HomeMy WebLinkAboutOSMOND OLSEN LT 1B
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROT!ECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
Fo¢-¢,- I4~'/' PHONE ~NEW
2~{~ 2~ ~ UPGRADE
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION
I Well
? v DISTANCE TO: I 0 c{ , ~
~- ~ Manufacturer
, Liq. capacity iq~a~o~s IF HOMEMAD E:
i
~ ~ DISTANCE TO:
~; ~ I No. of ~in,, I L.,,th of **oh ~i,*
grade
~ Top o*,,~,o*in~,h
~ ~ Length Width
~ P ~ Type of crib Crib diameter
~ DISTANCE TO: Well
~ IClass Be~t~
OTHER
PIPE MATERIALS
p',/C
SOIL TEST RATING
INSTALLER
REMARKS
Dwelling
NO, OF BEDROOMS
PERMIT NO. ~ ~ OS ¢ 2
Material oe.~ee No. of compartments ~
Inside length Width Liquid depth
Dwelling PERMIT NO.
Material Liquid capacity in gallons
Foundation Nearest lot line PERMIT NO.
Total length of lines Trench width Distance between lines
inches
Material beneath tile Total effective absorption area
Depth PERMIT NO.
Crib depth Total effective absorption area
Building foundation Nearest lot line
Driller Distance to lot line PERMIT NO.
Sewer line Septic tank Absorption area(s)
DATE LEGAL
DEF'ARTMENT OF HEALTH AND I:;.NVIf'~ONI~E. N I~L F'ROTECTIOIxl
I:1~,:~ I._ S]"REET, ANCHCI[~AGE~ AK 995C1.1.
264-4720
423 b,~ -.;,,..
F'IERIq I 'f' NO:
DATE ISSLIFD,
84, ;~6,:: UF'GRADE
07 / :[ 1/84
APPI... I CANT:
ADDRES!3 .~
CONTACT PHONE:
F~[]GER IcORAKER
3754 STRAWBIERIRY RD.
AI',ICH[]RAE}E, AK 99502
243-2838
L.f::GAL. ..)I=.,;:~CF~ I I='~
L lIT B I Z E:
FIUBD I V I c, ,
....... :~].01',1: OSMOND OI...8C)N LOT: :I,B
SECTION: 1 :L TDWNSHIF:'." 12N RANGE: zI.W
'l.&¢.,~(... (SQ.FT· OR ACRES)
LOCI. ,, .1.
ocr'Lily 'Lha'Lr,
I afn fam:l].J, ar with 'Lhe r'eClLtirem(m]ts for (;n-si, re ;...sewers and wells as set
foPth, by the MLmicipal:i. ty or Anch~rage~ (MOA) and the State of' Alaska.
I will insta'.l. 1 the system in acc~andance with ali HOA c:odes and regu'.l.a~.iens,
arid in compliance with 'Lhe des:i, gn criteria er this per'mit.
I wJ.].l adher(~ 'Lo all MC]A and S'Late of' Alasl<a requirements fc)r the set back
c:l:Ls'Lances From any existing well, was'Lewa'Lep d:Lsposal system or pL~bl~.c:
sewenage system an this ap any adjacerlt QP nearby lot.
IF: A LIFT STA'¥ION IS INSTAL. L. ED IN AN AREA COVERI:.D BY IdOA BLJILDING CODE.,:~,
'f'HEN (l) AN ELECI'RICAL PERIdlT AND INc~FECTION MUST BE (]BTAZNED; (2) AS.-.BIJILTS
WILl.: NOT BE AI~PROVED WI:THOU]" AN ELECTRICAL INSI::'ECTIQN RIE:F'OF~T~ AND (3) 'I"HIE
ELECTRICgL.. WORK IdlJ.::~T BE [)ONE BY A LIC[zNc~ED EI...EC'fRICI~N.
S ]: GNED
APPL I CAN]'
]. ~,uUb, D BY
ALASKA
enuiROnm~nTAL CORTROL $~RIJ~CSS, IRC.
~nqine¢ci~q $ ~nuironmer+lol ~lu~ies MU~IOIPALI~ OF AN~IO~(3~
DEPT, OF HEALTH ~
ENVIRONMENTAL PROTECTION
,~ ,~, ,,~ RECEIVED
Department of Health and
Environmental Protection
825 L. Street
Anchorage, Alaska 99501
Dear Susan:
This is in regards to Osmond Olsen Block 1 Lot lB. On May 14,
1985, the well on this lot was observed to be 1.1 feet above
ground level, and the wires encased nicely in conduit.
Sincerely,
Darcy Bevens
Engineering Geologist
1200 LUesI 33rd /~ueaue. 5uile B, ,qnchoro§e. Alaska 99503.{907) 561-50/40
Gr'"6,TER ANCHORAGE AREA BOROI'~'"H
HEALTH DEPARTMENT
327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511
N? 539
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
SEPTIC TANK/','
DISTANCE FROM WELL ~.¥-z'-" /":/~'~ '~
LIQUID CAPACITY ,~'="¢~'>-// .GALLONS.
NUMBER OF
MATERIAL '~ :)'~ COMPARTMENTS
INSIDE LENGTH z~---~- INSIDE WIDTH ~- DEPTH
SEEPAGE SYSTEM:
SEEPAGE PIT: ¢~-,~._,,¢-~.,~-~-_..~.¢//..~.~E.~,-'~z ~ - .
NUMBER OF PITS / OUTSIDE DIAMETER _OR WIDTH_ '""/'~'>/- ., LENGTH_ ~'~ , DEPTH /~2
LINING MATERIAl ~' ~ ~ ~D~ '~? ~. DISTANCE FROM WELL / ~/ / ~z~ BUILDING FOUNDATION:~'/~ c~-_
NEARES~ LOT LINE '~-'- ~OTAL EFFECTIVE ABSORPTION AREA (WALL AREA) '~ SQ. FT.
TILE DRAIN FIELD:
DISTANCE FROM WELL ~ .~.-~/~ , FOUNDATION
NUMBER OF~ DISTANCE BETWEEN LINES
ABSO~ION AREA SQ. FT. LENGTH OF EACH LINE
ST LINE.
LOT
TRE~H WIDTH
TOTAL LENGTH
OF LINES
.IN. TOTAL EFFECTIVE
DEPTH: TOP OF TILE TO FINISH GRADE DEPTH OF FILTER MATERIAL BENEATH TILE IN. ABOVE TILE__
--- --' TYPE - '-,',',',',',',',',~z.~..'-_ ' _~-':-~' , DEPTH ~.. ~ BUILDING /FOUNDATION. · .-/~ ~__.SAMPLE_ /(, , NEAREST
,- -- NEAREST SEPTIC ~ / / SEEPAGE --. ,-- _ OTItER ~. -
LOT LINE /''z'7 ¢~ , SEWER LINE ~'"- . TANK ';'-// SYSTEM -/'~2--,r~ ->/~ CESSPOOL/~//-g~'~'~ , SOURCE~'~'"r-~'~/'~/P'
DISTANCES:
,'~ c' ~:~
DIAGRAM OF SYSTEM
HEALTH AUTHORITY
DATE
, ,, ,i, GREATER ANCHORAGE AREA BOROUGH
,I~ I:)EPARTMENT OF ENVIRONMENTAl. QUALITY PERMIT NO.
SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT
NAME OF APPLICANT /'~ ~)[~'~/~75 /'~g'~*/~ ~--'W5 ~/'~ / //MAILINGZ/~JADDRESS ~ ~ ~_~ ~,~ z~PHONE ¢
/
FINANCED THROUGH ~/ *O BE INSTALLED BY /~/ r~ -
SOIL TEST RESULTS NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST
COMPLETION DATE ANTICIPATED / ~//
FINAL INSPECTION= 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPEC. TION BY THE
HEALTH DEPARTMENT AUTHORITY WILL BE SUBJECT TO PROSECUTION.
~~~...~ SEEPAGE AREA SIZE /~7~'~/~'/~~-~ - TYPE
MINIMUM DISTANCES, REQUIREMENTS
FOUNDATION TO SEPTIC TANK ~
FOUNDATION TO SEEPAGE PIT v~/~ __,
DRAIN FIELD
/~-/
SEPTIC TANK TO SEEPAGE PIT WALL
SEEPAGE PIT '~f
., , DRAIN FIELD
SEEPAGE PIT
ALSO CONSIDER AREA WELLS.
SEePage Pit
TG RIVER, LAKE, STREAM.
CAST IRON INTO AND OUT OF SEPTIC 'rANK AND INTO CRIB CROSSING GAP Of
EXCAVATION S FEET INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRTIGHT REMOVABLE CAPS.
GRAVEL BACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
LICENSED DESIGNER
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS Of GREATER A/~HORAGE/~ AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE
DESCRIBED~.///~____/SYSTEM IS IN ACCORDANCE WITH SAID CODE, t ' ~ (~/~'~ ~'~
DATE . APPLICANT'S SIGNATURE ~ ~/ ~
GP.U&TER ANCHORAGE AREA BOROUr,~H
HEALTH DEPARTMENT
327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511
INSPECTION REPORT ON-SITE SI--WAGE DISPOSAL. SYSTEM
ADORESS~'-t., -- '~ ...... '-'.~'~ PHONE
SEPTIC TANK:
DISTANCE FROM WELL MATERIAL -~-
LIQUID CAPACITY ~ t(~'="/~) GALLONS. INSIDE LENGTH
NUMBER OF
/~.~_.~ ~. C~C)M P A RTM E NTS '"'~
INSIDE WIDiH DEP1H ~
SEEPAGE SYSTEM: SEEPAGE PIT:
NUMBER OF PITS
LINING MATERIAL
NEAREST LOI LINE~.
OUTSIDE DIAMETER
OR WIDTH__ LENGTH / ~ ?
, , DEPTH ~'~ /
DISTANCE FROM WELt. /'5 ~"'~ / ~'
BUILDING FOUNDATION '~(' '
iO~AL EFFECilVE ABSORPTION AREA JWALL AREA~ ~' SQ. FT.
TILE DRAIN FIELD:
IOTAL LENGTH
DISTANCE FROM WELl , FO~.NDATION , NEAREST LOT LINEE OF LINES .,
NUMBER OF LI ~.~__._/. DISTANCE BE S j ~~'
ABSORPTION ARE~ SO. FT. LENGTH OF EACH LINE
DEPTH: TOP OF TILE TO FINISH GRADE
DEPTH OF FILTER MATERIAL BENEA1H TILE
IN. ABOVE TILE
E~.~ ~ y,~..l~ /' DISTANCE FROM
WELL: TYP r/~-~ ) . DEPTH_ , BUILDING FOUNDATION.
LOT LINE '~ , SEWER LINE ~ , TANK_ , SYSTEM
WATER ,
OTHER
CESSPOOL. ~'--- , SOURCES
DISTA NCES~,fl
.Il /0 '
DATE
DIAGRAM OF SYSTEM
APPROVED
AUTHORITY
GREATEF
327 Eagle St.
~,NCHORAGE AREA
ItEAL Fll DEPARI MENd
Anchorage, Alaska 99501
9ROUGH Cas~
279-2511
SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT
NAME 0~: APPL,CANT ~ MA,L,NC ADORESS~ (/'=- ?" 7~'~',P.0NE ~0.'" 't~/z
RESIDENCE ADDRESS ~ta//Z~ LOCATION OF INSTALLATION .-~.-~z~ ~
/
LEOAL DESCRIPTION d,~ / ~ ~ ~-¢~ ~Z~, ~~/4¢~
APPLICATION TO INSTALL: SEPTIC TANK X ,SEEPAGE PIT ~ ,DRAIN FIELD ,OTHER
T08ERVETHE F0kk0WINB FAGIklTY ~f~ t~-
PEBGOLATIO~ TEST RESOLT8 ANTIGIPATED 8ATE OF GOMPLETION
BELOW TO BE FILLED OUT BY I'tEALTH DEPARTMENT
THIS IS TO SERVE AS ?~'1 ~/-~-'/.-,~..~- ,PERMIT TO INSTALL A -~/)~"¢f ~'-'.-~
.AS DESCRIBED BELOW. SIZE OF UNIT TO BE SERVED c[~ g("ed[~2z~z,z~,,
.TYPE .4,r:.~ SEEPAGE AREA ______TYPE
..,-~ u~.r..(
DIAGRAM OF SYSTEM
I C~rtify that I am familiar with the requffements of Greater Anchorage Area Boroug]] Ordinance No. 28-68 and that tile
above ~ibed system is in accordance with said code.
ALasKa gEoLogicAL CONSULTANTS
TELEPHONE;
277.7602
272.4114
2227 SPENARD ROAD
ANCHORAGE, ALASKA ggSO$
June 11, 1970
Mr. William, Evans
204 Seventh Avenue
Anchorage, Alaska
Re: Soils study to determine percolation characteristics, Lot 1,
Olsen Subdivision, san'd Lake Area
Dear Mr. Evans:
This is to certify that we have examined the geologic and soil conditions
at the above-captioned site and have made a determination of the seepage
area required in accordance with specifications as set forth by the
Greater Anchorage Area Borough Health Department.
Soils at this site are poorly graded sands with minor lenses of silty
sands which constitute the Pleistocene Pitted Outwash deposits. Soils
of this WPe will reqaire a seepage area of 150 square feet per bedroom.
Please call us if you have any questions about this report.
Very truly yours,
HJM:js
Attach.
cc;
ALASI~ GEOLOGICAL CONSULTANTS
GAAB Health Department
qREATZR ANCHORA'~?E AREA BOROUGH
llEALTIt DEPAI<TML~NT 'CAS£: *~
327 EAGLE STREET
ANCHORAGE, ALASKA'99501
' Fo~ ' - ' Da~e Performed ~.-- O'~70
Legal Descz, lpt~on: Lo~lock~ ~ ,~d~vlslon~%~L~
This Fo-m RepopTs a: So~ls Log~ · .Percolation T~st
Depth
Feet Soil Chapacte~'istics Loca%ion Sketch
!f .Yes, At What DepthS-- ' ~~---- L~
Reading Date
~ ~ 1 : T~me ~ Depth To H20 { Net
z-ercoza~zon ~ate 1'7 ~"~t~ ................
Fpo~sed Install'atibn::-"Seepage Pit Dmain Field
Depth Of Inlet__ Dcp~~~it O~ '?~'~,nc~
~ :~ ·
Data Certified y'~% ~f ~~ .
Certified Well
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information Application Date
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or dJ~rectio~s) //
(c) Applicant is (c~e~.~ o=e) Lending Ins~itntio~ [.,---[__ ;
Bnyer I~----~ ; Other [~--~ (explain); ---
(d) Lending 'Institution Tel_~hone
Address
(e) Real Estate Co. & Agent
Address
(f)
Telephone
Mail the HAA to t:he following address:
e
T_jipe of Residence
Single-Family
Rumber of Bedrooms
Multi-Family ~--~
Other (describe)
Water Su ?~ol~
Individual Well ~ Community ~ Public F~
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status°
Se__wage Disop_gj~l-
Onsite
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status°
[Page 1 of 2]
Date
Eng__ineerin_g_ t. irm )rovidin~ Ins~e_ctio_~ns Tests~ File Searchz Data and Information
As certified by ~y seal affixed hereto and as of the validation date sho~m below, I
verify that ~y i~ ~zestigation of this Health Authority Approval shows that the on-site
water supply and ~ ~ wastewater disposal system is safe, function~ and ~equate for
the number o he~ ooms and type of structure indicated herein. I further verify that,
based on tb~ inf ~ mation obtained from the ~nicipality of Anchorage files and from my
investigatJo zm~ inspection, the on-site ~ter supply and/or ~stewater disposal
system is 2 com~ iance with ~1 Municipal and State codes, ordinances, and regula-
tions in e2 f ~ct on the date of this inspection.
Name of Fir~ ....... :.ff/~ Telephone ~/'-~ ~0
..Approved for ~
Approved
Disapproved
Condition~-~
CAUTION
THE MUNICII , £TY OF ANCHORAGE DEPARTEIENT OF ltEALTIt AND ENVIRON-MENTAL PROTECTION
(DHEP) ISS f ~ HF~LTH AUTHORITY APPROVAL CERTIFICATES BASEl) SOLELY UPON THE REPRESENT-
ATIONS GIX ~ IN PARAGRAPIt 5 ABOVE BY AN INDEPENDENT PROFI']S~IONAL ENGINEER [LEGISTERED
IN THE ST~ ? '; OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURC}tASERS OF HOMES AND
THEIR LEI ~i_NG INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. ,'IPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFIC ,TI'. IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OMIS'7 )i,~S IN THE PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
RR4/eJ/~ .Iii
[Page ~ f 2]
7-19-84
WELL DATA
Well Classification
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
NOV 6 198
Legal Description: _~/~ ~ I
If A, B, or C, D.E.C. Approved(Y/N)
Well Log P~esent~/N)
Total Depth ~) ~-¢) Cased to ._ .
Static Water Level ~7~
Casing Height Above Ground
Eie'~rical Wiring in Conduit (Y~
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Date Completed
Pump Set At
Depth of Grouting
Sanitary Seal on Casing 0~N)
Depression A~ound Wellhead (Y~
; On Adjoining Lots ~/O~7/'~
/~9.~-' ~f"; On Adjoining Lots
~/~To To Newest,Public
Clean, t/Manhole ~a~est ~ ~vice Li~ on ~t
Wate~ S~ple Collected By _; ~te .' /[//~
Wate~ S~le Test ~sults ~ I~ ~C']~/ ~/
SE~IC/HOLDING T~ ~TA
Standpipe ~) Ai~-tight CaperS) Foundation Cleanout~)
~p~ession ove~ Ta~ (Y~ Date ~st P~d
P~ing/Maintenan~ Contract on File (Y~) ~; fo~
' "
HoldSn~ Tank H~h-~ato~ Ala~ {Y~) 'Tem~ra~ H~ld~n~ Tank l?orm~ (~/N)
Separation Distance f~ ~ptic~tolding Tank:
To Water-Supply ~11_ /~t .~ To ~ilding Foundatio~
To ~o~rty Li~ ~/ To Dis~sal Field_
To Water Main/Se~vi~ Line .~/ To S~e~, Pond, ~e, ~ Major ~aina~
+ Qb' Z
Date Paid:
Amount: L~<~.
[Page 1 of 2] 2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (YQh
Results of Last Adequacy Test
/ ~O ~Type of System Design
Length of Field
Depth of Field /-~2
Gravel Bed Thickness
l~ '-/~z~, . Standpipes t~esent~)
Date of last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well i~cl~ l~z-- To Property Line /~_~
To Building Foundation ~/9~_ To Existing or Abandoned System on
Lot ~/LO ~ ; On Adjoining Lots .~t~ ~p/ '~
To Water Main/Service nine J~[~/~-- To Cutbank( if present)
To Stream/Pond/Lake/or Major Drainage Course .+-/~0
To Driveway, Parking Area, or Vehicle St?rage Area ,~ ~)/'~k~-
D. LIFT STATION .......
k?
~igh Water Alarm level at /~/' . Vent (Y/N)
Tested for ~mping Cycles du'r ing A~ ~
Electrical Codes (Y/~/
Date Installed
Size in Gallons
"Pump On" Level at
Meets MOA
Con~l~nts J
Check Permitted BedroomRating Against H~kARequest
certify that I have checked, verified, or confor~d to all MOA HAAGuidelines in effect
on the date of this inspection.
Signed
Co. any
KB1/dL/s
MOA No.
[Page 2 of 2]
2-15-84
ALASKA enUIRO ITII rlTAL CONTROL
APRIL 2 1984
ROGER FORAKER
3754 STRAWBERRY STREET
ANCHORAGE AK 99502
SELLER - SPENCER HINES BUYER -
SUBDIVISION - OLSON BLOCK - LOT - lB
ADEQUACY TEST FOR SEWER SYSTEM
THE TYPE OF ABSORPTION SYSTEM IS A SEEPAGE PIT WITH AN AREA OF 576 SQFT.
THE SYS~M IS CAPABLE OF ACCEPTING 750 GALLONS OF WATER PER DAY.
THE SURGE CAPACITY OF THE SYSTEM IS 1000 GALLONS.
BASED UPON THE TEST DATA THE SYSTEM IS ACCEPTABLE FOR A
4 BEDROOM HOME.
THE SEPTIC TANK WAS PUMPED ON MARCH 28 1984 .
SEPTIC 1~NK ADEQUACY
THE EXISTING SEPTIC TANK VOLUME OF 1000 GALLONS IS INADEQUATE BY
250 GALLONS FOR THIS HOUSE OF 4 BEDROOMS.
J
ADDITIONAL COMMENTS :
OWNER WILL CLEAR LOT OF TRAILERS AND PROVIDE THE ADDITIONAL
SEPTIC TANK C,~ACITY WHEN HE BUILDS THE NEW 4 BEDROOM
HOUSE.
1200 ~¢s1 33rd Avenue. 5ui1¢ ~ .Anc}~oro% ~loska 99503,/907) 561-50a0
ALASKA enuIBoI]m I]TAL COFII'BOL S [qUICES, IFIC.
Enqineerinq ~ ~nuir0nmental Sludies
November 26, 198#
Department of Health and
Environmental Protect[on
825 L Street, #th Floor
Anchorage, Alaska 99501
Re: Osmond Oison Subdivision - Block 1, Lot lB
On Noverrber 21, 198#, AECS performed a well flow test on the subject
property. The static water level was -87.90. Over 600 gallons was
pumped at a rate of 6.0 gpm. Drawdown was 30.08' with a recovery time
of 30 minutes.
This well is adequate for this 4 bedroom house.
Sincerely, ..~
"O~eH Tur'n~.r J
~_Environment~l Scient ist
Approved By:
1200 /aUesl 33rd Auenue. Suite [3 · gnehoraqe, Alosko 99503,(907} 551-5040
CHEMICAL & t,..OLOGICAL LABORATORII~ QF ALASKA, INC.
TELEPHONE (907)-279-4014
274-3364
ANCHORAGE INDUSTRIAL CENTER
5633 B Street
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
I.D, NO.
Water S~stem Name
Mailina Address
City "/ State
Mo. Day
SAMPLE TYPE:
lg-'l~outtne
[] Check Sample (for routine sample
with lab ref. no,_
[] Special Purpose
Phone No.
Zip Cod~
[] Treated Water
0~lJ*ntreated Water
SAMPLE
NO.
1
2
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.
/ Analytical Method:
[] Fermentation Tube
~Membrane Filter
Lab Ref. No. Result* Analyst
J CT]
J
J
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220 (b)
BACTERIOLOGICAL WATER ANALYSIS RECORD
Data CoUect ~ Source
Date Received Time Received _ p.m. Lib. HO.
Presumptive lOll 1Omi ZOml loll loll 3.,Omi O.lml
24 Houri
4B Houri
Confirm&tory
48 Houri
Multiple Tube Report=
Membrane Filter: DIr~:t ColJnt
Verification: LTD
eroth 48 houri,,
Coil form//OOml