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CHEMICAL & G~OLOGICAL LABORATORIES ~ ~? ALASKA, INC.
TELEPHONE (907).279,4014 ANCHORAGE iNDUSTRIAL CENTER l~.~:~i
274-3364 5633 B Street ~'~
Drinking Water Analysis Report for Total Coliform Bacteria
I,D. NO,
Water System Name Phone No.
Mailing Address
City State Zip Code
Mo. Day Year
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
[] Treated Water
[] Untreated Water
SAMPLE
NO.
2 I
4 I
I
LOCATIO~
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
I~ Membrane Filter
Lab Ref, No.
I
I
Result* Analyst
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-3.220 (b)
Rev. 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
Data Collected Source
acalved Lab. No.
24 Hours
48 Hours
Conflrmetory
24 Houri
. ~ i ~, ] Date
m ~ DATE'RECEIVED
INSPECTION APPOINTMENTS
I TiME TIME FIME
DATE DATE CATE
NSPEDTOR INSPECTOR INSPEDTO ,
MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAO~
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION DEP~. OF REALTtl &
82~ L Street - Anchorage, Alaska 99501 ENVIRONMENTAL pgO~EC'rlON
( ENVIRONMENTAL SANITATION DIVISION [)g'i' 9 1981
Telephone 264-4720
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
~AILING ADDRESS
PROPERTY RESIDENT {If different from above) / PHONE
MAILING ADDRESS ~, vc ~ ~O~F ~-~,
4. REALTOR/~ PHONE
MAILING ADDRESS
STREET LOCATION
6. TYPE OF RESIDENCE "~ NUMBER OFtBEDROOMS
'~ SINGLE FAMILY [] One [] Four
Two [] Five
[] MULTIPLE FAMILY Three [] Six
7. WATER SUPPLY
~ iNDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
[] Other
* ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior 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 REQUEST BEFORE PROCESSING CAN BE iNITIATED.
72-O10 (Rev. 6/79)
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
E~]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
TO'rAL ABSORPTION AREA MATERIAL
4, DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line
I
WELL TO:
Absorption Area to nearest Lot Line
5. COMMENTS
[] APPROVED FOR '~ BEDROOMS
L~'"'~CONDITIONAL APPROVAL (letter must accompany certificate}
[~-~/Di SAPP R 0 V E D
72-010 (Rev. 6/79)