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HomeMy WebLinkAboutHOCKER BLK 2 LT 3Development Services Department Building Safety Division ,t, a On -Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650LILiff Mark aegich Anchorage, A K 99507 Mayor www.muni.org/onsite (907)343-7904 Pump Installation Log Well Drilling Permit Number: SW Parcel Identification Number: 042•02 1, IS Date of Issue: 7 -5 --It Legal Description Property Owner Name & Address: tf 0C ker %i'rn 6014w 13L(Cz lo-+ 3 11 0399� cri,Wv " rot. YtwC�. 141C. Pump Installation Date: "7 —5--U Pump Intake Depth Below Top of Well Casing: / %1-1 feet Pump Manufacturer's Name: e—ed Sac.l,e� Pump Model: 5 0 t 3 11 9 S I Z Pump Size !Z hp Pitless Adapter Burial Depth: _)� feet Pitless Adapter Manufacturer's Name: Pitless Adapter Installer: Well Disinfected Upon Completion? 5] Yes ❑ No Method of Disinfection: Comments: n^, tote V�2W�� �:: p!C v� ANCHORAGE WELL&PUMP SERV. Pump Installer Name: 330 EAST 76M AVENUE ANCHORAGE, AK 99518 PHONE: 907-243-0740 AWPS.COM Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation Municipality of Anchorage Page 1 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well inspection Report Permit Number. 970206 PID Number. 042081 15 Name: Tim . othy J. Connolly & J Bantz Wastewater System: ❑ New pgrade Address: 10040 Flat Top Avenue, Anch., AK ABSORPTION FIELD Phone: No. of3Bedrooms: eBp Trench ❑ Shallow Trench ❑ Bed O Mound O Other LEGAL DESCRIPTION Soil Rating: Total Depthfromoriginalgrads: , I tri/ GPD/S . Ft. Lot: Block: Subdivision: Depth to pipe bottom from original grade: (travel depth beneath pipe 3 2 Hocker -3.5 Ft. , a Ft. Township: Range: Section: Fill added above original grade: Gravel length: O Ft Z Ft WELL: 4 S ❑ New ` .' ❑ Upgrade Gravel width:.F 5. rClassification Number f Iinas: Dista �lirm t. (Private, A,B,C): Total Depth: To. Total absorption area: Pipe material: AST �; �'� Ft.Ft. . Ft. It�B/fir Driller. Date Drilled: RStaficW=atwLev@k Installer. e i felled: Da;77674P s S s 876/ 97 Yield:Pump Set at: I Casing Height Above (around: TANK GPM FL Ft. SEPARATION DISTANCES optic ❑Holding 0S.T.E.P. To From Septic Tank Absorption Field uttt Station Holding Tank Putblwprivate Sever Lines Manufaccturer.'' __ ``//�� /e• %�vl<Tr Capacity in gallons: / OOG7 well, /-7 Of /-77LI Materi I: Numbs mpartmante Surface >/SO r >/So' �/' / LIFT STATION N LotS' 35-5' Size in gallons: Manufacturer. Line / Foundation"Pump on" level at "P level at High water alarm at Curtain`' 'V Pump Make Electrical Inspections performed W. Drain Remarks: Existincr septic tank and BENCH MARK Location and Description: crib were pumped, crushed backfilled Garage slab on grade and abandoned nplace - vSit<Apt04 r;'L4 n t?,.1bd=7L tl. iZ't%FL."iJA Assumed Elevation:. I00Q Ft EQIk9f_SEAL i �OA4_ ®�rrl �s �3 9�00 Inspections performed by: //, Dates: 1s el �9 M161AEL E. ANDERSON •F� � 3rd 113 11 Department of Health and Human Services approval �•. 4381-E II in Rand approved by. Date: 2� tai © 6FE §OA ;z- .Reviewed Permit No.. SW970206 Page 2 of 3 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION . I P.O. Box 196650 e Anchorage, Alaska 99519-6650 o Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Legal Descrip . tion: Lot 3, Block 2, Hocker Sub. PIDNo.: 04208115 WT . 1IZv%13+7- A 49 TM j. ............. MICHAEL E. .......00' ANDERSON A 100 WN. 4381-E WT . 1IZv%13+7- LEGEND SP1 Septic Pump, compartment I SP2 $1 11 2 C Clean Out MT Monitor Tube PLAN AS' -BLT 1" =-301 Permit No. SW970206 Page 3 of 3 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 a Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Legal Description: Lot 3, Block 2, Hocker Sub. plD No•: 04208115 � A Jc low 'i� c? •`QI� qtr 49 L* MICHAEL E. RNDERBC)fV 4381•EAw 1e ,., IN ftP— FESS_ v ELEVATION AS—BLT /' 1" = 1011 LEGEM SP1 Septic Pump, compartment 1 SP2 . n n to 2 C Clean Out MT Monitor Tube Iv 155 c_ .3z' L �, 11 3' Y, 7'et P%4=� '(lz�,W X04 (- upr PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW970206 DESIGN ENGINEER:ANDERSON ENGINEERING OWNER NAME:CONNOLLY TIMOTHY J & OWNER ADDRESS:10040 FLAT TOP AVENUE ANCHORAGE, ALASKA 99516 PARCEL ID:04208115 LEGAL DESCRIPTION: HOCKER BLK 2 LT 3 LOT SIZE: 34707 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: DATE ISSUED: 7/23/97 EXPIRATION DATE: 7/23/98 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED 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 DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) . (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED BY: DATE: DATE: "1 1Q%/f-'7 2ISSUED BY: (6/i3`ta' DATE: 7 - 23 ' 0 June 30, 1997 Municipality of Anchorage Department of Heath & Human 'Services 825 "L" Street Anchorage,, AK 99502-0650 Subject: Lot 3, Block 2, Hocker Subdivision Septic, System Design Impacts to Adjacent Properties Dear On Site Services Engineer: The existing absorption pit on Lot 3, Block 2, Hocker Subdivision has failed and must be replaced. In addition,both the pit and the existing septic tank fall, within the 100' protective radius of the well. We are therefore applying for a permit to upgrade the system to meet .current requirements and maintain 100' separation from the well. A testhole place on the property revealed clean poorly graded gravels and sands which percolated at 2 minutes per inch. Groundwater was encountered at 16' below the surface during placement of the hole. The level did not change during the` monitoring "period' and continues to be 16' below 'the surface.' The new absorption trench is designed for a total depth of 10' which will, provide more than 6' separation to groundwater. The ground surface of the lot is very irregular. The house sits nearly 20' above the area where the new absorption trench will be located. .The area of the new -trench is fairly_ flat, but; grades uphill from the trench vary from 15% to, 20% and 'somewhat steeper. Due` to the, placement ' of the house and the location of the well a long service: line with a- steep slope will be'required to the septic' tank.: Additional cleanouts will be placed , for future maintenance of the line. In addition, ' insulation will be placed above the line where it passes under driveways and parking areas. If the system is constructed as designed the following statements can be made: 1. The system, if constructed as designed, will have no adverse impact on the wells in the area or those to be constructed in the future. AREA MAP SCALE 1" = 100' i LAT TOP AVENUE THIS PROJECT NO WELLS WITHIN 100' ------------ ' III �yy e •r�2�"'�ffi It �`� q ,� VI pwcyaaxr xa n£w stsa �d i ; zL A . s 0 m 3.4' -i A ZZ X G) a> M Z M Is T LOT 3, BLOCK 2, HOCKER SUBDIVISION DESIGN FACTORS: SYSTEM REQUIREMENTS: Three Bedroom Home Deep Trench System Perc. Rate: 2 Min./Inch 1,000 Gallon Septic Tank Application Rate: 1.2 GPD/SF 7' Drainfield . Rock 3 Bedrooms X 150 GPD / 1.2 GPD/SF = 375 SF of Absorption Area 375 SF/14 SF/LF (Sidewail Area) 28 LF Trench Length Therefore: Construct a Deep Absorption Trench With One Lateral 28' in Length. Distribution Pipe in Trench Placed at 3' Below the Original Ground Surface. NOTE: �� << % -,-M7, /JATIRtAL.. URE ,Tix r J GeorGxTI LE . FAawc. )tour TYPICAL DEEP TRENCH SECTION (NO SCALE) Grade Area Over Trench to Drain Away. Minimum 3' of Cover over Septic System. Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST PERFORMED FOR: „M NtId LLT DATE LEGAL DESCRIPTION: Lv7 J, 13W"2-, ^ OCKETZTownship, Range, Section: SLOPE SITE PLAN DEP�FF) P7/DL 1 u 2 d' 3 p, o oe 4 a � r 5 g a .a o .G 8- 10- 11 1011 6 ,a 12 13 die 14 �O 15 `9 i 16- .17- 18- 19- 20- COMMENTS 6.17 181920COMMENTS 6F i4o L -c T—YzA s WAS GROUND WATER ES ENCOUNTEREDV S IF YES, AT WHAT / L O DEPTH? P E Mm�lodllo? Ilkx � � 1 mle L 7 PERCOLATION RATE Z (minutesiinch) PERC HOLE DIAMETER S TEST RUN BETWEEN 4 FT AND 7 FT PERFORMED BY/T ' • �A"1A 4-4 I "' �� � "A"'"w THAT T S T� WAS PERFORMED IN ACCORDANCE WITH ALL STATE.AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE DATE ���o' ' 7 — 72.008 (Rev. 4/85) ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION AND MATERIAL SPECIFICATIONS SUBJECT: LOT 3, BLOCK 2, HOCKER SUBDIVISION GENERAL: 1. The scope of this project includes the pumping, crushing and backfilling of the existing septic tank and absorption crib. Work also includes intercepting the distribution line at the foundation, placing a foundation cleanout, constructing a new service line, 1000 gallon septic tank and a new 28' long X7' effective depth absorption trench. Insulation must be placed over the new line under driveways and parking areas. 2. Construction shall be in accordance with the approved site plan, design drawings, Municipal Permit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. 3. The Contractor shall be responsible for obtaining all underground utility locates and for the layout of the septic system and verification of the location of all lot lines. 4. Unless specifically agreed otherwise, the contractor shall be responsible for final grading areas subsequently depressed from soil settling. Property owner shall be responsible for revegetation of affected areas unless specifically agreed otherwise. 5. Contractors installing wastewater disposal systems must be certified by the Municipal Department of Health and Human Services for system installations. Owners installing their own systems must receive prior approval from D.H.H.S. before beginning system installation. SEPTIC TANK INSTALLATION 1. A new 1,000 gallon septic tank must be procured from an approved source and installed at the location shown on the Site Plan. Lot 3, Block 2, Hocker Subdivision June 30, 1997 Page Two 2. A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. 3. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. 4. All standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 5. Tanks installed without 4' of cover shall have a minimum of 2" of direct burial insulation. 6. A foundation cleanout shall be installed one to four feet from the building foundation. Two cleanouts are required between the tank and the drainfield. 7. Final grading over the tank shall be such that a positive slope exists away from the septic tank. DRAINFIELD CONSTRUCTION: 1. The drainfield shall be constructed to the dimensions shown on the design. The bottom of the trench shall be within 2" of level. 2. Distribution piping must be placed level with perforations down atop a level bed of drainfield rock. Rock should then be placed over the pipe to provide a minimum of 2" of cover. 3. A silt barrier or geotextile fabric must be placed between the drainfield rock and the natural soil backfill. 4. Monitor tubes must be 4" in diameter and installed at the locations shown on the design. The portion below ground must be perforated. Lot 3, Block 2, Hocker Subdivision June 30, 1997 Page Three 5. Contractor shall verify the septic tank and drainfield are a minimum 100' away from any private water wells in the area, 150' from a Class "C" Well or 200' from any community well. 6. Direct bury insulation must be placed over the distribution system if less than 3' of backfill depth is available. Finish grade over the trench must be mounded to prevent settlement or depressions. 7. Grade area surrounding the absorption trenches to drain away. 8. A minimum 2' of accepting soil is required below the drainfield rock for a 5' wide trench. Contractor shall verify this condition prior to placement of the rock. All pockets of unacceptable materials must be removed and replaced. MATERIAL SPECIFICATIONS: 1. Septic tanks must be constructed by a Municipally approved septic tank manufacturer. 2. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Cast Iron (perforated and solid), ASTM D3034 or P.V.C. (perforated and solid), ASTM F810 or H.D.P.E. (perforated, but not solid) and ASTM D2662 or A.B.S. (perforated and solid). 3. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Co. Styrofoam HI or equal). 4. Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). Lot 3, Block 2, Hocker Subdivision June 30, 1997 Page Four 5. A permeable geotextile fabric (Typar, Mirafi or equal) must be installed between the final drain rock layer and the native soil layer. 6. All drain rock shall be .5" to 2.5" in diameter with less than 3% passing the #200 sieve. INSPECTIONS: A minimum of two inspections are required by Municipal Ordinance. These inspections must be conducted under the supervision of a professional engineer registered in the State of Alaska. The first inspection must be conducted after the excavation of trenches, beds or pits and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled. The second inspection must be conducted after the placement of the geotextile fabric, gravel, distribution piping, standpipes, cleanouts and insulation. No backfill should be in place at the time of inspection. Contractor shall provide a copy of all field survey layout and construction notes for use in preparing the certified as -built of the completed system. �p 4 a0C%C4AGE ARFA g o G 3 RREo AAnuee�•9 GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3330 "C" Street, Anchorage, Alaska 99503 274-4561 Date Received September 17, 1976 Time of Inspection11; 3� pm - -46) Date of Inspection REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR 3. Legal Description: Lot 3 Block 2 Hocker 4. Location: NHN Cannon Road 5. Type of facility to be inspected Single Family No. of bedrooms 3 6. Well Data: Individual A. Type C. Construction B. Depth D. Bacterial Analysis 7. Sewage Disposal System: On—site system A. Installed B. Installer C. Septic Tank: 1. Size D. Seepage Pit E. Disposal Field 8. Distances: 1. Absorption Area Total length of lines 2. Manufacturer 2. Material A. Well to: Septic tank , Absorption area Sewer Lines , Nearest lot line Other contamination B. Foundation to septic tank , Absorption area C. Absorption area to nearest lot line Fn_nia (1/7A) D�,,,, , P 4, ,. Conv. 1. Approval requested by: Alaska Mutual Savings Bank % Chris Anderson Mailing Address: Post Office Box 1120 99510 Phone:- 274-3561 x 235 2. Property Owner: Dwane and Joanne Burgess Phone: 344-9119 (h) 344-5117 (mrs.) Mailing Address: Star Route A Box 379 274-1534 (mr.) 3. Legal Description: Lot 3 Block 2 Hocker 4. Location: NHN Cannon Road 5. Type of facility to be inspected Single Family No. of bedrooms 3 6. Well Data: Individual A. Type C. Construction B. Depth D. Bacterial Analysis 7. Sewage Disposal System: On—site system A. Installed B. Installer C. Septic Tank: 1. Size D. Seepage Pit E. Disposal Field 8. Distances: 1. Absorption Area Total length of lines 2. Manufacturer 2. Material A. Well to: Septic tank , Absorption area Sewer Lines , Nearest lot line Other contamination B. Foundation to septic tank , Absorption area C. Absorption area to nearest lot line Fn_nia (1/7A) D�,,,, , P 4, ,. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Septcnibor 13, _1976 / 25" East Tudor Road, Anchorage, Alaska 99504 276-2221 C� REQUEST FOR APPROVAL OF INDIVIDUAL SEWER and WATER FACILITIES 1. Type of Inspection: CMRO VA FHA CONV xy 2. Property Owner: Dwane. and Joann rjur¢ess A_t4l 344-9119 :3A_/k/-.Sl/) cv9 Mailing Address: ,nn ,o„ 370 Day Phone: 27/i.-1534 tea_ 3. Name of Buyer: Mailing Ad 9 5. a 7. 3 0 Day Name of Lending Institution: ,AL -i. —,Im Ili tit ai S :vv .n -.s I,mn!----- t i r t <; Mailing Address: a'•�n no%� 1121) Anchoran(,. Phone: 274--35r,7_ X235 Name of Realtor or Agent: Mailing Address: Legal Description: L 3 r 2 Iioc''-ci- Phone: Location: N;N Czuavon '.d. (Iil.lsi_de `:)r-. area) Type of Facility to be Inspected: sr No. Bdrms. 3 Water Supply Type of Supply: Public Utility Individual If Individual, number of dwellings presently served Onc If Individual, depth of well Sewage Disposal System Type of System: Public Utility If Individual, date of installation 72-003(3/76) ndividual (on-site) 177 Page 2 of two pages - Rei— st for Approval of Individual F` --r & Water Facilities -Legat-Description Lot 3 Block 2 Hocker Comments Approved Disapproved Dat Approval,Valid for one year from date signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM I certify that the information contained in this request for approval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating satisfactorily. SIGNED Date Fn -0:14 (1/74) LAPPM OOP-mnuk--�, ,-I 9.,g mLes nax Lok - J`22 / .5�% /lan L "�7vtJ1 of P/L�I � O to �l�3 KVQ mtpY AOL I C 5 466,! ay VS - �ot�f gfd,,vv on 4,DP-�P-&Lcrn ©,2 4kv ho� 06-IU0(u)' Rev. 1973 DATE INDIVIDUAL El. - NAME ADDRESS CITY ADDRESS P SOURCE ADDRESS ALA,". DEPARTMENT OF HEALTH AND SOCIAL Sr, 'JES DIVISION OF PUBLIC HEALTH INDIVIDUAL AND SEMI-PUBLIC BACTERIOLOGICAL WATER ANALYSIS SEMI-PUBLIC [I CHLORINE RESIDUAL PPM REPORT RESULTS TO ZIP CODE Lab No OFFICE Analysis shows this Water SAMPLE to be: 0 Satisfactory Unsatisfactory ❑ Questionable El Sample too long in transit; sample should not be over 48 hours old at examination to indicate reliable results. Please send new sample. ❑ Bottle , broken in transit, please send new sample. SANITARIAN'S REMARKS COMPLETE THIS SECTION ONLY IF WATER IS. 14N INDIVIDUAL SUPPLY SAMPLE COLLECTED BY DATE COLLECTED TIME COLLECTED Sample Collected From ❑ Kitchen Top ❑ Bathroom Tap F] Basement Tap E] Other (List) Well — E] Dug E] Driven E] Drilled E] Bored SOURCE: 0 Spring E] Cistern ❑ Other --- Dug Well or Cistern Construction: Walls —I-] Wood 0 Concrete D Metal 0 Tile Brick or Top — 0 Wood Ej Concrete E] Metal ❑ Open Top 0 Concrete LOCATION: 0 In Basement Fl Basement Offset El Under House E]ln Yard 0 Other Building Sewer Septic DISTANCE TO: or Other Drainage Pipe --Feet. Tank Feet, Tile Seepage Cess - Field — Feet. Pit __ feet. Pool — Feet. Privy —Feet. Other Possible Sources of Contamination MATERIAL: Building Sewer - E] Cast Iron E] Wood E] Tile ❑ Fibre E] Asbestos Cement 0 Plastic Joint Material - Type GENERAL: Does Water Become Muddy or Discolored? ❑ Yes ❑ No When? Diameter of Well —_ Depth Feet. Well Casing Depth Material Diameter — Length of Water Depth Drop Pipe from Bottom — Feet. Offset in In Utility PUMP LOCATION: [] In Well E] Basement E] In Basement [_1 Room On Top r] Of Well El Other — PURPOSE OF EXAMINATION: Illness Suspected? ❑ Yes El No New Source of Supply? F] Yes 0 No Repairs to System? Ej Yes [I No Signature 06-1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD Rev. 1973 READ INSTRUCTIONS Date Received Time Received am 4 pm, Lab. No. Lactose Broth locc locc I dcc locc locc I.Occ 1.0cc 24 Hours ON .48 Hours Brilliant Green 24 Hours REVERSE SIDE 48 Hours EMB — AGAR BEFORE Lactose Broth, 24 hrs. 48 hrs. Gram's stain Coliform Density (Most probable No. per 100cc) MF Results COLLECTING SAMPLE a.m. Reported by Data —P.M. This analysis indicates Coliform Organisms to be: Absent Present 06-1220(a) Rev. 1973 �-' DATE - INDIVIDUAL ❑ NAME ADDRESS CITY ADDRESS OF SOURCE ALA, DEPARTMENT OF HEALTH AND SOCIAL S( CES DIVISION OF PUBLIC HEALTH Lab Na' INDIVIDUAL AND SEMI-PUBLIC BACTERIOLOGICAL WATER ANALYSIS OFFICE SEMI-PUBLIC ❑ CHLORINE RESIDUAL PPM REPORT RESULTS TO ZIP CODE _ -- Analysis shows this Water SAMPLE to be: ❑ Satisfactory Unsatisfactory ❑ Questionable ❑ Sample too long in transit, sample should not be over.48 hours old at examination to indicate reliable results. Please -send new sample. ❑ Bottle broken in transit, please send new sample. SANITARIAN'S REMARKS COMPLETE THIS SECTION ONLY IF WATER IS AN INDIVIDUAL SUPPLY SAMPLE COLLECTED BY — - DATE COLLECTED TIME COLLECTED - Sample Collected From ❑'Kitchen Tap ❑ Bathroom Tap ❑ Basement Tap ❑ Other (List) _ Well — ❑ Dug ❑ Driven ❑ Drilled ❑ Bored - ther— SOURCE: ❑ Spring ❑ Cistern ❑ Other--- Dug Well or Cistern Construction: Dug Walls —❑ Wood ❑ Concrete ❑ Metal ❑ Tile Brick or Top — ❑ Wood _ ❑. _Concrete ❑ Metal ❑ Open Top ❑ Concrete LOCATION: `' ❑ In Basement ❑ Basement Offset ❑ Under House []In Yard ❑ Other - Building Sewer Septic DISTANCE TO: or Other Drainage Pipe- Feet. Tank—Peet, - Tile Seepage Cess - Field _ Feet, Pit Feet. Pool Feet. Privy Feet. Other Possible Sources of Contamination _. MATERIAL: Building Sewer- ❑ Cast Iron ❑ Wood ❑ Tile ❑ Fibre ❑ Asbestos Cement ❑ Plastic Joint Material - Type GENERAL: Does Water Become Muddy or Discolored? ❑ Yes ❑ No When? Diameter of Well Depth Feet. - Well Casing Material Diameter Depth Length of Water Depth Drop Pipe 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 — 06-1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD Rev. 1973 READ INSTRUCTIONS Date Received Time Received — am — — -pm Lab. No. — Lactose Broth lOcc locc lOcc lOcc locc 1.Occ 7.Occ ON 24 Hours 48 Hours ` Brilliant Green REVERSE SIDE 24 Haar 48 Hours EMB 't — AGAR BEFORE Lactose Broth, 24 hrs.. 48 hrs. Gram's stain Coliform Density - _ - (Most probable No. per 100cc) MF Results COLLECTING SAMPLE a.m. Reported by Date p.m. This analysis indicates Coliform Organisms to be: Absent - ''Present-