HomeMy WebLinkAboutBRYANT LT 3,2..2..,/
~, ' ' DA~E RECEIVED '
INSPECTION APPOINTMENTS
'[~ATE [~ ~- / DATE DATE
INSPECTOR I NSP EC~,~:~R ' NSPECTOR' ~
~LIFALIrY OF ANCHORAGE
/ ' MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH &
~ Telephone 264~720
RECEIVED
~EQUE~T FOR APPROVAL OF INDIVIDUAL WATER AND 8EWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete ~equ~ will not be pr~ed. Please allow ten (10) days for processing. .
G ADDRESS ~ ~ ~ - ~ '
PROPERTY RES DENT ( f d fferent from above)rPHONE '
.
MAI LING ADDR ESS '
3, [ENDING INSTITUTION ~ ' ' " PHONE
5. LEGAL DESCRIPTION ' ~ -~ ' ' c~ -v ~ ' '
STREET LOCATION ~. // ~ r
I...~'.r~.f,~ ~ ~ , ~ 1. ....
6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS
SINGLE FAMILY
[] MULTIPLE FAMILY
?. WATER SUPPLY
[] INDIVIDUAL*
COMMUNITY
PUBLIC UTILITY
'~. SEWAGE 01SPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE**
PUBLIC UTILITY
One [] Four
Two [] Five
Three [] 'Six
[] Other
' ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, g ve well
depth (attach log if avai ab e.) _
YEAR ON-SITE SYSTEM WAS iNSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED,
i
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 i--IHolding Tank
Size: If Tank is homemade
give dimensions:
[] ONE
[] TWO
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
SOl LS RATING
NUMBER OFBEDROOMS
[] THREE [] FIVE
[] FOUR [] SIX
OTHER
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANOESwELL TO: Septic/Holding Tank IAbsorption Area ISewer Line [ Nearest Lot Line
Absorption Area to nea rest Lot Line
5. COMMENTS
DATE
;~.~'~P ROVE D FOR BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
72-010 ( Rev. 6/79)
CHEMICAL & GLo, LOGICAL LABORATORIES ,~Y ALASKA, INC.~
Dr TELEPHONE274-3364 (907)-279-4014 ANCHORAGE 5633INDUSTRIAL S Street CENTER
inking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
WATER SYSTEM:
Water System Name
Mailing Address
City
I.D. NO.
SAMPLE DATE:
~.,? Phone No.
.L ""!
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.
I
I
LOCATION
, J
I
Time Collected
Collected By
t~'. ,/~' ,
TO BE COMPLETED BY LABORATORY
Analys~s 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
*No. of colonies/100 m or No. of Positive oort~ons
06-1220 lb)
Rev. 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Date Collecte¢l. Source
Data Received Time Reealve¢l -- D.m. Lab. No.
Presumptive /0mi 10mi 10mi 10mi /Omi 1.0mi 0.1ml
24 Hours
48 Hours
Confirmatory
24 Hours
48 Hours
EMB Broth 24 hours: ,
Multiple Tube Report:
Membrane Filter.. Direct Count
Varlf~atlon: LTB
Final Membrane Filter Resultl
Reported By
Broth 48 houri:
10mi Tubes Polltlve/Total /Omi Portloni
Collform/t 00mi
BOB
Collform/100ml