HomeMy WebLinkAboutVALHALLA BLK 1 LT 5Valhalla
Block
Lot 5
#015-212-32
STATEMENT OF INSPECTION By ENGINEER
As certified by my seal affixed hereto and as of Ihe validation date shown below, I verify that my Inves[lgaliotl,
based on procedures outlined In the Health Aulhorlly Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system Is(are) safe, functional and adequate for the number of
bedrooms and lyl~e' of structure Indicaled herein. I I'urfl~er Verify {hat based on the Information obtained from the
Municipality of Anchorage files and from my Investigation and Inspection, Ihe on-site water supply and/or
wastewater disposal system is(are) In compliance Wilh all applicable Municipal and State codes, ordinances.
and regulations In effect at the time of installation.
Name of Firm $ & 5 ~.NGIN~ERING
17034 Eagle River Lo~,p Road No,
Address ~.._I,. giver. Alaska 99577
Engineer's Printed Name Robe,:t: C. Co~e.n .
Approved for ~-~
Disapproved.
Conditional approval for
bedrooms.
5. DSD SIGNATURE
Phone
Date
bedrooms, with Ihe J'ollowing stipulations:
Additional Comments
Municipality of Anchorage
Development Sewices Department
Building Safety Division
On-Slto Water & Wastewater Program
4700 South Bmgaw SL
P.O. Box 196650 Anchorage, AK 09519-6650
www.ci.anchomge.ak, us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Desm'lption:
A. WELL DATA
Wall type P,'~
Data completed _~' I<~-/
Total deplll '7 (~ ' ff.
If A, B, or C provide PWSID # _--'
Sanitary seal~J~/N)
Cased to ~o-I' ff.
J'/o Parcel ID:
Wall Log (Y/I~)
Wires properly pmtected~/N).
Casing height (above ground) .. I~,,.+ in.
FROM WELL LOG
Data of tast ,/'"'
Static watar level ._} !~ ff.
Wall preduction / g.p.m.
WATER ,~AMPLE RESULTS:
Coliform O colonies/100 mi.
B. SEPTIC/HOLDING TANK DATA '
AT INSPECTION
ft.
g.p.m.
Nllrata O' 6 ¥&mg./l.
Date of sample:
Olher bacteda _. 0 colonies/100 mi.
Collected by: lNG
17034 Fails Rh~' Loop Roed No. 2L
Tank Type/Matellal
Tanksize ¥O00 gal.
Foundation cleanout (~)
Data o~'pumping 7 '/
C. ABSORPTION FIELD DATA
I
Depression over tank (YJJj~ _fro
Pumper ,~ ./- ~/o~ t
~gle Rl*~er, Almska 99577
Data installed G/~/ ~' ~
Cleanouta (~) _
High water alarm~/N) _
Data installed r Soil rating (g.p.d./lt~ or ~rodrm). System type ~
Lengl~ ff. · V~ldlh .. ft. ~ pipe ft
Total depb~ ff. Eft. absorption ama ~be, Depression over field,
Data of adequacy tast. ~ (Pass/Fall) ~ For bedrooms
Fluid deplh in abso~st in. Water added gal. New depth in
Elapsed Time. ~,.min. Final fluid depth in. Absorption rate >=
~tmatment (past 12 mo.) (Y/N & type) If yes, give data g.p.d.
D. UFT STAllON
Date installed Size in gallons Ma~
'Pump on" level at in. .pu~water alarm level at
Datum ~..-------'---~es tested Meets alan~ & circuit requirements?
F.. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tenk/tiff station on lot N/,~ On adjacent lots I
Absorption field on lot /d lA On adjacent lots / 0 o t-/--
Public sewer main ~/R Public sewer manhole/cleanout
Sewer/septic sewtce line. ~- ,y '~" Holding tank '7 ~ /~'-
SEPARATION DISTANCES FROM SEPTIC~;~L~T~ON LOT TO:
Building foundation '~ O ~4.- Property line I o Abso
Watermain ~/A Water service line 3,:>-f-/- ...~o-~"-udacewater Ioo
Wells on adjacent lots / oO ~
Property line / Building foundation Water main
~dmin Wells on adjacent lots
F. COMMENTS
in.
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer'sPdntedNama /~O,~..Rr ~',
Date ] / 30 / O"z-
HAA Fee $
Date of Payment.
Receipt Number
(R~,. 12~1)
Waiver Fee $
Date of Payment
Receipt Number
F-908
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMEN'rAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
PHONE [] NEW
NAMEI~IhC, LIS~L: :>Wi I;T ~Z/~2.~gS/ ~'UPGRADE
MA, LINGADDRESS 12.220 C5I"//£NAN~OAH
LEGAL DESCRIPTION
VALHALLA ~UL~). LOT ~ ~L~GIL l
DISTANCE TO: ] Well I
Liq. capacity in gallons Well
OISTANCE TO;
IAbsorption area Dweging
Material
Inside length Width
PERMIT NO.
IF HOMEMADE: Liquid depth
Dwelling
Manufacturer
PERMIT NO. ~;~7~.~)~/~.~
Liquid capacity in gal]onsz~ 0¢~0
Well Foundation Nearest lot line PERMIT NO.
DISTANCE TO:
No. of lin0s Length of each line Total length of lines Trench width Distance between lines
inches
Top of tile to finish grade Material beneath tile Total effective absorption area
Length Width PERMIT NO.
Type of crib Crib diame Total effective absorption area
Nearest lot line
DISTANCE TO:
Class Distance to lot line PERMIT NO.
,tic tank Absorption area(s)
DISTANCE TO'.
OTHEI
PIPE MATERIALS
SOl L TEST RATING
NSTALLER ,
REMARKS
AP OVED, ~ ~ F~/~. DATE LEGAL
72-013 (Rev. 3/78)
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L' Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION:.~ ~'/'~/~/~ J'~//'~/'~'//~ ,._~'~"4.~' Township, Range, Section:
1
2
3
4
5
6
7
8
9-
10-
11
13-
14-
15-
17-
18-
19-
20-
SLOPE
SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
S
IFYES, ATWHAT ~. ~t (L)~
DEPTH? p I
E
Oeplh to Waler ADer
Monitoring? Dote:
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE
(minutes/inch) PERC HOLE DIAMETER
TEST RUN ~ETWEEN FT AND FT
I CERTIFY THAT THIS TEST WAS PERFORMED iN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFEC¥ ON THIS DATE. DATE:
72-008 {Rev. 4/85)
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L' Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
DATE PERFORMED:
'7
1
2
3
4-
5-
6-
7
8
9-
10-
11
13-
14-
15
16
17
18
19
2O
Township, Range, Section:
SLO
WAS GROUND WATER
ENCOUNTERED?
s
L
IF YES, AT WHAT
DEPTH? ~ ,~) O
P
E
Oepth to Water Alter
MonitorinD? . Date: __
SITE PLAN
Gross Net DePth to Net
Reading Date
Time Time Water Drop
PERCOLATION RATE __
(minutes/inch} PERC HOLE DIAMETER __
COMMENTS ,~°
FTAND FTz-
PERFORMED BY: ~ ~_C~ (/ I CERT FY THAT TH S TEST WAS PERFORMED"
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EF~EC~ ON THIS DATE. GATE: ~/~ ~
72-008 (Rev. 4/85)
May 26, 1987
MUNICIPAL Ty OF
ENVIRo,~,,~,._ ANCHoRA~
' ""'~-"~fAL SErVICEs OiV;$'~i~ON
RECEIVED
Mr. Stephen S. Morris
Department of Health and Human Services
Municipality of Anchorage
825 L Street
Anchorage, AK 99501
Re: Proposed Holding Tank
Lot 5 Blk 1 Valhalla Subdivision.
Dear Mr. Morris:
I completed to test holes on the subject lot on May 21, 1987 and
found the existing soil to be unacceptable for placement of a
drainfield, mound system or a bed system. The soil is organics
overlaying a very silty sand (hard pan). Water was encountered
at 5.5 feet in Test Hole #1 and 3.0 feet in Test Hole ~2. I
cannot find a place on the lot whore an onsite system could be
placed without encountering some physical conflict or poor soil
conditions.
My reco~aendation is to use a holding tank. At this point, I see
no other option.
After discussion with the owner, Marlene Swift, a 4,000 gallon
holding tank has been selected. The holding tank will be placed
directly in line with the septic ta~ and 5 feet west of the
septic tank. The septic tank will remain in service with
effluent flowing into the holding tank after primary settling in
the septic tank. (see attached sketch) A flow level indicator
(alarm) allowing 48 hours storage will be installed.
I am also attaching the soil logs for the two test holes.
ENGINEERING, PLANNING, SURVEYING
2220 E, 88th Ave./Anchorage, Alaska 99507/Telephone 907-349-6451/344-1352
"Providing a quality personalized service to those building Alaska's future"
.... ~f2 ,(/ 0 / d
z
(%0
/~0(
x,
C '~o P ~ 7,, d
/ unicipaslty P.O. 3X 196650
ANCHORAGE, ALASKA 99519-6650
O~ (907) 264-4111
Anchorage
MA YOFt
DEPARTMENT OF HEALTH & HUMAN SERVICES
May 7, 1987
Marlene Swift
12905 Chapel Drive
Anchorage, Alaska 99516
Subject: Septic System Serving Lot 5 Block 1 Valhalla S/D
Dear Ms. Swift:
I have enclosed a copy of our list of approved engineers and a
copy of permit requirements for on-site wastewater disposal
systems. Our walk-through inspections of the septic system on
the subject property indicate that the system is in a state of
failure. On April 17 sewage discharge was observed on the
ground near the septic tank standpipe. The tank was pumped a
few days later. Approximately three weeks later the septic
system was again inspected. Although there was no evidence of
recent overflow, fluid levels in the standpipe were near ground
level indicating that overflow was imminent. The tank and
absorption field should be pumped immediately to prevent
further sewage overflow. These observations indicate that the
septic system has failed.
Please contact one of the engineers on the list provided. The
engineer should be able to provide you with some options to
remedy this problem. Normally the engineering work required to
investigate the cause of septic system failure and obtain an
on-site permit takes less than two weeks.
Thank you for your cooperation in this matter. If this
Department can be of any assistance regarding the upgrade of
your system please let us know. Your prompt attention to the
matter of upgrading this failing septic system will be
appreciated.
Sincerely,
Stephen S. Morris
civil Engineer
On-site Services
CC
Gus Andresst P.E.
Manager, On-site / Water Quality Programs
Larry Montgomery, Environmental Sanitation
GRE ,,'ER ANCHORAGE AREA BOkvUGH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska ggs03
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
SEPTIC TANK:
DISTANCE gOr~ J~JO~
WELL '~ t~
FROM ~
INSIDE LENGTH
INSIDE WIDTH LIQUID DEPTH
N '(~.~.. I NUMBER OF
· 8LI:~ COM PA RTM ENTS ',,~
_ LIQUID CAPACITY J~OI) GALLONS.
'~i~' DRAIN FIELD:
*' I
,',.t.~.- t, ~ ~ --' TOTAL LENGTH ~'~ . J
DISTANCE FROM WELLJ~'~FOUNDATION ~ ~ NEAREST LOT LINE ~O ~ OF LINES
NUMU~R OF L,h~S t~D,ST*NC~ ~STW~SN L,N~S ~I~TR~NCH WIBTH~IN TOTAL EFFECTIVE
ABSORPTION ARE~/~ ~ SQ. F~. LENGTH ~H LINE ~ I '
J DEPTH OF FILTER
DEPTIh TOP OF TILE TO FINISH GRADE ~ MATERIAL BENEATH TILE ~ IN. ABOVE TILE
TYPE CONSTRUCTION DEPTH
BUILDING NEAREST NEAREST SEPTIC SEEPAGE
FOUNDATION__ LOT LINE SEWER LINE TANK , SYSTEM
CESSPOOL OTHER SOURCES
APPROVED DISAPPROVED REMARKS
DISTANCE FROM:
DISTANCES:
INSTALLED BY: 'J~'@'g/~L~.~J~)'~'~t~'S
SEWER LINE DEPTH:
PIPE MATERIAL:
LOT SLOPE:
REMARKS:
DIAGRAM OF SYSTEM
DATE~ APPROVED '~1 G)A,A.B.
Form LQ-032
l].,.ll EL< IL.. It .....
PERMIT' NO. ,:: '77~2]F79 )
DE1,:'I::I1,,;:TMENT :' I.-IEALTI-I I::IN[:, li~]'.,!',,,'II'4:1.]I'.4MEI'.,I'T'RL ROTE1.ii:TION
25::1..6 E. fUDOI:;;'. RI:,.., FINCH1.)RI:IGE, Ir:l[':::. ::......,5EI7
IF:Il lb..It
FIP F:'I.. I CFINT
I..OCFIT ]; ON
I~.E(:iFIL.
D F:II'.,I 1.4 ;1, E:'~;E
E;HENRI'.,I[:,O FI FI'..,' E
L5 E:::L ',,,'1,:IL H R L.L R
~;1:?.1::1 :t54.21.4 RI'.,tC1,4ORf:II]iE
1._.OT 5;:[;-!~E 2~:E~E~C~C~ SI:;!L.II::IRE FEET
TYPE C)F:' ~k]O):l... FISSORBTICflq ~;'~;'¢:E;"I"EM ]:~;: TRENCH
FIR',,.,',IMUM IqLIME:EF.: OF BEDROOMS
SOIl_ I;.:FI"rII'qG (~!~;1~! FI",.,'DR)= ::l.J. 5
THE I:~'.E6!U :[ RED S I ZE OF THE SO I I... FtSS:1.)RPT :1, C'llq S'¢STEM I ;;;:
"rile LIEN(~iTId 1.) I HIENE; ]: ON I E; THE L. ENGTH ,:: Z N F'EET) OF THE TRENCH 1,]R E:,I:;;'.F'I Z NF: 1' El_.[::,.
['FIE 1.)EF'TH OF I::1 'TI:~:ENCH OR F'ZT I:E; 'T'tfllE DISTF:INCE BETI.,.!EEN T'HE '.EgURF'R1.::E OF THE
GROIJN1.) FIN[;, TH1,:': 81.]TTCff,1 OF THE E',:.::CR',,,'FITIOI'.,I ,::IN FEET::,.
'['HIEI:~:E :1,:5 NO E;ET !.,O:.[:,TH I::'OR "FREI,,tCHES.
THE GI:~:I::i',,,'I~[I.... E:,EPTH IS THE MIN]:i',IUM DEPTH (::iF' GRFI',,,'EI.... BE:'T'!.qEEI'.,I THE I]IJTF'i::d...I... F:'IF'E
FiI'.,![:, TI4E 13OTTOM 1,)F THE Ei',,:1,:;FI',/WI"~[ON (ZN FEET).
13FICKF I I..L :[ NG 1,IF RN"r' :~:;"r":'5'T'EM 1.4 Z THOUT F' :1: NFIL I 1",I:SF'ECT I ON I'":Ii",IE:, I:"iPPRO',,,'RL B"r' TH Z %
I}EI::'FIRTMENT I.,.IILI._ IF.:E SUBJECT TO F'ROSECIJTI1.]I'4.
MINIMUM 1.)I'}.;'1.'I::INCE BE'1.]4EEI",I F:I WELl_ RND FIN'[ OI",I-SITIE SEI.,.IFIGIE
:IJ;Z~,Z~ FLEET' FOF..' R PRI',,,'RTE WELL 1,IR ;;;:~;!]lb FEET I:::'OR FI F'U[4:/L:1'C [414:LL..
I, IIELL L..OI]i$ FIRE RE(;!UIRE]]' FIN[:, MUST BE: RETLII~'.NE1,) TO THE DEF'FIRTI'qEN]' 14ITHIN
OF ]"I41E 1.4ELL.. CCIMF'L..EI-I(]I",I.
%F'EC:[i::'IE:I::tTIONS 1.::IND 1.:~OI'.,I%TRUC]~ION [:,IFIGRRM:E; FIRE FI',,,'FIIL1,::IBLE TO ZNSI_JRE PF~:OP1.-'U.R
I IqSTFI1,..LFIT ]: ON.
I CERTIF"r' THFIT
i: I FI['1 F'RMI1,_IF:IR I,.IITH THE REQUIREMENTS FOR ON-SITE SEWERS Fl['41:::, 14E1...L.S RS :.'~;E'I~
1,::CIR'T'H B'.¢ ]'HE MUI'.,IICII::'FIL. I-1,"¢ (;IF RNCHORFIEiE.
2: Z P.IIL. I... II'.,I:~TRI...I._ THE :E)r'STEM IN I::tCCOI~!DRNCE 1.4ITH THE C:ODE:~;.
3:: I UNE)ER%Ti::INI} TH, I::IT THE OI'.~-'.2, ITE SEI.4ER ~.;'~".5"FEI','I I"1,1=l"r' RE6!LIIRE ENLFIRGEMENT IF THE
RE%II}IEN1.}~:1,-Zf,'IO[:,E1...E[:,?~INCL.1.J[:,E MI]1,;~:E THFIN.~ Z~ IBE~I}ROCd"tS.
FIF'F'L. I ~T [:,FIN 1.41E:SE
TH-1
-22-77
~ ORGANIC MATERIAL
'~1 Dark Brown, Vo. ry Hoist
~J .................... 3.0'
SILT W/SO~ SAND
Moist, Occasional. CQbble
5.0'
SANDY SILT
W/TRACE GRAVEL
Moist, Medium Dense
SILTY SAND
W/TRACE GRAVEL
Moist, Medium Dense
].1.0'
........ 20,0'TD
q?l~ - 2
2-22-77
ORGANIC MATERIAL
Dark Brown, Hoist
SANDY SILT
Brown, Moist
SILTY SAND
W/TRACE GRAVEL
Hoist,
Boulder at 9~'
.................. 10.0'
SILTY SAND
W/SO~,U{ GRAVEl,
Very Moist, Dense
....... 20.0'TD
These logs represent subsurface sell
conditions within ]hots 4 and 5, Block l,
Valhalla Subdivision, Anchorage, Alaska
(;R~D 2736
PROJ ,'~0 75] 111
OwG ~;0 A 02
TH-2
PERCOLATION TEST
Lot 5, Block 1, Valhalla Subdivision
Anchorage, Alaska
R & M NO. 751111
ELAPSED
TIME TIME INCHES
2:53 0 12.00
2:54 1 13.50
2:55 2 14.00
2:56 3 15.00
2:57 4 15.25
2:58 5 16.00
2:59 6 16.50
3:00 7 16.75
3:01 8 17.25
3:02 9 17.75
3:03 10 18.00
3:08 15 19.50
3:13 20 20.50
3:18 25 22.00
3:23 30 23.25
3:33 40 25.00
3:43 50 26.25
3:53 60 27.75
DROP IN
INCHES
0.00
1.50
2.00
3.00
3.25
4.00
4.50
4.75
5.25
5.75
6.00
7.50
8.50
10.00
11.25
13.00
14.25
15.75
3.81 Minutes Per Inch
LOT G
LOT 5
LOT 4
T}I-1 ,'~ X , ¢}
LOT 2
LOT 1
}[UFFHAN ROAD
Test Hole locations are approximate
and have not been located by
survey methods.
valhalla Subdivision,
Anchorage, Alaska
.~/.,. ...... SI.PIER '?EST HOLE
February 23, 1977 R $, M No. 7511] ]
Hr. Dan Wiese
SRA Box 1542W
Anchorage, Alaska
99507
Test Hole and Soil Log Report for Sanitary System
Lots 4 and 5, Block 1, Valhalla Subdivision, SW¼, Section 22,
Ti2N, R3W, S.M. Anchorage, Alaska
Dear Mro Wiese:
We are submitting herewith the test boring results and our comments
regarding soil co~d~tions encountered at the subject site. This
investigation was performed Jn accordance with your request of
February 17, 1977 and those procedures outlined in a letter dated
July 15, 1975, by Mr. Roll Stick]and of the Municipality of Anchorage,
Departmeat of Environmental Quality.
A single test hole was bored on each lot within the subject area for
the ?urpose of defining genera] subsurface soil conditions for the
proposed sanitary systems. Excavation was accomplished with an auger
type drilling rig and each test hole was extended to a total depth
of 20 feet below grou~ld surface. The final logs prepared for the
test holes have been included ~n Drawing A-.02.
Groundwater was encountered in each test hole while drilling. III
Test Hole 1, groundwater was encountered at 13 feet. In Test Hole 2,
groundwater was encountered at 14 feet below ground surface.
A percolation test was performed from a depth indicated and reflects
average infiltration from that depth to the bottom of the hole.
We appreciate being given this opportunity to be of service to you.
Should you have any questions with regard to the above, please do not
hesitate to contact us.
Very truly yours,
R & M CONSULTANTS, INC.
James W. Rooney
Vice President
~R/pe
xc: Municipality of Anchorage
DEPARTMEN
825
MUNICIPALITY OF ANCHO..
}F HEALTH AND ENVIRONMEP, PROTECTION
1, Street, Anchorage, Alaska:' 99501
264-4720
ttl: Time _~F~Cr~ #2: Time
Insp~~ Insp
REQUEST FOR APPROVAL OF
Date Received: September 20~ 1977
It3: Time
Date
Insp
INDIVIDUAL SEWER AND WATER FACILITIES
Lending Institution Request:
Mailing Address: :
First National Bank of Anchorage
Phone:
2. Property Owner: Daniel G. Wiese
Mai~J. ng Address: Star Route A Box 1542W 99507
Phone:
344-0149
279-8686/302
3, Legal Description: Lot 5 Block 1 Valhalla Subdivision
4: Single Family Residence: (x) Number of Bedrooms: Three
Multiple Family Residence: ( ) Number of Bedrooms:
Well System: Individual Well (x) Community/Public System ( )
Permit It 77079 Depth of Well 76' Well Log on File
Construction BacterJ.al Analysis
( )
Sewage Disposal System:
Permit ~ 77079
Septic Tank Size
Absorption Area
On-site System (x) Public Utility ( )
Installed 1977 Installer ~~'~
____/_ ~.~,~ ~) Manufacturer __ ~ ~
~.. (~q SoJ. ls Rate ~ I ~ Material J~I~t~F/
Distances: Well to Septic Tank to Absorption Area
to Sewer Line Nearest Lot line Absorption Area
to Nearest Lot Line
Pag9 Two
DepartmenL of Health and Environmental Pro~:ecL.ion
Request for Approval of Individual Sewer and Water Facilities
Legal Description: Lot 5 Block 1 Valhalla Subdivision
Commen%s:
Affadavit Attached: ( ) Le'hter Attached: ( )
Approved: _-- _~ .......
Disapproved: Date:
Department Worksheet
MUNICIPALITY OF ANCHORAGE ,
Department of Health and Environmental Protection
! 825 L Street, Anchorage, Alaska 99501
/ 264-4720
-~' 7/~
~-~/~'-- ~quest for Approval of Individual Sewer and Water Facilities
Property Owner: ,~_.~. ~ ~. ¢_~.~- ~,~..
Mailing Address: -~dL~ ;,q-~,~/¢~ ~., ~> Phone:
2 o
Name of Buyer:
Mailing Address:
Phone:
Mailing Address: ~l~, :, .2.X,.~,~,......_>~ Phone:
Realtor/Agent:
Mailing Address:
Phone:
Legal Description:
Street Location:
Single Family Residence:
Multiple Family Residence: ( ) Number of Bedrooms:
7. Water Supply: *Individual Well (~) Public/Community System ( )
If Individual Well, well depth ~ ~
If Community System, name of system
Sewage Disposal System: On-site System (~ Public System ( )
If On-site System, date of installation: ~ - ~ ~
*NOTE: A well log is required on ALL wells drilled since 6/75.
3/77
ADHW - LAB - 2W
I hth/. 7'
STATE OF ALASKA
DE 'RTMENT OF KEALTH AND WEL! ~,E
DIVISION OF PUBLIC HEALTH
BACTERIOLOGICAL WATER ANALYSIS
OFFICE
SANITA RIAN'S REMARKS
When?
READ INSTRUCTIONS
ON
REVERSE SIDE
BEFORE
COLLECTING SAMPLE
BACTERIOLOGICAL. WATER ANALYSIS RECORD .,/~
.1"' --'/ ~L.h~""' .'.
Lactose Br of],J ·IOcc J 10~c J0¢¢ 10 JOcc [.0¢c 01¢c
Brillia nl Green
24 hours
48 hours
EMB AGAR
MF results