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Home My WebLink AboutSPLAWN Lots 11-A & 11-B Plat# 82-395 S-5444 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEAL. TH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL HEALTH CASE REVIEW WORK SHEET PLATTING BOARD L_] PLANNING & ZONING CASE NUMBER S-5444 '-~ E RECEIVED July 31, 1980 T15N R2W Section 25~_0ts ll-A,_ll-B~ Preliminary Plat and Vacation Plat COMMENT TO PLANNING BY August 22, 1980 See note I put on the soils test. ~ MEETING OF CASE OF Id PUBLIC WATER NOT AVAILABLE TO PE-FITION AREA L~ PUBLIC SEWER NOT AVAILABLE TO PETITION AREA 71-014 (Rev. 2/78) Russell Dy.ret 694-2774 O & E ENGINEERING & DEVELOPMENT CO. Box 90. Davis St.. Eagle River. Alaska 99577 694-2774 or 688-2280 SOIL LOG Performed for: Name:__ Mailing Address:__c/° Hz'. Robert Johnson Legal Description: Lot llB o£ Bi24 Lot l!, T15N, R~,W; SM Earl Ellis 688-2280 _ Tel. No.___6_88_-9_~24;~ ....... Depth (feet) Soil Characlerl~tlcS 10__ 12___ 14 15 16---- Silt 'topsoil with roots & erganics. 2?5 sa. £t,./ Percolation lo,.,t Silty Gravelly Sa~d ~,rith cobbles and boulders to 8 inches. Materials unifoz~ throughout pit. 250 sq. fto/ Soe 8tt~.vey Bottom of Pit PLOT PLAN ~;: ~; ..~ ; * t4 ,,, , ~'d ' ': ~ = 30,minutes/:tnc ~//o, % , ¢. 4,..,~.,. ,~,<¢.~; ~erco].at, ion Rate ~¢q<" % '"""'"':~ 250 sq.fto/Br. Ceo___ If yes, what depth........... Ground Water Encountered: ' ,' No.,,XX-.__ Proposed Installation: Seepage Pit ...... Drain Field__~_~ Comments:___ 1980 Performed by: Russ Oyster Date:___July 26, 1980 O.4 ¼ 0~(~6~-'~8) ' ~J C'., C"') Z) o_~ (~6~-~8) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES_ Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage,'Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D.# (J:~U-'u-(, 1. GENERAL INFORMATION Complete legal description Lot 4; .' ~:; .' · Block I; 'Spring BrOok Vista Subdivision #I J Location (site address or directions) Ea~l~ River, AK Estat~ of Joe L~corchick Property owner Dick Lochner ~,Cons. of ~stat~ Day phone Mailing address ¢/0 R~max of Eagle, River 16600 (~nterficld Driv~ 12308 East Prin¢~ of P~:tcc Driv~ Eaql~ Riv~, AK 99577 Lending agency Day phone Mailing address_ Agent A1 Romaszewsh, i/ REMAX OF EAGLE .RIVER Address 16600 C~nterfield Driv~ Ea,ql~ Riuer~ Day phone AK 99577 694-4200 Unless otherwise requested, HAA will beC/eld for pickup. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: e Individual well Community well Public water X×× NOTE: If community well system, provide written confirmation from State ADEC'attest- lng to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site ×XX ~ NOTE: Holding tank Community on-site 72-025 (Rev. 1/91) Front MOA~I Public sewer ': If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. ? :'!:~ ~ ~..,i:~:.; 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 of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is 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 in compliance .with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm · · l~4 I~1. River Lo~_? NO Address ........ EngineeCs signatu;7 m~~~ Phone Date I/ /,~/~1~ DHHS SIGNATURE Approved for ,~-~lSedroom~. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments B ~" Date 'f;l, mJit. J( The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorag~e is not responsible for errors or omissions in the professional engineer's work. : :. ~.- · 72-025(Rev. 1/91) Back MOA#21 : Municipality of Anchorage Department of Health and Human Services HE[AL,TH AUTHORITY APPROVAL' CHFCKLIST Legal Description: ~ ~ ¢"~..~ / ~-~P'f~,~N ?~r~o.CParcel I.D. A, Well Data Well type 120¢~.4._- Log present (Y/N) Total depth Sanitary seal (Y/N) Date of test Static water level If A, B, or C, attach ADEC letter. ADEC water system number Date completed Driller Cased to FROM WELL LOG Casing height Wires properly protected (Y/N) AT INSP~T~O~ Well flow g.p.m~ Pump level1 / SEPARATION DISTANCES FROM WELLT ,~/ Septic/holding tank on lot ~ ; On adjacent lots Absorption field on lot / Public sewer main Sewer service line WATE R/~ LP~E RESULTS: Nitrate ; On adjacent lots Public sewer manhole/cleanout Petroleum tank Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed G -~-7 ~ Cleanouts ~)N) t High water alarm (Y/~ Tank size Compartments Foundation cleanout (;~.N) ,7/ Depression Alarm tested (Y/N) "J'//4 Date of pumping SEPARATION DISTANCES I--ROM SEPTIC/HOLDING TANK TO: ,/ Well(s) on lot /J/A- On adjacent lots /"///~ To property line /6 /. ~ Absorption field .5- ' Sudace water/drainage /oo / ¢ Foundation Water main/service line /dl '/' 72-026 (3/93)' Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) ~ SEPA~OM LIFT STATION TO: W'e~on lot On adjacent lots Manufacturer Manhole/Access (Y/N) Surface water D. ABSORPTION FIELD DATA Date installed Length Total absorption area Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y~ L ..... Soil rating (GPD/FF) ~5' ~//~/-. System type Width :~ ',-~- Gravel thickness E, ' ------ 'Total depth // ~.a2.Z 5~ Cleanout present (~N) '? Depression over field ("~ /c~ / ?-~ ~ ¢ ' Results ~ail) ,~,,~s'-~ for ¢ Bedrooms 0" After test ,~,JE.- ,~z:,J'~ ~,[,,,/ If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ///~ '~ To building foundation On adjacent lots '~o ~ '~ Sudace water Curtain drain /.%/ lee On adjacent lots ,J/.,4- Property line /0 TO exist}ng or abandoned system on lot '"/~ Cutbank ¢J ~ Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I ce~'fy that I have checked, verified, or conformed to all MOA and HAA Signature Engineer's Name Date of this inspection. HAA Fee $ ~00o t/~ Date of Payment Receipt Number 72-026 (3/93)* Back Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE OF HEALTH AND ENVIRONMENTAL PROI'ECIi'IONI DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATI: OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Applicalion Dato ~ GENERAL INFORMA'rlON (a) (b) (c) (d) Legal Description (include tot, block, subdivision,.section, township, raege) Location (address or directions) .......................................... Applicant Name -~(?"~'~ ~ ¢,¢~'¢~ Telephone: Home _?.~t~:(/f.[%<:' Business Applicant Address _ ~¢' ~' ~ ~ ~ ~ ,- r- /?r, ,~'~ Z;~. [ ~ ~ Applicant is (check one): Lending Institution D; Owner/budder ~ Buyer EJ; Other [] (explain); Lending Institution /'"'/~z/'A Telephone ............. Address (e) Real Estate Company and Agent _.¢¢'/./~ ''",'/ Address Telephone (f) Mail the HAA to the following address: 'TYPE OF RESIDENCE Single-Family, S' Multi-Family,, [] Number of Bedrooms ~- Other WATER SUPPLY Individual Well [] Community'~ Public Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status, 4. SEWAGE DISPOSAL Onsite"~' Public [] Community [] Holding Tank [] / Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-U25 (I 1,84) Page 1 of 2 FIFIM PROVIDING INSPECTIONS, TESTS, ~'11.!.=; SEARCH, DATAAND INI~ORMATION , rny seal affixed hereto and as of the validation date 3ihown br~3w, I verdy that m~ investigation of this Heallh ~Approval shows that the on-site water supply and/or was~mwater O~posal ~ystem i~ 0nfe, functional and adequate number of bedrooms and type of structure indicated hereim. I further verify that based on the information obtained 1he Municipality of Anchorage files and from my investigmtion and mspection, tho on-site water supply and/or lief disposal system is in compliance with all Municipal an(~ State ~y~es, ordinances, and regulations in effect on his inspection. ~LE RIVER ENGINEERIN~ SERVIOES of Firm ~~ ~ Tedephone tess p. .._~,- 694-5195 Engineer's Seal Approved for ~'~/~ ~ _ be Date Approved Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 Legal Description: //, ~/--~ -~/ o~UNICIPALITY OF ANCHOraGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION !'jUN :lu:- RECEIVED WELL DATA If A, B, C, D.E.C. Approved (Y/N) Date Completed Yield Depth of Grouting Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) Well Classification Well Log Present (Y/N) Total Depth _ Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot c~O.4;¢.~ -h To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results ; On Adjoining Lots ~dx}-~- ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot Date Comments B. SEPTIC/HOLDING TANK DATA Date Installed /~) ? ~ Size //¢'~.5--o No. of Compartments Standpipes (Y/N) /V Air-tight Caps (Y/N) /? Foundation Cleanout (Y/N) ~;~. ~,~. ~?. Depression over Tank (Y/N) ]['/ Date Last Pumped Pumping/Maintenance Contract on File (Y/N) ~v'//~ ;for - - Holding Tank High-Water Alarm (Y/N) Separation Distances. from Septic/Holding Tank: To Water-Supply Well o~-~) To Property I.ine /O +' To Water Main/Service Line /":~ ~' Course ,/c,/o ,n~ ~_ Temporary Holding Tank Permit (Y/N) ~ To Building Foundation 1~. '7" To Disposal Field ~- / To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ,/'~ Width of Field Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation /,-~'- Lot To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Type of System Design Length of Field c'~ ~ z Depth of Field ,~/'~2 /' Gravel Bed Thickness c2~ ? Standpipes Present (Y/N) Date of Last Adequacy Test ; On Adjoining Lots To Cutbank (if present) To Property Line ?~ ¢' To Existing or Abandoned System on LIFT STATION ,~/'/~ Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments Page 2 of 2 72-026 (11/84) ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~ Company ~')¢, Receipt No. ~ ',~¢ .~'~,. 114 ! ~ ' ,. !i !/ t\.' I' , DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE/WESTERN DISTRICT OFFICE 437 "E" STREET, SUITE 303 ANCHORAGE, ALASKA g9501 BILL SHEFFIELD, GOVERNOR Telephone: (907) Address: 274-2533 TO Whom it May Concern: According to records on file in this office the _(/'..77~ ,,Water System is in compliance with . a e Drinking Water Regulations Sincerely, --%? INSPECTION APPOINTMENTS DA-iZE REClZIVED INSPECTOR NSPECTOR I NSPECTOF~ MUNIC~PALI~ OF ANCHORAQ~ MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEC~RONMENTAL P~OTECTiON 825 L Street - Anchorage, Alaska 99501 t981 ENVIRONMENTAL SANITATION DIVISION JUL Telephone 264-4720 DIRECTIONS: Complete all parts on page 1, Incomplete requests will not be proce~ed, Please allow ten (10) days for processing, 1, PROPERTY OWNER PHONE MAILING ADDRESS 2ouch 7-025 995[0 PROPERTY RESIDENT (If different from above) PHONE 2, BUYER PHONE De~s ~. D~vLGso~ 333-0860 MAILING ADDRESS 8630 H~L~ Co~ 99504 3, LENDINGINSTITUTIO~ ' I PHONE National ~a~ o~ Alaska - Ho~¢gage ~oanI 265~2883 MAI LING ADDRESS 2ouch 7~025 995[0 4. REALTOR/AGENT I PHONE MAILING ADDRESS 5. LEGAL DESCRIPTION Lot 4 Block ;L Springbrook Vista Subdivision I,~l STREET LOCATION 90 Prince of Peace Drive 99577 6. TYPE OF RESIDENCE NUMBER OFtBEDROOMS [] One :~ Four [] Other ~ SINGLE FAMILY [] Two [] Five [] MULTIPLE FAMILY [] Three [] Six 7. WATER SUPPLY [] INDIVIDUAL* ~ COMMUNITY [] PUBLIC UTI LITY *ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM [~ INDIVIDUAL/ON-SITE** [] PUBLIC UTILITY YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FFE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE r-I OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVI DUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [~DIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified iNSTALLER []Septic,T, ar~kbor []Holding Tank Size: ~ "- "~ If Tank is homemade SOILS RATING give dimensions: ~'" TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank lAbsorption Area Sewer Line I Nearest Lot Line I I WELL TO: Absorption Area to nearest Lot Line 5. COMMENTS ~APPROVED FOR d BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED 72-010 (Rev, 6/79) MUNICIPALITY OF ANCHORAGE Departm-' t of Health and Environme' ~51 Protection 82 L Street, Anchorage, Al., ~a 99501 264-4'720 uest for Approval of Individual Sewer and Water Facilities Property Owner: NATIONAL BANK OF ALASKA Mailing Address: 301 W. Northern Lights - Pouch 7-025 A~c~-~ge, ~Al~a~k~ 99510 Name of Buyer: Dennis J. Davidson Phone: 276-1132 Mailing Address: 8630 Muir Court ~unc~ge, ~l~-~a 99504 Phone: 333-0860 Lending Institution: Mailing Address: NATIONAL BANKOFALASKA Pouch 7-025 Anchorage, AK 99510 Phone: 265-2883 o Realtor/Agent: Mailing Address: None Phone Legal Description: Lot 4, Block 1 Springbrook Vista S/D #1 Street Location: 90 Prince of Peace Drive Eagle River, AK 99577 Single Family Residence: (X) Number of Bedrooms: four Multiple Family Residence: ( ) Number of Bedrooms: Water Supply: *Individual Well ( ) If Individual Well, well depth If Community System, name of system Public/Conmmnity System Sewage Disposal System: *'~On-site System (X) Public System ( ) If On-site System, date of installation: *NOTE: A well log is required on ALI, wells drilled since 6/75. ** If on-site sewer system is over two(2) years old, an adequacy test is required by this department. A fee of $25.00 must accompany each reque.gt before processing can be initiated. 3/77 825 "L." ST i\NCJFiO RA{:~E, ALASKA (907) 264-4i'11 t,.4/tY 0 R DE~'AJ~It..4~gT~_~F iN .Ad. fil AFH) [ix4'ViR()NME!fil,r,,I Vt:iOIECliOt,i July I0, 1.98.1. q..abjecL: Lot 4 Block 1 Springb~'ook. Vista Subdivision #]. Approval. lfor the individual sewer a~ld waher cannoh be gra}~ked uninii, t-he following items have been comple I;o.d :' (1) The sept:Lc tank pnmp:,d w:Lth a r(..ca]&,, submit:.ted to t: h i. s c, ~ f J c e, If there are any f/uL~thc:r questtions, please cal.], this of:i!:lce ,.~t 264-4720. S:J.llCe~e]y~ J'S R/L j w - -- ~:~I~,ff~tL~f OF ANCHOI~AG~ MUNICIPALITY OF ANCHORA~ ~! ~4/J ENVIRONMENTAL ENGINEERING DIVISION APR 2 ~ Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWE~,~ ~ DIRECTIONS~ Complete all parts on page 1, Incomplete requests will not be processed, Please allow ten {10) days for processing. 1, PROPERTY OWNER PHONE P~OP[~TY ~¢SI~T {If different fro~ above) .......... ) ~ ~ ....................... MAI,LINGADDRESS ' ,/ ~ . ~ -~. ~ 4. ~LTOR/A~NT ~ / [ PHONE I MAILING ADDRESS STREET I~I~ATION L ' 6. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] One ~ Feur ~ SINGLE FAMILY ~ Two [] Five [] MULTIPLE FAMILY ~[~"' Three [] Six [] Other 7. WATER SUPPLY r-I INDIVIDUAL* ~ COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. A well log is required for all wells dri led since June 1975, For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM **If individual/on-site, give installation date' ~'~"~"/¢['~'¢5 . ~ If system is over two (2) years old an adequacy test is reauired NDIVI DUAL/ON-SITE** [] PUBLIC UTILITY by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED, 72-010(3/78) THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1, TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE r--I FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX 2, WATER SUPPLY PERMIT NUMBER [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY (.~ _"~ ~) Connection Verified INSTALLER []Septic Tank or []Holding Tank ~ ~ Size: /,-.~.~"~ If Tank is homemade SOILS RATING give dimensions: ~ TYPE OF TANK MANUFACTURER./,.j4.~,{~ ,~...._., TQTAL ABSQRPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank Absorption Area ISewer Line Nearest Lot Line WELL TO: Absorption Area to nearest Lot Line 5, COMMENTS I];;~PP R OV E D FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED LEGAL DESCRIPTION · f 72-010 (Rev. 3/78) Date ALASK ZPARTMENT OF HEALTH AND SOCIAL S TICES DIVISION OF PUBLIC HEALTH Lab. No. Office BACTERIOLOGICAL WATER ANALYSIS PLEASE MAIL RESULTS TO: ADDRESS_. CITY ZIP CODE ~z-y 7 Specific place of collection REASON FOR SAMPLE SUBMISSION: [] Illness suspected [_~ tIealth Regulated Establishment [] Other WATER SAMPLE SOURCE [] Well Type of casing [] improved (Enclosed, Covered) Spring [] Surface (Reservoir, stream, lake) [] Holding Tank [] Other Analysis shows this WATER SAMPLE to be: ,[~,Satisfactory [] UnsaHsfac~ory [] Questionable [] submit other sample [] Sample too long in transit to indicate reliable results. Sample should not be over 48 hours old at time of examinatic{n. [] Bottle broken or leaked in transit. [] Other SANITARIAN'S REMARKS y0 Sanitarian's Signature: ~EAD INSTRUCTIONS BEFORE COLLECTING SAMPLE_ 06-1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD Rev. 1978 oa,, ~c~l~d ff'' I 7 "7 ~, ~im, n,c~i~d ~'r-~ ~ ~ab.,o.-- o/~.~ _ 24 Hours 48 Hours Confirmatory 24 Flours 48 Flours Verification: LTB ;~q~) Fna Membrane F[IteF~.~ es!jlts~-:"' Reported By___7~f'~.~F:'~'--~!5.~'~' -- --