HomeMy WebLinkAboutSPERSTAD BLK D LT 9If;
DATE RECEIVED
INSPECTION APPOINTMENTS /:)j j~.~_~
~i~E TIME TIME "
DATE DATE DATE
,NSPECTOR ,NS.~Om. .NS.~C~O.
MUNICIPALITY OF ANCHORAGE
MUNICIPALITY OF ANCHORAGE DEPT, OF ','
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMEN1, .:
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL SANITATION DIVISION A~)R 1 5 19~{0
Telephone 264-4720
DIreCTIOnS: Core,leto all parts on parle ~. Ineom~loto roquo~ls ~ill not b~ procoss~d. ~lease allo~ ten {10} dags for Orocessin~.
MAILING ADDRESS
PROPERTY RESIDENT (If different from above) PHONE
2, BUYER PHONE
MAILING ADDRESS
3, LENDING INSTITUTION (~ I PHONE
REALTOR/AGENT I__ PHONE
MA~LING ADD~S /
5. LEGAL DESCRIPTION
STREET LOCATIONCc~~'
6. TYPE OF RESIDENCE /
~%~'N~ E FAMILY
[] MULTIPLE FAMILY
k/."% ')
NUMBER OF~BEDROOMS
[] One [] Four [] Other
[] Two.. [] Five
~ree [] Six
7. WATER
~J~ INDIVIDUAL*
[] 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 log if available.)
8. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE**
[]~]~PU B LI 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
[] INDIVIDUAL 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
WELL TO:
Absorption Area to nearest Lot Line
5, COMMENTS
[~"~APPROVED FOR _.~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY~~
72-010 (Rev. 6/79)
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
P.O. BOX 4.1276
Anchorage, Alaska 99509
TELEPHONE (907)-279~,014
274-3364
ANCHORAGE INDUSTRIAL CENTER
5633 B Street
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
\/(~ · ) , ~.o. No.
Public Water System Name
Mailing Address
SAMPLE DATE:
Stero
Mo, Day Year
Zip Co(~ ~/-
SAMPLE TYPE:
E~ Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
[] Treated Water
[] Untreated Water
SAMPLE
NO.
2
3
LOCATION
Time Collected
Collected By
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
.J~ 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.
pats Rsoelved
Time Received //'~,~O
Analytical Method:
[] Fermentation Tube
~ Membrane Filter
Lab Ref. No. Result* Analyst
~
L-'I--I
~
[-'l-'l
*No of colonies/lO0 mi. or No of Positive porlions.
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220 (b)
Rev; 197a
BACTERIOLOGICAL WATER ANALYSIS RECORD
Presumptive 1emi 1Omi 1Omi 30mi , .1,0. mi 1,0mi__ O,Imt
24 ~-Iours
48 Hour~ ._ . . ~
EMB Broth 24 hours: Broth 48 hours.. ....
Membrane FIIter= Direct Count , CoUform/1oornl
Verification: L.TB .... BGB .
Final Membrane Fllte~Ras,u~ts ~(/'"- ,-/) C,o[~[orm/loOfnl