HomeMy WebLinkAboutSPERSTAD BLK A LT 21Slp,
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GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3500 Tudor Road, Anchorage, Alaska 99507 279~8686
/ Date Recetved
~,/ // INDIVIDUAL SEWER g ~ATER FACILITIES
1. Approval Requested By:
Address: Phone~ ~ 7p- Y.i-2-~
2. P~ooerty ~ner :~ ~ ~~Phone
5.Type of ~ac~fiy ~o be ~nspec~ed~
Number of Bedrooms:
6, We].] Data:
C, Construction D. Bacterial Analysis
A. Installed B. Installer
C. Septic Tank: 1. Size
Do Seepage Pit: 1, Size
2, Manufacturer
2. Material
Eo Disposal Field: Total Length of Lines
Distances:
Ap Well To: Septic Tank
, Nearest Lot Line
g. Foundation to Septic Tank
C. Absorption Area to Nearest Lot Line
, Absorption Area , Sewer Lines
, Other Contamination .
"';, Absorption Area ·
for Approval of Inc~ividual Sewer & Water Facilities
Approval '/;]lid for One Year From Date Signed [
greate~ Anchorage Area Borough, Department of ~nvi~onmentsl Quality
DIAGRAM OF SYSTEM
I certify that the information contained in this request for approval to be a true
and accurate representation of the subiect sewer and water facilities located at~
Signed Date
06-1220 (a)
Lab. No.
DATE
STATE OF ALASKA
DEP,' IENT OF HEALTH AND SOCIAL $' 'ICES
DIVISION OF PUBLIC HEALTH
BACTERIQLOGICAL WATER ANALYSIS
REPORT RESULTS TO
NAME ' ' '~ '; "'
ADDRESS
CITY
ADDRESS
~OF SOURCE
SAMPLE COLLECTED BY
DATE COLLECTED ' ' TIME COLLECTED ·
Sample Collected From' [] Kitchen Tap [] Bathroom Tap [] Basement Tae
[] Other (List)
Well ~] Dug [] Driven I~ Dd[led [] Bored
SOURCE: [] Spring [] Cistern [] Other r
Dug Well or Cistern Construct[on:
Brick or
Walls -- [] Wooc [] Concre[e [] Metal [] Tile ~] Concrete
Top -- I~ Wood ~] Concrem [] Metal [] O~en Top
LOCATION: [] Ir Basem0m [] Basement Offset [] Under House
[] n Yard {--IOther
Building Sewer Septic
DISTANCE TO: or Other Drainage Pipe Feet. Tank ' Feet,
Til~ Seepage Cess-
Field Feet. Pit Feet. Pool Feet. Privv Feet
Other Possible
Sources of Contamination
MATERIAL: Building Sewer -- [] Iron [] Wood [] Tile [] Fibre [] Cement
GENERA L: Does Water Become Muddy or Discolored? [] Yes ~1 No
When?
Diameter of Well Depth /; ~' :~ /
Well Casing ' , "'
Material Diameter Depth
Length of Water Depth
Drop Pipe From Bottom
Offset In [] In Basement
PUMP LOCATION: ~11~ Well [] Basement
On Top
[] Of Well [] Other
PURPOSE oF EXAMINATION: Illness Suspected? []Yes []No
New Source of Supply? [] Yes [] No Repairs to System? [] Yes
READ INSTRUCTIONS
ON
REVERSE SIDE
BEFORE
COLLECTING SAMPLE
Feet
OFFICE
EMB AGAR
--Lactose Broth, 24 hrs. 48 hrs. Gram's stain
-Coliform Density (Most probable No. per 100cc,)
-MF results · ·
Lactose Broth 10cc 10cc 10cc 10cc 10cc 1,0cc 0,1cc
24 hours
48 hours - ':: -
Brilliant Green
24 hours
48 hours
-Reported by · "' ,-
This analysis indicates Coliform Organisms to be: Absent
Feet·
In Utility
[] Room
[]No
' ' Signature :
06-1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Received , 'r '' ' ' '' /' ";'! 'i, Time Received : : ( p~)Lab. No.
If an "Unsatisfactory" or "Questionable" status is indicated above
you should take immediate action as recommended below,
1 . Not fy consumers water is polluted. Boil or chemically
treat this wa[er as outlined in the enclosed leaflet
"Drink It Pure,"
2, increase chlorination sufficiently to meet recommended residual standards,
Determine source of contamination and take action necessary to maintain
a safe water supply at all times.
3. Check chlorination and other mechanical equipment, Make certain it is
functioning properly,
__ 4. If after checking equipment a disinfecting residual is not obtained, please
wire this office for emergency assistance or advisory services,
-- 5. This is a surface water source and subject to pollution by man and animals.
An approved water suopl¥ source should be developed,
__ S. Improve your •spring []dug well []driven well []drilled well •cistern
__ 7. Relocate your well to a safe location in relationship to your sewage disposal
svstem, [] see enclosure
8. Sample too long in transit; sample should not be over 48 hours old at
examination to indicate reliable results, please send new sample.
[] Bottle Broken in transit, please send new sample.
9. Contact your nearest [] Local Health Department or [] Alaska
Division of Public Health, sanitation office for bulletins, consultation and
assistance,
SANITARIAN'S REMARKS
[] Satisfactory [] Questionable [] Unsatisfactory Sanitary Status.
Analysis shows this Water SAMPLE to be:
[] Satisfactory [] Questionable [] Unsatisfactory,
Records in thi~ office indicate this WATER SUPPLY to be of: