HomeMy WebLinkAboutHERBERT LT 3C
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
Pump Installation Log
Well Drilling Permit Number: _______________ Date of Issue: ____-____-____
Parcel Identification Number: ____-____-____
Legal Description Block Lot Property Owner Name & Address:
Pump Installation Date: _____-_____-_____
Pump Intake Depth Below Top of Well Casing: __________ feet
Pump Manufacturer’s Name: ___________________________ Pump
Model: _____________________________________
Pump Size: ____________hp
Pitless Adapter Burial Depth: _________ feet
Pitless Adapter Manufacturer’s Name: _________________________
Pitless Adapter Installer: ____________________________
Well Disinfected Upon Completion? XX Yes No
Method of Disinfection: _____________________________
Comments:
Pump Installer Name: __________________________________
Company: ___________________________________________
Mailing Address: ______________________________________
City: ___________________ State: __________Zip: _________
Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation.
:~ DATE RECEIVED
~-JSPECTION APPOINTMENTS
TIME TIME ' TIME
· ,.
INSPECTOR INSPECTOR INSPECTOR
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIO~EPT' OF HEALTH
825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL PROTECTION
ENVIRONMENTAL SANITATION DIVISION JUL 4 i981
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SE~ ~L~
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be proce~ed. Please allow ten (10) days for processing.
1. ~.P"OPERTY~ OWNER~ ~~ ~ PHONE
P~O~E~TY~ESlDENT(Ifdife ~ ) ~ PHONE
2, BUYER ~ PHONE
4. REALTOR/AGENT ~ PHONE
I
~AI LInG
5. LEGAL I~ESCRIPTION
;TREET LOCATION
6, TYPE OF RESIDENCE
[~ SINGLE FAMILY
[~ MULTIPLE FAMILY
NUMBER OF~BEDROOMS
[] One [~] Four
[] Two [] Five
~ Three [] Six
[] Other
7. WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
*ATTACH WELL LOG. Awell log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
[] 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 (Re',/. 6/79)'~ ~,,~
CHEMICAL & GL~£OGICAL 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:
I.D. NO.
Water System Name
Phone No.
Mailing Address
City State
Mo. Day Year
Zip Code
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
[] Treated Water
[] Untreated Water
SAMPLE
NO.
1
2
LOCATION
Time Collected
Collected By
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
[] Satisfactory
[] Unsatisfactory
--I Samole too long ~n transit; sample should
not be over 48 hours old at examination
to indicate reliaole resuts Please send
new sample,
Date Received
Time Received
Analytical Method:
[] Fermentation Tube
{~ Membrane Filter
Lab Ref. No.
I
I
I
Result* Analyst
*No. of colonies/lO0 mi. or No. of Positive oorkions.
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-[220 (b)
Rev. 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Collected Source
a.m.
Lab. No.
presumptive 1Omi lOml ].Omi 1Omi /Omi 1.0mi O.lml
24 Hours .
48 Hours
Confirmatory
24 Hours
48 Hours
Multiple Tube Reoort=
Membrane Filter= Direct Count
verification= LTB
Final Membrane Filter Results
Re, or ted By
Broth 24 hours;
Broth 48 hours:
1Omi Tubes Positive/Total 1Omi Portions
Collform/1OOml
BGB
Date
Collform/lOOml
Time- &.m.
p.m.
and bandiMg ~a¥ Lead to mialeadk~g resu~ts~
Water samples ,.rib have to reach the laboratow aa quiakl¥ as possible within 48 hours a~ior
A~e~' 48 hours, lhe $~g~a~fiea~me of ina bac~edo~ogiaa~ analysis ~s ~paked and rosampliag will be ~ec.~
a} ~emove any aerators or screens attached to the outlet.
b) Thoroughly flush tap or pumt} by aLlovein9 ~zeater to r~.m freeb/with a fully opened outlet fo~ three
o) Beduce ¢iow au that small
d} aer;r~ov¢ bottle from mailing tube. HoLd boi.'tie in one hand whi~e reaaovi~9 cap with the other.
Avoid touchb'tg the neck of the bott}e end the iy~side o$ the cap.
ti}ia bottle to its shoulder while attempti¢~g to avoid splashing. Lm~aediatel¥ tepiaae cap, being
that it is tight, but not so tidbt as to split the cap.
Complete the po~'tio~ of the ~ab for~a which is andieated "TO BE COMPLETE~} BY SUPPLIER."
Fiji in all appropriate blanks carefully, inchidin9 your public water system identification nuvf~bev
~D au~nber. {Pubt~c water supp~ae~'s only}
9) Pack bottle carefully ia mai~in9 tube with Lab form.
The requirereeats for anaLvsis of public water systems fo~' tota~ eot~fot'm bacteria are de'fh~ed in the
DdnMng Water veguiatio~s adrai~istered by the Bepartme~t o¢ Envkonmentat Conservation.