HomeMy WebLinkAboutSPERSTAD BLK G LT 12
TIME
DAT
DATE RECEIVED
INSPECTION APPOINTMENTS ~J_,L~CJ.X~¢..~-' '~¢2.~'
;TIME TIME
:: i ~ -~' I' ~)~' 0~) - DATE /:
'~;~ MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF_ ANCHORAGE
DE~ARTMENTOFHEALTH& ENVIRONMENTAL PROTECTION DEPT. OF H~ALT~
825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL pROTECTION
ENVIRONMENTAL SANITATION DIVISION 00T ~ ~ 1980
Telephone 264-4720
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OWNER
MA, L,NO ADDRESS
PROPERTY RESIDENT (If different from above
2. BUYER
PHONE
PHONE
MAILING ADDRESS
3, LENDING INSTITUTION
PHONE
MAILING ADDRESS
OR/AGENT
MAILING ADDRESS
PHONE
3~'q°l ~
5. LEGAL DESCRIPTION
L
STREET LOCATION
6. TYPE OF RESIDENCE
[] SINGLE FAMILY
.~ MULTIPLE FAMILY
NUMBER OF~BEDROOMS
[] One [] Four
[] Two ~ Five
[] Three [] Six i
[] Other
7. WATER SUPPLY
J~'"~ I NDIVI DUA L*
'~8~ 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**
~.~ 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 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 IAbsorption Area Sewer Line I Nearest Lot Line
WELL TO:
I
Absorption Area to nearest Lot Line
5. COMMENTS
~]-"~-APP ROY E D FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL {letter must accompany certificate)
[] DISAPPROVED
DATE BY ~..~_
72-010 (Rev. 6/79)
ACHEMICAL & GE~,~OGICAL LABORATORIES t..~ ALASKA, INC.
D TELEPHONE (907)-279,4014 ANCHORAGE INDUSTRIAL CENTER
274-3364 5633 B Street
rinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
WATER SYSTEM:
Water System Name
I,D. NO.
Mailing Address
City State
Mo. D.,y Year
Zip Code
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref. no,
[] Special Purpose
[] Treated Water
[] Untreated Water
SAMPLE
NO. LOCATION
1
2 I
l
Time Collected
Collected By
TO RE 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,
I
I
Result* Analyst
J
*No. of colonies/~ OO mi or No. of Positive po~t~ons.
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220 (b)
Rev, 1978
BAcTERIoLOGICAL WATER ANALYSIS RECORD
Dste Collected Source
Presumptive 1Omi 1Omi [Omi :tOml lOml 1,0mi O,lml
24 Hours
48 Hours ..I
Confirmatory
EMB Broth 24 hours: Broth 48 houri;.
Multiple Tube Report=__ 10mi Tubes Posltlvs/Tot&l 10mi Portions
Membrene Filter= Direct Count Collform/lOOml
Verlflcetlon= LTB BGB
Final Membrene Filter Re;ults r ' Collferm/100ml
Reported B~/ ' Date :