HomeMy WebLinkAboutNORTON PARK LT 30 S2 E2 LESS S 55'l ff
I
ID
APPLI¢ fit FILLS OUT UPPER HA! ONLY
Properly Owr, er /'~
/'"1 '~ <, . - - Phone
. ~ · . ~ ~ '-. ~ ~
Lending lnstitution '~::':¢'(' (' ,L ~-k}:~.--(,.~:, j' ' ~: ; (* ~ Phone
, . . _ , -, .% Zip Code
Address
Legal Description ~'~ f ~ ?.. C.. ~;: , :~." ~ .... -' b ~%-- .;~ ,A..~.}(~ ,
Type of Resi~nce .. ,, " '"'% / ' .'V '
~ Single Family
~, Mulliple Family No. of Bedrooms
~ Other
Water Supply
~ Individual A~ACH WELL LOG A well Icg is required for aH wells drilled since June 1975.
~ Community For wells drilled prior to that date, give well depth (attach Icg if available).
~ Public Utility
Sewer Disposal
~ Individual Year Individual Installed:
~ Public Utility When Connected to Public Utility:
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Insp~lor [nsp~tor inspirer Insp~tor/%
{~ APPROVEO BEDROOMS .~ 'CONDITIONS OF APPROVAL
( ) DISAPPROVED
Soils Rating Date ~wer Installed Well To Absorption Area Well Log Received
Well to Tank Septic T~k Size
CHEMICAL & GL LOGICAL LABORATORIES / ALASKA, 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:
Water System Name Phone No.
Mailing Address
Zip Code
City
SAMPLE DATE: ~
MO.
Day
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
State
Year
[] Treated Water
[] Untreated Water
SAMPLE
NO.
t
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
· ~o of colonies/100 rn]. or No of PosKive
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
o6-122e (b)
Rev. 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Collected Source _
a.m.
Date Received Time Received p.m. Lab. No,
EMB_
Presumptive 1Omi 1Omi 1Omi 1Omi /Omi 1,0mi O,lml
24 Hours
49 Houri
Confirmatory
24 Houri
48 Houri
Multiple Tube Report:.
Membrane Filter: Direct Count
Verification: L.TB
Final Membrane Filter Resulti
Reported By
Broth 24 hours: Broth 48 houYIt
],0mi Tubes Poiltlve/Totsl 3.0mi Portlonl
Collform/~,00ml
BGB
Collform/lOOenl
Date ,
Time=_ a.m.