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INSPECTION T
TIME TIME
DATE DATE
,NSPEOTOR .NSPEDTOR ,NSPEOTO}~.~
MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH &
DEPARTMENT DP HEALTH & ENWRONMENTAL P.OTECT~VlRONMENTAL
825 L Street - Anchorage, AlaskaO9501 [,;i/\Y 1~ 1981
ENVIRONMENTAL SANITATION DIVISION
Te.e.bo.e ~-~.~0 R E C E I V E D
REOUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts oil page 1. Incomplete requests will no,-be processed. Please allow ten (10) days for processing.
/
I. PROP£RTY OWNER ,/ ~ .~ ~ z
MAILING ADDRESS ~C/ ~ ~'~ ~.,~ t.~_~/
PROPERTY RESIDENT (If different from above) PHONE
2, BUYER PHONE
MAILING ADDRESS
3, LENDING INSTITUTION T PHONE
I
MAILING ADDRESS
4. REALTOR/AGENT PHONE'
MAI LING ADDRESS
E~ SINGLE FAMILY
[] MULTIPLE FAMILY
7, WATER SUPPLY
~ NDIVIDLJAL'
[] COMMUNITY
[] PUBLIC UTILITY
~] One L~ Four [~ Other
E~ Two E3 Five
[~ Three E~I Six
ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled orior 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 FIEQUEST 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
[] 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 ASSORPTION AREA MATERIAL
4, DISTANCESwELL TO: Septic/Ho]ding Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
5, COMMENTS
[~'~APPROV ED FOR ~'~ BEDROOMS
[] CONDITIONAL APPROVAL {letter must ~any cert~t~j~
accompany certif' e)
[] DISAPPROVED
CHEMICAL & GI~,LOGICAL LABORATORIES ~ ALASKA, INC.
274-3364 5633 B Street
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLE'rED BY WATER SUPPLIER
I,D. NO.
Water System Name Phone No.
Marling Address
City State Zip Code
Mo. Day Year
SAMPLE TYPE:
['~ Routine
1~3 Check Sample (for routine sample
with lab ref. no.
['~ Special Purpose
[] Treated Water
[] Untreated water
SAMPLE
NO.
1
2
3
4
5
LOCATION
Time Collected
Collected By
TO BE 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. Result* Analyst
*No otcolonies/lOOml or No of Pos~[ivepor[ions
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220 (b)
Rev, 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Collecte~ Source.
a.m.
Date Received Time Recelvecl p,m. Lab. NO.
~rssumptlve 1Omi 1Omi 1Omi 1Omi 1Omi 1,0mi O.~ml
24 Hours
48 Hours
;onflrmatory
24 Hours
48 Hours
EMB Broth 24 hours:
Multiple Tube Report=
Membrane Filter= Direct Count
Verification: LTB
Final Membrane Filter Results
Reported By
Brotll 48 hours:
ZOml Tubes Positive/Total 3.0mi Portions
Collform/100ml
BGB
Collform/lOOml