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Home My WebLink AboutLAKE RIDGE TERRACE BLK 9 LT 10 GRE -:R ANCHORAGE AREA BOROU("t DEPARTMENT OF ENVIRONMENTAL OUALIT, 3500 TUDOR ROAD ANCHORAGE, ALASKA 99507 279-8586 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM MAILING NAME C~'~/~L- ) ~/~/~ ~ ~/~ ADDRESS~ ~' LOCATION //~ ~~ ~ LEGAL DESCRIPTION SEPTIC TANK: DISTANCE FROM WELL LIQUID CAPACITY /~"-~"~ GALLONS. NUMBER OF MATERIAL ,,-~.';~'",~--~' COMPARTMENTS '~ INSIDE LENGTH ~"~INSIDE WIDTH. ~ DEPTH SEEPAGE SYSTEM: SEEPAGE PIT: NUMBER OF PiTS /' OU1SIDE DIAMETER / OR WIDTH LrNING MATERIAL J,~/-~' .~/",~,..rT, ~./~,;~- . DISTANCE FROM WELL NEAREST LOT LINE TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) LENGTH ~ '~ , DEPTH , BUILDING FOUNDATION /-~J-'~ ~'* sq. FT. TILE DRAIN FIELD: DISTANCE FROM WELL FOUNDATION , NEAREST LOT LINE NUMBER OF LINES~TRENCH W~ ABSORPTIO~ SQ. FT. LENGTH OF EACH LINE DEPTH: TOP OF TILE TO FINISH GRADE DEPTH OF FILTER MATERIAL BENEATH TILE TOTAL LENGTH , OF LINES IN. TOTAL EFFECTIVE IN. ABOVE TILE__ WELL: />,z~ z//~-/ '? DISTANCE FROM TYPE~//~/~/-~'~r~ : DEPTH ' , BUILDING FOUNDATION ? NEAREST SEPTIC / SEEPAGE LOT LINE ' , SEWER LINE ~T~/- ~.,~ . TANK ~ , SYSTEM WATER SAMPLE /'xt'/~ , NEAREST OTHER , CESSPOOl/-/~///~zF'- , SOURCES DISTANCES: ,/2- >~j~'--~ "' DIAGRAM OF SYSTEM I t I I ,b GRI:'A[ER ANCHORAGE AREA BoRdUGH DEPARTMENT OF ENVIRONMENTAL QUALI'T'Y SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT PERMIT ~O. --- INSTALLATION LOCATION LEGAL DESDR'PT,ON INSTALLATION OF: SEPTIC TANK MAILING ADDRESS SEEPAGE P~T DRAIN FIELD TYPE AND SiZE OF FACILITY TO BE SERVED FINANCED THROUGH COMPLETION DATE ANTICIPATED PHONE ~ OTHER TO SE INSTALLED BY /~/~// ~/~'~' NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST FINAL IN~PEGTION~ 24. HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY TH~' HEALTH DEPARTMENT AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEPTIC TANK SIZE. ~/'~ TYPE '"'~ SEEPAGE AREA SIZE TYPE ~ ~'~1~ MINIMUM DISTANCES, REQUlREMENT~ FOUNDATION TO SEPTIC TANK ~ / FOUNDATION TO SEEPAGE PIT ~,~,'3 DRAIN FIELD SEPTIC TANK TO SEEPAGE PIT WALL /~'"~ y . DRAIN FIELD SEEPAGE PIT ALSO CONSIDER AREA WELLS. . SEEPAGE PiT , SEPTIC TANK . SEEPAGE PiT .~/ / TO NEAREST LOT LINE. WELL TO SEPTIC TANK' c~"~ DRAIN FIELD ~ WATER MAIN TO SEPTIC TANK /~ DRAIN FIELD ' ~ SEPTIC TANK. ~-~"~' . SEEPAGE PIT /~:~ / , DRAIN FIELD ~ TO RIVER, LAKE, STREAM. OABT IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION S FEET INTO UNDISTURBED SOIL, 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FI'II'ED WITH AIRTIGHT REI~OVABLE CAPS, GRAVEL BACKFIll, CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. OR LICENSED DESIGNER DIAGRAM OF SYSTEM I CERTIFY THAT I AM FAt~ILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO, 28-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE, GRE?='XR ANCHORAGE AREA BOROUGH DEPARI~ :NT OF ENVIRONRENTAL QUALI 3500 TUDOR ROAD ANCHORAGE; ALASKA 99502 CASE # Performed For BillMosier Legal Description: Lot lu Block This Form Reports Soils~g Date Performed 7/6/72 S u b d i v i S i o n Lake Ridge T6'rrace Percolation Test Depth Feet l 2- 4- 5 6 7- 8--- lO~ Was Ground If Yes, At Soil Characteristics Brown Clayey Sandy Silt (CL) Brown Sand Silt Mix (ML) w/Clayey Sandy Silt Seams Water Encountered? No What Depth? Reading Date Gross Time Net Time Depth to H20 Net Dror nute Proposed Insta'~'lation: Seepage Pit Drain Field Depth Of Inlet Depth To Bottom Of Pit Or Trench COMMENTS: Permeability exceeds the 250 scI. ~t. per bedroom criteria and we make NO recommendations for on-site system. Test Performed By,., Carlisle ~ Data certified By: National TestingSvs., Inc Date: ,..-MUNICIPALITY OF ANCHORAGE, DEPARTME! 825 #1: Time OF HEALTH AND ENVIRONMENI ' PROTECTION L Street, Anchorage, Alask~ -99501, ] //~,-- 279-2511, ext. 224 or 225 ff~/~/~/~ Date Received: ~ril 28, 1977 Date Date ~ Insp Insp REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES 1o Lending Institution Request: National Bank of Alaska Shirley Jones Mailing Address: Post Office Box 3-3859 99509 Phone: 279-2506 2. Property Owner: Lyle F/CeCe Kirlin Phone: 688-9079 Mailing Address: General Delivery, Eagle River 99577 3. Legal Description: Lot 10 Block 9 Lake Ridge Terrace__ 4: Single Family Residence: ~ ) Multiple Family Residence: ( ) Number of Bedrooms: Number of Bedrooms: Well System: Permit # Construction Individual well ( ~ Con. unity/Public System ( ) Depth of Well Well Log on File ( ) Bacterial Analysis Sewage Disposal System: On-site System (~ Public Utility Permit # Installed .~3 -'~-7~IInsta]-ler _ /_~2~f_~ Septic Tank Size ~,~ Manufacturer ~ ..... Absorption Area ~ Soils Rate Material __~~ ' 7. Distances: Well to Septic Tank to Sewer Line Nearest Lot line / to Absorption Area Absorption Area to Nearest Lot Line Ps.ge ~°wo , -: Department of Health and Environmental Protection Request for Approval of Individual Sewer 'and Water Facilities Legal Description: Lot 10 Block g Ls~ Ridg~ m~rr~ Comments: ~~--~Jt~..~----t~ ~ ~ /~*~J~ ~'~r' . Affadavit Attached Approved: ,~~~ Disapprov~: Letter Attached: ( ) Date: Date: Department Worksheet: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L Street, Anchorage, Alaska 99501 279-2511, ext. 224, 225 REQUEST FOR APPROVAL OF INDIVIDUAL SEWER and WATER FACILITIES 1. Type of Inspection: VA XX 2. Property Owner: Lyle F. Kirlin & CeCe Kirlin Mailing Address: General I~tivery, Eagle River 3. Name of Buyer: Thomas H. Laney & Lynnette M. Laney FHA__ CONY, Day Phone: 688 9079 Mailing Address:.21-508 E. Camillia St. EAFB, Ak. Day Phone: 4. Name of Lending Institution:_~atl°nal ~ank o~ Alaska Mailing Address:__~.O. Bo× 3-3859, 99501 5. Name of Realtor or Agent:. N/A Mailing Address: Phone: 6. Legal Description: Lot 10, Block 9,,Lake Ridge Terrace 753-5369 Phone: 279 2506 X43 Shirley Jones Location: Harolds Loop Road, Eagle River SFR No. Bdrms. 3 Individual xx 7. Type of Facility to be Inspected: 8. Water Supply Type of Supply: Public Utility If Individual, number of dwellings presently served If Individual, depth of well 9. Sewage Disposal System Type of System: Public Utility If Individual, date of installation Individual (on-site) xxx Mrs. Kirlin will give directions when you call for appointment. get her at home. AM is best time to 72-003(3/76) 06-]220(a) Rev. ]973 DATE AL,4~'" DEPARTMENT OF HEALTH AND SOCIAL S DIVISION OF PUBLIC HEALTH INDIVIDUAL AND SEMI-PUBLIC· BACTERIOLOGICAL WATER ANALYSIS Lab No. OFFICE INDIVIDUAL [] NAME ADDRESS CITY ADDRESS OB SOURCE SEMI-PUBLIC ~ CHLORINE RESIDUAL PPM REPORT RESULTS TO COMPLETE THIS SECTION ONLY IF WATER IS AN INDIVIDUAL SUPPLY ZIP CODE _ SAMPLE COLLECTED BY DATE COLLECTED Sample Collected From [] Other (List) Well- ~ Dug [] Driven SOURCE: [] Spring E Cistern Dug Well or Cistern Construction: Wa]ls--~l Wood [] Concrete Top -- E Wood [] Concrele LOCATION: Analysis shows this Water SAMPLE to be: [] Satis~'act(~ry [] Unsatisfactory [] Questionable [] Sample too long in transit; sample should not be over 48 hours old at examination to indicate rellable results. P/ease [] Bottle broken in transit, please send new sample. SANITARIAN'S REMARKS TIME COLLECTED [] 'Kgchen Tap [] Bathroom Tap [] Drilled [] Bored [] Other [] Metal [] In Basement [- Basement Offset ~lln Yard [] Other Building Sewer DISTANCE TO: or Other Drainage Pipe Feet· Tile Seepage Cess- Field Feet. Pit__ Feet. Pool. Other Possible MATERIAL: Building Sewer- [] Cast Iron [] Wood [] Tile [] Plastic Joint Material - Type GENERAL: Does Water Become Muddy or Discolored? When? [] Tile Brick or [] Open Top [] Concrete [] Under House Septic Tank Feet, Feet. Privy Fee~. [] Fibre [] Asbestos Cement [] Yes [] No D~ameter of Well Depth Feet. Well Casing Material Diameter Depth Length of Water Depth Drop Pipe From Bottom Feet. Offset in In Utilily PUMP LOCATION: [] In Well [] Basement [] In Basement [] Room On Top [] Of Well [] Other PURPOSE OF EXAMINATION: Illness Suspected? New Source of Supply? [] Yes [] No READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING ,.SAMPLE [] Yes [] No Repairs to System? [] Yes [] No Signature B~-~220 <bi BACTERIOLOGICAL WATER ANALYSIS RECORD Rev. 1973 Lactose Broth 10cc 10cc 10cc 10cc 10cc 1.0cc 1.0cc 24 Hours 48 Hours Brilliant Green 24 Hours 48 Hours EMB __ AGAR Lactose Broth, 24 hrs. AB hrs Gram's slain Coliform Density . (Most probable NiB. per 100cc) MF Results Reported by Date p.m. Th~s analysis indlcates Collform Organisms to be: / Absent Present 3330 "C" Street 1. Approval requested by: Mailing Address: 2. Property Owner: Mailing Address: ·- Eagle River GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality , Anchorage, Alaska 99503 274-4561 Date Received November 16, Time of Inspection Date of Inspection REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR Cony. National Bank of Alaska Post Office Box 3-3859 William & Kathleen Mosier Phone: Phone: Post Office Box 314, Eagle River 99577 3. Legal Description: Lot 10 Block 9 Lake Ridge Terrace 4. Location: Upper Fire Lake 5. Type of facility to be inspected 6. Well Data: A. Type Individual C. Construction Sewage Disposal System: A. Installed 1972 C. Septic Tank: 1. Size D. Seepage Pit: E. Disposal Field: Single Family On-site system 1. Absorption Area Total length of lines 1976 279-2506 688-2859 No. of bedrooms 3 B. Depth 63' D. Bacterial Analysis B. Installer 2. Manufacturer 2. Material Distances: A. Well to: Septic tank Nearest lot line B. Foundation to septic tank , Absorption area , Other contamination , Absorption area , Sewer Lines C. Absorption area to nearest lot line EQ-034 (1/74) Paae 1 of two Daaes Page 2 Of two pa.ges - Re" st for Approval of Individual Y 'er & Water Facilities Legal Description r,ot 10 Block 9 T,&ke Ridge Comments A p p r o v ed~ ,~ ?~4~L/~L~ ~ .... / Disapproved Approval ._V~lid for one year from date signed Greater Anchorage Ar~a Borough, Department of Environmental Quality DIAGRAM OF 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) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 2510 East Tudor Road, Anchorage, Alaska 99504 276-2221 REQUEST FOR APPROVAL OF INDIVIDUAL SEWER and WATER FACILITIES 1. Type of Inspection: CMRO VA FHA 2. Property Owner: ~.;~(..£//~7~l ~!~L']77/(~/' Mailing Address: /~, Dr ~Z~-~J~ ¢~' ~M~/ Day Phone: 3. Name of Buyer:,/-- %Z~, ~ ~(~C~( k~- KtYC~/~ . Mailing Address:~7 7 ~j~:A/~z~ ~D~Z) Day Phone:c~Z/' 4. Name of Lending Institution: ~ F~~ Mailing Address: ~ ~ ,~ z~ Phone: 5. Name of Realtor or Agent: ¢~Z~) Mailing Address: '~ ~-/~ ~ ~/~, Phone: 6. Legal Description: ~ /~/ ~-~ ~/ ~ /~-l'~ CONV ~"'"/ Type of Facility to be Inspected: Water Supply Type of Supply: Public Utility If Individual, number of dwellings presently served If Individual, depth of well ~c'~2 / Sewage Disposal System Type of System: Public Utility If Individual, date of installation ./-- ? Individual (on-site) 72-003(3/76) 06-1220(a} Rev. 1973 DATE ALA,r' DEPARTMENT OF HEALTH AND SOCIAL SEt ;ES DIVISION OF PUBLIC HEALTH INDIVIDUAL AND SEMI-PUBLIC BACTERIOLOGICAL WATER ANALYSIS Lab No. OFFICE INDIVIDUAL [] NAME SEMI-PUBLIC [] CHLORINE RESIDUAL PPM REPORT RESULTS TO ADDRESS CITY ZIP CODE ADDRESS OF SOURCE COMPLETE THIS SECTION ONLY IF WATER I$ 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 SOURCE: [] Spring [] Cistern [] Other. Dug Well ar Cistern Construction: Walls--[] Wood [] Concrele [] Metal Top -- [] Wood [] Concrete [] Metal LOCATION: [] In Basement [] Basement Offset [lin Yard [] Other Building Sewer · DISTANCE TO: or Other Drainage Pipe Tffe Seepage Cess- Field Feet. Pit __ Feet. Pool Other Possible Sources of Contamination MATERIAL: Building Sewer- [] Cast Iron [] Wood [] Tile [] Plastic Joint Materlal - Type GENERAL: Does Water Become Muddy or Discolored? When? [] Bored [] Tile Brick or [] Open Top [] Concrete []_Under House Septic Tank Feet. Feet. Privy__Feet. [] Fibre [] Asbestos Cement [] Yes [] 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 Analysis shows this Water SAMPLE to be: [] Satisfactory' [] Unsatlsfactory . [] Questionable [] Sample too long in transit; sample should not be over 48 hours old at examlnation to ind)cate rellable resuhs. Please send new sample. [] Botlle broken in transit, please send new sample. SANITARIAN'S REMARKS PURPOSE OF EXAMINATION: Illness Suspected? [] Yes [] No New Source of Supply? [] Yes [] No Repa[rs to System? [] Yes [] No Signature READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE 06-m2o (bi BACTERIOLOGICAL WATER ANALYSIS RECORD Rev. 1973 Lactose Broth 10cc 10cc 10cc 10cc 10cc ].0cc 1.0cc 24 Hours 48 Hours - - ~ Brilliant Green 24 Hours 48 Hours EMB AGAR Lactose Broth, 24. hrs. 48 hrs. Groin's stain ' Coliform Density (Most pr6'bable No. per lO,cc) MF Results .~ Reported by This analysis indicates Coliform Organisms to be: Absent GREATER ANCHORAGE AREA BOROUGH ~' Department of Environmental Quality ~ ~)';~ /Q'~ 3330 "C" Street, Anchorage, Alaska 99503 274-4561 x Date Received August 31, 1976 Time of Inspection 1~.0~ a.m. ~...~..x.,..~ /~j~.~ Date of Inspection ~en~e~y .~,~TT~,~_ REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR Cony. 1. Approval requested by: % Dave Aquino Mailing Address: 3766 Arctic Blvd. 2. Property 0whet: William & Kathleen Moshier Mailing Address: 4. 5. 6. Phone: 274-2521 Phone: Legal Description: Lot 10 Block 9 Lake Ridge Subdivision Location: Upper Fire Lake, see map on back Type of facility to be inspected Well Data: Individual A. Type C. Construction 7. Sewage Disposal System: A. Installed 1972 C. Septic Tank: D. Seepage Pit: E. Disposal Field: 8. Distances: A. Well to: Septic tank Nearest lot line B. Foundation to septic tank Single Family No. of bedrooms 63' B. Depth D. Bacterial Analysis On-site system B. Installer 1. Size 2. Manufacturer 1. Absorption Area 2. Material Total length of lines , Absorption area , Other contamination , Absorption area , Sewer Lines C. Absorption area to nearest lot line __ EQ-034 (1/74) Paae 1 of two Daaes for Approval of Individual S, .r & Water Facilities Page 2 of two pages - Req Legal Description Lot 10 Block 9 Lake Ridge Subdivision Comments Approve ~i ~LJ,, J',c3 ~.~'.A~i sa pproved _ Da te ~..~ ~/ Approval ~Valtd for one year from date signed Greater Anchorage Area BIrough, Department of Environmental Quality DIAGRAM OF 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 (]/74) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 2510 East Tudor Road, Anchorage, Alaska 99504 276-2221 REQUEST FOR APPROVAL OF INDIVIDUAL SEWER and WATER FACILITIES 1. Type of Inspection: CMRO. VA FHA ~-'~CON~V 2. Property Owner: Mailing Address: Day Phone: 3. Name of Buyer: Mailing Address: 4. Name of Lending Institution: Day Phone: Mailing Address: Phone: Nameof Realtor or Agent: -~;'//~) ~(//~-f & Location: ,~//~ ~ ~/~ ~ ~/~) 7. Type of Facility to be Inspected: 8. Water Supply No. Bdrms. -~ Type of Supply: Public Utility If Individual, number of dwellings presently served If Individual, depth of well ~, 9. Sewage Disposal System Type of System: Individual Public Utility. If Individual, date of installation Individual (on-site). 72-003(3/76) 06d 220('a) Rev ] 97~,3 DATE ALASN JEPARTMENT OF HEALTH AND SOCIAL SER -"S DIVISIDN 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 COMPLETE THIS SECTION ONLY IF WATER IS AN INDIVIDUAL SUPPLY SAMPLE COLLECTED BY ZIP CODE _ DATE COLLECTED TIME COLLECTED Sample Collected From [] Kitchen Tap [] Bathroom Tap [] Other (List} [] Basement Tap Well- [] Dug [] Driven [] Drilled [] Bored SOURCE: [] Spring ~ Cistern [] Other Dug Well or Cistern Construction: Walls--[] Wood [] Concrete [] Metal O Tile Brick or Top -- [] Wood [] Concrete ~ Metal [] Open Top [] Concrete LOCATION: [] In Basement [] Basemenl Offset [] Under House []In Yard ~ Other Bu~ldlng Sewer Septic DISTANCE TO: or Other Drainage Pioe 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 When? Diameler of Weil Well CasTng Maleria, Diameter Length of Drop Pipe Offset in PUMP lOCATION: [] In Well [] Basement On Top [] Of Wel [] Other PURPOSE OF EXAMINATION: Illness Suspected? New Source of Supply? [] Yes [] No READ INSTRUCTIONS ON REVERSE SIDE BEFORE Depth Feel Depth Water Depth From Bottom Feet. m UtiEfy [] In Basement ~ Room SANITARIAN'S REMARKS EMB AGAR Lactose Broth, 24 hrs. Coliform Density MF Resulls Reported by ~ . This analysb ~ndicates Coliform Organisms to be: Date Absent 48 hrs.__ (Most probable No. per 100cc) COLLECTING SAMPLE Lactose Broth 10cc 10cc 10cc 10cc 10cc 1.0cc 1.0cc 24 Hours . . 48 Hours ~ Brilliant Green 24 Hours 48 Hours Analysis shows this Water SAMPLE to be: [] Satisfactory ~ Unsatisfactory ~ Questionable [] Sample too long in transit; sample should not be over 48 hours old at examlnafion to indicate rellable results. Please send new sample. E Bottle broken i~ transit, please send new sample. [] Yes [] No Repairs to System? [] Yes [] No Signature 06-1220 (b) BACT~ERIOLOGICAL WATER ANALYSIS RECORD Bev. 1973 am Date Received ~ ' ~ · Time Received . p.m Lab. No. 06-1220(a} Rev. 19Z3 ' ~ DATE ALAS[ JEPARTMENT OF HEALTH AND SOCIAL SEE £S DIVISION OF PUBLIC 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 ZIP CODE COMPLETE THIS SECTION ONLY IF WATER IS AN INDIVIDUAL SUPPLY SAMPLE COLLECTED BY DATE COLLECTED Sample Collected From [] Olher (List) Well-- [] Dug SOURCE: [] Spring TIME COLLECTED : : : [] Kitchen Tap [] Balhroom Tap [] BaSement Tap [] Driven [] Drilled [] Bored [] Cistern [] Other Dug Well or Cistern Construction: Walls--[] Wood [] Concrete [] Metal [] Tile BHck Or Top -- [] Wood [] Concrete [] Metal [] Open Top [] Concrete LOCATION: [] In Basement [] Basement Offset [] Under House Ii]In Yard [] Other But]ding Sewer Septic DISTANCE TO: or Other Drainage Pipe __Feet. Tank Febt. Tile Seepage Cass- Field Feet. Pit Feet. Pool Feet. PHvy Feet. Other Possible Sources of ContaminaHon MATERIAL: Building Sewer- [] Cast Iron [] W6od [] Tile [] Fibre [] Asbestos Cement [] Plastic Joint Material - Type GENERAL: Does Water Become Muddy or Discolored? [] Yes [] No When? Diameter of Well Depth Well Casing Malarial Diameter -- Deplh Length of Water Depth Drop Pipe Fram Bottom Offset in PUMP LOCATION: [] In Well [] Basement [] In Basement On Top [] Of Well [] Other Analysis shows this Water SAMPLE to be: [] Satisfactory '[] Unsatisfactory [] Questlc;nabl~ [] Sampl~ 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 [] Room PURPOSE OF EXAMINATION: Illness Suspected? [] Yes New Source of Supply? [] Yes [] No RepaTrs to System? READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE [] Yes [] No Signature 0B-~220 (bi BACTERIOLOGIC/AL WATER ANALYSIS RECORD Rev. ]973 Dale Received ~ 7~; / ~'~ i /~ Time Received. ~f al:~ Lab. No. Lactose Broth 10cc 10cc 10cc 10cc 10cc 1.0cc 1.0cc 24 Hours 48 Hours ' ~ ' Brilliant Green 24 Hours 48 Hours EMB AGAR Lactose Broth, 24 hrs. 48 hrs. Gram's stain Coliform Density (Most probable No. per ~00ccl MF Results This analysis indicates Coliform Organisms to be: Absent Present