HomeMy WebLinkAboutSASSE #1 LT 7c,bf6T (i V,1 : 11- 1l
CATH ANCHORAGE AREA BOROUGH
1MALTH DEL'ARP ENT
327 HAGLI: MEET
ANCHORAGE, ALASKA 99501
� 279-2511 _ 7
DATE RECEIVED
/.T INSPECT:'
TIT,IE:
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER. FACILITIES
FOR %
1.
Approval Requested By - 0 j v
Address
Phone �2J- L_1
2.
Property Owner S (-�°r� S 10 i Phone
_
3.
_�h9
Legal DescriptionC—/ G�i
4.
771
Type of Facility to be Inspected �Q-� STREE'C;^�ZC�
Number of Bedrooms 1�4" -G6�v�c
5.
Well Data:
A. Type �j�',r .�G'
B. Depth l -i l _,.-i .41 -
C. Size
D. Construction =Y Z
E. Bacterial Analysis
6.
Sewage Disposal System:
A. Septic 'rank (If homemade, show diagram on back)
1. Size
2. Age
3, Manufacturer
4. Installer
Approval Request for Sei a & Water Facilities
Page Two
B. Seepage Pit
1. Size
2. Lining
C._ Disposal Field
1. Number of Lines
2. Total Length
7. Required Measurements
A. Well to Septic Tank
B. Well to Seepage Pit
C. Well to Sewer Line
D. Well to Property Line
E. Well to Other Possible Contamination
F. Foundation to Septic Tank
G. Foundation to Seepage Pit
H. Seepage Pit to Property Line
8. COMMENTS:
APPROVED: %� l�lC DISAPPROVED:
DATE: ✓ DATE;
APPROVAL VALID FOR ONE YEAR FROM DATE SIGNED.
GREATER ANCHORAGE AREA BOROUGH HEALTH DEPARr4ENT
ED1170
ADHW - LAB - 2W
DATE
�•^•a yr r\YI9JI\A
D" 4RTMENT OF HEALTH AND WELT 'RE Lab. No.
DIVISION OF PUBLIC HEALTH
BACTERIOLOGICAL WATER ANALYSIS
PUBLIC SEMI-PUBLIC INDIVIDUAL
REPORT RESULTS T
NAME
ADDRESS
CITY
ADDRESS
OF -SOURCE
OTHER
SAMPLE COLLECTED BY—
DATE
Y DATE COLLECTED TIME COLLECTED pm
Sample Collected From ❑ Kitchen Tap ❑ Bathroom Tap ❑ Basement Tap
❑ Other (List)
• • •gm.1r
Well - ❑ Dug ❑ Driven ❑ Drilled ❑ Barad
SOURCE: ❑ Spring ❑ Cistern ❑ Other
Dug Well or Cistern Conslrucliom
Walls - ❑ Wood ❑ Concrete ❑ Metal ❑ TiloBrick or
❑ Convate
Top - ❑ Wood ❑ Concrete ❑ Metal ❑ Open Top
LOCATION: ❑ In Basement ❑ Basement Offset ❑ Under House
❑ In Yard ❑ Other
Building Sewer Septic
DISTANCE i0: or Other Drainage Pipe_ Feel. Tank Feat.
Tile Seepage Cess.
field --_Feel.
Other Possible Pil —Feel. Pool Foal. Privy Feel
Sources of Contamination
MATERIAL: Building Sewer . ❑ Cost ❑ Wood ❑ Tile ❑ Asbestos
Iron ❑ Fibre Cement
�.� Ploslic Joint Malarial - Type
GENERAL: Does Water Become Muddy or Discolored? ❑ Yes ❑ No
Wh ?
en _
locc IOcc
loco IOcc IOcc 1.Occ 0.1 cc
24 hours
Diameter of Well
Depth
Foat.
Well Casing
Brilliant Green
Malarial
Diameter Daplls
48 hours
Length of
Drop Pipe
Water Depth
_ From Bottom_
Feet,
PUMP LOCATION:
❑ In Well
❑ Offset Int ❑ In Bosemenl ❑
BasRoom
In Utility
On Top
❑ Of Well
❑ Other --
PURPOSE OF EXAMINATION: Illness
Suspected? ❑ Yes ❑ No
New Source of Supply?
❑ Yes
❑ No Repairs to System? ❑ Yes
❑ No
READ INSTRUCTIONS
ON
REVERSE SIDE
BEFORE
OFFICE
Records in this office indicate this WATER SUPPLY to be of:
Satisfactory ❑ Questionable ❑ Unsatisfactory Sanitary Status.
Analysis shows this Water SAMPLE to be:
Satisfactory ❑ Questionable ❑ Unsatisfactory.
If an "Unsatisfactory" or "Questionable" status is indicated above
you should take immediate action as recommended below.
I. Notify consumers water is polluted. Boil or chemically
(real this water as outlined in the 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 of all times.
3. Check chlorinafinn and other mechanical equipment. Make certain it is
functioning properly.
—4. If after checking equipment a disinfecting residual is not obfai tied, please
wire this office for emergency assistance or advisory services.
—5. This is a surface water source and subject to pollution by man and animals.
An approved water supply source should be developed.
--6. our Improve P Y spring El dug well ❑ driven well
Cl drilled well ❑ cistern.
__7. Relocate your well to a sale location in relationship to your sewage
disposal system. ❑ see enclosure
_8. Sample too long in transit; sample should not be over 48 hours old of
examination to indicate reliable results, please send new sample.
❑ Bottle Broken in transit, please send new sample.
^9. Contact your nearest ❑ Local Health Department or ❑ Alaska
Division of Public Health, sanitation office for bulletins, consultation and
assistance.
SANITARIAN'S REMARKS
Signature
BACTERIOLOGICAL WATER ANALYSIS RECORD
Dale Received - Time Received - - - pm Lab. No. ' •��""f cl!([�1+
Lactose Broth
locc IOcc
loco IOcc IOcc 1.Occ 0.1 cc
24 hours
48 hours
Brilliant Green
24 hours
48 hours
EMB
COLLECTING SAMPLE Lactose Broth, 24 firs. -- 48 hrs.
_®-
Coliform Density _
MF results_ -
Reported by Date_
This analysis indicates Coliform Organisms to be: Absent
I Present
stain _
ssf probable No. per IOOcc.j
um