HomeMy WebLinkAboutZODIAK MANOR ALASKA BLK 6 LT 11.Zol:) iA K ..
............ · :'<~¢:'::: '~c c:.::; ENVIRONMENTAL PROJECTION
"" ~ .................. :'~'":~"':"~ ' .... ' ' JAN ,5/979
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ACHIi'::MICAL ~ (~EOLOglOAL LABORA'FOI~.8 OF A[J~KA~
P.0, BOX 4.1:;776 4649 BUSINESS PARK 81,.VD,
ANCHORAGE, ALASKA 99509
TELEPHONE
(9O7) 27{)-4014
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
City State
Zip Code
Mo. Day Year
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
Treated Water
Untreated Water
SAMPLE
NO. LOCATION
1 I L // '~/r~
4 l
Time Collected
Collected By
TO BE COMPLETED BY LABORATORY
LABORATORY:
NAME
ADDRESS
CITY
Date Received ¢0¢
Time Received /, :~ D"~)
Analytical Method:
Fermentation Tube
XMembrane Filter
Lab Ref. No. Result* Analyst
J
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Form No. 18.310 (3-78)
06-1220 ~)
Date CoJlect ~d
Flna~ Membrane
BACTERIOLOGICAL. WATER ANALYSIS RECORO
~ Co[Iforrn/1O0rnl
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATE. R FACILITIES
(['ill out in Triplicate)
requesting approval /~, /~/~
4. Numbe~. nf ~drooms in house
S, Uater. Analysis:
a. Bact~mlal
b, Detergent
We]] data:
a, Type .... ~
b. Depth
c. Casing Size
Distance from well to closest existing or proposed:
1. Sewer line
2. Septic tank -----
3. Seepa?e Area_/~I
~. Cesspool~__L __.
5. Property Line
6. Other sources of possible contamination, i,e.~ creeks, lakes,
houses, barn, ra~nage ditch, etc.
d '
7, Sewage disposal system.
a. Age of system .....
b. Septic tank capacity in gallons,_
c. Name of septic tank manufactu~e.r
1, If "home made" show diagram on reverse side of this form,
d,' Disposal field or seepage pit size and
type
1. Distance to property iine ..... to house foundation
Pefco] at.[ em, T~st
f, Per¢oie'tion Tear performed by~
Use the reverse side of this form to show diagram Diagram should include
1;he foJl.owinf information: p?operty lines~.well location, house location,
n'>y~c tank ].ocatJoa, disposal area location~ location of percolation test~
at~d direction of ground slope,
The ~P~rma*ion on thi%~qrm is true/and correct to the best of my knowledge,
T_O._BE FILLED OUT BY HEALTH DEPARTqENT
The above described sanitary facilities are berek¥ approved, subject to the
Conditions:
The above described sanitary facilities are disapproved for the following
Approval is valid for one year following the date of approval.
CPJ:cw
DATE
D' 'MENT OF HEALTH AND WEL
DIVISION OF PUBLIC HEALTH
BACTERIOLOGICAL WATER ANALYSIS
PUBLIC [] SEMIPUBLIC 0 INDIVIDUAl E~ OTHER
REPORT RESUL1S TO
or SOU~*CE ¢ {' , ), , '
Records in Ihis office indicate Ihis WATER SUPPLY 1o be ol:
........ sal water supply ol a I t n es
l~J~J --4. ff ,,fle~ chocking equipment ,, d . ec g reskluc~l is noJ obtained
SOURCE: 0 Spring [] Cislern J] Olhor
SANITARIAN'S REMARKS
An opproved water supply source sJ~ould be developed,
6. Improve your [] spring [] du9well ~-~ driven well
[] drilled well [] cislern.
READ INSTRUCTIONS
ON
REVERSE SIDE
BEFORE
COLLECTING SAMPLE
BACTERIOLOGICAL WATER ANALYSIS RECORD
/
'"TMENT OF HEALTH AND WE[
DIVISION OF pUBLIC HEALTH
BACI'FRIOLOGICAL WATER ANALYJI$
~ Safisfaclary E] Questlo,mble (~ Unsa/islaclory.
Sarnplo Coflecled From [ } Kitch.n Tap E~ I~,throonl I'ap ~] ~senlen/ Tal~[
Wails - [~ Wood C] Concrete C~ MelM D Tile [] Concrete
5. This is a surlace water source and subject Io poJlulJon by ['non and animals.
An opproved waler supply source should bo developed.
6. Improve your ~ spring [] dug well C] driven well
SANITARIAN'S REMARKS
READ INSTRUCTIONS
ON
REVERSE SIDE
BEFORE
COLLECTING SAMPLE
BACTERIOLOGICAL WATER ANALYSIS RECORD
EMIl
Ladose Brolh, 24 hrs
Coliform Densily--__
MF results