HomeMy WebLinkAboutSPENARD LAKE PARK BLK 4 LT B2.42. 51
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DATE RECEIVED
INSPECTION APPOINTMEN'I~S ~
MUNICIPALITY OF ANCHORAGE
MUNICIPALITY OF ANCHORAGE DEPT. OF I',".LHt &
DEPARTMENT OF HEALTH & ENV RONMENTAL PROTECT~iRONMEi~IAL ;,:)~ECTION
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL SANITATION DIVISION [:~5~ g i981
Telephone 264-4720
I] ~ ~/~/~
DIREOTIONS: Complete all parts on pago 1. Incomplete requests will not be processed. Please allow ten (10) davs for processing.
1. PROPERTY OWNER PHONE
M ADDRESS
PROPERTYRESIDENT (If different from above) PHONE
2, BUYER PHONE
MAILING ADDRESS
3, LENDING iNSTITUTION PHQNE
MAILING ADDRESS
5. LEGAL DESCRIPTION
4~'- ,
STREET LOCATION
6. TYPE OF RESIDENCE
[] SINGLE FAMILY
[~ MULTIPLE FAMILY
NUMBER OF~BEDROOMS
[] One [~ Four [] Other
[] Two [] Five
[] Three [] Six
7. WATER SUPRLY
[~"~NDIvI DUAL*
[] COMMUNITY
[] PUBLIC UTILITY
* ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975, For wells drilled prior to that date, give well
depth (attach Io§ if available.)
8. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE**
[~,'"'"'P U B L I C 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 NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [~ OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVI DUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[]INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified iNSTALLER
[~Septic Tank or []Holding Tank
Size: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line
1
WELL TO:
Absorption Area to nearest Lot Line
5, COMMENTS
PROVED FOR '~/ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY
72-010 (Rev. 6/79)
CHEM;CAL & GI~£OGICAL LABORATORIES ~.' ALASKA, INC. .~,
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
I.D. NO.
Water System Name Phone No.
Mailing Address
City State Zip Code
SAMPLE DATE= F-F
Mo, Day Year
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
[] Treated Water
[] Untreated Water
SAMPLE
NO.
I
3 I
I
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
J [~
I FT~
*No. olcolonies/100ml or No of Positive portions.
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220 (b}
Rev. 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
Data Collected Source
a.m.
Date Received Time Received __ p,m. Lab, NO.
24 Houri
48 Houri
Confirmatory
24 Houri
48 Houri
EMS Broth 24 hours:
Multiple Tube Report=
Membrane Filter= Direct Count
Verification: LTB
Final Membrane Filter Results
Reported By
Broth 48 ~ourl: ,
t0ml Tubas Posltlvef1'otal 10mi Portions
Collform/1O0ml
BGB
Date
Collforrn/lOOml