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Home My WebLink AboutTURNAGAIN HEIGHTS BLK D LT 3A 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 GENERAL INFORMATION Complete legal/escription /oT $,~, Location (site address or directions) Property owner Mailing address Lending agency bT., A~c+¢. Ak' Day phone 5'Gl-237.3 Day phone Mailing address Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~/ ~ TYPE OF WATER SUPPLY: Individual well ~ Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer v"' NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/9~) From MOA 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 FLA'"PTOP Address 14530 ECHo Engineer's signature ~'~ DHHS SIGNATURE X Approved for [:~'-~¢) bedrooms. Disapproved. Phone 3~/,5~'' 135'~ Conditional approval for Date bedrooms, with the following stipulations: Additional Comments 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 DH HS 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. Municipality of Anohorage C E Iv Department of Health & Human Services E D HEALTH AUTHORITY, APPROVAL CHECKLIST , , 8EP 1 7 1992 Legal Description: ZoT 3A, '~zk'~ TU~'N/~,zI~N' ~TS. Parcel I.D. ~. ~ ' Dept. Health & Humea ~., ce~ A. WELL DATA Well type '~R!Y~TE Log present (Y/N) ~ Date completed Total depth L) ~ K Cased to '~ L[O ' Sanitary seal (Y/N) ~" If A, B, or C, attach ADEC letter. ADEC water system number /~o' omoer' Driller ()Nk'. Casing height ~" .45o~'g I~o-/"ro~ oF pIT Wires properly protected (Y/N) Y Date of test Static water level Well flow Pump level FROM WELL LOG AT INSPECTION ~0 ~ g.p.m. ~ ~"~ g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot ~ ,,~- Absorption field on lot Public sewer main '~ 7~' ' Sewer service line ~ ; On adjacent lots ; On adjacent lots Public sewer m.anhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ('~ ¢~,1 //oo~ Date of sample: 9 / 9 / 9 g Nitrate /-. O, / /~J/~_ Other bacteria O col / zoo ~ Collected by: FL,4TToff TgC~/ ~YL'$, B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) High water alarm (Y/N) Date of pumping Tank size Foundation cleanout (Y/N) · Compartment~ I -- Depression (Y/N) Alarm tested (Y/N) Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot On adjacent lots Foundation To property line AbsorptiOn field Water main/service line Surface water/drainage 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump off" level at High water alarm level Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots D. ABSORPTION FIELD DATA /~,/~. (,. Cycles tested Surface water Date installed Length Width Total absorption area Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots_ Surface water Curtain drain E, ENGINEER'S CERTIFICATION Soil rating Gravel thickness Cleanouts present (Y/N) Date of adequacy test for If yes, give date System type Total depth bedrooms On adjacent lots Property line To existing or abandoned system on lot Cutbank Water main/service line Driveway, parking/vehicle storage area HAAFee$ ~/7D 'CY~ Date of Payment ¢~'//-~ ~-~'~"- Receipt Number ¢'~/"~'-~¢~" (/" 5'7 7/-~) 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. ..... Date t2¢. CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99516 TELEPHONE (907) 562-2343 ANALYSIS RESULTS for INVOICE t 58101 Chemlab Ref.t 92.4833 Eample $ 1 Matrix: WATER FAX: (907) 561-5301 Client Sample ID PWSID Collected Received Preserved with L3A R D TURNAGAIN MO~ S/D UA SEP 9 92 @ 14:00 b~s. SEP 9 92 @ 15:00 AS REQUIRED 2244 * Client Nams :FLATTOP TECHNICAL SRV Client Acct :FLATTOT BPO$ : PO{ :NONE RECEIVED ReqE : Ozde~ed By :TED MOORE Analysis Completed : SEP I1 92 Send Reports to: Labo[ato=y Supe~¥isor~: STEPHEN C. EDE I)FLATTOP TECHNICAL Released By : ~,~ Pazamete~ Results Ur, its Method Allowable Limits NITBATE-N ND(O.iOJ mg/1 EPA 353.2 lO Sample ROUTINE SAMPLE COLLECTED BY: T.F.M. * LOUSSAC DR. E. ROSE BIB. Nemarks: 1 Tests Pe~£ozmed See Epecial Instructions Above HA=Unavailable ND= None Detected "See Sample Remarks Above NA- Not Analyzed LT=Less Than, GT-Gzeater Than ~SGS Member of the SGS Group <Soci~t~ G~n~rale de Surveillance) CHEMICAL & .GEOLOGICAL LABORATORY orws o oe cot% Ci resrm e vom va v c°. TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518 Drinkin:g Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER [] PUBLIC WATER SYSTEM I.D. #~ [~ PRIVATE WATER SYSTEM ~ Mo. Day ' Year SAMPLE TYPE: [~' Routine [] Check Sample (for routine sample with lab ref. no. ; [] Special Purpose , ) [] Treated Water ~' Untreated Water SAMPLE Time Collected No. LOCATION /:Ir ~' Collected By 31 I T~) BE COMPLETED. BY LABORATORY Analysis shows this Water SAMPLE to be: [] Unsatisfactory .~: [] Sample too long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send new sample via special deliyery mail Date Received (~ lq ~Z Time Received [ ,~:)~ Analytical Method: Membrane Filter * No. of colonies/100 mi. Lab Ref. No. Result* BACTERIOLOGICAL WATER ANALYSIS RECORD READINSTRUCTIONS BEFORE COLLECTING SAMPLE Membrane Filter: Direct Count Verification: LSB Fecal Coliform Confirmation Final Membrane Filter rl~ult Reported By TNTC = Too Numerous To Count OB = Other Bacteria RGB Collfornt/100 mi Coliform/100 mi PART ONE OF TWO REMAINDER TO FOLLOW APPLI FILLS'OUT UPPER HAI jONLY Property Ow~ner~:~_~. ,.~ (~ ~. \..~. A ~.~;~ L ~ ~/ ~ 'L~. ~ ~. ~.~ ~"~ Pho~ ;' / ~ ~ (, ~ ~ ~ Zip Code * ~ -~ - Mailing~ddre~ .;~ >? /,/ ~ , ( -~ , .... , _ -- .. ,-~ ( Buyer ~ ([, Address Zip Code ~ ~. ~ ¢-- ~~ ~ Phone Lendinglnstitution ~%~. ~. ~ ~ ~ ~ ~ ' ~ ~ k ( ~ .... Zip Code Address ~ ~ ~ ~ ~ C ~ -" ,) ~: t~ ~x / / ':~ ~- ~ealty Co. & A~nt i Phone Address ~ Zip Code Street Locati~ ~qq ~ . ~'l ~ ~ ~ ~ (' - Type of Resi~nce g Multiple Family NO. of Bedroo~_~ ~ Other Water Supply ~Jdual A~ACH WELL LOG. A w~l Icg is required for all wells drMed since June 1975. ~ Community For wells drilled prior to that date, give well depth (attach Icg if available). ~ Public Utifity Sewer Disposal ~ Individual Year Individual Installed: ~Pu~Iic Utility When Connected to Pubfic Utility: g Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSlNG CAN BE INiTIATEd. Inspector Inspector - fiNVIRONM~-NTAL pROTECTION ~ ~)~b~'PROVED BEDROOMS *CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDIT~NAL AJ~.~)VAL* BATE Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received Well to Tank Septic Tank Size 72-023 (3182) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date '-~-~'~ - GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) {a) Legal Description (include lot, block, subdivision, section, township, range) Location ~address or directions/ (c) Lending Institution' · " Mailing Address , (d} Real Estate Cpmpany a0d Agent Add~:ess ...... Telephone: Home --;~"¢'/-~'oc'~ Business ~'~--/--~,.~-.~ Telephone Telepho'ne i - ~ (e) Mail the HAA t~) the followina address: or: Check here E], if hold for pick up. List contact person and day phone number below. TYPE OF RESIDENCE Single-Famil,~ Number of Bedrooms WATER SUPPLY Individual W Community [] Public [] Note: If community well system, must have written confirmation from the State Department of, Envirqnmental Conservation attesting to the legality and status. 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. Page 1 of 2 leUO!SSejoJd eql u! suo!ss!Luo Jo 9JOJJ~) Joj elqlsuods@J lou s! eS8Joqouv lo Xl!led]o!un~ aq.L 'panss] @! el8o!tiHeo ~ eJoleq elep eZ~leUe ~o suo!loadsu! lanpuo9 lou op SHHO ~o SeeXOldLU~ 'sluatueJ!nbaJ e~els pue leJepal ule~eo Xis!les ol Jap Jo u! Suo!lnHlsu! 6u!puel Jlaql pue SeLuoq ~0 sJeseqoJnd ol/,se~noo e se s!ql seop SHHQ eqJ. 'eaSelV ~o alelS eql u! peJels!beJ Jeeu!bue leUO!SSelOJd luepuedepu! ue iq e^oqe ~ qdeJ6eJed u! ue^!b suo!le~ueseJdeJ eql uodn Xluo paseq se~eo!l!peo le^mddv Xl!Joqln¥ q~leeH senss! (SHHQ) s@o!^JeS UeLUnH pue qlleeH ~o luempedeo abeJoqouv lo XUled!o!unv~ eqJ_ NOl£n¥o 7/ leUO)))puoo Ie^oJddv leUOlHpuoo 1o sLuJeJ. pet, oJddesl'(] "--~..~ pa^ruddy /iq smooJpeq ~ .~o~ pe^oJddv 'IYAO ElddV SHHO '9 .§ MUNICIPALITY OF ANCHORAGE (MOA) MUNICIPALITY OF ANCHORACFtFEALTH AUTHORITY APPROVAL (HAA) ENVIRONMENTAL SERVICES DIVISION CHECKLIST - FEBRUARY 1984 264-4744 APR 6 1987 WELL DATA RECEIVED Legal Description: Well Classification Well Log Present (Y/N) .~/ Total Depth ~..5' / 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 To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line -;~"' Cleanout/Manhole ,/~o If A, B, C, D.E.C. Approved (Y/N) Date Completed Yield ~',5~.,.~,~/ Depth of Grouting Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot ~'?'~"' ~ Water Sample Collected by ///~''4''-'''~¢~?-z-a--~ ; Date Water Sample Test Results .~..~' .,'~'~<'~/ ~/~ ~ Comments ~ ~¢~ ~/~ ~u~ ~ SEPTIC/HOLDING TANK DATA ~ Date Installed Standpipes (Y/N) Air-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well To Property Line To Water Main/Service Line Course. Size No. of Compartments Foundation Cleanout (Y/N) Date Last Pumped ; for Temporary Holding Tank Permit (Y/N) To Building Foundation ·.. To Disposal Field To Stream, Pond, Lake, o~'Major Drainage Page 1 Of 2 72-026 (Rev 8/861 Front 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 Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) 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 ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I bay, e che. ck¢.cl, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ,~/~2~"~"~ Date Company ~¢~'~t/,¢-~.~ ~ MOA No. ReceiptNo. ~- 00 /- ~¢¢~ Date of Payment ~ ~ ~7 Amount: $ / ¢ ~ ~ Page 2 of 2 BEVAN ENGINEERING Approved Well & Sep'dc Engineers P.O. Box 112852 Anchorage, AK 99511 (907) 522-1383 (907) 258-0584 April 6, 1987 Municipa].ity o'f Anchorage Deparbnent of Health & Envir-or-unental 825 "L" Street Ar:thor"age, Alaska 995';~I Re :: Whitney Jenes H.=.altl"l Au'~lnority Approval App].:~cat:[on Lot .IA Gen'[lemen ~ ):)ur'lng the per"iod fr"em I~la~'ch ,)'~r to March .~, :1.9L']7 ]: per.Formed research, site ir',.ve~-l:iga'll:i, orls and well .f:].p~ 'l:eeting pLU'"suarff. ]: per.~:oriiled a ,4ell flow L,...d.. and found the ..... p~er minute (gpm). This Eexceeds the JAq-167 ~Ipm rEequir-ed .For' a 4 b~dr'oom heine,, -.~ · ~ .... ' '-. ~= ' negative. The sea].ed well head is contairied :i.n a 4..2~x4..2~x4.5~' subsurface corlc:rete well is adequately r)rotec:ted by the ~,.~e].]. house. The we].l house ha~e a f].oor ~ and is insulated. The ~e:l. 1 heuse ie loc:areal in th~%s~halt (:h~'iveway :[rrlmed:[.~a!:e].y fr-ont ef the cjar"age door,, The wooden covering considers of 2x6 J. nd-i dec'king under'lain with a c:ontinueus sheet ef p].ywood,, The dec:: !¢: :[ O_~ ]:t J.~ v opirui, on d"at tine clang~,~)r ef col-,'~_:aminat:[oe o¥ this ~,~'el! by sur-f.ace irr¢iltr.~¢.tiorl '[:brough the ¢:4~n:i. tary seal :i.:4~ r-emotca. Te ~'~, l.::L'~e~,,,g, edge I have assembled all of f. he in'FoL'"mation requested on I.-IAA al:]plic:atior~ and Checl.::].ist~ I am subm:['[.ting this data to you for" your Please contact n~e if I can provide ar"y additional ir'tfoF'mat, ion,, (ph .'Si n c er"el y, Attac:hments HAA App ]. :i. cat :i. HAA Checkl J. st No '4eli. log available 8 7 2 ]. 5-~,~ NORTHERN TESTING LABORATORIES, INC. 2505 FAIRBANKS ST. ANCHORAGE, ALASKA 99E03 907-277-8378 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY CLIENT [] P"RLICWATERSYS~'EM'.".~I I I I I II /~' PRIVATE WATER SYSTEM 2 3 4 5 Mailing Address ,~.~ City State Zip Code SAMPLE DATE: ~, Z~' ~7 Phone MO. Day Year Purchase Order No. SAMPLE TYPE: ~('~outine [] Special Purpose [] Check Sample (for original contaminated sample with lab reference no.. Sample Time No. Locstion Collected [] Treated Water ~Untreated Water ) Collected by ~ory Ref. No. 6 7 8 10 Signature of Representative J~/'//~ FOR LABORATORY USE ONLY TO BE COMPLETED BY LABORATORY Received at: ~Anch. [] Fbks, Date Received7-'--~/~,~ ~ l ~~ Time Received /L///'0 Next Sample Due COMMENTS: SATISFACTORY ~ UNSATISFACTORY U RESAMPLE R OTHER BACTERIA OB TOO NUMEROUS TNTC TO COUNT Direct Verh'ication Final Count LSB BGB Result* *~~olif0rm Colonies per Reported by~ [53a 100 mis. Time & LABORATORIES ~¢~' ALASKA, INC. CHEMICALT TS, L. EPh'eNEG~'-~"~-OGICAL(9o7> 562-2343 ANCHOR^GS INOUSTR.^L CENTSR ~ ~ 5633 B Street r~.~ Drinking V~ter Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER WATER SYSTEM: ; I.D. NO, Water System Name · Mai~ing AddreSs State City MO. Day Year Phone No. Zip Code SAMPLE TYPE: [] Routine [] Check Sample (for routine sample with lab ref, no. r ~ [] Special Purpose SAMPLE NO. LOCATION [ [] Treated Water [] Untreated Water Time Collected Collected By 06-)220 (b) Rev, 1978 READ INSTRUCTIONS BEFORE COLLECTING SAMPLE TQ~BE COMPLETED BY LABORATORY Analvs~s snows this Water SAMPLE to be: ~"~atisfactory [] Unsatisfactory [] Samole tOO lOng mtrans~t; samDleshould '-r~ot De over 48 hours old at examination to ind cate rehable resutrs. Please send new samole. D;~e Received Time Received A~lytical Method: [] Fermentation Tube ~ Membrane Filter I Result* Analyst BACTER IO LOG ICAL WATER ANALYSIS RECORD BGB ~UNICIPALI~ OF ANCHORAQE ~UNIOIPALITY OF ANgHOBAgE DEPT, OF HEALTH D~PA~T~NT OF H~ALTH ~ ~NVI~ON~ENTAL P~OTEOTIoN~NVIRONMENTAL PROTE~ON 825 L Street- A.chorage, Alaska 99501 ENVIRONMENTAL SANITATION DIVISION ~EOUEST FO~ APPROVAL OF INDIVIDUAL ~ATE~ AND SE~E~ FA01LITIES PROPE TYOWNER PHONE MAILING ADD~ESS PROPERTY RESIDENT {If different from above) PHONE 3, LENDIN INSTITUTION PHONE MAILING ADDRESS 4. REALTOR/AGENT [ PHONE MAILING ADDRESS STREET LOCATION 6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS [] One ~ Four ~ SINGLE FAMILY [] Two [] Five [] MULTIPLE FAMILY [] Three [] Six [] Other WAT SUPPLY 7. ~ INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY 8. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON-SITE** '~ PUBLIC UTILITY * ATTACH WELL LOG. A well log is required for all wells drilled sinde June 1975. For wells drilled prior to that date, give well depth (at~ach log if ay;liable.) .~/~ Z .YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY ' 1. TYPE OF RESIDENCE SINGLE FAMILY [] MULTIPLE FAMILY 2. WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM E~]INDIVI DUAL/ON -SITE []PUBLIC UTILITY Connection Verified []Septic Tank or [] Holding Tank Size: If Tank is homemade give dimensions: NUMBER OF BEDROOMS E~] ONE [] THREE [] FIVE [] TWO [] FOUR [] SIX PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATEINSTALLED INSTALLER SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Absorption Area to nearest Lot Line OTHER Nearest Lot Line 5. COMMENTS DATE [~ APPROVED FOR L~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED 72-010 (Rev, 6/79) C.?EM. ICAL & Glo. LOGICAL LABORATORIES ~' ALASKA, INC.~ " TELEPHONE (907)-279-4014 ANCHORAGE INDUSTRIAL CENTER ~ 274-3364 6633 B Street Drinking Water Analysis Report for Total ColifOrm Bacteria TO BE COMPLETED BY WATER SUPPLIER WATER SYSTEM: Water S~stem Name I.D. NO. Phone No. Mailing Address CiW State -Zip Qede Mo. Day Year SAMPLE TYPE: [] Routine [] Check Sample (for routine sample with lab ref. no. [] Special Purpose [] Treated Water [] Untreated Water SAMPLE NO, t I I § I LOCATION ..... : ,,. /. 4 i Time Collected Collected By TO:BE COMPLETED BY LABORATORY Analyms shows this Water SAMPLE to be: r~- Satisfactory [] Uhsatisfactorv [] Samme too long in transit; sample should not be over 48 hours old at examination to indicate reliable results. Please sene new sample. Date Received Time Received Analytical Method: [] Fermentation Tube [~-Membrane F tar Lab Ref. No. Result* Analyst I J 06-1220 (b) Rev. 1978 BACTERIOLOGICAL WATER ANALYSIS RECORD READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Date Collected S~urce Date ReCelVe¢ Time Received 13,m. L.ab. 24 Hours 48 Hours Confirmatory Final Membrane Filter Results ~ , E':,.') ,''