HomeMy WebLinkAboutALYESKA NORTH #1 Block 8 Lot 8
4.1
4.1
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C" Street, Anchorage, Alaska 99503 274-4561
Date Received February 23, 1976
Time of Inspection 2: 30 p.m.
Date of Inspection February 25, 1976
REQUEST FOR APPROVAL OF Les Wednesday
INDIVIDUAL SEWER &.WA/ER FACILITIES
FOR
1. Approval requested by: Lomas & Nettleton
e
Mailing Address: 4449 Business Park Boulevard
Property Owner: ~%Lampe
Phone: 274-7661
Phone: 279-6040 message
Mailing Address: General Delivery, Girdwood, Alaska 99587
3. Legal Description: Lot 8 ~ock 8 First Addition, Alyeska Subdivision
Turn left at the road into A£yesK~, follow road %ii yuu uu. LLe to
'4. Location: sign "end of pavement", Alyeska Avenue,it is the 3rd right, then
it 'is the 1st house ~n the right, brown log ~%h £ed~imi~ C~-im.
5. Type of facility to be inspected Single Family No. of bedrooms ~'
6.
We
Well Data:
A. Type Community B. Depth
C. Construction~ ~ Bacterial Analysis~
Sewage Disposal System: - ' em. ~.~ 0_~ ~
A. Installed
C. Septic Tank:
D. Seepage Pit:
E. Disposal Field:
Distances:
B. Installer
1. Size
2. Manufacturer
1. Absorption Area
2. Material
Total length of lines
A. Well to: Septic tan~
Nearest lot line
B. Foundation to septic tank
, Absorption area
, Other contamination
, Absorption area
C. Absorption area to nearest lot line
, Sewer Lines
EQ-034 (1/74) Page 1 of two pages
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF ENVIRONMENTAL QUALITY
3330 'C" Street, Anchorage, Alaska 99503 - :274-4561
Rec'd
2-23-76
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER and WATER FACILITIES
1. Type of Inspection:
2. Property Owner:
Mailing Address:
3. Name of Buyer:
CMRO VA
Chris Lampe
General Delivery, Girdwood
Same
FHA CONV
995~a7y Phone message: 279-6040
Mailing Address:
4. Name of Lending Institution:
4449
Mailing Address:
5. Name of Realtor or Agent:
Mailing Address:
Lomas & Nettleton
Day Phone
Business Park Blvd.
Phone
Totem Realty - Dan Zantig
274-7661
516 West Fireweed Lane
Phone
6. Legal Description:
o
Lot 8 Block 8 First Addition, Alyeska Subdivision
Locatiqn: Turn left at the road to Alyeska, follow road til you come
to sign end of pavement, Alyeska Avenue it is the 3rd right, then
it is the 1st house on the
Type of Facility to be inspected: Single
Water Supply
Type of Supply:
right, brown log with reddish trim
Family No. 8drms. 2
Public Utility Community Individual
If Individual, number of dwellings presently served
If Individual, depth of well
Sewage Disposal System
Type of System: Public Utility
If Individual, date of installation
Individual (on-site) xxx
EQ-037 (1/74)
Page 2 of two pages - Re :st for Approval of Individual ,er & Water Facilities
Legal Description Lot 8 Block 8 First Addition, Alyeska Subdivision
Comments
id for one year from date
Greater Anchorage Area Borough, Department of EnvirO'6mental 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
EQ-034 (1/74)
GREATER ANCHORAGE AREA BOROUGH
, Department of Environmental Quality
3330 "C" StreEt, Anchorage, Alaska 99503 274-4561
L~F~ ~i~(~n~'d Date Received ecember 1 5 1 975
[,iD ~:5~ ~ ..~ ~.~),~' .a q~ Time of Inspection
S ~ Date of Inspec~on
INDIVIDUAL SEWER & WATER FACILITIES ql
Cony.
1. gpproval requested by: komas and ~et~le~on Company
Mailing Address: 4449 Business Park Boulevard Phone: 274-7661
2. Property Owner:
William F. Mc Clure
Phone: 344-1707
Mailing Address: Totem Road
3. Legal Description: Lot 8 Block 8 First Addition Alyeska Subdivision
,4. Location: Girdwood, Alaska
5. Type of facility to be inspected
6. Well Data: Individual
A. Type
Single Family
No. of bedrooms
B. Depth
D. Bacterial Analysis
C. Construction
7. Sewage Disposal System:
A. Installed
C. Septic Tank: 1. Size
D. Seepage Pit: 1. Absorption Area
E. Disposal Field: Total length of lines
8. Distances:
A. Well to: Septic tank
Nearest lot line
B. Foundation to septic tank
C. Absorption area to nearest lot line
On-site system.
B. Installer
2. Manufacturer
, Absorption area
, Other contamination
, Absorption area
,, Sewer Lines
2. Material
EQ-034 (1/74) Page 1 of two pages
MUNK'I?ALI1Y OF ANCHORAG~
Department of Environmental Qual tE~RONMENTAL PROTECTION
GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF HEALTH &
3330 "C" St., Anchorage, Alaska 99503 - 2'~4561 U~U],
-"~' 1. Typ~ of Inspection: CMRO VA FHA
RECE. IVED
CONV ×
2. PrOperty Owner: wllZlam F. NeClare
Mailing Address:
Totem Road
Day Phone 344-1707
3. Name of Buyer:
.... Chris J. Lam~e .
Mailing Address: 3101 Brookside Dr. Day Phone 279-6040
Name of Lending Institution: The Lomas & Nettleton Company
Mailing Address: 4449 Business Park Blvd. Phone 274-7961
5. Name of Realtor or Agent:
Totem Realty, INCo
Mailing Address: 516 E. Fireweed Lane Phone 272-0571
Legal Description: Lot 8, Block 8, First Addition Alyeska S/D
Location: Girdwood, AK
8'. Water Supply
Type of Facility to be inspected: Residenoe
No. Bdrms.
Type of Supply: Public Utility Individual
If Individual, number of dwellings presently served
X
If Individual, depth of well
Sewage Disposal System
Type of System: Public Utility
If Individual, date of install'ation
Individual (on-site) x
NO'¥ P~',~ ....... "' ....
EQ-037 (1/74)
Page.'2'of two pages - Re~ st for Approval of Individual S ar & Water Facilities
Legal~escri'ptio,n ...,,,L°t 8 Block 8 First Addition Alyeska Subdivision
Girdwood, A.laska
Comments
Approved
Disapproved Date
Approval Valid for one year from date signed
Greater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM DF SYSTEM
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
EQ-034 (1/74)
DATE ~
TO~
FROM'
SUBJECT'.
Mu . ,:ipality of Anchorc. je
MEMORANDUM
June 10, 1976
Environmental Services Manager
Principal Environmental Control Officer
Alyeska Sampling
At 10:00 a.m. on 5-17-76, I drove to Alyeska and took water
samples from five (5) different locations.
The first sample was taken from under the skiers bridge and
above the car bridge which allows cars to drive from the
main parking lot to the hotel condominium parking lot.
The second sample was removed from below the car bridge and
thirty (30) feet or so above the Jade Shop.
The third sample was taken from an unnamed stream to the
west of the main parking lot and just below two (2) chalet's
which have septic systems. The approximate location is the
corner of Alyeska Avenue and Lower Terrace Avenue.
The fourth sample was taken at a point one block below the
day lodge's parking lot at the first crossing street.
The fifth sample was taken thirty (30) yards upstream from
where Alyeska Creek joins the main river (Crow Creek). All
of the samples below the lodge turned up positive. The
sample taken above the lodge's leachfield had a very small
count of 2 ppm, almost negligable.
Robert P. ~o e~~nt~a'~~O~f~ic~er
Principal ' '
RPN/ljh
Municipality of Anchorage
MEMORANDUM
June 10, 1976
To: The Record
From: Principal Environmental Control Officer
Subject: Alyeska Sewage Overflow
At approximately 11:30 a.m. on June 8, 1976, Cory Willis
and myself dumped Rodaminewt two (2) of the toilets
in the men's public restroom. We then ate lunch and
at approximately 12:30 p.m. inspected the kitchen because
the power was off and we were afraid the refrigeration
units were not keeping the foods at a safe temperature
and, also no power fed the dishwasher. At this time,
Cory Willis and myself made a chlorine residual test
on the water supply. This test showed that there was
no chlorine present (0.0 ppm). A normal bacterial
water sample was also taken. As we left at approximately
1:00 p.m. we checked Alyeska Creek, which flows past
the lodge to see if dye had shown yet. At a point
opposite where I took sample 92 on 5-17-76 the dye
poured out from the creek bank opposite where the leach-
field for the lodge is, Mr. Willis and myself witnessed
this, took colored pictures and a sample of the emerging
dyed effluent.
Robert P. Neale ~~-~~'~--~
Principal Environmental Control Officer
RPN/ljh
cc: Ken Norman
iii
A~ XO~O0 o.n, on $-X7-7E~ X drovo ~ A3.~eoke end. ~
~Xm;:L~:L ~MvX~onmentaX ~roX
06-1220(a)
Rev. 1973
ALASK ~EPARTMENT OF HEALTH AND SOCIAL SER'"-",S
DIVISION OF PUBLIC HEALTH
INDIVIDUAL AND SEMI-PUBLIC
BACTERIOLOGICAL WATER ANALYSIS
398Z
Lab No.
INDIVIDUAL [] SEMI-PUBLIC [] CHLORINE RESIDUAL PPM
REPORT RESULTS TO
ADDRESS
SOURCE
COMPLETE THIS SECTION
ONLY IF WATER IS AN INDIVIDUAL SUPPLY
SAMPLE COLLECTED BY
Sample Collected Froj~'/[] Kitchen Tap [] Bathroom Tap [] Basement Tap
[] Other (List)
Well- [] Dug [] Driven [] Drilled [] Bored
SOURCE: [] Spring [] Cistern [] Other.
Dug Well or Cistern Construction:
Walls- [~] Woad [] Concrete [] Metal [] Tile Brick or
Top -- [~ Wood [] Concrete [] Metal [] Open Top [] Concrete
LOCATION:
[] In Basement [] Basement Offset [] Under House
[lin Yard [] 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- [] Cast Iron [] Wood [] Tile [] Fibre [] Asbestos
Cement
[] Plastic Joint Material - Type
GENERAL: Does Water Become Muddy or Discolored? [] Yes [] No
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 rellable results. Please
send new sample.
[] Bottle broken intransit, please send new sample.
~ /~/)SANITARIA REMARKS
When?
Diameter of Well Depth Feet.
Well Casing
Material Diameter Depth
Length of Water Depth
From Bottom Feet.
Drop Pipe 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(a) Rev. 1973
DATE
ALAS DEPARTMENT OF HEALTH AND SOCIAL SEI ,ES
DIVISION OF PUBLIC HEALTH
',,' INDIVIDUAL AND SEMI*PUBLIC
BACTERIOLOGICAL WATER ANALYSIS
Lab No.
OFFICE
INDIVIDUAL []
SEMI-PUBLIC [] CHLORINE RESIDUAL PPM
REPORT RESULTS TO
NAME
ADDRESS
CITY ' · .'
ADDRESS -~! ' . , ~ . ~ )
OF SOURCE .'
ZIP CODE
COMPLETE THIS SECTION
ONLY IF WATER IS AN INDIVIDUAL SUPPLY
SAMPLE COLLECTED BY ; ' ~ / " / ~ '
DATE COLLECTED TIME COLLECTED
Anatysis 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
s~,nd new sample.
[] Bottle broken Jn transit, please send new sample.
SANITARIAN'S REMARKS
Sample Collected From [] Kitchen Tap [] Bathroom Tap [] Basement 'Tap
[~ Other (List)
Well- [] Dug [] Driven [] Drilled
SOURCE: [] Spring [] Cistern [] Other
Dug Well or Cistern Construction:
Walls- [] Wood [] Concrete [] Metal
Top -- [] Wood [] Concrete [] Metal
LOCATION:
[] In Basement [] Basement Offset
[]in Yard [] Other
Building Sewer
DISTANCE TO: or Other Drainage Pipe.
Tile Seepage Cess-
Field Feet. Pit Feet. Pool
Other Possible
Sources of Contamination
MATERIAL: Building Sewer- [] Cast Iron [] Wood [] Tile
[] Plastic Joint Material - Type
GENERAL: Does Water Become Muddy or Discolored?
.Feet.
[] Bored
j~l~ Tile Brick or
Open Top [] Concrete
[] Under House
Septic
Tank Feet
Feet. Privy ~__.£eet.
[] Fibre [] Asbestos
Cement
[] Yes [-1' No
When?
Diameter of Well Depth
Well Casing
Material Diameter Depth
Length of Water Depth
Drop Pipe From Bottom
Offset in
:. PU~P LOCATION: . [] In Well [] Basement [] In Basement
,,~ On Top
[] Of Well [] Other
PURPOSE OF EXAMINATION: Illness Suspected? [] Yes
New Source of Supply? [] Yes I'-I No Repairs to System?
Feet.
In Utility
[] Room
[] No
[] Yes [] No Signature __
06-1220(a) Rev. 1973
. DATE/
I' INDIVIDUAL ~1' -i~ cHLORINF~?REsIDUAL PPM_ .'~ '. ',_
SEMI-PUBLIC
II ,EPORT RESULTS .TO .. ' "
COMPLETE ;THIS-':SECTI~ -
ONLY_ IF WATER Is,AN _iNDiVIDUAL.sUPPLy- ~ '
// .I
SAMPLE COLLECTED BY ~:-: : ., / ..~ ~-~ .-'-- ~ -
~ .~- ,, /" ~ / ~ ~. -?.~L-.~ ·
~ Other (LI~I,)- ' ,, - , ;' ..... ~ , ' '., , %~ ,,
Well ~ ~Dug , ~ Driven ~ Drilled ~ Bored _-~..~
SOURCE~ -' ~;Sprlng - Cistern ' ~'Other :. , -: '
,Dug We or Cl~t.rn Constru¢tlom __ .r. ' - .~ .... ~ "
~ Walls~Wo~ ' ~ Concrete ~t~l .... ~iie '~: ' Br~ck~
Top- -- ~ W0~ ~ Concrete ~ ,Metal ~ Open Top ~ Concr~
LOcAtION: '
~ In Bas~ment ~ Basement Offset ~ Under House*
~ln Yard ~:~her , ' r ', ~ ~ ~;.-. m,- , ~ .~
Building ~ewer Septic
DISTANCE TO: or Other Dralnage:Plp~ '- _ . Feet. Tan~ .... ~peth
Tile Seepage Cess- ·
Field ' F~I. Pit . Feet. Pool Feet. Privy
Other Possible ';
Sources of Contamination
"~% _ / . .,~, ~
MATERIALs Building Sewer- ~ Cast Iran ~.'W~d' ;~-Ti I6 ' ~' Fibre ~ 'Xsbedos- ~ -
~ P!~st c Joint Materlai - ~ype ~'--':~ -~ ....... '- * '; -~em~ -"~.*
GENERXL: Does Water Become Muddy or Discolored? - ,~' ~ '~Yes . - ~'~o
When? , , ?/ I
-~._
Diame~r' bf WeiJ D~th .,_ ~t~'-
Well ~slng
Mates,al ' Diameter_ ..... Depth
r~'~ Length- of Water Depth
~.~ Drop Pipe , From Bottom ' ,. ~eet.
~,~ .~'; ,' ' Offset In In UIIllt~.
:~LQCATIONs- O'ln Well ~ Basement ~ In Basement ~ Room- %
PURPOSE OF EX~XTION, Illness Suspecte~? ~ Ye, ~' No '~
New Source of Supply? ~ Yes ~ No Repairs to System? ~ Yes ~;N= Signature
READ INSTRUCTIONS
REVERSE SIDE
BEFORE
COLLECTING. SAMPLE
~ -Analysl~*s_hows_ thls Water SAMPLE tO' be:
I-~ Satis'fadory - -
l'-I' Unsatisfactory
i-1'-Questionable
I--I. Sample too-long_ in transit; sample should not be over 48
· hbb~s old'df ~X~Mt~a'ti-on to indlcate reliable results. Please
.. -diAled:new W-r~ple. -
'[-I Bottle broken in transit, .please send new sample,
. :,"" .r. /..:. ,
" ' ,S~NITARIANS REMARKS
b~.l'~o ~b) -~A~TERIOLOGICAL WATER ANALYSIS RECORDr '
Rey. 1973 .-' - '
Dote R~eived t ~ '~,~ '-
48 Hours
Brilliant Grin
48 Hours
EMB i,- AGAR
Lactose Broth, 24 hrs. , .. i. 48 hrs. , , Gram's stain
Coliform Density ~- r ' (~st probable No, per 100cc)
MF Re~lts ,t ,' ~! . ., . ~ __ ,
/
This an~ysls .indicates Collferm ~g~nlsms
06-1220(a) Rev. 1973
DIVISION OF-FtUBLIC HEALTH
INDIVIDUAL AND SEMI.PUBLIC
BACTERIOLOGICAL' WATER ANALYSIS
Lab No.
OFFICE
INDIVIDUAL []
NAME
ADDRESS
CITY
ADDRESS
OF SOURCE
SEMI-PUBLIC [] CHLORINE RESIDUAL PPM
REPORT RESULTS TO
.-' "~ .I / .-.~ )
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 rellable results. Please
Z s_end new sample.
~l~..4t~ttle broken in transit, pl,e~ase send nq~ sample.
COMPLETE THIS SECTION
ONLY IF WATER I~, AN INDIVIDUAL SUPPLY
SAMPLE COLLECTED BY
.../- ~/~,~ - /.~
DATE COLLECTED r?/ ,,/ ~///~,,.~ TIME COLLECTED '" ' ,'
Sample Collected F~om ~ Kitchen Tap ~ Bathroom Tap ~ Basement ~Tap
~ Other (List)
Well- [] Dug [] Driven [] Drilled [] Bored
SOURCE: [] Spring [] Cistern [] Other__ ~'-.~.,
Dug Well or Cistern Construction:
Walls-- [] Wood [] Concrete
Metal
Tile
Brick
Or
Top -- [] Wood [] []
Metal ~'Open Top [] Concrete
Concrete
LOCATION:
[] In Basement [] Basement Offset [] Under House:
[]In Yard [] Other
Building Sewer Septic
DISTANCE TO: or Other Drainage Pipe Feet. Tank 'Feet.
Tile Seepage Cess-
Field_ Feet. Pit_ Feet. Pool- Feet. Privy ~~'~
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
Well Casing
Material Diameter
Length of
Drop Pipe
Offset in
PUMP LOCATION: [] In Well [] Basement
On Top
[] Of Well [] Other
PURPOSE OF EXAMINATION.' Illness Suspected?
Depth ~eet.
Depth .~
Water Depth
From Bottom J~eet.
In Utility
[] In Basement [] Room ..
New Source of Supply? E] Yes
[] Yes [] No ~'
[] No Repairs to System? [] Yes E~ No ~Signature
06-1220('a) Rev, 1973
; / Lab No, -:-
/ DATE OFFICE
INDIVIDUAL []
'AnalYsis shows this Water SAMPLE to
[] Satisfactory
:-(~C)MPLETE:THI~SEGTION ~-~
ONLY~ IF WATER IS~.AN INDI¥tD~IAL-SUPPLY
Sample Collected ~(om ~ Kitchen Tap ~ BathrOom Tap
~ Other {List).-. . ~ . r
REPORT RESULTS TO
" ' - ' ' ~ '. 's ~ SamPle too long in transit~ sample sbou d n~t be over 48
Well- ~]Dug Drlyen [] DrilledL. [] Bored
SOURCE: []'$~flhg ' B Cistern I-l'Oth'eF', - , . - ' ,,,
· Dug Well or ~l~t~m:Co~structiom. . .. ~ ... _ ~ : ~ - ~ ~
Top -- ~ Wo~ ~ Concrete Metal ~ .Open Top ~ Cont~e
LOCATION~
~ In Basement ~ B~s~ent Offset ~ Under
~ln Yard ~,Oth~r -- '~ ...... ~ --- ,: ,
Building ~ewer Septic "
DISTANCE-TO~ or Other ~alnage Pipe . Feet, T~hk
Tile Cess-
Seepage
Field , F~t, Pit , Feet, Pool __ Feet, Privy,
Other Possible
Sources of Conlamlnat]on ,
-Cemeqt -~: .
~Plasfle Joint Material - Type : ' ~ ~ - ~ '." ' ~ ~
GENERAL:
Does-Water
Become
Muddy
ar Discolored? ~-~ :Yes .
Diameter of .Well Depth ' ,l~,'~t.~
Well Caslng .... 1
Material , Diameter ..... Depth ii' ....
Length of Water Depth
Drop Pipe From Boffom
Offset In In Utili
PUMP LOCATION: [] In Well [] Basement [] In Basement [] Room
On Top ~
PURPOSE
New
Source
Supply? [] Yes , . I-'1 No Repairs to System? [] Yes ~No
" 06.1220 (b) ' ,BA~TERjOtOGICAL 'WATER ANALYSIS' RECORD
READ IN UCTIONS O.to ,.,.,ved /C .~j--'/.
.... ..~ (c~ Time Received b. No. L
/ R,IEVERSE ~'DE
EMB, T; : ~' ~ i .... AOAR
BEFORE Lactose Broth, 2;4 hrs. 48 hr,,.. Oram's stain
Coliform Density "~ ~'~ [Most probable No, per 100cc)
-'--~ - MF Results
, ' : '~ ~..,. ~ ~ - ,
COLLECTING SAMPLE, ~eCZY
' / This-analysis Mdlcat~ ~cellfetmO~antsms t~ be~ ~ Absent..,,__ r r
· _ ..... ': .,
, , _ -.,..
' ~' . " .~' j ~ - , · .
06-1220(a) Rev. 1973
ALAS[ JEPARTMENT OF HEALTH AND SOCIAL SER'
DIVISION OF PUBLIC HEALTH
INDIVIDUAL AND SEMI.PUBLIC
BACTERIOLOGICAL WATER ANALYSIS
3983
Lab No.
OFFICE
INDIVIDUAL []
NAME
ADDRESS
CITY
ADDRESS
OF SOURCE
SEMI-PUBLIC [] CHLORINE RESIDUAL PPM
REPOI~ RE~SULTS TO
COMPLETE THIS SECTION
ONLY IF WATER IS AN INDLVIDUAL SUPPLY
SAMPLE COLLECTED BY ~~ .
Sample Collected Fr,~'m "l"'l Kitchen Tap [] Bathroom Tap [] Basement Tap
[] Other (List)
Well- [] Dug [] Driven [] Drilled
SOURCE: [] Spring [] Cistern [] Other
Dug Well or Cistern Construction:
Walls -- [] Wood
Concrete
Top -- [] Wood []
Concrete ~MetaIMetal
LOCATION:
[] In Basement [] Basement Offset
J"'11r~ Yard [] Other
Building Sewer
DISTANCE TO: or Other Drainage Pipe
Tile Seepage Cess-
Field_ Feet. 'Pit Feet. Pool __
Other Possible
Sources of Contamination
MATERIAL: Building Sewer- [] Cast Iron [] Wood [] Tile
[] Plastic Joint Material - Type
GENERAL: Does Water Become Muddy or Discolored?
[] Bored
Tile Brick or
Open Top [] Concrete
[] Under House
Septic
Feet. Tank
Feet. Privy,
[] Fibre [] Asbestos
Cement
Feet,
Feet.
Feet.
Feet.
In Utility
[] Room
[] Yes [] No
When?
Diameter of Well Depth
Well Casing
Material Diameter Depth
Length of Water Depth
Drop Pipe From Bottom
Offset in
PUMP LOCATION: [] In Well [] Basement [] In Basement
On Top
[] Of Well [] Other
PURPOSE OF EXAMINATION: Illness Suspected? [] Yes
New Source of Supply? [] Yes [] No Repairs to System?
[] No
[] Yes [] No Signature
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
06-1220(a) Rev. 1973
DATE
NAME
ADDRESS
CITY
ADDRESS
OF SOURCE
INDIVIDUAL AtIID. SEMI*PUBLIC
BACTERIO£OGICAI?WATER ANALYSIS
INDIVIDUAL [] SEMI-PUBLIC [] CHLORINE RESIDUAL PPM
REPORT RESULTS TO
~.- ,, ,z~,T.,{ : / ,- , .
'.~...~:,~ .,' ~ .v . -- i~ .~":~ 1- ~.~"',
COMPLETE THIS SECTION
ONLY IF WATER. IS AN IND,~/IDUAL SUPPLY "'
~,~ ,'~ ,.~.r~-' ,/
SAMPLE COLLECTED BY ~.~,; ....
DATE COLLECTED ("/" ~ "~? TIME COLLECTED ,/ ;?'
Sample Collected From [] Kitchen Tap [] Bathroom Tap [] Basemen~iTap
[] Other (List} "
Well-- ~ Dug B Driven B Drilled [] Bored
SOURCE: Spring Cistern Other.
Dug Well or Cistern Construction:
Walls -- [] Wood [] Concrete
Metal
Tile
Brick~or
Top -- [] Wood [] []
Concrete Metal
Open Top ~ Co~
LOCATION:
[] In Basement [] Basement Offset [] Under House
[lin Yard [] 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- [] Cast Iron [] Wood [] Tile [] Fibre [] Asbestos
Cement
[] Plastic Joint Material - Type
GENERAL: Does Water Become Muddy or Discolored? [] Yes [~j ~1~
When?
Diameter of Well
Well Casing
Material D~ameter
Length of
Drop Pipe
Offset in
PUMP LOCATION: [] In Well [] Basement
On Top
[] Of Well [] Other
PURPOSE OF EXAMINATION: Illness Suspected?
Depth
Depth
Water Depth
From Bottom
[] In Basement
:Feet.
Feet.
In Utilily
[] Room
Lab No.
OFFICE
Analysis shows this Water SAMPLE to be:
[] Satisfactory
[] Unsa~tory
[-~ 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
*- [] Yes
New Source of Supply? [] Yes [] No Repairs to System? [] Yes [] No Signature
INDIVIDUAL [] SEMI-PUBLIC
SAMPLE to ,be~': ' '
ADDRESS
I:::L,~Battle broken in transit, please send new sample.
CITY
Ct..
' ,,. -SANITARIAN'S-REMARKS
~.' Sample:Collecl~ Fr~m ~_ Kitchen Tap ~ Bathroam Tap _
When?
k:' ' ' PUMP LOCATION~ B In ~.11 B Bas~ent% ~- !n laem~t ~'Roo~' _ / · - -'
06-1220(a)
Rev. 1973
ALASI( :EPARTMENT OF HEALTH AND SOCIAL SER' ~S
DIVISION OF PUBLIC HEALTH
INDIVIDUAL AND SEMI-PUBLIC
BACTERIOLOGICAL WATER ANALYSIS
Lab No.
3956
INDIVIDUAL [] SEMI-PUBLIC [] CHLORINE RESIDUAL PPM
REPORT RESULTS T~.,.~
.AME . ,
CITY ,_ _ _ _/y~ Z
ADDRESS
COMPLETE THIS SECTION
I
SAMP~ co~cz~. ~Y ,~ / ~~
Sample Colloct~ F~m ' ~ Kitchen Tap ~ Bathroom Tap~ Basement Tap
[] Other (List)
Well- [~ Dug [] Driven [] Drilled
SOURCE: [] Spring [] Cistern [] Other.
Dug Well or Cistern Construction:
Walls -- [~] Wood Concrete Metal
Top-- []Wood ~ ~Metal
Concrete
LOCATION:
[] In Basement [] Basement Offset
[lin Yard [] Other
Building Sewer
DISTANCE TO: or Other Drainage Pipe
Tile Seepage Cess-
Field __ Feet. 'Pit __ Feet. Pool .-
Other Possible
Sources of Contamination
MATERIAL: Building Sewer- [] Cast Iron [] Wood [] Tile
[] Plastic Joint Mater~al - Type
GENERAL: Does Water Become Muddy or Discolored?
When?
Diameter of Well
Well Casing
Material Diameter
Length of
Drop Pipe
Offset in
PUMP LOCATION.' [] In Well [] Basement
On Top
[] Of Well [] Other
[] Bored
~ T~l;en Top [] Brick or
Concrete
[] Under House
Septic
Feet. Tank Feet.
Feet. Privy .__Feet.
[] Fibre [] Asbestos
Cement
[] Yes [] No
Depth Feet.
Depth
Water Depth
From Bottom Feet.
In Utility
[] In Basement [] Room
Analysis shows thls 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
PURPOSE OF EXAMINATION: Illness Suspected? [] Yes [] No
New Source of Supply? CZ Yes [] No Repairs to System? [] Yes [] No Signature
06-1220~) Rev. 1973
DATE
DIVISION OF ' LIC HEALTH
INDIVIDUAL' SEMI-PUBLIC '
BACTERIOLOGICAL' WATER ANALYSIS
Lab No.
OmCE
INDIVIDUAL []
NAME ,'L ~-('~ ,., .~/
SEMI-PUBLIC [] CHLORINE RESIDUAL PPM.~
REPORT RESULTS ~0- ~ ~
ADDRESS
CITY , ~..w,'; .'~,' :~> '-~ },-~',/'~:~ '/
ADDRESS
OF SOURCE
ZIP CODE
COMPLETE THIS SECTION
ONLY IF WATER IS, AN INDIV?DUAL SUPPLY
SAMPLE COLLECTED BY / " / ~ .~. ,.~ ,
DATE COLLECTED .r- ' /~" TIME COLLECTED '
Sample Collected From [] Kitchen Tap [] Bathroom Top' [] Bosement :',Tap
[] Other (List)
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.
Well -- Drilled
SOURCE: B Dug
Spring B Drlven
Cistern B Other__
Dug Well or Cistern Construction:
Walls-- E] Wood [] Concrete
Metal
Top -- [] Wood [] Concrete []
Metal
LOCATION:
[] In Basement [] Basement Offset
[]In Yard [] Other
Building Sewer
DISTANCE TO: or Other Drainage Pipe Feet.
Tile Seepage Cess-
Field __ Feet. Pit __ Feet. Pool
Other Possible
Sources of Contamination
MATERIAL: Building Sewer- [] Cast Iron [] Wood , [] Tile
[] Plastic Joint Material - Type
GENERAL.' Does W, ater Become Muddy or Discolored?
When?
[] Bored ;~.
BTile Brick or
Open Top [] Concr~
[] Under House
Septic
Tank Feet,
Feet. Privy, ~e,et.
[] Fibre [] Asbestos
Cement
[] Yes CN~o
Diameter of Well Depth I~eet.
Well Casing
~.,Material Diameter Depth
Length of Water Depth
Drop Pipe From Bottom
Offset in In Utilj~y~'
SANITARIAN'S REMARKS
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 J-I,N~o, Signature
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:
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o!ldeg J~eg Bu!Pllng
, -:~ ~NOILV~O1
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_... . >. -... .~ SSgBOOV
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osbeld 'qlnte2_eJgOlJe~ oimJpUl ~ UOllaUtw~x{ I~ PI9 safioq ~:.. (/ ~' ~ / / ~_ ~ · : ~ _./
~: --. * · " , - - : , ~' , ,* , ~ · 4 ' ~- ~" '~r '
~Ol~O~syosu~ ~ "; { ~.01 SL1~Sg~ /BOdg~
06-1220(o)
Rev. 1973
ALAS[ ')EPARTMENT OF HEALTH AND SOCIAL S~' TS
DIVISION OF PUBLIC HEALTH
iNDIViDUAL AND SEMI-PUBLIC
BACTERIOLOGICAL WATER ANALYSIS
Lab No. /J~)8~
INDIVIDUAL [-I
NAME
ADDRESS
CITY
ADDRESS
OF SOURCE
SEMI-PUBLIC [] CHLORINE RESIDUAL PPM
COMPLETE THIS SECTION
ONLY IF WATER IS AN INDIVIDUAL SUPPLY
Sample Collected From / J~] I~che~ Tap [] Bathroom Tap [] Basement Tap
[] Other (L~st)
Well- ~ Dug ~ Driven ~ Drilled [] Bored
SOURCE: -- Spring
Cistern ~.~ Other .....
Dug Well or Cistern Construction:
Walls--[] Wood Concrete ~ Tile Brick or
Top-- []Wood B ~Metal
Concrete Metal
Open Top [] Concrete
LOCATION:
[] In Basement [] Basement Offset [] Under House
~llq Yard [] 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 Passible
Sources of ContaminaHon
MATERIAL: Building Sewer- [] Cast Iron [] Wood [] Tile [] Fibre [] Asbestos
[] Plastic Joint Material - Type Cement
GENERAL: Does Water Become Muddy or Discolored? [] Yes [] No
When?
Diameter of Well
Well Casing
Material Diameter
Length of
Drop Pipe
Offset in
PUMP LOCATION: [] in Well [] Basement
On Top
[] Of Well [] Other
PURPOSE OF EXAMINATION: Illness Suspected?
New Source of Supply? [] Yes
Depth Feet.
Depth
Water Depth
From Bottom Feet.
In Utility
[] In Basement [] Room
[] Yes [] No
[] No Repairs to System? [] Yes [] No Signature
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.
REMARKS
06-1220(a) Rev, 1973
D'~TE
BACTERIOLOGICAL WATER
,,,o soc,,,,
DIVISION OF PUBLIC HEALTH
INDIVIDUAL ANBSEMI-PUBLIC
ANALYSIS
INDIVIDUAL [] SEMI-PUBLIC [] CHLORINE RESIDUAL PPM
REPORT~ RESULTS TO
NAME ,, ..~
ADDRE~
CITY '"
ADDRESS
OF SOURCE ,
COMPLETE THIS SECTION
ONLY IF WATER,~: IS~,. A~.;.. INDIVIDUAL// SUPPLY ..... -.
,"'~," ' /2.:,~? ~ ,"-~ ' '~ ~'"""
SAMPLE COLLECTED BY v~ / ,/,~/' - .~,- ..
DATE COLLECTED ,./,'" ? /" TIME COLLECTED ~/ /
Sample Collect~ From ' ~ Kitchen Tap ~ ~athroom Tap ~ Basement Tap
~ Other (List)
Well- ~ Dug ~ Driven ~ Drilled ~ Bored ~:~
SOURCE: ~ Spring ~ Cistern ~ Other. -~
Dug Welt or Cistern Construction:
Top ~ ~ Wood ~ Concrete ~ Metal ~ Open Top ~ Conc~te
LOCATION~
~ In Basement ~ Basement ~fset ~ Under Hou~
~ln Yard ~ Other
Building 5ewer Septic
DISTANCE TO: or Other Drainage Pipe Feet. Tank Feet.
Tile Seepage Cess- ~'
F~eld_ Feet. Pit Feet. Pool ~ Feet. Privy.
Other Possible
Sources of Contamination
MATERIAL: Building 5ewer- ~ Cast Iron ~ Wood ~ THe ~ Fibre ~ Asbestos
Cement
~ Plastic Joint Material - Type
GENERAL: Does Water Become Muddy or Discolored? ~ Yes ~. No
When? ~
Diameter of Well Depth ~eet. ~-
Well Caslng
Material Diameter Depth
Length of Water Depth
Drop P~pe From Bottom Feet.
~fset 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 ~o Signature
Lab No.
OFFICE
Analysis shows this Water SAMPLE to be:
[] Satisfactory
[] Unsatisfactory
I-I 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.
REMARKS
INDIVIDUAL [] SEMI.PUBLIC
~RESULTS TO
CiTY
. Lab No.
~-'Analysi~ shO~s. JI~iS~ W.ater SAMPLE to
~ ~, .~. - -:~--~o.~-i--
-broken in transit, please send new sample.
STANCETO= or Other~ Drainage Plp~ ..... _~' .......... Feet. Ta~k ..........
TUe ' Seepage . hCess- '
Field F~t 'P t. ; ~ Feet P~ Feet Prvy .
Length of Water'D~plh ' · '
Dro~ Pipe; r', ' r~ ' Prom Bottom .... '~, ~et. I
PUMeJ~ATIO~ ~ In Well ~ Ba~em~t ~ In Besmear' ~-Reom
:~'PURPOSE-OF EX~~= Illne. SuSpected? .~ ye ~No
New-source of ~G~ply? ~ Yes . .~-Ne Repairs fa. System? ~ Yes
REVERSE SIDE
06-1220(a) Rev. 1973
BACTERIOLOGICAL
ALASi JEPARTMENT OF HEALTH AND SOCIAL SER ,:S
DIVISION OF PUBLIC HEALTH ,ab No.
INDIVIDUAL AND SEMI-PUBLIC
WATER ANALYSIS '-' - '.~,oCE
Analysis shows this Water SAMPL 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.
INDIVIDUAL [] SEMI-PUBLIC [] CHLORINE RESIDUAL PPM
REPORT RESULTS TO
ADDRESS
OF SOURCE
[] Bottle broken in transit, please send new sample.
SANITARIAN'S REMARKS
COMPLETE THIS SECTION
S,~P,E CO,,ECTE. BY /~r~. tJ~ 1o ' $ b ~
co. c.
Sample Collected Fr~' ~ Kitchen Tap ~ Bathroom Tap ~ Basement Tap
~ Other (List)
Well- O Dug [] Driven [] Drilled
SOURCE: [] Spring [] Cistern [] Other
Dug Well or Cistern Construction:
Walls -- E] Wood f-I Concrete
Metal
Top -- [] Wood [] Concrete []
Metal
LOCATION:
[] In Basement [] Basement Offset
I-'llr~ Yard [] Other
Building Sewer
DISTANCE TO: or Other Drainage Pipe
Tile Seepage Cess-
Field ,, Feet. Pit ~ Feet. Pool __
Other Possible
Sources of Contamination
MATERIAL: Building Sewer- [] Cast Iron [] Wood [] Tile
[] Plastic Joint Material - Type
GENERAL: Does Water Become Muddy or Discolored?
[] Bored
BTile Brick or
Open Top [] Concrete
[] Under House
When?
Septic
Feet, Tank Feet,
Feet. Privy ~.Feet.
[] Fibre [] Asbestos · Cement
[] Ye~'~ [] No
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
06-12~0~a!~; Rev. 1973
DATE '
BACTERIOLOGICAL',
DIVISION OF BLIC HEALTH Lob No.
INDIVIDUAL AG SEMI.PUBLIC
WATER ANALYSIS
INDIVIDUAL [] SEMI-PUBLIC [] CHLORINE RESIDUAL PPM' ~
REPORT RESULTS TO
ADDRESS ~
OF SOURCE Y
COMPLETE THIS SECTION
ONLY IF WA~CER, IS AN INDJ~VIDUAL SUPPLY
)'..' ,' ~ ~ /t,~ '
SAMPLE COLLECTED BY / .-~"?.'~? ~, J, J '~ ~'u'' / ~ , ~"., ~'.., ~,,~ ~, ~,~'
DATE COLLECTED L,-Z?i' '/ /'' TIME COLLECTED
Sample Collected From/ 1~ Kitchen Tap [] Bathroom Tap [] Basement-S'ap
[] Other (List) -.,
Well- [] Dug [] Driven [] Drilled [] Bored
SOURCE: [] Spring [] Cistern [] Other.
Dug Well or Cistern Construction:
Walls-- [] Wood [] Concrete [~ Metal ~ Tile Brick ~"r-
Top -- [] Wood []
Concrete [] Metal
Open Top [] Concre4e
LOCATION:
[] In Basement [] Basement Offset [] Under House
i-Un Yard [] Other
Cess-
Feet. Pool-
Building Sewer
DISTANCE TO: or Other Drainage Pipe
Tile Seepage
Field __ Feet. Pit
Other Possible
Sources of Contamination
MATERIAL: Building Sewer- [] Cast Iron
[] Plastic Joint Material - Type
Feet.
Septic -
Tank ~eet,
Feet. Privy __F~lif.
[] Wood [] Tile [] Fibre [] Asbestos
Cement
GENERAL: Does Water Become Muddy or Discolored? [] Yes
When?
Diameter of Well
Well Casing
Material
Length of
Drop Pipe
OFFICE
Depth
Diameter Depth
Water Depth
From Bottom Feet.
Offset in In Utility
PUMP LOCATION: [] In Well [] Basement [] In Basement [] Room -i~.--
On Top
[] Of Well [] Other
PURPOSE OF EXAMINATION: Illness Suspected? [] Yes [] No
New Source of S~¥pply? [] Yes [] No Repairs to System? [] Yes ~ No S_ignatur? __
[]~'No ,
SANITARIAN'S REMARKS
Analysis shows this Water SAMPL~-'to be:
~ Satisfactory
[] Unsatisfactory
[] Questionable
[] Sample too long in transit; sample should not be ove~; 48
hours old at examination to indicate reliable results. Please
send new sample.
[] Bottle broken in transit, please send new sample.
~ ;, .~-. -'._, _. .~ ._.:' . ,.'.~'"'z'~.. ~ ._ DIVt~ION:0F ~BL. iC~'HEALTH . ?,.a,' L.~, No
~-. / / ..... '.-;-~.;~ - . :- -_ -
'DATE/ ..... BACTERIO:EOGtCA;L~'--:rWAiTiER ANAL Y S I S ' e-,ce -
· ' _ --, ' . A~:alysls-show~' this Water SAMPLE"'~o be:
.INDIVIDUAL 1'71' SEMI-PUBLIC r']. - CHLORINE-RESI I: PPM~=-'-~_ . .~ . ' [~-Satisfactory
IJ ' · REPORT RESULTS TO ' ';;"~ ' : [] Unsatisfactory
IIADDRESS ( /' -~/~' ~ ~ ': -' hbu~, olda! ex, nflnat~on to ind|cale reflable~ results P ease
%/ ...... ' · ~. . *'" sand. new sampla.
II CITY . ' ."-,'-,~ .-/~' ~ .:~, /~-b~ ..' ~ZIP CODE' ~ [] Bottle broken I~ tmnslt, -please send new sample.
IIADDRESS f~?
lief SOURCE * .~.?~ ..
,~ , , , ......................... :~ ' ~,: .... .~-. SANITARIAN'S~ REMARKS
-- .COMPLETE-THIS SKTION - '-. :~ "
ON~Y IF WArER<:, :IS'~.AN"IND~!DuALX, fi;, ...... SUP,LY .. :'7" . ' <~"'-'4 '~' '-'
', ...:.. ~ ._.'.r .x~
DAT~a~LeLECTED ~-J~//{~' '~IME COLLECTED ~' ' ' ~ , ¢'
p ColIec,~ Fr~/ ' a' Kilche'n ,p ~ Bathroom Tap m Basem~; ~:,P ''
:' ' ' ' J ..c~ '" '''?:' '
~ Other (List) .... : ,. -~__. . :, : :. . A(y~:z._.: . , _ ~ .,
W~II- ~Du~ ~ Dr yen ~ Drilled ~ Bore~ "'
SOURCE: ~-S~rl"~ ~ Cist~r~ - ~ -~h~r~ ,, :' ':- _ :~ ..... , .
Du~ Well or G~]~r~Censtrug~om - - :- ., - .- -~'
Top- ~W~ - "' ~ Concrete ~Metal ~OpenTop~ Concr~ ~ ~- ._ . -
LOCATION: ~ I~ Basement ~ B~sement ~fset ~ Under Hous~ '
.~ln Yard ~Other : '- - , '--.- _...- ~ 4~ . . - r ' -- .
Building S~er Septic
DISTANCE TO~ or Other Drainage Pipe - _ Feet. Tank . ~ ~et. '- ·
Tile . . Seepage -"~' 'tess- - '
Field r~t. Pit- Feet. Pool- Feet. Privy . ~- ' '
Other Possible
Sources af Contamination
MATERIAL: Building Sewer- ~ Cast Iron ~ ~'~ '~ TIJe' ~F~'~e: ~'~Xs~estos -~-~ - ~
~ Plastic Joint Material Type .... ~,- ' C~ment
:
GENER~ Does Water Become Muddy or Discolored? ~--Yes- . - - ~ ~o _- ~ , , ,._
When? -~.
a lameter of Well Depth
ell Ca~lng
terlal ~ ~ Diameter _ . , Dapth
Length of ' ~ Water Depth -
Drop Pipe Offset in' From Bot~m , Feet~
In Utlilty '- ~
PUMP LOCAT~'QN: [] In Well ~ Basement ~ In Basement ~ Room
OnTop ....
PU~PO~ OF~X~INATION~ IIIness,,,~uspecfed~ ~ Yes
New ~ourCe o~ ~u~ly~ ~ Yes'~ ~ No ~e~alrs ~ ~yslem~
. - ~ev.
[] No
[] Yes [~:No Signature
BAc~RIO.LOGICAL WATER-ANALYSIS' 'RECORD ''
, ~ . ~ ~. Time Received . _
READINSTRUCTIONS Date Received
,
Brilliant Grin
24 Hours ,
~ Hours -'
.REYERSE SIDE
BEFORE
COLLECTING;~.SAMPLE
EMB AGAR .
Lactosa Broth, 24 hrs. . '~ . 48 hrs. Gram's stain
Coliform Dansity '-'~ ~-~: (Most probable No. per 100cc)
MF Results , .-
Report~ by ~' Date a.m.
This analysls-ln~cat~CoIIfo~m-~anisms to be: Absent
'?