HomeMy WebLinkAboutSPERSTAD BLK I LT 3
MUNICIPALITY OF ANCHORAG~-
DEPARTME.. OF HEALTH AND ENVIRONMEN - PROTECTION /i~Q
825 L Street, An chora~, Alaska 99501 ./ ~/~
264-4720
Date Received: January 6, 1978
#1: Time 10:30 a.m.
#2: Time #3: Time
Date 1-9-78 Monday
Date Date
Insp Pratt Insp Insp
REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES
Lending Institution Request:
Mailing Address:
2. Property Owner: Thomas L. Alexander
Phone:
Phone: 243-4007
Mailing Address: 6636 Linden Drive 99502
3. Legal Description:
4: Single Family Residence: (x)
Multiple Family Residence: ( )
5. Well System: Individual well (x)
Permit #
Construction
Lot 3 Block I Sperstad Subdivision
5405 Dorbrandt
Number of Bedrooms: Three
Number of Bedrooms:
Conm~unity/Public System ( )
Depth of Well Well Log on File
Bacterial Analysis
Sewage Disposal System:
Permit ~
Septic Tank Size
Absorption Area
On-site System ( ) ? Public Utility
Installed Installe~
Manufacturer
Soils Rate Material
7. Distances: Well to Septic Tank to Absorption Area
to Sewer Line Nearest Lot line Absorption Area
to Nearest Lot Line
Page Tw9
Department of Health and Environmental Protection
Request for Approval of Individual Sewer and Water Facilities
Legal Description: ]hot 3 Block I Sperstad Subdivision
Affadavit Attached:
Approved:
Disapproved:
Letter Attached: ( )
Date:
Department Worksheeu:
ADHW - LAB - 2W
DATE
STATE OF ALASKA
' .TMENT OF H ALTH AND WE(
DIVISION OF PUBLIC HEALTH '
BACTERIOLOGICAL WATER ANALYSIS
Lob. No.
OFFICE
OTHER
NAME
SAMPLE COLLECTED BY.
DATE COLLECTED TIME COLLECTED
L~ Olher (List
Well- [] Dug [] D-ivan ET Drilled
SOURCE: [] Spring [] Cislern [] Olher.
Dug Well or Cislerr Conslrucfion:
[] Wood ~ Concrele [~ Meld
[] In Bosemenl C Basement Ogset
[~ Tile '~ Fibre [~ Asbestos
Cement
[] Ye,, J~ No
WEen?
Diameter of Well. Det)m Feel·
Well Casing
Brick or
WalKs- ~ Wood [] Concrete L~ Mete [] Tile [] Concrele
TOD - [] Oaen Too
LOCATION [] Under House
0 In Yard ~ Olher
Bdldlng Sewer Sepllc
DISTANCE TO: or OJher Drainage Pine Feel TanJ~ Feet
Tile Seepage Ces$-
~ eld Feel. o Feet Pool Feet. Privy-- Feel
Olher Possible
Sources at ConlamJnalion-
MATERIAL: Building Sewer · [] C~sl [] Wooc
iron
F~ Plastic Joint Moferial .* Tv~e
GENERAL: Does Water Become Muddy or Discolorecl?
On Top
[] Of Well [] Other
PURPOSE OF EXAMINATION: Illness Sus~ecled? [] Yes
READ INSTRUCTIONS
ON
REVERSE SIDE
BEFORE
COLLECTING SAMPLE
[] No
[] yes [] No
Records in this office indicate this WATER SUPPLY to be of:
Satisfaclory ~ Questionnble [] Unsaflsfaclory Sanitary Status.
Analysis shows this Water SAMPLE fo be:
:~ Satisfactory ~ Questionable [] Unsatisfactory.
Il an "Unsatisfactory" or "Questionable" stalus is indicated above
you should take immediate action as recommended below
Noilly cansumeFs water is polluted. Boil or chemically
treal Bds woter as outlined in the enclosed leaflet
"Drink Il Pure."
2 Increase chlorinalion suflicienlly Io meet recommendbc~ residual standards.
Determine source of contamination and Ioke action necessary to maintain
--3 Check cBIorinatinn anc other mechanical equipment. Make cerlain il is
functioning properly.
4. Ii after checking equipment a disinfecling residual is not obtained, please
wire 'his office for emergency assistance or advisory services,
5 This is a surface water source and subjecl to pollution hy man and animals.
An approved waler suppW source should be developed.
b. Improve your [] spring [] dug well [] driven well
[] drilled well [] cistern,
7. Relocate your well Io ~ safe location in relationship to your sewage
8. Sample lDO long in Iransih sample shoulcl nol be over 48 hours old al
examinalion lo indicate refiable results, please send new sample.
[~ Botlle Broken in Iransit, please send new sample.
9. Contad your nearest [] Local Health Departmentor [] Alaska
Division of Public Heallh sanitation office tot buJlelins, consultation and
SANITARIAN'S REMARKS
Signature
BACTERIOLOGICAL WATER ANALYSIS RECORD
Dole Received-// -/ r ~' r ~
om
Time Received __ r pm _~Lah. No
p0.
AGAR
48 hrs.
Laclose Broth
24 hours
48 hours
Brilliant Green
24 hours
48 hours
EMB
Lactose Broth, 24 hrs.
Coliform Density
MF resulls
Reported by ,' z ~ __Date
This analysis indicates Coliform Organisms fo be:
__1
(Most probable No. per 100cc.)
· Abs?nf '.
Presenl
MUNIClPALIIY OF ANCHORAGE proteckS '~n;
,/2)~ ~,, [)epar~ment of Health and Environment:al 9¢581
~~?. 825 L Street, Anchorage, Alaska
Mailing Address: ~.. ~ ~. Phone
2. Name of Buyer:
Mailing Address: Phone
Lendin9 Institution:
Mailing Address: Phone:
Realtor/Agent:
S:inclle Family Residence: (~-~Number of Bedrooms:
Multiple Family Residence: ( )
Water Supply: * Individual We].l
If Individual Well, well depth
Number of Bedrooms:
(L-~'~'Public/Conmtunity System ( )
If CormnunJ_ty System, name of system
Sewage Disposal System: *~Dn-site System ( ) Public System ( )
If On-site System, date of installation:
*NOTE: A well log is required on ALL wel].s drilled since 6/75.
** If on-site sewer syst;em is over two(2) years o]cl, an adequacy
test is required by this department.
A fee of $25.00 must accompany each request before processing
can be initiated.
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