HomeMy WebLinkAboutMANSFIELD LT 2Mansfield
Lot 2
#018-332-28
Municipality of Anchorage
Development Services DepartmentBuilding
I
Safety Division
— On -Site Water and Wastewater Program, 4700 Elmore St.
P.O. Box 196650 Anchorage, AK 99519-6650 Page f of Z
www.ct.anchorage.ak.us (907)343-79D4
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: S tf/ O 600491 PID Number: O f - 2- Z
No.
Irn elftof
Wastewater System: ❑New ® UpgradeTun k
Owf
Addfae{
3F701 Pfiarm. cFn Ttrromee 9 9's-0 1<
ABSORPTION FIELD
Plwne Numoar of Bedrooms
3 MS - <7 9 9 y
O Deep TrenUr O sMnow Tnntll O Bed O Movnd O Omer.
sat Robng
Total Depth 1i Wginel 911de
LEGAL DESCRIPTION
GPDnr
Ft.
eiorA La subdmp/m'`'
Depth Pp. bona, Nom bngnW gmde
Gravel depth bones, PIPe
NZ4A Fere(
Ft.
Ft
To,insmp, Fsng. seabon
Fin added Wow dnynal pada
Gravel Length
Ft.
Ft.
Well: [:]New ❑ Upgrade
Grata v M.
Number of Ines
Dut; oex e.n I.xs
f5)c1S r
Ft.
Ft
Clas ri,aben (Pnvele. A. S. C)
Total Dapth
Ces.d to
Tinel absoipuon was
Pipe w1anai
FL
F1
Fr
Dnaer
Dole DNied
slWa Walb Level
bi.taMr
Dow Mum,".
Ft
saStlfn
I S -/2.f /09
Ywd
Pempset at
WungHmgntAboWGWIW
TANK
GPM
FI.
Ft
SEPARATION DISTANCES
&septic ❑ Holding ❑ S.T.E.P. ❑ Other.
To
Septic
Absorption
Lift
Holding
ubiirlPnvalewlaa/�
w•r��
apacitr
I,SOD
From
Tank
Field
Station
Tank
Sewer Line
YlTLFf
Gel
M.l.nal
Number of Lompbt"nol
wee
1004
PC, (y if T^ V ',*Ae I
2
LIFT STATION
su".0aWllb
>1150.
as
YUWb
Lot 4n.
52. I +
•J�
Gal
*Pm ben' NvN b
'Prop Wlevel b
mgh.atsr ab at
Faurgeuon
f !/ f
m
N
in.
Pump Make & Model
ElsMpecbons W norrrwd bF
pnrtl
Can.. Dian
N•"°
BENCH MARK
Q.- m4k l w k 12w,02olrify
Lonbon and Daampbdn
46ps11/
!
�6�- rel oT Sfdrw ..f' IUCG%7U/.
wm.d .....on
WWW n n P 2 f gyp, 0 Ft
Engineers Stamp
Inspections performed by: F'fe.f-ltor Tie% Sa.c Dates: 1" 5'12-1 169
pit
2nd
t10
+i�;OF
xc'G
Development Services Department Approval
Conditional Approval Date:
............ a.........E...�
.: .........q
CE - 3589 P
l t/ 3 -� �- o
.
'
Reviewed and approved by: Date:
e..�
:,yd.R. ;_.•.tE, o
PERMIT NO: SW 080081
PID NO: 018-332-28
SWING TIES:
LOT 2
MANSFIELD SID
NEW
1500 -GALLON
GREER —
POLYETHYLENE
SEPTIC TANK
w
m
FROM: COR. "A" COR. "B" o y
TO:
FDN. C.O. "C"
S.T. C.O. "D"
23.5'
S.T. C.O."E"
28'
DBL. C.O. "F"
30'
TANK M.T. "G"
23'
Z Q
10' E
o
19' m
24'
26'
22'
PAGE 2OF2
'4-BDRM
HOUSE
R=100'
---
t
----- ----------------
'r-------------
PTARMIGAN TERRACE
PLAN VIEW
SCALE: 1" = 30'
GRADE
PROFILE VIEW
NOT TO SCALE
INV.
94.0'
49
........................
I'.Z, ._ CE -3589
!rots
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water d Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Initial
Permit Number: SWO80081
Legal Description: MANSFIELD LT 2
Design Engineer: 0019 FLATTOP TECHNICAL SERVICES
Owner Name: STEVEN TALBOT
Owner Address: 3801 PTARMIGAN TERRACE
ANCHORAGE, AK 99516 -
Date Issued: Jun 16, 2008
Expiration Date: Jun 16, 2009
Parcel ID: 018-332-28
Site Address:
Lot Size: 40499 SQ. FT.
Total Bedrooms: 4 Permit Bedrooms: 4
This permit is for the construction of:
❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction must be In accordance with:
1. The attached approved design.
2. All requirements specked in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72 ) and Drinking Water Regulations (18AAC80 ).
3. The engineer must notify DSD at least 2 hours prior to each Inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By:
Issued
Date: rj �Y7�0E
Date: O a/J
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, Alaska 99519.6650
www.muni.org/onsite
(907) 343-7904
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcell.D. mg- 3-3�9--?8
Property owner(s) 5ftvtn 'TR Il & / Day phone 766 - 3-7
Mailing address 3001 P*rrlmiyc,n 7 -armee Zip Code 975'/6
Site address Sort _Zip Code N•4.
Legal description (Sub'd., Block & Lot) 1,/ 2, _r4h
Legal description (Township, Range & Section)
Lot Size L/` -'t q I / Sq. Ft.
THIS APPLICATION IS FOR (❑ all that apply):
Absorption Field ❑
Septic Tank
Holding Tank ❑
Privy
❑
Private Well
❑
Water Storage
❑
Number of Bedrooms
THIS APPLICATION IS AN:
Initial
❑
Upgrade
Renewal
❑
I certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: /1/ 60=` Waiver Fees:
Date of Payment: 6 / / Z / 04 Date of Payment:
Receipt Number. 1022-72— Receipt Number:
(Rev. 11/05) pfn
FLATTOP TECHNICAL SERVICES ..
CIVIL & ENVIRONMENTAL ENGINEERING ENERGY CONSERVATION & ANALYSIS
TED MOORE, P.E.
PH.IFAX: (907)345-1355
E -Mail: tgmoore@gci.net
M.O.A. DSD
P.O. Box 19-6650
Anchorage, AK 99519
Dear Sirs:
June 12,2008
14530 ECHO CANYON ROAD
ANCHORAGE, AK 99516
The purpose of this letter is to provide the required design narrative in support of our application
for a permit to replace aseptic tank that is nearing collapse on Lot 2 of Mansfield S/D. A site plan and
specifications are enclosed for your review.
Please give me a call at 345-1355 if you have any questions on this submittal.
Sincerely,
Ted Moore, P.E.
1
LOT 1
I
MANSFIELD SID ;
----------------
I
SEPTIC
AREA
`,
I
HOUSE
DRIVE
' '
NI
p
R=100' ;
10
2
' '
1
J
.
LOT - - -_
-'
MANSFIELD SID
ABANDON
EXISTING
I
SEPTIC TANK
- - ; 4-BDRM ;
1
RETAIN EXISTING
HOUSE ;
SOIL ABS. BED
INST. DBL. C.O. \_INST. ;
M.T. VIELL
' INSTALL NEW R =100
1250+ GALLON
SEPTIC TANK DRIVE
I—
— — — - — ---------
I`
I
I PTARMIGAN TERRACE
VACANTLOT
LOT 2, MANSFIELD SID
�~• '� �� �'JJ���''��, SEPTIC TANK PREPL CEMENT
S
pFLATTOP TECIINICAL SERVICES 1 INCH = 50 FEET
9 :� THEODORE F. MOORE � 14530 FCIIO CANYON ROAD DRAWN BY TFM
E
�� •., C� 3589 �: A ANCI IORAGE, ALASKA 99516 JUNE, 2008
\ 4p NOTE: THIS IS NOT A SURVEYED PLAT.
,��=fe s�lo!:,P, _ ALL LOCATIONS SHOWN ARE APPROXIMATE.
Tmttop 7echnica[Sen ices
14530 Echo Canyon gZ9a4Anchorage, AX 99516
Thone (907) 345-1355
Lot 2, Mansfield S/D
3801 Ptarmigan Terrace
Septic Tank Replacement
Specifications
1.0 General:
1.1 The scope of the project consists of abandoning a 1250 -gallon steel septic tank with a
collapsing baffle and replacing it with a new approved 1250 -gallon steel or 1300 -gallon plastic septic
tank located as shown on the site plan. Care shall be taken to maintain 100' separation from all wells.
1.2 Construction shall be as depicted on the approved site plan. Minor deviations from these
drawings may be allowed or required by the engineer conducting the inspections. All construction
procedures and material specifications shall conform to Municipal and State requirements.
1.3 The installer shall be responsible to obtain any necessary utility locates, and to work around
any buried utilities.
1.4 The installer shall provide adequate cover material and rough grading over the tank to ensure
that proper drainage is achieved after settlement and that there are no residual depressions.
1.5 The homeowner shall be responsible for finish grading after the soil is compacted, as well as
placement of topsoil and reseeding all areas disturbed by the construction.
2.0 Septic Tank:
2.1 The existing 1250 -gallon steel septic tank must be properly abandoned by thoroughly
pumping, removing the top and backfilling with soil.
2.2 The new 1250 -gallon steel or 1300 -gallon plastic, 2 compartment septic tank shall be
Municipally approved and shall be set level on undisturbed soil. Each compartment shall be equipped
with a watertight manhole cover and a 4" cleanout. If the tank is buried less than 4 feet it shall be
insulated with 2 inches of rigid insulation plus 2 feet of soil cover.
2.3 The existing line from the residence shall be properly connected into the tank. A double
cleanout shall be installed in the discharge line within 5 feet of the tank prior to the point of connection
with the existing soil absorption bed. If an approved plastic tank is installed, it shall be properly bedded
and backfilled with sand with an adjacent perforated monitor tube to the depth of the bottom of the tank.
3.0 Inspections:
3.1 A total of 3 engineering inspections will be required during the course of the project: (1)
initial discussion with the contractor to finalize the location of the tank and construction procedures, (2)
after the tank is set level and piping connected but prior to backfill, and (3) after rough backfill and
grading is complete. The installer shall coordinate the timing of the inspections with the engineer
sufficiently far in advance to ensure the availability of the engineer
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
I ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
n �
Port, h g' JVS� QJ �Cy�f .
�H;NE
s :. �'
�INEW
❑UPGRADE
MAILING ADDRESS
LEGAL DESCRIPTION
�v � Z
/plan s• e
LOCATION
/'/J:'�4—/Y2 �2
NO. OF BOOMS
U
DISTANCE TO:
Well
/r+
Absorption area
Dwelling
PERMIT NOv
Arbx--k .
Y
F
wy Q
Manufacturer
!
Materii
No. of conn rtments
(6.+
Liq. ca acitt�in gallons
����
IF HOMEMADE:
Inside length
Width
Liquid depth
DISTANCE TO:
Well
Dwelling
PERMIT NO.
= z
Manufacturer
Material
Liquid capacity in gallons
w xDISTANCE
TO:
Well
Foundation
Nearest lot line
PERMIT NO.
J E Z
F z wz
No. of lines
Length of each line
Total length of lines
Trench width
inches
Distance between lines
FTop
p
of tile to finish grade
Material beneath tile
inches
Total effective absorption area
%(, ®�
w
Length
Width
Depth
PERMIT NO.
(7
Q F
wa
Type of crib
Crib diameter
Crib depth
Total effective absorption area
U) LU
DISTANCE TO:
Well
Building foundation
Nearest lot line
Class
Depth
Driller
Distance to lot line
PERMIT NO.
Lu
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATERIAyL ,S
SOIL TEST RATING �s
O
3
i
`
t
INSTALLER
�'z.r-I �s L-� c air. � fi.•
REMARKS
e�rZ'
APPOOVED
DATE LEGAL
1 a2
Alz�ts
72-013 (Rev. 3/78)
r�
` P-11 99��C--] ����� �� ��������
DEPARTMENT OF HE8LTHHND ENVIRONMENTHL PROTECT�ON
STREET/ HNCHQRHGE/ HK. 99�--Cel1
264~4720
Flu P- 14 POEEF-�-"frl I T
PERMIT NO. ( 810899 )
HPPLICANT ROUNDHOUSE BUILDERS SRH BOX 156jZ 99507 ]45-]875
LQCHTION PTHRMIGHN TERRACE
LEGHL L 2MHNSFIELD
SIDLOT SIZE 45500 SQUHREFEET
TYPE OF SOIL ABSORPTION SYSTEM IS� TRENCH
MAXIMUM NUMBER OF BEDROOMS - 4 SOIL RATING (S8 FT/BR)= 85
THE REQUIRED SIZE OF THE SOh- ABSORPTION SYSTEM IS:
��F-`11 - F-1 =--: �C� ���Ci'T- �-Q =nil �3 F? F71 %o'E: I- �FEE uz::' -T- "l -=:. �
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD.
THE DEPTH QF H TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCHVHTI8N (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRHYEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET),
������� ����� :7-"; -T" ;;:-`EE�- ��ICE.', F -f L- 1- f `F-4 S'
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIONSOF Fir -,!Y WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
",1*- 0-4 0_3 J�F-��������� ���� �������� ��—
BHCKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION HND HPPROYHL BY THIS
DEPFlRTMENT WILL BE SUBJECT TO PROSECUTIQM.
MU4IMUM DISTHNCE BETWEEN A WELL HND HNY ON-SITE SIE -WAGE DISPOSAL SYSTEM IS
lf..'J0 FELET FOR H PRIVATE OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDINC-i
UPON THE TYPE OF PUBLIC WELL
MINIMUM DISTFlNCE FROM H PRIVATE WELL TO HPRIY8TE SEWER LINE IS 25 FEET AND
'Cl R COMMUNIT9 SEWER LINE IS 75 FEET
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN ]0 DHYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICHTIONS AND CONSTRUCTION DIHGRHMS FIRE
HVHILHBLE TO IN -SURE PROPER INSTALLATION.
�-T EE>��F- It' C:a E -E -A -41E3 E� lze �:: L � - J'����
I CERTIFY THAT
1: I HM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPHL�TY OF' ANCHORAGE.
2: I WILL INSTALL. THE SYSTEM IN HCCORDHN1-M WITH THE CODPS.
]: I UNDERSTAND THAT THE ON~SITE SENER SYSTEM MA-.' RE, U' RE ENLHRGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS.
SIG�E��~~_�.�.~~~_~�~~,�~~~_~___~~~~~~�
APPLICHNT ROUN�HOUSE BUILDERS
\
ISSUED ------- V4,0
Q1UNICIPALITY OF ANCHORAGE, --
Department Health and Environmenta rotection
825 L Street, Anchorage, AK. 99501
264-4720
# # # HANDWRITTEN PERMIT # # #
WELL AND/OR ON-SITE SEWER PERMIT
Applicant: Crab 44 -,UGe �0r5 Mailing Address:
Location: P� vrti -� cL,.,. r- Phon/e� Number: ?S
Legal Description: 'o f i 1 S Lot Size: / a (I r�-�
Type of Soil Absorption System Is:
Trench: Drainfield: _ Seepage Bed: Holding Tank:
Maximum Number of Bedrooms: Soil Rating(sq.ft/br) rCaS
The Required Size of the Soil Absorption System Is:
DEPTH 1 y LENGTH . GRAVEL DEPTH WIDTH
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(HOLDING) TANK SIZE _ �a GALLONS # #
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
# # #
TWO(2) INSPECTIONS ARE REQUIRED # # #
Backfilling of any system without final inspection.and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31, 1 9 u 1 # # #
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
the residence is remodeled to include more that`f5 bedrooms.
Signed:/ -,r) Issued by:2FQ
App 'cant
Date: AN- /
SWP/024(1/81)
T.H.
a D'
'0
Silty Sand
w/some gravel
.D
P.
'0
Sandy Silt
B W/Tr Gravel 17'
Silt W/Tr Sand
20' T.D.
No Water Table
This log represents subsurface
soil conditions With 31A Section
Lot 248A; Section 33
organic Material
'+ Silty sand w/some
Gravel
Brown
4 '
6.51
'.r
:r•
t+ j
D' �' �►.
Sandy Gravel w/ Trace �r •,
silt, Trace Cobbles
r +:
o•�
.y
°
r'
ry
r.r .
4
r/.
13.51
avel
r 1 Sand w/Trace Silt, Tra14.5 TD
Auger Refusal (Boulder)
No Water Table
This log represents subsurface
soil conditions within BLM
Section Lot 248B; Section 33
T12N, ROW, SM.,-nchorage Alaska
PERCOLATION TEST
TEST HOLE 2
R & M NO. 656285
ELAPSED
TIME
0
1
2
3
4
5
6
7
8
9
10
15
20
25
30
40
50
60
DROP IN
INKS
0
5:0
2.0
2.5
3.5
2.0
f
2.5
1.5
2.0
2.0
1.5
7.5
5.0
4.0
2.0
3.0
1.5
0.5
48 ID
1.25 M
TIME
9:12
9:13
9:14
9:15
9:16
9:17
9:18
9:19
9:20
9:21
9:22
9:27
9:32
9:37
9:42
9:52
I
3
10:02
i
i
3
10:12
i
;3
i
PERCOLATION TEST
TEST HOLE 2
R & M NO. 656285
ELAPSED
TIME
0
1
2
3
4
5
6
7
8
9
10
15
20
25
30
40
50
60
DROP IN
INKS
0
5:0
2.0
2.5
3.5
2.0
f
2.5
1.5
2.0
2.0
1.5
7.5
5.0
4.0
2.0
3.0
1.5
0.5
48 ID
1.25 M
I
t0
L
Time
..is
Date
Date
Date
Inspector
Inspector
Inspector
Comments /
Conditional Approval
.r :;tirF droo s
I
.16
Date Sewer Installed /i
Permit No.
Septic Tank Size j
Holding Tank Size
Soils Rating
Well To Absorption Area
Well Log Received
Well to Tank
APPLICANT_ FILLS OUT LOWER HALF ONLY -
`PropertyOwner
OL
Phone
Mailing Addresss/e/-) /s6 /a) /1/l/(// cl g5 -O7
h
Buyer % C> /} G�
/%/ '/ /
Addressu.S 5�7 w/. 4Jdd ' 1-�Se vUi(-e-.d jt)i 1 E,
Lending Institution `j / 6<71 CAL
Phone
/L�a
p
Address/6—,/),5/�/,��� �. �/?. / �SQ�
,/
Realty Co. & Agent
Phone
Address��
Legal Description
Street Location
Typ5residence
..��55 Single Family
❑ Multiple Family No. of Bedrooms
❑ Other
Wauppiy
VIndividual ATTACH WELL LOG. A well log is required for all wells drilled since June
❑ Community 1975. For wells drilled prior to that date, give well depth (attach log if
❑ Public Utility available.
Sewage Disposal
Individual Year Individual Installed:
❑ Public Utility When Connected to Public Utility:
❑ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
CHEMICAL & GE :OGICAL LABORATORIES k._ ALASKA, INC. O,NOEV ENpENl
TELEPHONE (907).279.4014 ANCHORAGE INDUSTRIAL CENTER - 90
g 274-3364 5633 B Street 3 n
�e.Ma,e8 Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER " TO, BE COMPLETED BY LABORATORY
WATER SYSTEM:7 E71
Analysis shows this Water SAMPLE to be:
LD.NO.
p Satisfactory
:,r: f rz�f,,Eri�,, ❑ Unsatisfactory
Water System Name Phone No. El
-
t r__ Sample too long in transit: sample should
'r'0 1 not be over 48 hours old at examination
Mailing Address to indicate reliable results. Please send
}t._.. view sample.
City - - State.. Zip Code
SAMPLE DATE:
Mo. Day Year
SAMPLE TYPE:
❑ Routine
❑ Check Sample (for routine sample
with lab ref. no. ) ❑ Treated Water
❑ Special Purpose ❑ Untreated Water
SAMPLE Time Collected
NO. LOCATION Collected B
7�t"
2
3 III
4 t
5
Date Received
Time Received
Analytical Method:
❑ Fermentation Tube
El Membrane Filter
Lab Ref. No. Result' Analyst
i..'
.f I I , "
m
FTI
TO
*No. oYcolonies/100 ml. or No.: of Positive portions.
06.1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD
-Rev. 1978
Date Collected Source -
READ INSTRUCTIONS - a.m.
BEFORE
- - EMB - - Broth 24 hours: Broth 4a hours:
COLLECTING SAMPLE Multiple Tube Report: < 10ml Tubes Posltive/Total 10ml Portions
- Membrane Filter: Direct Count Coliform/loom)
Verification: LTB BGB
Final Membrane Filter Results`, Collform/100ml
Reported 8Y Date
-. .. _. :Time- a.m.
P.m.