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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL ENGINEERING DIVISION
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processln[~,
PROPERTY RESIDENT (If different from above)
PHONE
PHONE
3. LENDING INSTITUTION ~.-~
MAILING ADDRESS
PHONE
LEGAL DESCRIPTION
6. TYPE OF RESIDENCE NUMBER OF BEDROOMS
~[;~" One [] Four
~ SINGLE FAMILY [] Two [] Five
[] MULTIPLE FAMILY [] Three [] Six
[] Other
7. WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTI LITY
8. SEWAGE DISPOSAL SYSTEM
I~ INDIVIDUAL/ON-SITE**
[] PUBLIC UTI LITY
* ATTACH WELL LOG. A well log is required for all wells drilled
~ince June 1975. For wells drilled prior, to that date, give well
depth (attach log if available.) / ~v~~''''
**If individual/on-site, give installation date
If system is over two (2) years old an adequacy test is required
by this Department,
NOTE; THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72q)10(3/78)
THIS SIDE FOR OFFICIAL USE ONLY ,~ ~ -
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR
DIRECTIONS:
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/HoldingTank Absorption Area Sewer Line I Nearest Lot Line
I
WELL TO:
Absorption Area to nearest Lot Line
5. COMMENTS
[~APPROVED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certi~q,cate)
[] DISAPPROVED ,//
DATE BY (Title}
LEGAL DESCRIPTION /
72-010 (Rev. 3/78)
61
73 ~:~I> 75
85
Spenard Area Reference N1ap-P7
ALAF~-~ DEPARTMENT OF H~ALTH AND SOCIAI~ ~VICES
DIVISION OF PMBLIC HEALTH
Lab. No.
BACTERIOLOGICAL WATER ANALYSIS
Office
PLEASE MAIL RESULTS TO:
-. ........ ., . , '::? "-~ /.
~ "-.' ,':- ~1.
NAME--" ~'_
Sample collected by ~ ~ ~'-
Phone No,
ZIP CODE
Date Collected
Sampling Address
Time
Specific pla~e of cullecfion
REASON FOR SAMPLE SUBMISSION:
[] Illness suspected
[] Heal~h Regulated Establishment
[] Othe~ ......
WATER SAMP~LE SOURCE
[~-Well Type of casing
[] Improved [Enclosed, Covered) Spring
[] Surface (Reservoir, stream, lake)
[] Holding Tank
[] Other
z
Analysis shows this WATER SAMPLE to be:
[] Satisfactory
[] Unsatisfactory
[] Questionable [] submit other sample
[] Sample too long in transit ~o indicate reliable results.
Sample should not be over 48 hours old at time of
examination.
[] Bottle broken or leaked in transit,
[] Other
SANITARIAN',S REMARKS
Sanitafian's Signature:
BEAD INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220 (b) '::~ACTERIOLOG- ICAL WATER ANALYSIS RECORD
Rev. 1978
Date Collected .
24 Hour~
Membrane Filter: Direct Count
Verification LTB;'
Final IVlernbrane FIIte} Results.
BGB