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GREATER ANCHORAGE AREA 80ROUGH
Department of Environmental Quality
3500 Tudor Road, Anchorage, Alaska 99507 279-8686
Date Received --t/
Time of Inspection
Date of Inspectione317 -7
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
FOR
1. Approval Requested Bw
Address: Phone:
,2 -2
2. hone:,
-P-��
:
3. Legal. Description
CY--j
4. Location:
5. Tvpe of Facility to be
Number of Bedrooms:-—,
6. Well Data:
A. Tvo.e B. Depth
C. Construction—.— D. Bacterial Analysis
7. Sewage Disoosal Svstem:
A. Installed----- 8. Installer__.
C. Septic Tank- 1. Size---- 2. Size Manufacturer__..
D. Seepage Pit: 1. 2. Material
posal Field: Material—
Disposal Total Length of Lines
8. Distances:
A. Well To: Septic Tank Absorption Area Sewer Lines
Nearest Lot Line---, Other Contamination—
---
B, Foundation to Sentic Tank Absorption Area
C. Absorption Area to Nearest Lot Line---—
Regwest for Approval of 7 ividual Sewer. & Water Facilitie
Annroved Disapproved
Date
Approval Valid for One Year. From Date Signed
Greater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
I certify that the information contained in this request for approval to be a true
and accurate representation of the subect sewer and water facilities located at:
Signed Date
DEP 9MENT OF HEALTH ANU NUTAL Ur"IIIULN
DIVISION OF PUBLIC HEALTH
BACTERIOLOGICAL WATER ANALYSIS
DATE
PUBLIC 0 SEMI-PUBLIC INDIVIDUALL`�-l•�OTHER
,T� REPORT RESULTS TO
NAME __-'..-^ m^�•.'.- j..
ADDRESS - - - -
CITY
ADDRESS
OF SOURCE
Lab.
i_ OFFICE
Records In this office indicate this WATER SUPPLY to be of:
:J Satisfactory ❑ QuestIonable ❑ Unsatisfactory Sanitary Status.
Analysis shows this Water SAMPLE to be:
❑ Satisfactory ❑ Questionable ❑ Unsatisfactory.
H an "UnsalWactory" or "Questionable'stalusisIndicated above
you should take immediate action as recommended below.
1. Notify consumers water Is polluted. Boil or chemically
treat this water as outlined in the enclosed leaflet
"Drink It Pura."
SAMPLE COLLECTED BY
2, Increase chlorination sufficiently to meet recommended'; residual standards.
arm:
Determine source of contamination and take action necessary to maintain
DATE COLLECTED - - --- = ---TIME COLLECTED.-- - pm
a safe water supply at all times.
Sample Collected From r❑- Kitchen Top ❑ Bathroom Tap ❑ Basement Tap
3. Check chlorination and other mechanical equipment, Make certain it is
❑ Other(List)functioning
properly,
4: If after checking equipment a disinfecting residual is not obtained, plea -so
Feel.
wire this office for emergency assistance or advisory services,
Well ❑ Dug ❑ Driven ❑ Drilled ❑ Bored' --.i
5. This is a surface water source and subject to pollution by man and animals.
SOURCE: ❑ Spring ❑ Cistern E] Other -
An approved water supply source should be developed.
Dug Well or Cistern Construction: Brick or
a --. 6. Improve your EJspring EJ dug well El driven well
Walls • El Wood ❑ Concrete El Metal El Tile ❑ Concrete
❑drilled well E] cistern
Top • ❑ 'good ❑ Concrete El Mctcd [I Open Top
LOCATION: ❑ In Basement ❑ Basement'Offset ❑ Under House
7. Relocate your well to a safe location in relationship to your sewage disposal
C,J In Yard ❑ Other e-
system, ❑ vre enclosure
Building Sower Septic
DISTANCE TO: or Other Drainage Pipe --Feet. Tank _._._ _Feet•a,,,_
B, Sample too long in transit; sample should not be over 46 hours old at
Tile Seepage Coss.examination
Field ...,..._ Feet, Pit _Feel„ Pool ,.,,_,____ Feet, Privy -. o,,,.e,_.,Feol,
to indicate reliable results, please send new sample.
Other Possible_ -
❑ Bottle Broken In transit, please send now sample.
Sources of Contamination -�""'""'- Asbestos
MATERIAL:. Building Sewer - ❑cont ❑ Wood ❑ Tile ❑ Fibre ❑ Cement
---.. 9. Contact your nearest ❑ Local Health Department or ❑ Alaska
am
Division of Public Health, sanitation office for bulletins, consultation and
❑ Plastic Joint Material -'type
assistance.
GENERAL: Does Water Become Muddy or Discolored? [7 Yea ❑ - No -
SANITARIAN'S REMARKS
When?..,......_..�..
7Fcc
IOac
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Diameter of Well —Depth---
Feet.
O.lcc
Well Caring
Material--`-.--•...-_--•--^-"-.-�"-- Diameler __ Depth
!'
Length of Water Depth
Drop Pipe - _ ---- Front Rollom .F-------....------
Feel.
._. ------ --n------^^•-�^- �-
PUMP LOCATION: E] In Well ❑ Offset In ❑ in Basement ❑
Basement,
inutility
RoomOn
-
_
Top
❑ Of Well ❑ 011ier ...._,....�....--
---
PURPOSE OF EXAMINATION: Illness Suspected? ❑ Yes ❑ -No
_
New Source of Supply? [] Yes ❑ No Ropaboto Sysiom? ❑ Yes
❑ No
Signature
Signature
06-1220 (b)
BACTERIOLOGICAL WATER ANALYSIS RECORD
READ INSTRUCTIONS
am
Dano Received
Time Received. pm +Lab. No, .d„e.,_,..._...�.._�......
ON
REVERSE SIDS.
r
BEFORE
Lactose Broth
7Fcc
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IOcc
loco ca
S.Occ
O.lcc
24 hours
T_40 hours
�®
Brilliant Green
-- -
-- -
24 hours
48 hours
_
_
EMB — AGAR
COLLECTING
LLCTING SAMPLE ,,,`..,....o. �..,-
Lactose Broth, 24 his. 40 Grams slain
C Morrn Density-.-. -----(Most probable No. per 100ced
SMF results
.. Detergent Test _ --s,^^,-,-•- - ^^'^^�'e""""'^_"�'""`am
_Reported by - - - _-Date P•m.
TMs a;talysla Indicates Colifoim Organiems to be: Absent
present_....----..-�--.
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