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HomeMy WebLinkAboutGORDON LT 1A-1 MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCI-IORAGF  DEPARTMENT OF HEALTH & ENVIRONIVIENTAL PROTEC'rlON r~r-~ ~ ........... B25 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL ENVIRONMENTAL ENGINEEFIING DIVISION (~ ,¢.Dr2r r~ Telephone 264-4720 ol24 0 ~ REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWE~I~]~ D 1 PROPERTYOWNER ~- ~ . ~ PRON~~ MAILING ADDRESS ~-~0"'~ --~ ' ~, BUYER ~ PRONE / MAILING ADDRESS 3, LENDING INSTITUTION ~ PRONE MAILING ADDRESS MA~G AD~R ESS , ........... . 5, LEGAL DESCRIPTION STREET LOCATION 6, TYPE OF RESIDENCE NUMBER OF BEDROOMS ~ One ~l Four ~ Other ~~ SINGLE FAMILY ~ Two ~] Five ~ MULTIPLE FAMILY ~ Three Six 7. WATER SUPPLY INDIVIDUAL* COMMUN TY [] PUBLIC UTILITY SEWAGE DISPOSAL SYSTEM tNDIV DUAL/ON-SITE PUBLIC UTILITY ATTACH WELt. LOG, A well log is required for all wells drilled since June t975. For wells drilled prior to that date, give well depth (attacl~ log f available,) **If individu~d/on-site, give installatio~ date If system is over two (2) years old an ac~equacy test is required hy this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED, THIS SIDE FOR OFFICIAL USE ONLY INSPECTION APPOINTMENTS 'IME TIME DATE DATE INSPECTOR INSPECTOR DIRECTIONS: DATE RECEIVED TIME DATE INSPECTOR 1. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY NUMBER OF BEDROOMS {~ ONE [] THREE [] FiVE E3 OTHER [] TWO [] FOUR [] SIX PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 2. WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM E~] INDIVI DUAL/ON -SITE []PUBLIC UTILITY Connection Verified []Septic Tank or []Holding Tank Size: If Tank is homemade give dimensions: PERMIT NUMBER DATEINSTALLED INSTALLER SOILS RATING TYPEOFTANK MANUFACTURER TOTALABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Absorption Area to nearest Lot Line Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line 5. COMMENTS DATE LEGAL DESCRIPTION 72-010 (Rev, 3/78) · CHEMICAL & G~.,£OGICAL LABORATORIESv.F ALASKA,.__ INC. ........ ~ Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER WAT -'R SYSTEM [-I1 I I I I I.D. NO. Water System Name Phone No. Mailing Address City State Zip Code Mo. Day Year SAMPLE TYPE: [] Routine [] Check Sample (for routine sample wlth lab ref. no. [] Special Purpose [] Treated Water [] Untreated Water SAMPLE NO, LOCATION Time Collected Collected By TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: [] Satisfactory [] Unsatisfactory [] Sample too long in transit; sample should not be over 48 hours old at examination to indicate reliable results. Please send new sample. Date Received Time Received Analytical Method: [] Fermentation Tube [] Membrane Filter Lab Ref. No. Result* Analyst I~ JFTq JE%-] J i F-Tq *No olcolonles/100rnl or NO of Positive READ INSTRUCTIONS BEFORE COLLECTING SAMPLE 06-1220 (b) Rev. 1978 BACTERIOLOGICAL WATER ANALYSIS RECORD Date Collected Source. Date Received Time Received p.m, Lab. No, Presumptive 1Omi 1Omi 10mi Z0ml ].Omi 1,Omi O,lml 24 Hours 48 Hours Confirmatory 24 Hours 48 Hours EMB. Broth 24 hours: Multiple Tube Report: Membrane Filter= Direct Count Verification: LTB Final Membrane Filter Results Reported By Broth 48 hours: 1Omi Tabes Positive/Total ~,Oml Portion! Collform/3.00ml BGB Date Collform/ZO0ml (.?)?) *i,'1 ,~ 1 t I i)ecembet' 5, 15)80 Skel] (;©cns Anchol:aqe, Alaska 99503 St~b'}ecL: [,eL IAi {;ocdon Stfl)divisJon 'Phis del)a]rtment: has no objection in conve]-hing the existing individual we]] Lea public well - Class C as long as the subject_ il. oh call be resubdivJded. lii~ there a}'e any ~ucthoc questions, [)]_ease call this ()?[ice at 264--~720. Sincere]y, Robert C. Pratt, Associahe SpecialisL RC P/1 j w