HomeMy WebLinkAboutABBOTT LOOP MANOR BLK 2 LT 11Abbott Loop Manor
Block2 Lot 11
#014-181-24
Municipality of Anchorage
On -Site Water and Wastewater Program
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 014-181-24
1. GENERAL INFORMATION
ExpirationDate:
Complete legal description Abboft Loon Manor Block 2 Lot 11
Location (site address) 7631 Rancho Drive, Eagle River, AK
Current Property owner(s) L&N Properties Day phone 441-4114
Mailing address same
Real Estate Agent Craig Lightle Day phone 441-4114
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
4. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class C Well
Public Water System
2
TYPE OF WASTEWATER DISPOSAL:
®
Individual
❑
❑
Holding Tank
❑
❑
Community
❑
❑
Public Sewer
Received by: 90
Date: 5116116-
COSA
7%s /6COSA to be released to the engineer, unless other a requested by the engineer.
COSA Fee $ e2111:7
Date of Payment �J
Receipt Number 023I2_D
COSA # Det CP il5b
Date of Payment
Receipt Number
Waiver #
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.
Name of Firm NorthRim Engineering Phone 694-7028
Address PO Box 770724, Eagle River
Engineer's Printed Name Steve Eng
Date 5/3/2016
6. DSD SIGNATURE
System #1 Approved for bedrooms.
i�'b 00.........e
—
—
System #2 Approved for bedrooms.
"V
Disapproved.
Conditional approval for bedrooms, with the following stlpul tiory&,,,k:,
M
M
vvni �L....--
Original Certificate Date: _�d _tf rn
The Municipality of Anchorage Devlopment 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 blue sheet 9-0-12.doo
If more than 1 septic system is on the lot:
COSA Checklist # of
Structure served by this system
Certificate of On -Site Systems
Approval Checklist
Legal Description: U�O�T add /'/{iAJQ/0� BZ
�. �� Parcel
A. WELL DATA
Well type /7 If A, B, or C provide PWSID #
Well Log (Y/N)
Date completed Sanitary seal (Y/N)
Wires properly protected (Y/N)
Total depthAIW ft I' Cased to Aft. t
Casing height (above ground) /a in.
FROM WELL LOG
AT INSPECTION
Date of test
Static water level 5� ft.
• `1 ft.
Well production g:p.m.
9 -
p.m -WATER SAMPLF,RESULTSi
Coliform d - colonies/100 mL Nitrate ND mg/L
Arsenic ND ug/L Dateofsample: 24!�'/6
Collectedby:��m
B. SEPTIC/HOLDING TANK DATA ftSt-1 c, S&�jf-/Z
Tank Type/Material
Date installed
Tank size gal. Number of Compartments
Cleanouts (Y/N)
Foundation cleanoVt (Y/N) _ Depression over tank (Y/N) _
High water alarm (Y/N)
Date of pumping Pumper
C. ABSORPTION FIELD DATA PU&10-S
Date installed Soil rating (g.p.d./ft2 or ebdrm)
System type
Lengthft. Width
ft. Gravel below pipe ft.
Total depth ft. Eff. absorption area fe Monitoring tube _ Depression over field
Date of adequacy test Results (Pass/Fail)
For bedrooms
Fluid depth in absorption field, .before test in. Water added gal.. New depth- in.
Elapsed Time.' min. Final fluid depth in.
Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type)
If yes, give date
-:f 1
D. LIFT STATION Aft
Date installed Size in gallons Manhole/Access (YIN)
"Pump on" level at in. "Pump off" level at in. High water alarm level at in.
Datum Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot w/A On adjacent lots /t?a
Absorption field on lot AM Ort adjacent lots
Public sewer main
%5 t Public sewer manhole/cleanout
t
Sewer/septic service line Holding tank
Animal containment areas J-C) '` Manure/animal excrete storage areas
SEPTIC/HOLDING TANK ON LOT TO: n/.q ,
Building,foundation Property line Absorption field
Water main Water service line Surface water
Wells on adjacent lots
ABSORPTION FIELD ON LOTTO: N.+
Property line Building founda# on Water main
Water Service line Surface water Driveway, parking/vehicle storage
Curtain drain Wells on adjacent lots '
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and-
review of Municipal records that the above systems are in ®��6
conformance with MOA COSA guidelines in effect on this date.
Engineers Printed Name 16 r hl -
-J
5l�jiw.tno
Date ! � 6e °a eE q? 6 r
COSA yellow sheet-2-6-1 5-doc -
PaCPa�FD fW131ED ftttR
4.EV. tA591MfU)
movoso wxuna caRxen
EF.v. lASSV.Ma)
FRONT 91Anfic WPI"
9cE wLwo !WNIAN
.rs oulsallo SESAM _.
12
I
N90e 00' 00"W 143.70'
W
:-4
>
W/l
W
0
47.0' N
o
WELL t D
CO
w 0 ro
EXISTING O1
26.3' a HOUSE `� 1
U LU
....... 0'
C:)
I Z o
..,...
iv
N�y O.
N90e 00'00"W 127.40'
30'
I
I
10
UNDER NO CIRCUMSTANCES SHOULD AN AS—BUILT BE USED FOR CONSTRUCTION OR FOR ESTABLISHING BOUNDARY OR FENCE UNES.
THE SURVEYOR TAKES RESPONSIBIUTY FOR THE INITIAL TRANSACTION ONLY AND ASSUMES FINANCIAL UABIUTY ONLY FOR THE COST OF THE SURVEY.
LISTED DISTANCES PREVAIL OVER SCALING. REPRODUCTION MAY CAUSE ERRORS IN SCALE.
....
LOT SURnEY SURVEY TYPE
SYMBOLS
r
FOUNDATION AS—BUILT
• SET REBAR DRAINAGE ASPHALT
El FINAL STRUCRIRE AS-8ULT
El SURWY TOPWRAPHY
0 FOUND REBAR CONCRETE
FENCE
8"I(
PLOT " ... AS—BUILT ... LOT ...
��"� ASSUMED ELEV. 3(--)f—)F METAL FENCE ® W000 DECK
I( META
AS— UCT ... NO C NERS i RECER Dc ORAA-WILT .. T
PLOT PLANS & LOT SURVEYS
NOTE:
IT IS THE RESPONSIBILITY OF THE BUILDER OR OWNER, PRIOR TO
ONLY THOSE IMPROVEMENTS ABOVE GROUND AND VISIBLE WILL BE
CONSTRUCTION, TO VERIFY PROPOSED BUILDING GRADE RELATIVE
SHOWN. FENCES, WELLS. SEPTIC CLEANOUTS. SIDEWALKS, DRIVEWAYS,
TO FINISHED GRADE AND UTILITY CONNECTIONS AND TO DETERMINE
ETC.. ARE SHOWN IN THEIR APPROXIMATE LOCATION. ONLY, SNOW
THE EXISTENCE OF ANY EASEMENTS. COVENANTS OR RESTRICTIONS
MAY PREVENT SOME IMPROVEMENTS FROM BEING SEEN AND LOCATED.
WHICH DO NOT APPEAR ON THE RECORDED SUBDIVISION PLAT.
ALL DISTANCES ARE RECORD UNLESS OTHERWISE NOTED.
SURVEY CERTIFIGATION•••.•,►r�M\��+,
OF
Prepared by
Robert E. Johns, Jr. & Assoc.
PLOT PLAN
.. •, •q
��j
Ih.rvAYa.,elYeat IbamPhYrmeY ".M
w IN a+a.n and arwve.a h..an. a Mat I
P. "••.,
�•��,
Professional Land Surveyors
now fwM rc MWII.M1M a6 of pa Wt arnw
a:.ea.n •, Me M. and to M. ent 0y
+ : • .
t }
7700 Brink Drive.
ANCHORAGE, ALASKA 99500.
Hq.IMge vb d cQ91tbI. tlMn.bi. Mm ONn
mq w.aet.
i
r j '; i}
49th
Seale; ,
111 = 30
Rae, Lot S.F.
Rea Plot File No.
FOUNDATION AS—BUILT
y .... 4AQ. 1 •�
J
-
Date Surveyed;
05/06/16
Drawn b .
YREJ
Checked byn AV
JIV'f\
.. RaElfl E_ ym.. J.. wmt.r wub Mdt I
AmPmA.e�t.m,a�..
0 'L.* lA
i`r,�.'`�1#....x
lasgotm m MN IM mq 11w1 atl IM1 ,
nrdmataa °• .h^+n her. , '
} ROBERT E. JOHNS JR
}}
--
Data Drawn:
GNd;
W.O.
�.mµ MtlP?T' mnM wwt ow.a
p a`
05/06/16
2233
16-147
FINAL STRUCTURE A5—BUILT
Mat I
} a % 4121—S aj�
##010,a,
�Y .,,.. ,�~
R , rl
.,.
Legal Description:
P
I. HWx't a .Wn. J.. h...b, (YNIr
now a.M,.Mw m A.Z' .a. '.1 M.
6 ... 5 .f♦
/ ..,, ....•
*asp •••• .•
Lot 11 BLOCK
.vv=wmaA.w.bt qd Mat ON
dxnmxm. ,,, wTamaua+a. d.amt
a w dAa.�.adw.w �w1.
a„a
+�p��:::::�•••
ABBOTT LOOP MANOR
pla.a OM,M4
2833 La t :2nd Aeeaea
DAILY DRILLING LOG
PENN JERSEY DRILLING CO.
. AAttwraje, Aku" S4Se2 Nl-2622
s
0WNE9 OF LAND.__.T,._'1Phn CPvder� ExCavaEinG_..........<.<.... -
DEFTtt OF
......
STATIC STATIC LEVEL.OF WATER .......
ii"CLL-•SIIE...e.1.4......., ,1}kn...2..tdb. Q1.C._1�R.Q&.HBF1002........_....._
DRAW DORM FT...._._._.,.r__.._..____.___._......_._...__.__..._
DATE -.•STARTED -.....Y10-21-74 __.._ _._._...a,...,.,,,..__.._...,..
CALS. PER tlA..__._,,.._..._40 GPM plus .T.
SO -73-7A
DATE—ENDED ,....._.<_..,......,...................... ........,__...m_.._.,_..�_._._._..:
ch welded
XtND OF GASLYC __�.<_.,..__.,.._.._.,
KD(D OF FUR.MATION:
FROEL___.,0___
..... ,....FT. TU........._2,3_..�.F1'SxLL1tR1,..1�_.Sdnd....
FROOE.._.1I!$.-„<..JT. TO.:...I.2�..._.....F[....tt�'•.B 4i...E._tia,tc,;
FR03L..__3..._..,....FT.
Ta-_ 3a Red._Sand
127........_..F1'. TO...Y._...._.._aT._Kat'.er... ._...... ....._.
.- FAOAI..__..2A...
...._.FS. TO....__.26._..,.FT.Rrnvn.,Sand.,..._.,.,
FROat..-....,........ __.FT. TO...,......,._....._...FL......._.................. ......_..
FRO-11..._...26..._......FT.
TO...III ... .L�1.........FT GT$£,4i,..°!..SaR$._.
FROAt.__._.................F1: TO. .... ........... ......._.FT....... ....... ........ _..... ..
FROM......, ..._
....... FT. TO..........3G......._FTDanI Gra... _.._...
_ FROM. -.__ .................i2 TOe..... .... ............ F'7........_.....:...:_ ........... .....
vaum..._.... 3A...........FT.TO..,_.
.
..... �iA�_.,.FT.Qaep.,G:e}:.,Clog..
FROM..._..__....._.__F[.70.._....____.__...iT.........
Fao-\I....._,9_.
... ...... FT. To__.._...M......:TPry,_G[e}:..C12)^gid GravekROat...__._
... ...._..._..”.TO..-._ ...... ...._.__.FT._...._.._......_ ............. _.. .
FROM__...78.........._F'r.
To._...._._82...... tT C1ay.. 6,_ Gravul v%
FR03t.._...._.._... M TO........
lurle eater
...... ........._....
-............__FT_._......_......_.
FR03L..___...._...._..,M.
TO... -__._..-....._._Fr. ....... ....,__..„......„<.....,....
FR031__....._..._._._.FT. TO._............_.._. -F!_._._.._.,_...-_........_.....
FR0]L_...... eh......._JT.
TO.- ..... _,__FT T!.Z;k:...iCn_.Gke,Y..Grasell'EO3i..........._._._.......FT. TO.._........_ ........ _.Fr... ........... .._._._.
MOM..... ...................FL
TO....«.. -._._......_...}7.....,.,_......__.._.._........_
FltOat._.,......._._..._FT. TO........_....__..... FT.......-.-_.........'-"'.__....
. .. - FRO}L..... _,.._.......
... FT- TO....<....,.._...........FT.._.__..,._�._._..___...
FROM..._._.._.._...... -FT. TO...............__..FT ._._._._......_........_.._..
MISCL INFOMATION:
• DRII ISR'S NAME EAStGS
Parcel I.D. 014-181-24
GENERAL INFORMATION
Complete legal description
, Municipality.of Anchorage
DevelopmentSentices Department .
. Bulldlng Safety Division
' On-Site Water & WasteWater Program ', ' ' '
4700 South Bragaw SL ,
PO Box196650 Anchorage AK99519-6650 ' '
· ' ~vww.d.anchorage.ak.us ' ' '~ ,. ",' ., .
~ ",' (907) 343.-7904 . , ,, ..
'CERTIFICATE OF HEALTH'AU HORiTY :.ApPROvAL.,'... ,,
'FoR'A SINGLE FAMILY, DWELLING:' "'*':: .... :,'
.. Explra.tto~ Date:*
ABBO']-D LOOP MANOR LOT 11~ BLOCK 2
Locauon (site address or directions) 7631 *RANCHO DR.
Current Property owner(s)
Mailing address
Lend[r{g agency
Mailing address
Real Estate Agent
THOMAS CRAIG
7631 RANCHO DR. 99507
'Dayphone 1 (714) 890-'0404
"* Dayp~0n'e' ~'
RICHARD BISHOP/CENTURY 21
Day phone 529-1657
Mailing address
3330 'C' ST 99503
Un/ess otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY.'
Individual Well
Individual Water Storage
Community Class Well
Public Water System
TYPE OF WASTE'WATER DISPOSAL.'
Individual On-sita ~E~
Individual Holding tank
Community On-site ~
Public Sewer
The Municipality of Anchorage Development Sen/Ices Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given In paragraph 5 by an Independent professional civil
engineer reglstered In the State of Alaska. Certificates of Health Authority Approval are requlrad for tho transfer
of title (except between spouses) for properties sewed by a single family on-site wastewater disposal and/or
water supply system. DSD also Issues HAAs upon request to homeowners. Certificates of Health Authority
Approval are valid for 90 days from the date of Issue for preperUes served by a private or Class C well and may
be reissued with new water sample results less than 30 days old. (Certificates may be reissued fora peded of
up to one year with vaIId water samples.) Ceraficates are valid for one year for properties sewed by Class A or B
wells or a public water system. The Municipality of Anchorage Is not responsible for errors or omlsslons In the
professional engineer's work.
Note:Alaska Water and Wastewater Consultants, Inc. shall be pald $8OO. OO at, or prlor ' I
to closlng for the en£1neerlng sen/Ices provided.
I
'4.
STATEMENT OF INSPECTION BY ENGINEER
As serb'fled by my seal affZxed hereto and as of the valldab'on date shown below, I verity that my
Invesb'gation, based on procedures outlined In the Health Authority Approval Guldellhes for thls applicetion,
shows that the on-site water supply and/or tsastewater disposal system Is(are) safe, fun~'onal and adequate
for the number of bedrooms and type of structure Indicated herein. I further verify that based on the '
information obtained from the Munldpalily 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 regulab'ons In effect at the time of Installation.
Name of Firm . ALASKA WATER ,*,, WASTDVATER CONSULTANTS. INC. Phone. 357-6179
Address 6901 DEBARR ROAD. SUffE 2B * ANCHORAGE. AK 99504-
Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date
.... En'glneefs comments:
. In conducting this eva/ua#on, AWWC, In& attempted to prot4do a thorough,
consdenZlous eng/nesrlng ana~/~ls of the system In accordance w~th ADEC and MOA
DSD Guidelines & Regulaffons. The reported resu#s desc#bed the performance of the
system under the cand~ons encountered et the time of the test, and separa§on
d/stances measured to readily Iden~fiable features. The operational life of all wefts and
· sopticsystemsdepondonthelesalso#scand~on, grounoWatorlevelsthatmay
t~uctuate during the year, and the water usage of the family being served by the system.
These conditions are outsMe the con~l of the matuator of the system. Satisfactory test
resulte do not guarantse futura performance of the system, nor do they guarant~e that
there are no hlddon defects or ~ncroachmen~s. AWWC, In& can therefore not provfde
any warranty or future estimate of how long the system will continue to meet the
operational requlremente of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other per, on or party Is not authorized, nor ~II It confer any lugal dght whatsce~er.
5. DSD SIGNATURE
L/ Approved for '~ bedrooms.
Disapproved.
Conditional approval for ~
E~"~..' ON-SITE '-.'~
~'"~." WATERAND :
b ........ ~ ~ WASTEWATER ~
eorooms, w~m me n~ow~ng stipu~atior~.j. · m~3r~r,m ^ a ~ ·
Attachments:
I.-IAA Checklist
Septic System Advisory
Well Flow Advisory
Manitenance Agreements
Supplemental Engineer's Reort
Other
Original Certificate Date:
Municipality of Anchorage
Development Services Department
8-~g sar~y
O~.S~ Water & Wastewater Program
47(X) ~ Bragaw ~t.
P.O. Box 10Q650 Anctx)fage. AK 00510-~
Date of test
Stetlo water level
Well production
Legal Description:
~LL DATA
Weft t~pe P~vA'r[
Datecon~pleted 10-18-80 Sanlte~yseal(Y/N) ~'
Toteldepth 115'+ fL Casedto 115'+ fL
FROM WELL LOG
10/18/80
50'+ fL
50 g.p.m.
WATER SAMPLE RESULTS:
HEALTH AUTHORITY APPROVAL CHECKLIST
ABBOT LP. MANOR LOT 11~ BLOCK 2 Parcel ID:
ff A, B, or C provlcle F~'VSlDft N//A
Wen Log (Y/N),
Wtms pro~rty Ix'otected (Y/N)
Casing height (above ground)
AT INSPECTION
5/8/Ol
62'+ fL
7.0 g.p.m.
014-181-24
YES
12' in.
Collform 0 colonies/lO0 mL Nllzate 9.500 regaL. Other bacteria 0 colonies/100 mi.
Date of sample: 5-8-01 Collacted ~ AWWC, INC.
B. SEPTIC/HOLDING TANK DATA ~
Tank Type/Mateflal ~ ~ ~
Tank size gal. Num~ Cleanoute (Y/N) --
Foundation ~ ~_~.~...~---""t~'-pmsalon over tank ~/N) High water alarm (Y/N)
Da ng Pumper
C. ABSORPllON FIELD DATA
Date Installed Soil rating (g.p.dJft~or ~redrm) System type ~
Length m fL Width fL ~.J~~pe fL
Total depth fL Eft. absorption area ~...~efl~tube Depression over flald~ _
Date of adequacy lest ~ (Pass/Fell) Fo~ bedrooms
Flald depth in abso~m test In. Water added gal. New depth in.
Elapsed · min. Final fluid depth in. Absorption rate >=~ g,p.d.
y rejuvenation treatment (past 12 mo.) (y/N & type) Byes, give date
Cycles tested Meets alam~ & drcult requirements?
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift ~tafion on lot
Absorption field on lot N
PubllG ~ver main 75'+
Sewer/septic service fine 25'+
On adjacent lots N/A
On aolacent lots N/A
Public sewer manhole/cleanout 100'+
Holding t~nk N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Al3sorpfion field ~
Building foundation Property line ~_
Water main Water sewlce line. ~ water.
Wells on adjacent lots ~
Property line ~.--'"'~BuDdlng foundation Water main'
Sun'am water Driveway, parldng/vehlcle storage
Wells on adjacent lots.
F. COMMENT~
G. ENGINEER'S CERllFICATION
I cerflTy that I have determined through field inspecUone ?nd
review of Murdclpal recon~s that the above ayatema am ~n
conformance w/th MOA HAA guldellnee in effect on this date.
Eng;neefs Pdnted Name JEFFREY A. GARNESS
Date
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
,~. CT&E Envlmnmem,~l Se
Projt~,t Namem
Client Sample ID
O~ered ~y
1O12343001
AI~ Water & Wnstewa~er Consuhan~ lac.
Abbott Loo~ l~nor Lot I 1 ]3Jk 2
Abbott Loop Manor LOt 11 ~Ik2
Drinking Wa}er
Cllen f PON
P~lnfed Date/Time
Collected Date/Time
Received Dafe/l'lme
Technical Director
05/10/2001 16:23
05/08/2001 10:35
05/08/2001 12:29
0 Stephen C'. Ede
Resells I~L Un/ts Method Allowable Prep An, '
Nittate-N
ll'tcrobtology ~boral:ory
Total Colitor~
0.500 U
0.500 mg/L EPA 300.0
0 coI/I00mL SMIg9222B
(<10)
05m~/01 SCL
05/08/01 KAP
14AY*II-Of 09:20
· · 'f-54; P.OZ/02 F-790
ZtK C T&E En.vlronrnenta! Services 'nc ..
Laboratory Dwi~ion '
200 W, PoETer Drive
Drinking Water Analysis Report for Total Col/form Bacteria ~..~r~3~fi~e.~fio6
RE~D INSTR ~]C~ION$ ON I~EFERS£ $ID£ B£FORE CO£LECTING $dMP1.E
MUST ' -
:3 PUBLIC WATER SYSTEM I.D. #
:3 PRIVATE WATER SYSTEM
Day
SAMPLE DAT~:
Month
SAMPLE TYPE:
13 Ro.tioe
Repent Sample (for rouffne lample
~llb lab ~L no. _ )
D S~eIal Pu~ose
SAMPLE
alysia shows, this Water SAMPLE m be'
Sada facto~x,..~ ·
:3 Unsatisfactory
~ un.liable
X~le ~ I~ in ~ ~]e s~ld
n~ ~ ove~ old ~ end,on
m indicate ~liable ~ul~. p~ ~
n~ lampte ~a ~Jal~liv~
TImR..~ __ /~"
AlM~k~l M~h~: ~mb~e Fi~
~ MM~MUG .
~ Nu~fcoloni~100 mi.
A~yst
UnI~nl~ Wider xb ~ks Jun
Time . Collected
Co]leeted By'
Dare:. _ Time: __
C'~lenf notified of onsatlsfatfory rffuBa:
- . ~J
· Pb~ ~ w~ Faz~
Due: ~ Tiw,~: '- ' .
-BSC'I~mOLOOlC~. WATER A,'~,~,, ,~;,- ..__":T"_ ....
' · · . . . x a~ ~COl~ : ..? '.,..
MM~MUG~ To, ca'em ~ ' .... "' "~" ' :"'.':. . ...
. ~ C~ · ......: '~r:,~,-,~ .
M~b~ne ~ ~ Conat ~ ~ . ' -- ~ ~. · .
'" . Coati.mi "" -,
Ved~ffo.: L~ ~B " "'
COLI~RM_ ~- r~ r, c~
finaIM~bme ~~ ~ ~.. : Of -~ ~
· ...-.. .....: ..
'--'~unaL% r~l~A. ILUNO4~, MAj?y./~D, MICHIGAN, MI$SO4JRI, NEON JEI~Ey, OHfO, W~ST V~IGINIA