HomeMy WebLinkAboutUS SURVEY 3043 LT 3 OF 65A
CHEMICAL & Glz~LOGICAL LABOR/ITORIES'oF ALASK.4, INC.~
TELEPHONE {g07)-279.4014 ANCHORAGE INDUSTRIAL CENTER
274-3364 5633 B Street
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
WATER SYSTEM:
Water System Na~ne
I.D. NO.
Phone No.
Mailin~ Address
..... ~tat~~
Z p Code
Mo. Day Year
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
[] Treated Water
[] Untreated Water
SAMPLE
NO. LOCATION
1 I /f<- <" , ~: · / ':'~,
Time Collected
Collected By
TO BE COMPLETED BY LABORATORY
Analysis shows mis Water SAMPLE to be:
~ Satisfactory
[] Unsatisfactory
[] Sample too long in transit; samole should
not De over 48 hours old at examination
to nd~cate reliable results Please send
new samole.
Date Received
Time Received ' ~. ~
Analytical Method:
[] Fermentation Tube
,C]' Membrane Filter
Lab Ref. No. Result*
I
I ICI
Analyst
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220 (0)
Rev. 1918
BACTERIOLOGICAL WATER ANALYSIS RECORD
24 Hours
48 H0urs
Confirmatory
48 Hours
Verification: LTB
Reoor tMi By
BGB
~ DATE RECEIVED
TIME TIME
DATE DATE DATE
MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION DEPT. GE NEALTH &
825 L Street 7 Anchorage, Alaska 99501 ENVIRONMENTAL PROTECTION
( ENVIRONMENTAL SANITATION DIVISION AUC ~. 8 1981
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER ~;~lFL ITVE~ b
DI RECTI ONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPE ¥OWNER ~,, ~ PHONE
PROPERTY RESIDENT (If different from a~ove) ~' ' PHONE
2. BUYER PHONE
MAI El NG ADDR ESS
MAILING ADDRESS
5. LEGAL DESCRIPT~/
6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS
[] On~ [] ~-~Our
[] SINGLE FAMILY [] ~wo [~ Five
[~ MULTIPLE FAMILY [] Three [] Six
[] Other
WATER SUP LY
7. ~NDIVI DUAL* * ATTACH WELL LOG, A well log is required for all wells drilled
[] COMMUNITY since June t975. For wells drilled prior to ti)at date, give well
[] PUBLIC UTI LITY depth (attach log if available.) ~;;~ ~'~ ~
8. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE** YEAR ON-SITE SYSTEM WAS INSTALLED.
UBLIC UTILITY - ,~
/
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST 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
[~3 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, DISTANCESwE/L TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
5, COMMENTS
[~'~'~A~ FIOV E D FOB BEDROOMS
[] CONDITIONAL APPROVAl- {letter must accompany certificate)
[] DISAPPROVED
72-010 (Rev, 6/79)