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HomeMy WebLinkAboutANGELA HEIGHTS LT 11HEALTH AND EN,, IRLNMENTAL . ,~:O~E,::TION ~ / i-JELL PER ~ 76~0 OLD HARBOR AVE HGTS ~ ~/ LOT SIZE t227~ ~IJ~RE FEET LEGAL Lii ANGELA MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS ±00 FEET FOR A PRIVATE WELL OR 200 FEET FOR A PUBLIC WELL. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN ~0 DAYS OF THE WELL COMPLETION. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS 8RE AVAILABLE TO INSURE PROPER INSTALLATION. PER"11 T %""AL I [~ FOR ONE '9EAR FROF1 I I CERTIFY THAT i' I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. "'~' I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. El I GNED' 'APPLICANT' GREINER CONSTRUC ( erlifie rtlliug DRILLING COMPANY BOX 97, EAGLE RIVER, ALASKA 99577 · TELEPHONE 694-2588 OWNER OF LAND ADDRESS LEGAL DESCRIPTION DATE-Started q/?/7' PERMIT NUMBER 7 Ended ~_/~/',TG DEPTH OF WELL STATIC LEVEL OF WATER FT. DRAW DOWN FT. GALS. PER HR KIND OF CASING KIND OF FORMATION: From ~-2 Ft. to ~' Ft. From ~;' Ft. to ~,~ From<](:~ Ft. to '7,5- Ft. From ~]'ff' Ft. to--Ft. From'~/C~' Ft. to I.~ Ft. From /3~]- Ft. to l~'i] Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft From__ Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft, From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From.__.Ft. to Ft From Ft. to Ft. From Ft. to .... Ft. From Ft. to Ft. ~ From~ft. to Ft From~Ft. to Ft, qT~From From~Ft. to Ft. From~Ft. to Ft. From~Ft. to Ft. From~Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to__Ft. ~ From Ft. to~Ft From~Ft. to Ft. From~Ft. to Ft. From Ft. to Ft. MISCL. INFORMATION: DRILLER'S NAME .L~-at4~IL~-~ ' MUNICIPALITY OF ANCHORAGE !10Development Services Department 3.- On-Site Water & Wastewater Section Phone: 907-343-7904 Fax: 907-343-7997 Certificate of On-Site Systems Approval Parcel I.D. 050-283-47 Expiration Date: IVO 1. GENERAL INFORMATION Complete legal description ANGELA HEIGHTS LT 11 Location (site address) 10249 CHICKALOON STREET, ANCH AK Current property owner(s) CONNOR & ABBY PAULSON Day phone Mailing address SAME Real estate agent Day phone 2. TYPE OF DWELLING: Ej Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well Q Private Septic ❑ Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer Waiver request for: Distance: • Received by: Date: COSA to be released to the engineer,unless otherwise requested by the engineer. COSA Fee $ �.-Q Waiver Fee $ Date of Payment 72..-/// Date of Payment Receipt Number Z-ctd $5 9 Receipt Number COSA# 05C/q 136 IWaiver# 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. I acknowledge that On-Site staff may visit the site to verify the information submitted. Name of Firm MIKE N ANDERSON, P.E. Phone 727-8864 Address 4661 NATRONA AVE ANCH AK Engineer's Printed Name MIKE N ANDERSON, P.E. Date 7-27-19 ��d®®N®O0k � .4.1::. O F "4..�19 a'_•_\ •• • • d 6. DSD SIGNATURE ,*:49TH ,� Ird .....d System #1 Approved for 4 bedrooms System #2 Approved for bedrooms of�.M CHAEL N. ANDERSON ;� Disapprovede CE- 4o .•�. % JI .• • Conditional approval for bedrooms, with the followingstip ` ', -. p $ -,SSIr�� ,q ON.Nw"`" y1Sit0 147.7-4.,,, 4--in'vfr rO pGRTR -N g..... zz- V)) 0? ICES IS)Nlj I))1)))))) t)„� .�tGCGo/recitec 17ec�r�oo " Lawn t/ By: Y /ik�(A04 Original Certificate Date:/6j /� 1 /�q The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory X Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet . MUMCPALITY F ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate OfOn-Site Systems ADD[OVB| D�O-9A�_�7 Parcel ~~~ ^-~~ '' Expiration Date: 1. GENERAL INFORMATION ANGELA A�|(�AT�[T11 Complete kago| description ' `� `~^-^' ` HEIGHTS ' ' " � ^ ' ' 1O�����A|[���|�1����T���T ��J��A�� Looaton(a���ddr�an) '~^- '~ ~' ''~'" `�^'`''` ~''`^-^-'`' "`^'' ^' "` Current property owner(s) Mailing address Real estate agent Day 7 2. TYPE OFDWELLING: 06 F Single Family kx/vvoADU\ 1771 Duplex 171 Multiple Dwellings (Single Family and/or Duplex) � 3. NUMBER OFBEDROOMS: / ---- 4. TYPE OFWATER SUPPLY: TYPE OFWASTEWATER DISPOSAL: Private Well El Private Septic Fx� Water Storage El Holding Tank 1771 Community Well Fx_1 Community 1771 Public Water System I—] Public Sewer R Waiver request for: Distance: Received by: Date: cOSAmbe released mthe engineer, unless otherwise requested uythe engineer. CDSA Waiver Fee $ Date ofPayment. Date of, Payment Receipt Number - Receipt Number C[)8A# VVaivar# 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (arb) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm MIKE N ANDERSON, P.E. Address 4661 NATRONA AVE ANCH AK Engineer's Printed Name MIKE N ANDERSON, P.E. DSD SIGNATURE System #1 Approved for bedrooms System #2 Approved for bedrooms Disapproved Conditional approval for bedrooms, Phone 727-8864 Date 7-27-19 c OF Al \�0 49T �,I� . • .... a . o . • ...... e e e o J • :.. e e o ♦ e • 31 -,,0 • MICHAEL N. ANDERSON ••, CE - 9 69 • `� with the following stipulations: ..tail tfat" x/11 "CnVIVG� l�1`' T'— Original Certificate Date: The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory_ Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet COSA Checklist Legal Description: ANGELA HEIGHTS LT 11 Parcel ID: 050-283-47 If more than 1 septic system on lot: COSA Checklist # of Structure served by this system A. WELL DATA R21 Well log is filed with Onsite (or attached) Date drilled 718176 Total depth 142.33 ft Cased to UK ft 0 Sanitary seal is functioning correctly ® Wires are properly protected Casing height (above ground) 12+ in. Date of flow test for COSA 7123119 Static water level at beginning of test 108 Comments B. TANK DATA Age of tank(s) years Tank type/material Measured operating fluid level in septic tank © Standpipes/foundation cleanout per record drawing Date of pumping AWWU D. ABSORPTION FIELD DATA Which system tested (date installed) ❑ ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Comments/Deficiencies: COSA Checklist yellow sheet Well production at time of test 5+ gpm Water storage tank volume 0 gallons Well disinfected for coliform test? ❑ Yes ®❑ N ❑O- Coliform bacteria is Negative Nitrate 5.21 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ® Arsenic less than MRL (ND) Collected by MNA Date of Sample 7/23119 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date Results ❑ Pass For bedrooms Fluid depth prior to test in Water added gal New depth in Elapsed time min Final fluid depth in Absorption rate gpd Any rejuvenation treatment (past 12 months) If yes, enter date E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' ❑ Yes if No ft Wells on Adjacent Lots: Community Sewer Manhole/Cleanout > 100' ❑ Yes if No ft ❑✓ Yes if No Neighboring Tank > 100' ❑ Yes if No ft Private Sewer/Septic Line > 25' ❑✓ Yes if No Absorption Field on Lot > 100' ❑ Yes if No ft Holding Tank > 100' Yes if No Neighboring Absorption Fields > 100' Animal Containment > 50' ❑✓ Yes if No ❑ Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' El Yes if No ft ❑ Yes if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑ Yes if No ft Surface Water > 100' ft ft ft ft ft ❑ Yes if No ft Property Line > 5' ❑ Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' ❑ Yes if No ft Private Wells > 100' ❑ Yes if No_ Water Main > 10' ❑ Yes if No ft Community Wells > 200' ❑ Yes if No Water Service Line > 10' ❑ Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ❑ Yes if No ft If absorption field is under driveway comment below Property Line > 10' ❑ Yes if No ft Wells on Adjacent Lots: Water Main > 10' ❑ Yes if No ft Private Wells > 100' Water Service Line > 10' ❑ Yes if No ft Community Wells > 200' Surface Water > 100' ❑ Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION / certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. COSA Checklist yellow sheet ft ft ❑ Yes if No ft ❑ Yes if No ft � moi,•° � �"d• a eooa ,•eo• e•• •• ae a P A1fCHAEL 'N ANDERSON ; 9 �i�f'.•• CE -r41,9 ���Fo • yjch .���w� MUNICIPALITY01F ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT On -Site Water and Wastewater Section 14 www.muni.org/onsite —� Nitrate Advisory Certificate of On -Site Systems Approval # OSC191361 Subdivision: Angela Heights Lot 11 907-343-7904 Fax: 343-7997 A water sample revealed a nitrate concentration of 5.21 milligrams per liter (mg/Q. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. M**�,ei'kWIN ' �, ANN'. ��Y+i�S tV gAds 696650 n t�ageA�asa 5 9�665Q'`v u�: un�orgg - N,` MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519~6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Comple~'e'legal description Location (site address or directions) /4~ ¢~¢ ~__~" JC.~---cL t oodl Property owner ~'~ ~r~6~k.c.~'-~", 0 Day phone Mailing address. / D Z Z-t ~ ~..~i('~.~A~.~r_.~ Lending agency Mailing address Agent Address Day phone Day phone e Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: L-/ N If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025(Rev. 1/91) Front MOA#21 STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. KND Engineering Phone ~ ~ -~/// Name of Firm 2044~ F-iarmigan f:~vd. Address Eagle River. AK 99577.8736 Engineer's signature DHHS SIGNATURE !./' Approved for ~-~ c, I/ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: The .Municipality of Anchorage Department of 'Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska, The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements, Employees of DHHS do not conduct inspections or analyze data before a certificate is issued, The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work, 72-025(Rev. 1/91) Beck MOA#21 t<ECEIVI:u Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVI~P^uT¥ oF Environmental Services Division ~NVIRONMENTAL SJ~R¥ICE$ DIYl~ 825 L Street, Room 502 · Anchorage, Alaska 99501 ° (907) 343-4744 Legal Description: A. WELL DATA Well type ,/~4~ Log present (Y/N) Total depth Sanitary seal (Y/N) Health Authority Approval Checklist ~r3o~ ~ '~, Parcel I.D.: If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to z./~' ~- Casing height (above ground) Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test ~/7~' ~.,~/~/~ ! I Static water level ! / 0 / D 7 Well production ! G* g.p.m. &'/"'/~ g.p.m. Be WATER SAMPLE RESULTS: Coliform Date of. sample: SEPTIC/HOLDING TANK DATA Date installed Foundation cleanout (Y/N) Date of Pumping Nitrate Collected by: /I//V'/"~ Other bacteda Y Pumper em ABSORPTION FIELD DATA Date installed Length Width Effective absorption area Date of adequacy test Soil rating (g.p.d~or ~/bdrm) ,/ -'~e, bloniton, ng ;2~i:k;r~nlel°~;ipe Result~ (P~tFail) System type ,,// Total/~h Depressio~ver field (y/N) / / Fluid depth in absorption/fidld// before test (in.); Immediately after~,/gal, water added (in.): .bedrooms Fluid depth J(ins) Minutes later: Peroxide tr te~ment (past 12 months) (Y/N) g.p.d. 72-026 (Rev. 3/96)* LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested Size in gallons / "Pump on" level at* / Pump off" level at* *Datum E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main ~.~~~li~' ~7J~- / Sewer/septic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station F. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation // Properly line /Absorption field Water main/service line./ Surface water/drainage / Wells on adjacent lots / SEPARATION DISTANCE FROM ABSORPT~)N FIELD ON LOT TO: Property line Bu~/J~ foundation Water main/service Iin~// Surface water // Driveway, parking/vehicle storage area Curtain drain / Wells on adjacent lots ENGINEER'S CERTIFICATION HAA Fee $ Date o' Payment ~'---/~/~ ~ ReoeiptNumber ~'~'~:F~' ~ ~'~'~-' '~ I certify that I have determined thru field inspections and review of MunicipallY_ it,,,~,. ~ systems are in conformance with, MOA HAA guidelines in effect on this date. ~.:'°°' "~'*.~?~_, ~~ /.-[ ,co..' ~ .; ~-,. Signature Date ~' Waiver Fee $ 72-026 (Rev. 3/96)* Date of Payment Receipt Number keY-11-99 17:40 , P,~k~-,.:lS £NVIRON},~ENTAL 5615301 T-~7G ~ $?/03 F-634 CT&E CT&E Ref.# Client Name Project Name/a Client Sample Matrix Ordered I]y PW~ID 991992001 KN D fingineering Lot 11 Angla His Lo[ t I Angela HTs Drinking Water 0 Sample Remarks: Client PO# Printed Date/Time 05/11/99 13'14 Collected Date/Time 05/06/99 14:30 Received Date/Time 05/07/99 12:30 Technical Director: Stephen C. Erie Nitrare-N b OB/lO0 HL~ NO £OLI 2_~9 units s~18 9222~ 0~/87/99 ~P EPA ~O0.0 10 max 05107/99 05/07799 SCL RECEIVED MAY 1 1999 Municipality o'I Anchorage Oept, Health & Human Service~ ApPLI( NT FILLS OUT UPPER HA: ONLY r ~ Property Owner ~)b ~/~ ~T',' ~(~ y~---~ Phone Buyer .... ~ ......... / ...... X~ .......... Address Zip Code Lending Institution Phone Address Zip Code Realty Co. & A~nt Phone Address ~ ~ ~ Zip Code Legal Description ~ CF /i ~ d~ ~7~ Type of Resi~nce ~ Single Family ~ Multiple Family No. of Bedroo~ ~ Other Water Supply  Individual A~ACH WELL LOG. A w~l Icg is required for all wells drilled since June 1975. Community For wells drilled prior to that date, give well depth (attach Icg if available). ~ Public Utility Sewer D~po~ .~ ~ Individual Year Individual Installed:  Public Utility When Connected to Public Uti~y:/~~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSlNG CAN BE INITIATED. Time Time Time, ~'~/~ .~ //,'~;:~- ~' Time Date Date Date Date Inspector Inspector Inspector Inspector Field Notes: JUN 2 ~ 1983 ( c~)~ROVED BEDROOMS ~ *CONDITIONS OF APPROV~nvir0nmen~aI Pro~ecti0n" ( i D,SAP~OVE~ ( ) CON DITIONAL ~A PPROV~*.~ DATE t ~'~ 7 [~- ~ Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received Well to Tank Septic Tank Size 72-023 (3/82) AL~ ~ICES o~-l~O~o) R~v. ~ DEPARTMENT-OF HEALTH AND SOCIAL ' DIVISION OF PUBLIC-HEALTH _, _ ,o~, No. ,: ~ ~:~ ~ -~ INDIVIDUAL AND SEMI-PUBLIC "o~T~ BACTERIOLOGICAL ~WATER .ANALYSIS ~ omc~  ~ -~ '~ ' ~ ~ ~Anolysi~ sho~s this Wofe~ SAMPLE lo ~e: INDIVIDUAL ~/ 5E~I.PUBLIC ~ CHLORINE ,RES[DUAC PP~ . - ~ II REPORT,.RESULTS TO ~ ' lINagE ~ · ~ / .... -- , . . . ~ . ADDRESS /. .-'~- . ' " " ' ' ' ~-' ' , . CITY ' -"- ~- "-';-- '~-~ .... · ZIP CODE OF SOURCE *- ~..' - ~'u'~ / ~ / ~- COMPLETE THIS SECTION ONLY IF WATER IS AN INDIVIDUAL SUPPLY SAMPLE COLLECTED BY DATE COLLECTED ~---' ~ -/ '~ / I~'IME COLLECTED / ('' ' '~. ~ ' '~ Sample Collected From [] Kitchen Tap [] Bathroom Tap [~'~'asement [] Other (List) Well- [] Dug ~ Driven [] Drilled I-I Bored ' SOURCE: ~] Spring ~'~ Cistern ~1 Other-- ' . Dug Well or Cistern Construction: Walls -- [] Wood ' [] Concrete [-I Metal [] TJte Brick or Top -- ~] Wood [] Concrete Metal [] Open Top [~] Concrete LOCATION: [] In Basement [] Basement ~[ffset [] Under House.~ f-lin Yard [] Other Building Sewer Septic' DISTANCE TO: or Other Drainage Pipe Feet, Ta~k F~et, Tile Seepage Cess- Field --Feet. PJl . Feet. Pool Feet. Privy, , Feet. Other Possible Sources of Contamination , MATERIAL: Building Sewer - [] Cast Iro~ [] Wood [] Tile [] Fibre [] Asbestos Cement [] Plastic Joint Material - Type GENERAL: Does Water Became Muddy or Discolored? [] Yes [] No When? Diameter of Well Well Ca~ng Material Length oT Drop Pipe [] Unsatisfactory [] Questionable ,. [] Sample too long in transit; sample should not be over 48 hours old at examlna'tl.on to indlcate reliable results. Please send new sample~ [] Bottle broken in transit, please send new sample. SANITARIAN'S REMARKS Depth Feet. Diamete~ r Depth .... Water Depth From Bottom Feet. Offset In In Utility PUMP LOCATION: [] In Well [] Basement [] In Basement [] Room On Top [] Of Well [] Other , ~_ .' PURPOSE OF EXAMINATION: Illness Suspected?~ '~ [] Yes [] No New Source of Supply? [] Yes ' [] No Repairs to System? [] Yes [] No Signature READ INSTRUCTIONS ON EMB AGAR Lactose Broth, 24 h~./-~- Coliform Density r ,' MF Results ,-- ~ -~ Reported by ,, , , This analysie Indicates Coliform Organisms to be: .., 48 hrs, Groin's stain , (Most probable No. per 100cc) ~r~ent COLLECTING SAMPLE Lactose Broth . · 10cc ! 10cc 10cc 10cc 10cc 1.0cc 1.0cc 24 Hours - Brilliant Green ~- - ~- 24 Hours' r ' ~ I 48 Hours ~ " BEFORE REVERSE SIDE 06.1220Rev. 1973(h) BACTERIOLOGICAL WATER ANALYSIS RECORD ~ Time Received ,-