Loading...
HomeMy WebLinkAboutEAGLE RIVER HEIGHTS BLK 2 LT 31 Mr. l)wiyne Le~ P.O. Box Z0 ~ ~%lr. Lee: RECEIPT FOR CERTIFIED MAIL--30~ (plus postage: O'T'ONALSIE*VIG[$ FOR AODITIO#AL [iE,S PS Fo.. 3800 ~ NO INSURANCE COVERAGE PROVIDED-- (So, other Apr. 1971 #OT FOR INTERNATIONAL MAIL *oPO:Z~r~ 0.4eO-V4S It h~ been brou~t to our &Uentic~ thud publie t~wd~ is mmflfbl, to Blo~k ~, Lots St and 32, Eagle Itiver Hei&,hts Subdivision. Ao0ox~Ln~ to Greeter Anchorefe Area l~Fou~h Or,finance. Chapter 18, Article 16.4.5, Se~tlim 16.L5.050: ."Septic ~ank-aee~a~e syetem ~ewage dlai~ f~fllltlaa shall not be instilled oF .usod on any premtm where s~ttary ~ewere m &volisbis within ~vez~' (TO) feet of the n~m'eet lot line or The Greeter Aneho~eg~ At~ee Borough Public Works D~t h~ ~ ~ ~ ~ ~t~ ~er. W~ ~ pl~ ~ ~ ~ ~ ~ t~ ~e st~u~(s) is or Is ~ ~ md 'h~ ~. I~ we do not hear from you w!thl~ o~ve~ (7) ~ ~ a~ ~r~. ~e. ~eFef~, ~u~ ~ ~8 ~ ~ the m~J~ p~ must ~ppl~ for a oo~msetion permit from ~e ~it ~ ~ ~e .O~ ~r~ Ar~ ~, 3500 E~ Tud~ ~. If~ h~ ~~ ~ ~ ~T4-~81, e~ 141. John Lee Xarle Rtv~ D~h. tet $~nittri~n MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P,O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # ~r'?-(, ..~,-. -~ ,~ 1, GENERAL INFORMATION Complete legal description Lot 31; Block 2; Eagle River Heights Subdivision Location (site address or directions) 10219 Caribou, Eagle River, Alaska Property owner Mailing address Lending agency Mailing address P{c~ n~ay Day phone P.O. Box 4069, Eagle River, Alaska 99577 NATIONAL BANK OF ALASKA Day phone ATTENTION: Jeanette 257-30~4 Agent Address Day phone 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup, 4 NOTE: Individual well XXX Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site Holding tank Community on-site Public sewer xxx If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. Se Se STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. S & S ENG[NEE,~ING 17334 Eagle River Loop I(oad No. -;'04 ~aa_le River. Alaska 99577 Name of Firm Address Engineer's signature .~ SIGNATURE ~ Approved for ~:~'--{/' edroom~. Disapproved, Conditional approval for Phone. Date bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DH HS does this as a courtesy to purchasers of homes and their lending institutions in order to satisf'/certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. , Municipality of Anchorage DepaYtment of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST A. WELL DATA Well type Log present (~VN) Totaldepth Sanitary seal.N) If A, B, or C, attach ADEC letter· ADEC water system number Date completed Cased to ~ T.- ~ Casing height Wires properly protected {~'N) AT INSPECTION g.p.m. '~, ~ FROM WELL LOG Date of test ~ 'q ~,1 Static water level ~o~ ~.. Well flow '~,o ~.~'l'. Pump level OIZ-~ ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot ~ ~,~. Absorption field on I~)L Public sewer main ~ '~"~ ~ S~. er service line .~ ,.~'~ WATER SAMPLE RESULTS: Coliform ~ ~ ~"/~,~,....X. Nitrate Date of sample: ~ ~ I 0 -. '/7.-. B, SEPTIC/HOLDING TANK DATA Collected by: Other bacteria ~-~o,,J E S & S ENGINEERING 7034 ~agl® River t.._~_ E~gle River, Alaska 99577 Date installed "' Tank slze Compartments 'i~'/N) '* ......:;" 'Foundation cleanout (Y/N) Depre )~rt~ Cleanout. s High water alarm (Y/N) ' ' ' ~' "* Date of pur~ping : ~~Pumper SEPARATION DIS lNG TANK TO: Well(s) on lot ~ " On adjacent lots Foundation ~ "Absorption field .Wate~:main/servic~ Ii,ne- ....... Surface water/drainage c. .CONTINUED ON BACKPAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level Meets MOA '~*lectrical co~ ,, / / ,, r~: ~'-SEP~/ANOE FROM LIFT STATION,T,O: eW~o~ lot~ ' * · On adjacent lots D. ABSORPTION FIELD DATA Manufacturer Manhole/Access (Y/N) "Purnpon"le~elat ' ~e~ Surface water ; Date ihstalled Lengtt,,~ _. Total absorption ~r. ea Depression,over fleid (Y/N) Soil rating System type Width ~ Gravel thickness Total depth Cleanouts present (Y/N) Date of adequacy test ~ bedrooms Re~u[ts (pass/fail) Pero~/de treatment (past 12 months) (Y/N) j.~lf yes. give date':'~ SEPARATION DISTANCE.:,, - FROM ABSORPTI~ON~IELD TO:. ~ ., I' L W~II onlot - , ' _Ch~adjace~t lots Prop, ertyline ~, To build~n~ foundation~_~ To existing or abandoned sy~t~,m on lot,_ On adjacentlots ~' Cutbank, Water main/se~iceline : Sudace~ Driveway, parking/vehicle storage area ENGINEER'S CERTIFICATION . I ce~i~ that I have checked, verified, or confo~ed to all MOA and H~ guidelines I~ effect ~n~___the date of'this inspection. Engineeffs Name HAA Fee $ Date of Payment Receipt Number Waiver Fee: $ Date of Payment Receipt Number CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE. ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301 AIIAL~$I$ R~$UL~$ ~oz I~OICE ! $8227 Che~eb REA.! 92.4915 SeaRle ! S ~tztz: WA~ER Client ~ample ID = t31 02 ZACLE RIVER ES $/D P~JID : UA Collected ~ecetved : Pze:etved vita : AS REQUIRED inalyitt Completed : StP 14 92 LabotatoEy Super[tso~ ~PHER C, EOE Client Acct :$H$ENSP IPOI : EOf :MOME RECEIVED PareMter RetuXtl U~t8Netted Allowable Lt~tts ........ ;i~;~;:; ........................................ -~ ....... ;il ........ ;;;';~;~ .............. i; .......................... ROU?I~ SAMPLE C0£[EC~D ?ettt Per[ozMd * See $~ectal Instructions Above UA-U~avatlable ~one Detected ** ~ee ~mple ~eMtks Above Rot i~l~ea LT-Lets ~Sr~qS Member of the SGS Group (Sociate Oan~rale de Surveillance) SAMPLE TYPE: ~ Routine .~: ri Check Sample (for routine sample '; with lab ref. no. '~ ) I-I Special Purpose ~*T /' [] Treated Water [] Untreated Water ,. SAMPLE ~me Collected TO ~BE COMPLETED BY LABORATORY ~Analy$1s shows this Water SAMPLE to be: /~Sa~sfactory ':' r'l Un;:atisfactory ~, [] ,S~mple too long in transit; sample should not be over 30 hours oki at examination to (ndicate reliable results.' Please send new sample via special dative.r/mail Time Received 15Db. Analytical Method: Membrane Filter *. 'No. of colonies/100 mL No. LOCATION Collected Lab Ref. No. Result* Anely~ A l"l I~.C. ~;~//~Y/~ BACTERIOLOGICAL WATERANALYSISRECORD MM~lorlne Filler: Direct Count Coliform/100 mi BEFORE Verltrlcatlon: LSB BGB Fecal Colllorm Conflm~allon COLLECTING SAMPLE Flnll Membrane F~eeult. // \ Reported By ~',',~'~' ~ "'~ Date TNTC = Too Numerous To Count ~' OB = Other Bacteria ~ ~ PART ONE OF TWO REHAIND~R TO FOLLOW Collformf~O0 mi lance) .~PPLIC-".~IT FILLS OUT UPPER HAt~.ONLY Address Zip Code Type of Resl~nce ~ ~mm~lty / For wells eill~ prior to Ih~ date. give well depth (attach I~ ff available). Sewer Disposal , ~ ~lndlvid~l ~ ~ ~ Year IndivMual Installed: ~ Public ~llily When ~mected to Public Utility: NOTE: THE INSPE~ION ~E MUST ACCOMPANY EACH RE~EST BEFORE ~ESSING CAN BE INITIATED. Time Time Time ~"/' :/~,~' "q// Time Da,e Oa,o Dale / ~--i0--:~' Inspector Insp~lor Insp~tor Insp~tor , ~ MUN1CIPALI~ OF AN~O~GE RECEIVED ( ) APPROVED ~DROOMS 'CONDITIONS OF APPROVAL { ~ , CONDIT~NAL APPROVAL* ~~ . I -- DATE J~--I~--~ ~~~ ~ ~lls Rating Date ~wer Install~ Well To ~sorption Area Well L~ Received o Well to Tank Septic T~k Size Jennifer Lezak 28 Caribou Eagle River, AK 99577 SubJect~ Lot 32, Block 2, Eagle River [teights Approval for the individual sewer end water facilities cannot be granted until the following items have been completed~ · Expose well for our inspection to determine proper .~onstruthe ction, also to insure minimum distan~.e requirements ~po~are met between the well and sewer system.~ noted discrepancie., have been corrected, l~ there are any further questions, please call this office at 264-4720. Sincerely, CW64/eJ/E1 Cory Willis, R.S. Acting Sewer & Water Program Manager .CHEMICAL & CE~,OGIC,4L L,4BOR,4TORIES'~"'~ ,,IL,4SK,4;.~iN¢. e (907) 562-2343 ANCHORAGE JNDUSTRIAL CENTER . ~*~[ ' " 5633B Street , _ .?*., Drinking water Analysis Report for Total'Coliform Bacteri~ TO BE COMPLETED BY WATER SUPPLIER WATER SYSTEM: /¢ ,.o.,o.//' Water System Neme SAMPLE DATE: SAMPLE ~PE: D Routine ' D Ch~k ~ple (for with I~b ~f. no ~ S~lal SAMPLE NO. 1 TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: .,.. J':"l Satisfactory [] Unsatisfactory [] Sample too long in transit; sample should not be over 48 hours old at examination to indicate reliable results. Please send new samble. Date Received ~',~Tlme. Received,.., Anelytlcal Method:" ,,-. ',El Fermentation Tube ~, ~Membrane Filter Lab Ref. No. Result* I'.:' ~,'o~.~,.,.,oo~ *,ho o,,~,,,~,,,o,,, Analyst READ INSTRUCTIONS , ........... soe*ltl, o Cot ..... BACTERIOLOGICAL WATER ANAr~YSIS RECORD BEFORE OOLLECTING SAMPLE DATE RECEIVED · INSPECTION APPOINTMENTS DATE DATE t~, ~. INSPECTOR ~UNICIPALI~ OF A~O~G~ MUNICIPALITY OF ANCHORAGE E~IRONMENTAL ~2OTC~ION ENVIrONMEnTAL SANITATION ~IVISlO~ RECEi VED REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES 1. PROPERTY OWNER J PHONE MAIL~G-AD~R'E~S · - - _ PROPERT~ RESlOENT Of ~ifferent from a~) ' ~ PHONE 2. BUYER /~ /~ PHONE MAILING AD0~ESS ' I I ' · LENDING INSTIT~ION ~AILI~6 ABDREss ~ . 4. REALTOR/AGENT PHONE MA~G ADDRESS 5. LEGAL DESCRIPTION STREET LOCATION 6. TYPE OF RESIDENCE ~t~. SINGLE FAMILY I--I MULTIPLE FA. MILY !7. WATER SUPPLy NUMBER OF,BEDROOMS ~Ct_A L~ L~ t-~. [] One [] Four . [] Other, [] Two ~ Five r'l Three [] Six C~ INDIVIDUAL' I-1 COMMUNITY [] PUBLIC UTILITY SEWAGE DISPOSAL SYSTEM · ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) [] INDIVIDUAL/ON-SITE** PUBLIC UTILITY , YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) THIS SIDE FOR OFFICIAL USE ONLY · - 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [--I FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY :)ATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER []INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified NSTALLER []Septic Tank or [] Holding Tank Size: If Tank is homemade ;OIt. S RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL WELLTO: Absorption Area to nearest Lot Line 5. COMMENTS ~ APPROVED FOR ~ ~' BEDROOMS [] CONDITIONAL APPROVAL {letter must accompany certificate) [] DISAPPROVED 72-010 {Rev, 6/79) TELEPHONE (907)-279-4014 ANCHORAGE INDUSTRIAL CENTER 274-3364 5633 B Street Drinking.Water Analysis Report for Total ColifOrm Bacteria TO BE COMPLETED BY WATER SUPPLIER WATER SYSTEM: ~o~ No, ZiD Code City State SAMPLE DATE: ~-~ ~ [-~ Mo. Day ' year SAMPLE TYPE: [] Routine ri Check Sample (for routine sample with lab ref. no. rq Special Purpose I-I Treated Water [] Untreated Water SAMPLE NO. I I I R LOCATION /_. ~' -~ Time Collected Collected By BE COMPLETED BY LABORATORY ~ Analysis shows this Water SAMPLE to be: ~'-( Satisfacto~ · [] L~nsatisfactory [] Sample too long in transit: sample should not be over 48 hours old at examination to indicate reliable results· Please send new sarc Die. '~Date Received ,'~ '-~ / - ~'O Time Received //2~) 't/~'---~ Analytical Method: r-I Fermentation Tube ~ ~, Membrane Filter Lab Ref. No. Result* Analyst i' II ~-~ II r-~ II ,READ INSTRUCTIONS BEFORE COLLECTING SAMPLE o~.122o lb) BACTERIOLOGICAL WATER ANALYSIS RECORD GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3330 "C" Street, Anchorage, Alaska 99503 274-4561 · Time of Inspection Date of Inspection REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR 1976 10:30 a.m. 9-28-76 Tuesday Neale 1. Approval 'requested by: Mailing Address: 2. Property Owner: Mailing Address: 3. Legal Description: 4. 5. 6. DAY CARE Phone: D~a~ne I~e Phone: Box 20 Ea~le River, 99577 Lot 32 Block 2 Eagle River Heights Location: 4th house in on Caribou Street on the right, cream with bro~rn trim, chain'link fence Type of facility to be inspected. Single Family No. of bedrooms Well Data: Individual ® e A. Type C. Construction Sewage Disposal System: A. Installed C. Septic Tank: 1. D. Seepage Pit: 1. Size Absorption Area B. Depth D. Bacterial Analysis B. Installer 2. Manufacturer 2. Material E. Disposal Field: Total length of lines A..Well to: Septic tank Nearest lot line , Absorption area , Other contamination , Sewer Lines , B. Foundation to septic tank , Absorption area C. Absorption area to nearest lot line ~, EQ-034 (1/74) Pag~ 1 ,~ two -a-A- 1. Type of Inspection: 2. Property Owner:. MUNICIPALITY OF ANCHORAGE ............ - .... DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION t*~;/, 2510 E~t Tudor Road, Am:hm*~, Alml~ 99504 27~-2221 REQUEST FORAPPROVAL OF INDIVIDUALSEWERandWATER FACILITIES FOSTER HO~ CMRO VA, FHA. Dwayne Lee CONY Mailing Address: Box 20 Eag'le River 99577 DayPhone: Name of Buyer:. n/a Mailing Address: Name of Lending Institution: n/a Day Phone:. Mailing Address: Name of Realtor or Agent:. Mailing Add~:, P~one:. Legal D~cription: Lot 32 Block 2 Eagle River Heights Subdivision Location: 4th house in on ric{ht on Caribou Street 7. Type of Facility to be Inspected:. 8. Water Supply Type of Supply: Sinqle Family No. Bdrms. Public Utility Individual. xxx If Individual, number of dwellings presently served. If Individual, depth of well. Sewage Disposal System Type of System: Public Utility If Individual, date of installation Individual (o~-site) XXX Page 2 of two pages - Re~.~'~.t for Approval of Individual .~"'~r & Water Facilities Legal Description Lot 32 Block 2 EAgle River I{eights Comments Approval ~Valid for one year from date signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM certify that the information contained in this request for approval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating satisfactorily. SIGNED Date EQ-034 (1/74) 06-1220Ia) Rev. 1973 .,EPARTMENT OF HEALTH AND SOCIAL SF.,, '",S DIVISION OF PUBLIC HEALTH INDIVIDUAL AND SEMI.PUBLIC BACTERIOLOGICAL WATER ANALYSIS INDIVIDUAL ~ SEMI-PUBLIC f-I CHLORINE RESIDUAL PPM REPORT RESULTS TO ¢' '" / 7~ ?:','-, ,I-~.-,.~ ' .- ZIP CODE COMPLETE THIS SECTION ONLY IF WATER IS AN INDIVIDUAl. SUPPLY SAMPLE COLLECTED BY ' '~"; ~ ~ ~,/ :' ~. lOCATION: [] Sample too long ;n transit; wmple should not be over 4~ hours old o! examlnatlon Io |ndIeote relbble resu~. Plome SANITARIAN'S REMARKS COLLECTING SAMPLE EMil AGAR BEFORE ON REVERSE SIDE ~.1:~o Cb) BACTERtOLOGICA~L WATER ANALYSIS RECORD READ INSTRUCTIONS D.:.,. n,..;.,.e ,,t' --/~., T;,-. R,..;¥,.~ ~ ~,,,~.oS. REQUEST FOR APPROVAL OF INDIVIDUAL SEI~AGE AND WgTER FACILITIES (Fill out In Triplicate) ~., Numbu~, m£ l~adx~-m~s tn house S. Water Analysis: b. Deterrent__ '" 6. Well data: b. Depth ~" c. Castn~ Size d. J Distance from well to closest existinE or proposed: 1. Sewer line 2. Septic tank_ /~93I 3. Seepage Area... / Cesspool~... 5. Property Line Other sources of ~osslble contamination, l.a., creeks, lakes, houses, barn, drainaze ditch, etc. Sewage disposal system. a. AEe of systez /~ ~3 . b. Septic tank capacity in gallons_ ~ . c. Name of septic tank manufactur~ 1. If "home made" show diagram on reverse side of this form. d.' Disposal field or seepage plt size and type.. 1. Distance to property llne to house foundation e. Perco]atio~xT~t'x~sults" f. Percolation Test performed Use the ~evet~e side of this form to show die,ram. DlaE~a~ should ~nclude . ~he foil~nZ ~nfo~at~on~ ~operty l~nes; .well location, house location, ~[~]c tank location, disposal area location, location of percolation test, a~ d~ct~on of g~ound slope, The [~Jo~Ation on this fo~m is t~ue and co~ct to the best of my knowledge. t %%~na~u~ of Applican~ ba~e SiFned T__O BE FILLED OUT BY HEALTH DEPAP, T~.IENT PERSONNEL r~e above described sanitary facilities ere hereby approved, ~ub~ect to the .... ~llowin~ conditions: Conditions: The above described sanitar~ facilities are disapproved for the following ~easone: Signature of ~.f~ici~l.¢ ~. - ~: · · Approval is valid fo~ one year followinz the da~e of approval. CPJ: cw osD April File ~o.: 4-1 lJr. Dwayne P.O. Box 2O Eagle River, Aleske ILS?? It h~s bo~n b~mgM to our ~enflou ~hat public sewer is avoLleble to Lot 31, l~loek 2. ]~rle River Heights Subdivision. · Ac~ordlni~ to the AnohoraKe Code ef Ordimm~z ~$~wSge DispoGal Pra~ieos", Chapter le, Artiele IB.4S, Section Ie.45.050: If we da m:4 heM' f~n you wiJ_hl~_ men (?) days, we will enume tho~ "J~ 30, lite. ' You must q)ply flu. s eounecflou permit from the peFmlt offie~u* for the Mun~ip~ of An~bo~*ofe, ISO0 Edmt Tudor Roed. If you have an7 questions Te&~flnr the above, pbes~ do not beeitato to oontact the permit c~f1~r ~J-ISS~, exteuslon 2S9 or the D4j)srtment of Health omi RECEIPT FOR CERTIFIED MAIL---30¢ (plus postage) Apr. ]971 3800 NO INSURANCE COYERAGE PAOVIDED-- kOT FOR INTERNATIONAL MAIL WE SERVE ALL ALASKA - ; - POST OFFICE BOX 42 - CHUGIAK~ ALASKA ~gf~7 - , ~ ADDRESS .............. :...3. ........................................... ~.2 .... DATE - STARTED ...... ~.TJ.~..-.~.~: .......... :. ..................... ~-1-~31 ' DATE - I~DED ........................................... :_ lO,ND OF FORMATIOn: FROM ...~.C ........ FT. TO .._?.~ .......... FT. T." :?- FROM ............. FT. TO ................................................ FROM -~ ............ FT. TO ................. FT .............. FROM_J~. ..... FT.~O...i{.~. ...... =; FROM ._..~ ....... Fr. To ...'..~. ........ - KODIA-~, ALASKA 4864826 · i~'~ o£n. OF~U.._~ ........... : ..... '~ hO' est. STATIC LEVEL OF WATER FT. - '6" r~h ~ OF CASi~ .................... '. .............................. . FROM ....... .2.....:.. FT. TO ................... ... FT ................................. ~OM .......... :L....~.T0.: ............... FT .......: ........................ FROM ._..: ............ FT. TO ................. ~ FT ............... 2..' 2.: ..... · FROM ..J. .............. FT. TO ;..lJ. ............ FT..~ ..................... ... FROM ............ .;~. Ff. TO ___:- ....... ~-. I~ ......................... FROM _~..g. ....... FT,--Tn .'......._......~8 ~ ...l:'r L~su 2 d'er ----.-----.......-._' FROM ........ ~.....~FT. TO ......... ~OM ~]' ..... FT.'ro....:~.::.'<___.~ n-.'2.Y~_l~'~...':~_~,~=: "FROM...:_' _. FT. TO.i ............. FT .............. : ............ .... --2 ........... ER~--~f~!...L:..~.TO' ]20 ~w~l -' ~er ~OM.~--: ........ J..:~.TO ......... ~...h ................. - ~oM :~.L.'.:'~.~ l:.: ....... ~ ........... ~:: -:~"'"' E.OM... :~:,, ~.h~ ~. To ...... : ....~.: ................. MISCL INFORMATION: - ' :'7 "' :' ~. - ' APPLI~"~NT FILLS OUT UPPER HA~"-~,ONLY ~Pi:operty'Owner ~J ,/~ /f-//~ /~ ~ ~ Phone Type of Resi~nce D O~er ~'~ Sewer Disposal NOTE: THE INSPECTION ~E MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED, Time Time Time Time Dale Date Date Date Inspector Inspector Inspector Inspector (~APPROVED ~DROOMS *CONDITIONS OF APPROVAl. ( ) DISAP~OVED ( ) CONDIT~NAL APPROVAL' AREA BOROUGH [] Podfive , · \ Office: PW-062 (7-74) CHEMICAL & GEL ,OGICAL LABORATORIES £.~'~.ALASKA, INC.~ TO BE COMPLETED I~y WATER SUPPLIER TO BE COMPLETED BY LABORATORY WATER SYSTEM: I.D. NO. Mailing Address Mo. Day yom' Analysis shows this Water SAMPLE to be: J~:$atisfacto~ ITl 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 / SAMPLE TYPE: D Routine r-I Check Sample (for routine sample with lib ref. no. r-i Special Purpose [] Treated Water [] Untreated Water Analytical Method: [] Fermentation Tube :~ Membrane Filter SAMPt. E NO. I I , I LOCATION L?. ~ 4? -' I T~m~ Co,.clod Lab Ref. No. - Result* Analyst CoIl~l~ By I m i ~ I ~ I ~ READ INSTRUCTIONS _,BEFORE ,COLLECTING SAMPLE 06-1220 BACTERIOLOGICAL WATER ANALYSIS RECORD ® © ® j'® ~ 77lA 70..~ ® ® vi, ® ®