HomeMy WebLinkAboutMARIE ESTATES LT 9 ) DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
I ENVlRONMEN'rAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAl_ SYSTEM AND/OR WELL INSPECTION REPORT
NAME pRONE J rNEW
MAI kIN~ ADD~
LEGAL DESCRIPTION
I We~ I Absorption area PERMIT N~
~ DISTANCE TO: ~ ~ ,~ ~ ~j~ I ~ Dwelling
E~ Manufacturer ~ [' ~ ' I ~p~) O~ ~
~ ~ ,) ~ ~ %~ ~ P~ ~ ~ ~ L C~-J M~erid No.~ compartments
/Liq. capacit~ in gallons Inside length Wid~[~ % ~t~ depth
[ ~ ~ IF HOMEMADE:
O Well F ° u n~ O~ INearest '°t 'i~ ' PERMIT NO.s O~
~ DISTANCE TO: ~O~ t~ '~? Distanceb~ines'~ ~
No, of lines Lehgth off~ ~e, Total lengt ines i Trench width
p~ 0t~. Material ben~h~e ~ ~ inches
Top of tile to finish grade
~ ~ G ~: Total effective ~orption area
~ Length Width Depth PERMIT NO.
~ ~ ~ DISTA~ ~ell Buildin~ foundatio~ ~earest lot line
~ ~t~ Depth ~riller Distance to lot line ~[SMlI SO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATING
INSTALLER
~ ~ }
.I
APPROVED DATE LEGAL
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME . PRONE [] NEW
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION NO, OF BEDROOMS
e ] Well Absorption area Dwelling PERMIT NO.
~¢~$f~ DISTANCE TO:j /C&2 ~ [2 6 / &¢ /
~ ~ Manufacturer Material No. of compartments
Liq. capacity in gallons Inside length Width Liquid depth
/~ 6--~ IF HOMEMADE:
~ ~ DISTANCE TO: Well Dwelling PERMIT NO,
O ~ ~ Manufacturer Material Liquid capacity in gallons
~ DISTANCE TO: Well .~ Foundation ¢. Nearest I~t line ~ PERMIT~O,,
~ ~ ~ No. of lines Length of each line ¢ Total length of lines Trench width / Dist~etween lines
~ ~ ~ ~¢Top~¢ ¢''~<~°f tile to finish~grade / ¢ ~t/~ --,.~ I ~aterial beneath tile ¢ Total effective absor~ion area
Length Width Depth PERMIT NO.
< ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
~T~ ~-r ~c. ,
SOIL TEST RATING ,
IN~TAELER
REMARKS r ......./
C. '~. '% CE 6736
Lot ?
72-013 (Rev. 3/78)
COl,It AL. 1 PHONEE~
850644
10/() .t. 18 ~.~
J AMES I_E I B 11'4
SR2 BO× 4485
CHUGIAK, Al<
9956'?'
.... t::,JAt ..... )[...~[.,R.,
L.. L~ l .I.Z.c.:
MAX BEDROOMS
SUBD I V I S I ON: MAR ]: E tESTA'TEES
SEC'r I OIq,' 10 TOWNSH i I::': .1.5N
1.65A (SQ. FT,, OR ACRES)
4
LOT: 9 BLOCK: NA
RANGE: 1W
List..:-)d below ar'e the optic~ns av~i].a...)le 'Lo you in designing ycmtr' septic
system. Choose the op'Lion that best. Fits yC)L(P site.
DEPTH ]"0 P II::'E BOTTOM (F:T",,) 4.0 4. (.) 4.0
GRAVEl_ DEEF:'TH (F'T.) 4.0 -
~,,-J 3.5
TOTAL. DEF:'TH (F"T'.) 8.0 4.5 7.5
GRAVEL WID"FH (F'T.) ,2.5 ~ 20. C 5. 0
(: RAk, El... I...E I,Ib IF~ (F:"F',) 63;. 0 38, 0 54.0
GRAVEL. VOLUME (C,I.'" . '~"D,:~.c" ) 26.3 '",=:.S. ~,~: 4 '). ')
TANK SIZE ([=Al~ ....... q~ :1.,2~.5C).C),~ 1,250.0 '~'~ - 1,2::5().C~ .~
SO]:L~ RAT:lNG (SQ.F:'T'. /BR) 125 :t25 ~' 125
..,v....~. TANK MUST HAVE A]" '
,..E.A,:) I TWO COMPAR'TME-N"FS
I cer'{'.iCy 'Lhat~
I am famitiap with the pequi~-ements fop on-site sewe~-s and wells as set
for'th by the Municipality e¢ Ancher'age (MOA) and the State o¢ Alaska.
2. ~1: will install the system in accoPdance with all MOA codes and r'egulations,
and in compliance with the design chided-ia of this penmit.
3~ I will adher'e to all MOA and State ef Alaska PequiP~m~ents for' the set back
distances fr. om any existing well, wastewatep disposal system of public
sewei-age system on this c)p any adjacent op neanby lot.
4,. I undepstand that this per. mit :i.s valid for. a maximum of 4 bedr'oems and
any enlar'gement will r'equi~-e an additional per'mi't:..
IF: A L.]:F'T S'TATiOIq IS !NS'I"AL, LEED IN AN AREA r
.... OVI...,,[...L BY MOA BUIL. DING CODEES~
.alLL NOT' BE' APPROVED W. Z THOUT AN ,:.l...r:L. 1K Z t,~_. . *c~r'~:.u,~ ZON t'd:.t-..]R 1 '~ AND ) THE
ELEEC]f:;:iCAI. WORK MUS'T :EE DONE BY ¢:~ L. ICENSIED EL. ECTRIC]:AN,
· .OE.,FARflIE, NI OF. HE. AL.~H
;~64.--4720 '
F'ERM :[ T ?'-10 ."
t.)ATE ~SSUED;
-,r FL I [,A. IT:
ADDRESS
CONTACT F"HONE:
850564
09/05185
JAMES W LEIBIN
SR 2 BOX 4483
CHLIG I Al.,::, Al< 99567
688-98 :L ,1
LEGAL DEESCR I F':
L.OT SIZE:
MAX BEDROOMS:
SLIBDIVISION: HARIE ESTATES
SE[;'[;-I OIq: ],0 TOWNSHIP:
71934 (SQ. F'T'. OR ACRES)
4
LOT: 9
RANGE: 1E
BLOCK: NA
Listed belmw are 'Lhe mp'Lzons available t.o you zn des:Lgr~zng your sr='ptzc
Choose the opt ion that. best Fit. ss your si'Le.
DEPTH TO F'IF:'E BOTTSM (Fq'.)
GRAVEL.. DE.']F']"H (F'T.)
]"OTAL DEPTH (1:::']'.)
GRAVEL WIDTH (FT.)
GRAVEL LENGTH (FT.)
GRAVEl._ VSL. UME (CU. YDS, )
TANK SIZE (GALS)
SOIL. RATING (SQ. FT., /BR)
'~'~ GRAVEL LFNB]"H > 75 F:'T. REQUIRES MLJLTtF:'LE RUNS (NB'[' EXCEEDING 75 F'T. EADH)
~"~ ]"ANI< M~JST HAVE AT LEAST TWO COMPARTMENTS
I cer'LiFy t. hat:
1. I am £amiliar with the requi?ement, s For (2n-si'Le sewers and, wells as cet
Forth by the Municipality oF Anchorage (MOA) ahd the State oF Alaska.
2. I will instal], the system in accordance with'all MOA cedes and pegulations,
· and :i.n compliance with the design cF'iter, ia of this per'mit. '
3., I will adher'e to all MOA and Ctat(¢ of Alaska requir'ements For the set back
distances Fr'om any existing well, wastewatep disposal system of public
.~.w,,.t age system on th:i.s' or any adjacent or nearby lot.
4. I under'star'id that t. his permit is yalid for a maximum ~F 4 b~)dr'moms and
any enlargement will 'r'equir. e an additional pePmit.
IF A LIFT ,~i~...ilIOII INSTAL.LED IN AN AREA CO~ERED BY MOA BUILDING CODES,
'T'FIEH (1) Aht ELIEC;TRZCAL "PE;RMIT AND ZNSPECTION PILJST: DE OB"f'AZNED,~ (2) AS-BU]:LTS
NILI... NOT,BE ~F;'~'ROVED NITI-.IOU]'~ELECTRZCAL INSPECTZON REF'ORT~ AND (3) "r'HE
F'ERMI T NO.
I-:IF~ F L I .~tNT
LOCI:t'T' t ON
I._EI3FIL
WESLE'¢ ..'f. :,E ,,,EF..:,L~N
"- ..REEf.
PETER,:, ~ ' "
L9 MRRIE E_,THTE_-,
" g --" ' '"-- "T" ff .... '--i--" '
i'1 Jhl I L- I F PilL I T JF
[:,EPRRTMENT C'-- FtERLTH RND ENVIRONMB~TRL F"73TECTION
:~25 'L STREET., RNC:HORRGE., R~ .... LE~gt,..,.~. ' - 7~ . %--
t.4EJLL RfqE:, C,~q--S' ·
BEI,~
SR2-'-'-' ~-' -
, %L~=.4 %LqlJRRE FEET
LOT SIZE
T'¢F'E OF SI]IL PIB_,URFTION S'¢STEM I:'5,: TF. EN_.H
I'"tR;:.::IMtlM_ NUME, EF.. r~F_ BE[.,F..OUM..,' ' ' - "-- = 4
_~UIL RRTING (SI2 FT,.-'BR)= 125
THE F. Ei...UIF..E[ _,I,=E OF THE-,L IL RBSOF.:PTI~Z~N $~r'STEM IS:
C, EF"Tt4= ::.t2 L. F I'-4,.3 T H = -3F..: GRFi'v"EL IDE F" TI'-1=
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD.
THE DEPTH OF R TRENCH OR PIT IS THE DISTRNCE BETWEEN THE SURFFICE OF THE
GROUND I:IND THE BOTTOM OF THE EXCR',/RTION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRR',/EL ~.,EPTI~t IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTFRLL PIPE
RIq[:, THE BOTTOM OF THE EXCRVRTION (IN FEET:.',.
RE[:, SEPT I C: TRi'41-:::
F'ERMIT RF'PLIC:FINTliP::-'-' THE R.E:,PuNz. IE, ILIT'~'''- ' '- ' TO INFORM THI'----, DEPRRTMENT DURINI3 THE
INSTitLLRTION INSPEZ:TIONS OF laN'T' ['-IELLS RDJRC:ENT TO THIS F'ROPERT'¢ RNa.' THE
N,JI~BER OF RESIDENCES THRT THE WELL WILL SERVE.
....... T 1..-I C, ,:'. ~ ."":'- ':. ! t.-I_.PECT'. ._-- · ~ C,l'-,t :5 RRE F-'E6-'-'4LI 1' RF [:..
E:FICKFILLING OF RN'¢ S'¢STEM WITHOUT FINRL INSPECTION RND RF'PRO'.,,'RL B'r' THIS
DEPFIRTMENT WILL BE S_D.TEC:T TO F'F.'_'SEE:UTICN.
I"'IINIMUM DISTFINCE BETWEEN iB WELL l~N[:, F~N'¢ ON-SITE :,BIB.E [>ISPOSF~L :,rz, TEM
ZOO FEET FUF:, F~ F'RIVFITE WELL OR Z~t TO 20~ FEET FROM B FUBLI. WELL [>EPENC, ING
'1
UF'ON THE T'T'F'E OF F JBL!C I.,~ELL.
MINIMUM C,!- - ~"
=,TP.IN_.E FRZM FI PRI'¢FI"rE WELL TO R F'RI',/FITE SEWER LINE I~ '"=
l._, FEET FIND
TO FI COMMUNIT'¢ SEWER LINE IS ~5 FEET.
~.~:l DFI'¢S
[,.IELL LOG5 ,t,,;.E RE~ZIIRED RND MUST BE RETIJ~.NE[ TO THE DEPRRTMENT WITHIN ~-
OF THE WELL COMPLETIOf-~.
}~"""~"' ~'E:~ IREMENT5 MR'¢ FF'F'L'¢. sPB-:IFICRTInN~ RND ~]IN~TRL~':TION DZI.II.~RlaM_ RRE
F~',,,'F~ZLRBLE TO INSURE F F. JFE~. INSTRLLRTION.
F"E~:F.~ ~ ~' E:-:F" ~ ~:F"~_. C=EC:Er.~E:E~: ~l.. l"~:=:~_ _ _
I CERTIFY THRT
1: I I::/i't FRMILIRR P~ITH THE REQUIREMENTS FOR ON-SITE SEWERS RND ~4ELLS RS :=]ET
FORI'H B'.r' THE MUNICIPRLIT'.,.' OF I.:INCHORIRGE.
2: I WILL INSTttLL THE S'.r'STEM IN RCCORDF~NCE I,.IITH THE CODES.
---.':: t UNDERSTFiN[:, THFiT THE ON.-SITE SEWER S'¢STEM M~]'¢ RE~;~IJIRE ENLRRGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THRN 4 BEDROOMS.
t:,F'F'L I CFIf~T [.IE:qLE ¢ J. ;E',, ERSOf~ ~ ~ ~
L 0 C: F! T ]: 0 N
LEGRL
L'S MRR:iE: E?,'"'Fi'TE~;
LOT "' '~
-::
i"tJ:N}:HU,'"'! [::'ZST.RNC:E E:['YFHEEN FI k!ELL. RND RN','? ON-tSZ'FE :SEP.!FiGE
::LSEi FEET i::'OR R F'R]:V.STE: HELL OR ZDE~ "i"O 2EH:3 FEET FROM R PUBL..T.C NELL [:'EF"ENDZNG
UF'ON 'THE T?PE OF' PL!BL. ZC I.,IEL. L..
HIN:[F'!UH D:£S]"Fi.NCE FF:OH R PF:J:?FITE [,IEL. L 'TO ?I F:'RZ',,,'FI"I"E SENER L. ZNE }:S ;T.':L:;.FEET F:.,'ND
TO F¢ COMt'!LIN:[T'¢ SE:NEE: L. ZNE J:S 75 FEET.
b.!ELL L..EH3S FiF:E' REQU]:REF.:, i:.,f.,E:, i"!U';'ST DE.' F:IE'FUF;:NE[) TO THE DEF'FIR"FMEF,IT i.,.iITH:[N
OF THE k!EL..L COHF'L.ETZON.
C!THEF~: F:EQU.T. REHENT'.:.:; i"!Fl'.r' F!F"PL?. SF'ECZF'ZC:FiT~ONS FiND C:O?',}STI':.':UCTZON
F'I',/F~.T. LF:..'E~LE 'TO Z,*'..I$1...iRE Pi~:OPEF--".: ):HS'FF~L. LFCFZOFL
by
DOC Co, dba
SULLIVAN WATER WELLS
P. O. BOX 272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-2759
OWNER OF LAND
ADDRESS
LEGAL DESCRI~ION
PE~IT NUMBER
/ /
DEPTH OF WELL
STATIC LEVEL OF WATER FT.
DRAW DOWN FT.
GALS. PER HR '?~ ':~ 0
KIND OF CASING
'7
KIND OF FORMATION:
From -/ Ft. to '- ....Ft, - .... . -
From '~' Ft. to ,
From __ Ft. to Ft.
From __ Ft. to Ft,
Fromm. Ft. to Ft.
From Ft. to__Ft.
From -~ '~ Ft. to ~ ~'gFt.
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
From Ft. to
From Ft. to
MUNICIPALITY OF ANCHORAGE
[?FOT C? 1,7',.T:, &
ENVIR'd,i (,',: 2N ; A. ; .,c),SC[ION
!982
Ft
From Ft. to. Ft
From Ft. to .Ft.
From Ft. to Ft.
From Ft. to Ft~
MISCL. INFORMATION:
DRILLER'S NAME
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG- PERCOLATION TEST
SOILS LOG
[] PERCOLATION
TEST
PERFORMED FOR:
'EGA1 DESCR,PT,ON:
DATE PERFORMED:
SLOPE
SITE PLAN
WAS GROUND WATER S
ENCOUNTERED? /~4¢) k
0
P
IF YES, AT WHAT E
DEPTH?
PERCO L~TION RATE
3
4
5
6 /
8
9
10-
11
12
13
14
15
16
17,
18-
19-
2O
COMMENTS
PERFORMED BY:
Reading Date Gross Net Depth to Net
Time Time Water Drop
TEST RUN BETWEEN
~'=} ~-- ~,¢"~. (minutes/inch)
FT AND -- FT
72-0o8 (6/79)
Eagle River Engineering Services
P. 9. ~;z 773294
Eagle River; AK 99577
694-5195
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVl RONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG- PERCOLATION TEST
SOILS LOG
PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
SLOPE
SITE PLAN
10
11
12-
13
14
15
16
17
18
19
20
E
IF YES, AT WHAT
DEPTH?
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE '~ (minutes/inch)
TEST RUN BETWEEN ~ FT AND ~ FT
PERFORMED
CERTIFIED BY: ~
72-008 (6/79).
77°~o ~o.
FIE, LD ~DR.~N¢= LO~$
WALLAC. JE
'NT FILLS OUT UPPER HAl' ' NLY
Mailing
Buyer
Zip Code ~ ~. 5'~ ~
JPhone
Address
Lending Institution ,.. // ~ .~_ ;
Address
Zip Code
Address ~'~ ~ /~, ,-,'~ /' -- ~'~r'"'~ ~'-~' ~
" ~-~ Zip Code
Phone
Phone
/
Street Location ~'- ~
Type of Residence
[~ Single Family
[] Multiple Family No. of Bedrooms z_/
[] Other
Water Supply
~ Individual ATTACH WELL LOG. A well 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 Disposal
{~r Individual Year Individual Installed: ~ ~ ~ /
[] Public Utility When Connected to Public Utility:
[] Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN RE INITIATED.
Time Time Ti'~ Time
Date Date Date Date
Inspector , ~ Inspector ~c~/ Insp~tor Insp~tor
~) APPROVEO 8EOROO~S 'CONDITIONS OF APPROVAL
(
( ) CONDITIONAL APPROVAL'
BY:
Soils Rating Date ~wer Installed Well To Absorption Area Well Log Received
~ ~ ~ Well to Tank Septic T~k Size
72-023 (3182)
M n .c pa .ty Ancho age
MEMORANDUM
DATE:
TO:
FROM:
SUBJECT:
November 18, 1982
Laura Crow .:.
Sewer and Water Program
Request for Refunds - Account #2460
Please make the necessary arrangements for the following
refunds:
Thank you.
K~ren Vavra
SEar Route Box 9379 Hiland Road
Eagle River, Alaska 99577
She has called and cancelled the inspection as they do not
need it now.
Lot 22 Block 5 Mountain Valley Estates Subdivision
Receipt #210106
Amount $25.00
Sewer and Water Other
Arvid Severson
8531 Little DiPper Avenue
Anchorage, Alaska 99504
Receipt #210104
Amount $25.00
Sewer and Water Other
This is ~ duplication in paperwork. We have already made the
necessary inspections for this property.
Lot 9 Marie Estates Subdivision
Laura J. Ward
Senior Office Assistant
LJW
attachements
91-010 (5/78)
~. APPLI¢ "NT FILLS OUT UPPER HA[" '"' ONLY
Prop:--..r~yOwn'er . '-~-&~/ f./,-,rj/. ~ ~/~'/~'/~///-, -'~-')/,/Z/./ ~f~../-~. ,C..g Phone
Mailing ~ddre~ ,~ /~ f~ ~ ~ ~ '~) /~- //~.~ -5~/~ Zip Code ~ ~ "~ .
Buyer ~/ /~' f/--4~ I ~ 1 1~
Address Zip Cod~
Lending Institution ] ~ /~z~ ~, Phone
Address ~ '~2} C W //~/~Tff~"/ /T.~ Zip Code
Realty Co. & A~nt /~ 7~/~ _ ~gg~ ~ ~/~ Phone
Address ~_~.... Zip Code
Legal Description ~ ~ T ~ ~/~ ~ 7~{~ ~,
Type of Resi~nce ' ~ )
~gle Family ~ /
~ Multiple Family No. of Bedroo~ /'-/ ~ J
~ O~er ~ ~ /
. / &
~dividual ~ A~ACH~LL LOG/A wall Icg i~, requi{ed~for all wells~rilled since June 1975,
~ Community 'X ~ For wells dH[l~d pri~r to that date, ~ive w~l ~epth (attach~og if available).
Sewer Disposal ~ ~ .;~ . _~
~dividuM ~ Y~r Individual Installed: /~ /
~ P.b,~ utmty X'~ WhACo,.~oted to Pub,oUt,ity:' '~ /
~ Holding Tank ~~ ~ /
NOTE: 'HE~ECTION FE~MUST ACCOMPANY EAcH RE~EST BEFORE ~N~ CAN BE INITIA/D.
Date Date ~ ~'~ /Date
Inspector Insp Inspector
Field Notes: ~ \\
X~~ 'CON
5 RECEIVED
( ) APPROVED BEDROOMS DITIONS OF APPROVAL
( ) DISAPPROVED
( ) OONOITIONAL APPROVAL'
DATE
BY:
~oil8 Ralino Date ~wer In~talled Well To ~orption Area Well Log Reoeived
Well to Tank 8eptio T~k Size
?2-023 (3/82)
CHEMICAL & GA JLOGICAL LABORATORIES ~F ALASKA, INC.~.
' TELEPHONE (907)-279-4014 ANCHORAGE INDUSTRIAL CENTER
/~'~ O 274-3364 5633 B Street
rinking ~'(ailr Analysis Report for Total ColifOrm Bacteria"
TO BE COMPLETED BY WATER SUPPLIER
WATER SYSTEM:
Water System Name
Mailing Address
I.D. NO. ,~
~-~'~ -
Phone No.
City
SAMPLE DATE: ~
MO.
State
Day Year
Zip Code
SAMPLE TYPE:
F3 Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
~1 Treated Water
[] Untreated Water
SAMPLE
NO.
I
LOCATION
Time Collected
Collected ~ By~
TO BE COMPLETED BY LAB0 RATORY
Analysis shows this Water SAMPLE to be:
~] Satisfactory
[] Unsatisfactory
[] Samole too long in transit; sample should
not be over 48 hours old at examination
to r~dicate reliable results. Please send
new sample.
Date Received
Time Received '-
Analytical Method:
[] Fermentation Tube
~. Membrane Filter
Lab Ref. No. Result* Analyst
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220
Rev, 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Collecte~ Source
Date Received Time ReCeived, p,m. Lab. NO.
Presumptive 10mi 10mi 10mi 10mi 10mi Z.0ml 0,1mi
24 Hours ~
48 Hours
Confirmatory
24 Hours
48 Hours
EMR Rroth 24 hours:
Multiple Tube Report;
Membrane Filter: Direct Count
Verification: LTB
Final Membrane Filter Results
Reporte¢l By - '''~' : *" ~
Broth 48 hours:
10mi Tubas Positive/Total 10mi Portlool
Collform/100ml
RGB
Collform/100~l