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Home My WebLink AboutLot GY� On o ( C) vo- I 13 — oz 3 mo 00 AIL 5. LEGAL DES/0 'CRI TION ) W DATE RECEIVED INSPECTION APPOINTMENTS 4vc TIME TIME TIME NUMBER OF,BEDROOMS ❑ One ❑ Four ❑ Other DATE DATEDATE ❑ MULTIPLE FAMILY Three ❑ Six ,� � -- L -- Y L'SY-\ INSPECTOR INSPECTOR INSPECTOR /��7 1 MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIp N DEPT. OF HEALTII & ENVIRONMENTAL PI:OFECTION 825 L Street - Anchorage, Alaska 99501 • —� ENVIRONMENTAL SANITATION DIVISION APR 9 1981 Telephone 264.4720 PUBLIC UTILITY REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER �_iQ�II ITY,,//Ek DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. P OPERTYOWNER Gp tv PHONE p q MAILINGADDR SS loo a PROPERTY RESIDENT (If different from above) PHONE 2. BUYER I� PHONE SS MAILING_►O(.FaREJTaY✓6C r"�' C� 3. LEND NG INSTITUTION 54y,�1 PHONE 2W --Iel crL�t c. MAILINGADDRESS _ S;3 �" If AA,aEo✓1kTG-,;,- 4 f 4. RE LTOR/AGENT & PHONE aNjq L^, e Z G . Q? MAI LI GADDRESS g. 5. LEGAL DES/0 'CRI TION ) W Ei. d STREET LOCATION IAA Gy/,L 4vc %007• d thAK 6. TYPE OF RESIDENCE NUMBER OF,BEDROOMS ❑ One ❑ Four ❑ Other SINGLE FAMILY _ ❑ Two ❑ Five ❑ MULTIPLE FAMILY Three ❑ Six 7. WATER SUPPLY INDIVIDUAL* xfo" *ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) B. SEWAGE DISPOSAL SYSTEM —� ❑ INDIVIDUAL/ON-SITE** YEAR ON-SITE SYSTEM WAS INSTALLED. PUBLIC UTILITY OTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. L 72-010 (Rev. 6/79) .� Vl� CHEMICAL & GLoLOGICAL LABORATORIES t`.r' ALASKA, INC. TELEPHONE (907)-279.4014 ANCHORAGE INDUSTRIAL CENTER 274.3364 5633 B Street Drinking Water Analysis Report for Total Coliform Bacteria ® TO BE COMPLETED BY WATER SUPPLIER II TO BE COMPLETED BY LABORATORY . WATER SYSTEM: I ==__F_1 I.D. NO. Water System Name Phone No. Mailing Address City Stele Zip Code SAMPLE DATE: CZl L—�J Mo. Day Year SAMPLE TYPE: ❑ Routine ❑ Check Sample (for routine sample with lab ref. no. t ❑ Treated Water ❑ Special Purpose ❑ Untreated Water SAMPLE Time Collected NO. LOCATION Collected By 2 3 II — 4 L —- 5 DEAD INSTRUCTIONS BEFORE COLLECTING SAMPLE 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 ED L --_J L— I — I m *No. o1 colonies/ 100 ml. or No. of Positive portions. 06-1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD Rev. 1978 Date Collected Source _ a.m. Data Received Time Received p.m. Lab. Noo..'��1_ Presumptive 10ml loml loml loml I 10m1 I 1.0ml I 0.1ml 48 Confir Multiple Tube Report: Membrane Filter: Direct Count Verification: LTB Final Membrane Filter Results. Reported By —_ Broth 24 hours: _Broth 48 hours: 10ml Tubes Positive/Total 10ml Portions Coliform/100m1 _BGB Coliform/loom) _ Data Time; —a.m. p.m. a GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3500 Tudor Road, Anchorage, Alaska 99507 279-8686 Date Received—__L_: i �Z - -7 (� Time of Inspection Date of Inspection REQUEST FOR APC �KOJAL OF�,C �v INDIVIDUAI, SEINER & 'NATER FACILITIES— FOR 1. Aoproval Requested By: �� ,� \, � g `- jl64, tem Address: (:I" C" `�_ e> - APhone L 2. Prooerty Owner Phones 3. Legal Description: 4, Location: )-O�- _ 5. Type of Facility to be (Inspected: Number of Bedrooms: 6. 'Nell Data: A. Type B. Depth // D. Bacterial Analysis C. Constructi on�� 7. Sewage Disoosal System: A, Installed B, Installer C. Septic Tank: 1. Size 2. Ma.nu_acturer D. Seepage Pit: 1. Si 2. Material E,Disposal F1old: Total Length of Lines 8. Distances: A. Well To: Septic Tank^/Absorption Area, Sewer_ Lines Nearest Lot Line Other Contamination B. Foundation to Septic Tank Absorption. Area C. Absorption Ares--to`Nearest Lot Line Requsst for Aporoval of idividual Sewer & Water Facilit ; Page Two 9, Comments: e alkll-ti-e- Aporoved dam a- sapproved Date Approval Valid for One Year From Date Signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM and accurate representation of the subject sewer and water facilities located at: Signed Date DATE--s...m��_..�..� ULF TMENT OF HEALTH AND SOCIAL S' 110ES Lob, No. DIVISION OF PUBLIC HEALTH BACTERIOLOGICAL WATER ANALYSIS PUBLIC SEMI-PUBLIC INDIVIDUAL 11 OTHER . REPORT RESULTS TO NAME. ADDRESS CITY ADDPSSS OF SOURCE SAMPLE COLLECTED BY— can DATE COLLECTED - TIME COLLECTED Pm Sample Collected From ❑ Kitchen Tap ❑ Ballroom Tap ❑ Basement Tap Wel ❑ Dug ❑ Driven -❑ Drilled ❑ Bored SOURCE: ❑ Spring ❑ Cistern-[] Other Dug Well or Cistern Conslruclion: Walls - 11Wood ❑ Concroto ❑ Metal ElTile Brick or ❑ Concrete Top - ❑ Wood ❑ Concrete ❑ Metal ❑ Open Top LOCATION: ❑ In Basement ❑ Basement Offset ❑ Under House ❑ In Yard ❑ Other Building Sower Sciatic DISTANCE TO: or Other Drainage Pipe Feet. Tank Tile Seepage Seepage Cess• - Field -- Faet, Pit _Foet.- pool __Feet. Privy �.,d�,_, Fccl, Other Possible Sources of Contamination MATERIAL: Building Sewer - ❑ tit ❑ Wood ❑ Tile ❑ Fibre ❑ Asbestos Iron Cement ❑ Plastic joint Material — Type�� GENERAL: Does Water Become Muddy or Discolored? ❑ Yes ❑ No OFFICE Records in this office Indicate this WATER SUPPLY to be of: - ❑ Satisfactory ❑ Queslionable ❑ Unsalisfactory Sanitary Staltm. Analysis shows this Water. SAMPLE to be: d Satisfactory ❑ Questionable ❑ Unsatisfactory, H an "Unsatisfactory" or "Questionable" status is indicated above you should take immediate action as recommended below. 1. Notify consumers water is polluted. Boil or chemically treat this water as outlined in fire enclosed leaflet Drink It Pure." 2. Increase chlorination sufficiently to meet recommended residual standards. Determine source of contamination and take action necessary to maintain a safe water supply at all limen, _.._,._.. 3. Check chlorination and other mechanical equipment. Make certain it is functioning properly. .- -.. 4. If after checking equipment a disinfecting residual is not obtained, please wire this olfica for emergency assistance or advisory services, -.�..� S. This is a surface water source and subject to pollution by man and animals. An approved water supply source should be developed, - _� 6. Improve your ❑ spring ❑ dug well ❑ driven well ❑ drilled well ❑ cistern 7. Relocate your well to a sale location in relationship to your sewage disposal system. (7 see enclosure �._ 8. Sample too -long In transit; sample should not be over 48 hours old al examination to indicate reliable results, please send new sample, ❑ Bottle Broken In transit, please send new somple. 9. Contact your nearest ❑ Local Health Department or ❑ Alaska Division of Public Health, sanitation office for bulletins, consultation and assistarice. SANITARIAN'S REMARKS When?Diameter of .—Depth--- Feet. Well Cashig - - - Material Diameter,,,_„__ Depth - Length of Water Depth Droppipa- - From Bottom---- ._„_Feel. PUMP LOCATION:Offset In In Utility ❑ ]n Well ❑ ❑ In Basement ❑ Room Dn Topp Basement 13 Of WSJ ❑ Other— PURPOSE ther PURPOSE OF EXAMINATION: Illness Suspected? ❑ Yes ❑ No — — - Now source olsupply? ❑ Yes ❑ No Repotrstosystem? ❑You ❑ No Signature 06.1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD REACH INSTRLICTIONS Dale Received _ v� Time Ilecelved,.,,,L..,a.:,: Pm ; Lab. No. ON REVERSE SIDE BEFORE Lrcioso Broth '� loco �z ,Be, loco loco f� �lBcc ]Acs �. 0.1cc 24 hours 48 hours -. m®rat".,.,� Brilliant Green �,.. --�• _ - .c -.cam- - -' esw.z cru-r�erf - .T.eaxra.a, maz�ca 24 hours 48 hcum EMB .�.�. AGAR;_,. - COLLECTING SAMPLE 46 hru._ _ Grams plain Coliform Density __ Most probable No. per IGOcc-) Detergent Test- are _ Reported ley Date This analysis indicates Coliform Organisms to bot - Absent Present..,....--.�.�-, THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified__ PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON -SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATE INSTALLED INSTALLER ❑Septic Tank or ❑Holding Tank Size: If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL n. DISTANCES WELL To: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS L4� APPROVED FOR BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE BY 72-010 (Rev. 6/79)