY to be of:
[] Satisfactory n Questionable [] Unsatisfactory Sanitary Status.
Analysis shows this Water SAMPLE to be:
S~[isfactory [] Questionable [] Unsatisfactory.
__ 1. Notify consumers water is polluted. Boil or chemically
An approved water supply source should be developed.
6, Improve your []spring []dugwell []driven well []drilled well []cistern
__ 8. Sample too long in transiu s~lmpto should not be over 48 hours old at
-- 9. Contact your nearest [] Local Hea~th Department or [~ Alaska
Division of Public Health, sanitation office for bulletins, consultation and
SANITARIAN'S REMARKS
06-1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD
Lactose B rot h ; 10cc 10cc 10cc 10cc 10cc 1.0cc 0.1 cc
24 hours
24 hours
EMB AGAR
-Lactose Broth, 24 hrs, 48 hrs, Gram's stain
-Coliform Density. ~ (Most probable No, per 100cc,)
--MF results r ~
-Detergent Test
--Reported by ? ~
This analysis indicates Coliform Organisms to be:
