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Home My WebLink AboutBLAKE Lot 1 "~ DATE'R ECEIVE~) INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR MUNICIPALITY OF ANCHOP. AGE MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & I DEPARTMENT OF HEALTH & ENVIRONMENTAL PRO~I~:/~ENTAL P,~OTECTION 825 L Street - Ancho~a~, Alaska 99501 ENVIRONMENTAL SANITATION DIVISION JUL 2 1981 Telephone 264~720 RECE REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SE~ER lES DIRECTIONS: Complete all parts on page 1. Incomplete reques~ will notbe proce~ed. Please allow ten (10) days for processing. 1. PROPERTY OWNER ~ PHONE MAI LING ADDR ESS PROPERTY ~ESID~T (If different from above) PHONE ' PHONE MAI 3. LENDING INSTITUTION ' I PHONE MAILFNG ADDRESS ' ' 4. REALTOR/AGENT PHONE MAILING ~DRES~ 5, LEGAL DESCRIPT~)N STREET LOCATION ~. TYPE OF HE~IDENOE ~. SINGLE FAMILY ~ MULTIPLE FAMILY NUMBER OF~BEDROOMS [] One [--I Four ~E~" Two [] Five [] Three [] Six [] Other 7. WATER SUPPLY /1~ INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. A well Icg is required for all wells drilled since June-1975. For wells drilled prior to that date, give well depth (attach Icg if available.) 8. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON-SITE** ,'~Q'~ PUB LIC UTILITY YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY 2. WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTI LITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON -SITE I--I PUBLIC UTILITY Connection Verified []Septic Tank or [] Holding Tank Size: If Tank is homemade give dimensions: NUMBER OF BEDROOMS [] ONE [] THREE [] FIVE [] TWO [] FOUR [] SIX PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATE INSTALLED INSTALLER SOl LS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Absorption Area to nearest Lot Line [] OTHER Septic/Holding Tank IAbsorption Area Sewer Line INearest Lot Line 5. COMMENTS [] APPROVED FOR BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE IBY 72-010 (Rev, 6/79) ..... DA'I;I~ RECEIVED - iNSPECTiON APPOINTMENTS TIME TIME " TIME DATE DATE DATE I NSPECTO~ INSPECTOR INSPECTOR MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PRO~I~LI~ OF ANCHORAGE 825 L Street - Anchorage, Alaska 99~01 DEPL OF HSALTH & . ENVIRONMENTAL P~O~SCTION ENVIRONMENTAL SANITATION DIVISION Telephone264-4720 M~ ~ 8 19~ DIRECTIONS: Complete all parts on page 1. Incomplete reques~ will not be proce~ed, Please allow ten (10) days for processing. MAILING ADDRESS / -~ PROPERTY R~SI D~NT (If differ~t {~om absve) PHONE MAILING AD~RESS- / 3. LEND~G INSTITUTION PHONE 4. REALTOR/~GENT ~ I PHONE" MAI LIN~ ADDR~S / 5. LEGAL DESCRIPTION ,g",~ o 6. TYPE OF RE~E~~ - ~ NUMBER OF~BEDROOMS ~ SINGLE FAMILY ~ T%; ~ MULTIPLE FAMILY ~ Three ~ Six 7. WATER SUPPLY INDIVIDUAL* [] COMMUNITY [] PUBLIC UTI LITY * ATTACH WELL LOG. A wel log is required for all wells drilled since June t975. 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. THIS SIDE FOR OFFICIAL USE ONLY .... ~ 1. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY 2. WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON -SITE []PUBLIC UTILITY Connection Verified []Septic Tank or [] Holding Tank Size: If Tank is homemade give dimensions: [] ONE [] TWO PERMIT NUMBER NUMBER OFBEDROOMS DEPTH OF WELL DATE DR I LLED LOG RECEIVED [] THREE [] FIVE [] FOUR [] SlX [] OTHER PERMIT NUMBER DATE INSTALLED INSTALLER SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA 4. DISTANCES WELL TO: MATERIAL SelStic/H~lding Tank [AbsorPtiOn Area ISewer Line I Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS DATE [];~APPROVED FOR BEDROOMS 'Z._- [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED 72-010 (Rev. 6/79) For...~;.:.~.~. ......... Locati~ Date Distance to water while pumping.....~..~..i..: ......................................... .at rate of ............. ~ ........................... gallon! per hour. ' Description of Fommti~n';' ' ' from ? to : itl' LCHEMICAL & GL £OGICAL LABORATORIES . _: ALASKA, INC. TELEPHONEv~~74.3364(907)-279-4014 ANCHORAGEB633 B SIreeIINDUSTRIAL CENTER Drinking ter Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER WATER SYSTEM: Water System Name I.D. NO. Phone No. State Zip Code Mailing Address City SAMPLE DATE: Mo. Day Year SAMPLE TYPE: [] Routine [] Check Sample (for routine sample with lab ref. no. [] Special Purpose [] Treated Water ) [] Untreated, water SAMPLE NO. I 5 LOCATION Time ColleGted Collected By TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: ~':Satisfactory [] Unsatisfactory [] Sample too ong in transit; sample should not be over 48 hours old at examination to indicate reliable results. Please send new sample. Date Received ,. Time Received ' ' J ~r, Analytical Method: [] Fermentation Tube ,,E~_ Membrane Filter Lab Ref. No. Result* Analyst I I I I ~-~ *No. of colonies/lO0 mi. or No, of Positive Portions. READ INSTRUCTIONS BEFORE COLLECTING SAMPLE 06-1220(b) Rev. 1978 BACTERIOLOGICAL WATER ANALYSIS RECORD Date Collecte<l Sourca a.m. Date Received Time Recalv~l p.m. Lab. No. Presumptive lOml 1Omi lOml 10mi 1Omi 1.0mi 0.1mi 24 Houri 48 H, Ours ' Confirmatory 24 Houri ,48 Houri EMB. Broth 24 hours: Broth 48 hours: Multiple Tube Report: 10mi Tubas Positive/Total 10mi Portlonl Membrane Filter: Direct Count Collform/100ml Verification: LTB BOB Final Membrane Filter Results ~- ' ,' - Collform/lO0ml Reported By / ' ~ Data -,--' / Tlme~ - · .;, a,m,