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HomeMy WebLinkAboutSUMMIT ESTATES BLK 2 LT 14Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME ~O LOCATION MAILING ADDRESS "~/~ ~ t~J~ ~/'~ LEGAL DESCRIPTION PHONE SEPTIC TANK: DISTANCE FROM WELL /g2~- / INSIDE LENGTH MANUFACTURER INSIDE WIDTH MATERIAL NUMBER OF COMPARTMENTS / LIQUID DEPTH .LIQUID CAPACITY /~g GALLONS. SEEPAGE PIT: NUMBER OF PITS / DIAMETER OR WIDTH LINING MATERIAL/g4'J;/~/Z~)-CRIB SIZE: DIAMETER BUILDING FOUNDATION ~ /'/- NEAREST LOT LINE / /~J LENGTH /~', DEPTH DEPTH DISTANCE FROM: WELL TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) ~g~ SQ. FT. ADDITIONAL ABSORPTION WELL: TYPE BUILDING FOUNDATION CONSTRUCTION ~ u z~)/,~/zj.~O NEAREST /~ NEAREST LOT LINE 2~ SEWER LINE DEPTH DISTANCE FROM: SEPTIC SEEPAGE /'--~ TANK /~ ~/, SYSTEM /~-~ CESSPOOL- OTHER SOURCES APPROVED / DISAPPROVED REMARKS DISTANCES: INSTALLED BY: LOT SLOPE: REMARKS: ~ DIAGRAM Of SYSTEM ,~O/L ,~7~//' G.A.A.B. Form NO, EQ-031 GREATER ANCHORAGE ArEA BOrOUgh DEPARTMENT OF ENVIRONMENTAL QUALITY 3330 "C" STREET ANCHORAGE, ALASKA 99503 TELEPHONE 274-4561 SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERM~.~3 ' NAME OF APPLICANT ~ ~/! ~/~ ~ ~ INSTALLATION LOCATION~ ~ ~/~/~ FINANCED THROUGH SOIL TE~T RESULTS ~~ COMPLETION DATE ANTIC~PATED ., DRAIN FIELD OTHER NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCES, REQUIREMENTS FOUNDATION TO SEPTIC TANK FOUNDATION TO SEEPAGE PIT ~ DRAIN FIELD SEPTIC TANK ~ SEEPAGE PIT DRAIN FIELD TO NEAREST LOT LINE. WELL tO SEPTIC TANK I ~ DRAIN FIELD WATER MA{N TO SEPTIC TANK DRAIN F[ELD · SEEPAGE PIT /00 t ALSO CONSIDER AREA WELLS. SEEPAGE PIT lot SEPTIC TANK, I.K'~O' /(~0 ~ , SEEPAGE PIT , DRAIN ]FIELD TO RIVER, LAKE· STREAM. CAST IRON INTO AND OUT Of SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT ~EMOVABLE CAPS. GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDINg I TALLAT~ON. I CERTIFY THAT [ AM FAM[LIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE 'ATDESG~''EDSYSTEM[SiNAOCORDANC'W'TH'A'DCODE'~--/+-~ AFPLI~ANT', S''NATO~E ~ ~ ..... ~/'~, ~ ~/Z~. , / Perfommed for Legal Description:~.ot 1LF~ This form reports: GREATER ANCHORAGE AREA BOROUr" (..~.Department of Environmental Qur~.jty 3330 "C" Street Anchorage, Alaska 99503 SOILS LOG -PEROLATION TEST Donald MacMillan Block 2 summit Estate~ Date Perfo~ed 9/7/74 Soils log. Yes Percolation test No Depth Feet 1 - p~at 2 - Silty Sand SM 3 4 - Well Graded Sandy Gravel SW predominately with some 5 - Silty Sandy Gravel GM in thin strata 12~ 7 - / ci ~!']// 9 - Well Grade~Gravel and: ~ Sand GW ll - I2' 13- Bottom of Test Pit 14- II I Il L . ,11 J Was ground water encountered? No If yes, at what depth? Reading Date Percolation rate Gross Time minute. Net Time Depth to Water Net Drop -Proposed installation: Seepage Pit Yes Drain Field Depth of Inlet . Depth to bottom of pit or trench ---i~Z-']~-~]]]~_-_-"_--_] COHHENTS: 3 Sz~ ....... 9~--O~ib No water bo 16'. -- .... .,_ No bedrock encountered ~e~-~q'--Eg~m ........ Lab BQ--040 (6/74) MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include 10t, block, subdivision, section, township, range) Location (address or directions) (b) Property owner Mailing Address (c) Lending Institution Telephone: (home) ~'//~',,~/?"-~ Business _ ~.' 'c~'e (/ Telephone ~ -~1~1 Mailing Address (d) Real Estate Company and Agent Address ~ ~'0 ~::2 Telephone (e) Mail the HAA to the following address: (or check here Bi, if hold for pick up.) List contact person and day phone number below: too,- 3' ¥,¢'- 13.4-5" 2. TYPE OF RESIDENCE Single-Family [~ Number of bedrooms 3. WATER SUPPLY Individual Well [] Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and s~atus. 4. SEWAGE DISPOSAL On-site r~ Public [] Community [] Holding Tank [] Note: if community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (Rev. 7/88) Page 1 of 2 ~ ,to ~ ODed '~JOM s,Jeeulbua leuoissejoJd aq~, u! SUO!SS!LUO JO sJoJJe JoJ elqisuodseJ ),ou s! eBeJoqouv ,to ,qlled!o!u n V~ aqJ. 'penss[ s! eteol,tllJao e eJo,teq etep eZ/,leUe Jo suoRoedsu! lonpuoa ~ou op SHHQ ,to see~oldLU3 'siueLueJlnbeJ a~e~s pus leJepe,t u!elJeo X,tsRes oh Jap Jo u! suoBn~Rsu! 6ulpuel Jleq~ pue SeLUOq ,tO sJaseqoJnd o~, Xsaunoo e se s!q~ seep SHHQ eq/ 'e~Sel¥ ¢o eie~9 eql u! peJeis!BeJ JeeU!bue leuolssejoJd ~uepuedepu! ue,{q e^oqe S qdejBmed u! ua^ih suoRe~ueseJdeJ eq~ uodn ,quo peseq peieoi,tpeo le^oJddv/~poq~n¥ q~leeH senss! (SHHQ) seol^JaS UeLUnH pue q),leeH ,to 1UeLU~JedeQ eSeJoqou¥,to,q!led!e!un~ aqJ_ leUOliipuoo le^oJddv leUOR!puoo ,to suuJe/ pe^oJddes!C] ~ pe^oJddv ,~q sLuooJpeq ~ Jo~ pe^oJdd¥ 'l~AOl=ldd¥ SHHO '9 ~21-~ ¢ euoqdsleL ~¢?~ )~2~y3~ ~¢j~ · uo!loedsul siq3 Io eiep eq~ uo ~oajje uI suo!19lnSeJ pu9 'seou9ulpJo 'sepoo pub [edlo!un~ I1~ ql!M eoUe!ldmoo ui si mels~s lesods!p JeleMBlSeM Jo/pu~ ~lddns JS~eM 8~I9-UO 8q~ 'uo~osd9u~ puc UOIieS!ISeAUl ~ ~OJ] pu9 Sel!~ e6eJoqouv Jo Xllled!olun~ eql ~oJ~ peule~qo uo!le~Jo~u! emi uo peseq 19ql ~JIJOA JoqiJnj I 'u[oJeq pe~eo!pu~ eJnlonJis jo ed~l pub s~ooJpeq jo Jeqmnu eq~ Joj o~enbepe pue' leUOBOunj 'eCes si mees~s lesods!p Jel~MelSeM Jo/pue ~lddns JeleM el!s-uo eql leq~ SMOqS leaoJddv ~i!Joqlnv qlleeH s!ql~o uoReSRseAu! ~ leql X~peA I '~oleq UMOqS elep uoBepHeA eql ~o se pue o~eJeq pax!l]~ leas ~ ~q pa!¢ieJeo sV .g ~ MUNICIPALITY OF ANCHORAGE (MOA) (,*~,1 Health Authority Approval (HAA) i¢i~/^N~H0~A~HECKLIST - FEBRUARY 1984 MUN ~ Ol ls~oN 343-4744 ~NVIRONMENTAL SERVICES V Legal Description: MAR 2 3 1989 A. WELL DATA RECEIVJ D Well Classification ~¢-~ v~x f"C Well Log Present (Y/N) ,H Date Completed Total Depth ,4'~'~ Cased to ~ 4'$" Depth of Grouting Static Water Level 80 ! Casing Height Above Ground Electrical Wiring in Conduit (Y/N) If A, B, C, D.E.C. Approved (Y/N) Yield ;;~ ¥, 6" ¢z~ PumpSetAt ~ ~'~ Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line . N,~ To Nearest Sewer Service Line on Lot Water Sample Corlected by -~. Water Sample Test Results $¢,~£~,v Comments D~ ~-,,~¢ 4,u~[[ ~ ~:.0. ; On Adjoining Lots f~?' ~ ¢,o, 1~.~.7'~ c.o. ; On Adjoining Lots t~(~ To Nearest Public Sewer Cleanout/Manhole ;Date ~/~t [~ B, SEPTIC/HOLDING TANK DATA Date Installed ¢/1~"/7¥ Size iOoo~at NO. of Compartments Standpipes (Y/N) ~ Air-tight Caps (Y/N) Depression over Tank (Y/N) N Pumping/Maintenance Contact on File (Y/N) N,,~'. Holding Tank High-Water Alarm (Y/N) N. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well I0,¢.. To Property Line ~ ~" To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course T FOundation Cleanout (Y/N) IV Date Last Pumped ,.~/8.Z /~)' by ~_c,c~z c..c ; for t~. ,4, Temporary Holding Tank Permit (Y/N) N. ,~ To Building Foundation To Disposal Field Comments 72-026 (Rev. 7/88) Front Page 1 of 2. C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~/I,¢ / 7 Width of Field I~J Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test Type of System Design Length of Field Depth of Field Gravel Bed Thickness Sta#ndpipes Present (Y/N) Date of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation ~ ~'¢ ~ To Property Line ~- ~¢ Lot NrA, ; On Adjoining Lots To Existing or Abandoned System on ~ 3o~ To Water Main/Service Line ~ ~-5'~ To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments To Cutback (if present) t~,A. D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA g.uj~.d~l~q.ft~jp effect on inspection. Signed ~'~~ MOA NO. Amount: $ 72-026 (Rev. 7/88) Back the date of this Engineer's Seal Waiver Fee: $ Date of Payment Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 B STREET ANCHORAGE,FEDERALALASKATAx ID #9951892-0040440TELEPHONE (907) 562-2343 ANALYSIS REPORT BY SAMPLE for Work Order ~ L2270 Date Report Printed: MAE 23 89 @ 13;40 Client Sample ID:L14, B2, SU~IT EST. PWSID :UA Collected MAR 21 89 @ 10:45 Received MAN 21 89 @ 14:00 h~s. Preserved with :NONE Client Name : FLATTOP TECHNICAL SRV Client Acct: FLATTOT P.O.~ NONE REC'D geq ~ Ordered By Analysis Completed :MAR 22 89 Send Reports to: Laboratory Supe~viso~ :STEPHEN C. EDE I)ELATTOP TECHNICAL SRV Released By : ~.~ 2) Special Instruct: Chemlab Ref ~: 4603 Lab Smpl ID: I Matrix: WATNR kllowable Parameter Tested Result/Units Nethod Limits NITRATE-N 2.5 mg/l EPA 353.2 lO Sample ROUTINE SAMPLE. Remarks: SAMPLE COLLECTED BY T.F. MOORE. 1 Tests Performed See Special Instructions Above UA~Onavailable ND= None Detected ** See Sample Remarks Above NA= Not Analyzed bT=Less Than, GT=Creater Than CHEMICAL & GEOLOGICAL LABORATORIES OF TELEPHONE (907) 562-2343 5633 B Stree Anchorage, Alask~ Drinking Water Analysis Report for Total Colifon TO BE COMPLETED BY WATER SUPPLIER TO BE PRIVATE WATER SYSTEM dLASKA, INC. 99518 Bacteria COMPLETED BY LABORATORY Name Mailing Address SAMPLE DATE: Phone NO. ~St ate Zip Code Mo. Day Year SAMPLE TYPE: ~ Routine [] Check Sample (for routine sam pie with lab ref. no. [] Special Purpose ) [] Treated Water ~ Untreated Water SAMPLE (~) NO. LOCATION ] Time Collected Collected By [] Un~{~t[sfactory [] Sample too Io0g in {ransit;Sample should not ~e over 30 hours old at examinahon to ~nd~cate tel able results. Please send have, sample via special dehve y mail. Date R~ceived Time Received[ Analytical Method: Membrane Filter * No. of colonies/100 mi. Lab R~f. No. Analyst Result* I I READ INSTRUCTIONS BEFORE COLLECTING SAMPLE BACTERIOLOGICAL WATER ANALYSIS RECORD Membrane Filter: Direct Count. ~ Verification: LTB BGB Final Membrane Filter Results ~) Reported By ~ a e Time: TNTC = Too Numberous To Count OB = Other Bacteria ~ '~'~ D ~'i~ E RECEIVED INSPECTOR INSPECTOR I NSP EC'~,~, MUNICIPALITY OF ANCHORAGE ~UNICIPALI~ OF ANCHORAG~ ~ 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL SANITATION DIVISION ~[J ~ ~ ~ Telephone 264-4720 DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be proceed. PJease allow ten (10) days for processing. P~PE~TYRES DENT If different from above) ~ PHONE MAILING~bDR E~' ' ~ MAI LING ADDRESS / / ~ / 6, TYPE OF RESIDENCE NUMBER OF~BEDROOMS [~ One [] Four [] Other__  SINGLE FAMILY [] Two [] Five MULTIPLE FAMILY ~;~ Three [] Six 7. WATER SUPPLY [~ INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled [] COMMUNITY since June 1975. For wells drilled prior to that date, give well [] PUBLIC UTILITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM ~ INDIVIDUAL/ON-SITE** 1'~'~/7'/ ? YEAR ON-SITE SYSTEM WAS INSTALLED. [] PUBLIC UTI LITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-O10 (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 [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTI LITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER []INDIVIDUAL/ON -SITE DATE INSTALLED []PU LICUT,UTY % Connection Verified INSTALLER []Septic Tank or []HoldingTank Size: I ~ ~-~O If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER .~&~ TOTAL ABSORPTION AREA MATERIAL 4. DISTANCESwELL TO: Septic/Holding Tank/L ~:' ~ Absorption( ~ o Area~,__ Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5, COMMENTS E~APPROVED FOR . g BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED ~ DATE BY 72-010 (Rev. 6/79) Tobben Spur land P.E. 8155 Cranberry St. Anchorage, Alaska 99502 Phone(907) 243-5302 MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION MAR 1981 RECEIVED Municipality of Anchorage Department of Heslth and Enviromental Protection 825 L. Street Anchorage,Alaska 99501 Feb. 25,1981 SEWER ADEQUACY TEST Legal: Location: Residence: Water System: Sewer System; Date of Test: Test Procedure: Test Result: Lot 14, Block 2, Summit Estate S/D On E 98° Briley Two storey 3 bedrooms On-site well From Municipal accords: Tank - 1000 gal Sunset fiberglass, Absorption System; Log Cr&b 8x8x6 Absorption Area 288 sq. ft. Soil Rating 98 Installation Date. Sept. 1974 I compartment Feb 20- 23 1981 System was inspected on Feb° 20. Crib was 12 feet deep with 53 inches of standing water. ~ank was pumped. On feb. 21 liquid level in crib was 51 inches and on ~%bo 23 18f2o On Feb 23 approx~nately 1200 gal of water was'introduced i~to crib° Waber depth in crib rose to 54 inches° On the 24 water depth was. back to 48}~. The system absorbed 120~ ~al in 20 hours. This rate exceeds the r rate required by the.~unicipal code. CHEMIC.4L & GIz~£OGICAL L.4BOR.4TORIES ~,~; .qL.4SKA, INC.~ 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: t I I '1 I I I I.D. NO. Water System Name Phone No .',i?,/,..~ ~ Mailing Address City ~ - State MO. Day Yesr SAMPLE TYPE: [3 Routine [] Check Sample (for routine sample with lab ref. no. [] Special Purpose [] Treated Water [] Untreated Water SAMPLE NO. i I LOCATION Time Collected Collected By TO BE COMPLETED BY LABORATORY Analysis snows this Water SAMPLE to be: [] Satisfactory [] Unsatisfactory [] Sample too long m transit; sample should not De over 48 hours old at examination to nama[e rehable results. Please send new sample. Date Received Time Received Analytical Method: [] Fermentation Tube [] Membrane Filter Lab Ref. No. Result* Analyst r-l-I *NO ot colonies/lO0 mi. or No of POSKIVe OO~JlOnt READ INSTRUCTIONS BEFORE COLLECTING SAMPLE 06-1220 (0) Rev. 1978 BACTERIOLOGICAL WATER ANALYSIS RECORD Date Collected Source ~.m. Lab, NO. PresumPtive lOml 1Omi lOn3t 1Omi 1Omi 1.0mi 0.1mi 24 Hours , 48 Hours r I._ 825 ..... ~'~"' ANCHORAGE, ALASKA 99501 (9071 264-4111 GEORGE M. SULLIVAN, MAYOR February 183 1981 Donald G.B./Jan A~ Mac Millan % Terrie Pisa Transalaska Realty, Inc. 1577 C Street - Suite 1.03 Anchorage, Alaska 99501 Subject: Lot 14 Block 2 Sm~]it Estates Subdivision ApproVal for the individual sewer and water facilities cannot be granted until the zo].lowln~ items have been completed: (2) The water analysis report needs to be delivered to this office from the Chem Lab, 5633 B Street, for our review~ The septic 'tank pumped with a receipt submitted to this office° ~ adequacy test needs to be performed on the existing leaching area. This test will determine if the system is adequate according to National Standards. A listing of private firms performing the test is enclosed. This report needs to be submitted to this department for~:our review° If there are any further que~tlons~ please call ·this office at 264-4720. Sincerely, Robert C. Pratt~ R.So Associate Specialist RCP/ljw cc: Alaska Statehank 310 East Northern Lights Boulevard 99503 GREATER ANCHORAGE AREA BOROUGH Department of Enviro.nmental Quality 3330 "C" Street, Anchorage, Alaska 99503 274-4561 Date Received /O- Time of Inspection Date 'of Inspectio'n ~ REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR & Approval 'requested 'by: Mailing Address: Property Owner: Mailing Address: Legal Description: Location: ~o~ 77-E Jorn~ c~s ~o~© Phone: Phone: £0~' ILl. 81k o] .S'umrn/~' Type of facility to be inspected Well Data: A. Type C. Construction Sewage DisPosal. System: A. Installed /~q~- ?~J C. Septic Tank: 1. Size D. Seepage Pit: 1. Absorotion Area E. Disposal Field: Total length of lines Distances: l ~' A. Well to: Septic tank ~ No. of bedrooms B. Depth ~9-' D. Bacterial Analysis Installer 2. Manufacturer ~ 2. Material , Absorption area~ Sewer Lines Nearest lot line -~10 , Other contamination B. Foundation to septic tank {~' , Absorption area C. Absorption area to nearest lot line 7t~o EQ-034 (1/74) Page 1 of two pages Page 2' of 'two pages - Req for Approval of Individual S~ ~]& Water Facilities L e;~a 1 Description Comments Approved ~ ~ Disapproved 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 subject sewer and water facilities and these facilities are operating satisfactorily. SIGNED Date EQ-034 (1/74) GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quali~ty 3330 "C" St., Anchorage, Alaska 99503 274-q561 REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES 1. Type 'of Inspection: CHRO VA 2. Property Owner: ,DC) ~4 [r~( Mai,ling Address: 3. Name of Buyer: Mailing Address: 4. Name of Lending Institution: Mailing Address: FHA CONV h1¢_ ,ll ,q , Day Phone ~,,~?- Day Phone Phone 5. Name of Realtor or Agent: Mailing Address: Phone Legal Description: Location: 7. Type of Facility 8. Water Supply Type of Supply: to be inspected: ,~ No. Bdrms. Public Utility Individual If Individual, number of dwellings presently served If Individual, depth of well 9. Sewage Disposal System jType of ~ystem: Public Utilit. y \ If Individual,. date of installation Individual 'on-site) Lq-037 ~/7~) 06-1220(a) Rev. 1973 · DATE ALA~ ~ARTMENT OF HEALTH AND SOCIAL SE..~ -- ~. ~'? DIVISION OF PUBLIC HEALTH ..... '" ,-a~, No INDIVIDUAL AND SEMI-PUBLIC BACTERIOLOGICAL WATER ANALYSIS OFFICE INDIVIDUAL[] SEMI-PUBLIC [] CHLORINE RESIDUAL PPM REPORT RESULTS TO NAME ADDRESS ZIP CODE CITY : ADDRESS · . · ~ OF SOURCE .~ ' _ ,- . COMPLETE THIS SECTION ONLY IF WATER IS AN INDIVIDUAL SUPPLY SAMPLE COLLECTED BY DATE COLLECTED TIME COLLECTED Sample Collected From [] KitcBen Tap [] Balhroonr Tap [] Basement Tap E Olher IList] Well -- [] Dug ~ Driven [] Drilled SOURCE: [] Spring [] Cistern [] Other_ Dug Well or Cistern Construction: [] Tile Brick or [] Open Top[] Concrete [:]Under House []Fibre []Asbeslos Cement [] Yes [] No Diameler of Well Well Casing FAaterial Diameler Length of Drop Pipe Offset in PUMP LOCATION: [] ]n Well [] Basement On Top [] Of Well [] Other PURPOSE O~ EXAMINATION: Illness Suspecte~? [] Yes New Source of Supply? [] Yes [] No Repairs to System? Depth F~et, Depth Fro~ Bollom Feet. ~ In Basement [] Roo~ READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE ,~nalysis shows Ibis Water SAMPLE to be: ~/Satisfa cra r y Unsatisfactory QuesHonable Sample ~oo long in transit; sample should not be over 48 ~ours old at examination to indicate reliable results. Please send new sample. Baffle broke~ in lranslt, please send new sample. SANITARIAN'S REMARKS Reported by rhls analys~s indicates CoBform Organisms fo be: -~MB AGAR Lactose Broth, 24 hrs. 48 hrs Gram's staTn Coliform Density _ (Mosl probable No. per 100cc) MF Besmts 10cc 10cc 10cc t0cc 10cc 1.0cc 1.0cc ~actose Broth , 24 Hours 48 Hours · 06-1220 (b) BAJOTERIOLOGICAL WATER ANALYSIS RECORD ,,. .-.-om', :..