HomeMy WebLinkAboutZODIAK MANOR ALASKA BLK 5 LT 4
Certified Well·
Depth of well .........[[~.O....E~,,.e.t ................................................... ..................................
Sizo of ' . ................................................. [ ...................... j ............. ~: ............
of ................. 1.LQO........f[:.; .......... gallons per hour.
Description of Formation'. -' frozn to
2a~ ;~ Gravel -'B~in-.' Med. 0
O, lay: 9and;~ Gravel ' Bm." Med. 15 25
Sand & G~avel ' G~ey Hard 25
C]_av, Sand&Gravel .'BlueGre~ So:'t 75 90
Sand & Gravel ' .. ' -:Gre.~ Hard 90 95
Clav~Sand&G~avel G~e~ Sof~ 95 105
Clav~San_d&Oravel' ~ B~.Soft 105 i15
C].~$and&G~avel~ BluaG~ey-Sof~ 115 125
Sand % Gravel ,~ .HaF~ 125 129
Wate~ Sand & Graval , ~'~' 129
I certify the abo{e true and correct.
Driller
FOSS DRILLING
1338 INGRA. PH. 279-2849
.ANCHORAGI~, ALASKA. 99501
We advise you to attach this certificate to your deed.
C
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL ~2'~- tfL...~ ,/-~ L/
OF ON-SITE SEWER AND WATER FACILITY
264-4720
GI-'NERAL INFORMATION
(a)
Application Date
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name _l,o~t~-.~nl,,. IPc/~'(f¢~' Telephone: Home -~/'~' ~..5- '~ Business
ApplicantAddress ,95'YI plu. l~ Pr*l',~¢. _) Anc/io,"~7~., .4-~ 9¢/..¢1
(c) Applicant is (check one): Lending Institution []; Owner/builder []; Buyer []; Other [] (explain);
(d) Lending Institution ~"~"(~ I"fO£~'~'~/~. Telephone ,.¢~,~ -07d~O
Address l..(0.5- M../. ;~ ¢'h /~/¢E/ ~.nc/?o¢-~'~/~ .' /~ ~¢~
(e) Real Estate Company and Agent N,~. - ~'~
Address
Telephone
(f)
Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family [] Multi-Family []
Number of Bedrooms ~
Other
WATER SUPPLY
Individual Well [] Community [] Public Fl
Note: If community well system, must have written confirmation from the State Department of Environmental 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 I of 2 72025[11,84)
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
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 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.
NameofFirm r=(.cl/",Lc'f ']"-~c/~.,li¢c¢( 5~.¢'u'(c,~f Telephone
Address 1ff ,~ 3 ~ (~ c ~o ~ ~' ~ v
Engineer's Seal
Approved for ,~ bedrooms by _
Approved Y~ Disapproved
Terms of Conditional Approval
Conditional
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
72 025 (11/84)
.~C~(~9\"~\5'~MUNIC!I3ALITY OF ANCHORAGE (MOA)
.:,t. ,~,~q HEALTH AUTHORITY APPROVAL (HAA)
,..x~Y"~.~c''''J ~,,q,,~ CHECKLIST. FEBRUARY 1984
~ r,~~ ~. 264-4720
Well Classification ~)~ I ~ ['~- If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) ~ Date Completed ~ / I~ [ 7 3 Yield
Total Depth ( ;30 ~ Cased to __ I ~ 0 ~
Static Water Level I I O'
Casing Height Above Ground ~..~
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
Depth of Grouting /V./L _
Pump Set At _/~ 115-~
Sanitary Seal on Casing (Y/N) Y
Depression Around Wellhead (Y/N)
To Septic/Holding Tank on Lot ~I,A. ( F~4 bl,,~ 5e~e~'); On Adjoining Lots /V,/¢.
To Nearest Edge of Absorption Field on Lot _ N~A. ; On Adjoining Lots /~0 .4.
To Nearest Public Sewer Line fid I To Nearest Public Sewer
Cleanout/Manhole ~ ( ~ To Nearest Sewer Service Line on Lot
Water Sample Collected by '~ ~ ; Date _ ,~/d I'~ ~
WaterSampleTestResults ~e~ A"~/~l~ ~ ~'t~- /l~ Co/t~' ~
Comments ~g(( .-~e~ e~ ~ ~e~.U er* Nta~a(e K~o~ ~¢~nc~
SEPTIC/HOL. DING TANK DATA ~,~, ( P~bf~ ~a~e,*) ,~$J~11¢~ 0c~6e¢5
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, 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
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 (it present)
D. LIFT STATION N/~.
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 have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~fl~.,,'~.~-¢,~'~- ¢ ¢?/.¢4.,~_ Date
Company ~(¢~/'~'¢¢ '~¢d~ ~¢~ MOA No,
ReceiptNo. /~0/ 0 ~ ~
Date of Payment ~//2/~
Amount: $ /~/~ ~
Page 2 of 2
72-026 (11/84)
Engineer's Seal
NORTHERN TESTING LABORATORIES, INC,
600 UNIVERSITY PLAZA WEST, SUITE A FAIRBANKS, ALASKA 99709 907-479-3115
6957 OLD SEWARD HIGHWAY, SUITE 101 ANCHORAGE, ALASKA 99518 907-340-8623
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY CLIENT
[] PRIVAT[" WATER SYSTEM
NAME
CiW State
Zip Coda
SAMPLE DATE: ~' ~" ~'7 Phone
Mo, eay Year
Purchase Order No.
SAMPLE TYPE:
[~ Routine
[] Special Purpose
[] Check Sample (for original contaminated
sample with lab reference no.
[] Treated Water
[~ Untreated Water
Sample TIr~e
No, Location Collected Collected
L b~rato~ Ref, No.
3
4
6
8
9
10
Signature of Representative
FOR LABOFIATORY USE ONLY
CAStl ClIARGE PREPAIO TRANSMIT(AL SPECPAL INS~R[JCT[ON$MAIL
HOLO FOR
TO BE[ COMPLETED BY LABORATORY
Received at: ~/Anch. [] Fbks.
Date Received
Time Received
Next Sample Due
COMMENTS:
SATISFACTORY ~
UNSATISFACTORY U
RESAMPLE R
OTHER BACTERIA
TOO NUMEROUS TNTC
TO COUNT
Direct Veri[icetion Final
LSB BGB Result*
*l~,~,T. otal Coliform Colonies per 100 mis.
Date
0 ~ Oo
Time
-- -O 'rI ERN TESTING LABORATORIES, INC,
FNRBANKS, ALASKA 99709
ANCHORAGE, ALASKA 99518
800 UNIVERSITY pLAZA WEST, SUITE A
6957 OLD REWARD HIGHWAY, SUITE 101
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE cOMPLETED BY CLIENT
PRIVATE WATER SYSTEM
907-479-3115
907-349-8623
NAME
CiW State
Zip Code
SAMPLE DATE: ~ ii
Mo. Day
Phone ~ ~/,~- - 1 3,5'.5-
Purchase Order No.
SAMPLE TYPE:
[] Routine
[] Special Purpose
[~ Check Sample (for original contaminated
sample with lab reference no. ??~-~'~/
[] Treated Water
[] Untreated Water
rator¥ Ref. No,
8
9
10
Signature of Representative
CASH
FOR LABORATORY USE ONLY
Received at: ,,~Anch. [] Fbks,
Date Received <'~'////~ ,~
Time Received /~-'~ ~-~'~ (~
Next Sample Due
COMMEN'rS:
SATISFACTORY :~)
UNSATISFACTORY U
RESAMPLE R
OTHER BACTERIA OB
TOO NUMEROUS TNTC
TO COUNT
Direct Verification Final
Count LSB Bee Result~
*No. of q;ot~l Coliform
Time
Colonies per 100 mis.
'~ -- ~'ATE"R EC ElY E D
INSPECTION APPOINTMENTS
TiME
TIME TIME
DATE DATE DAT
MUNICIPALITY OF ANCHORAGE ENV RONM, ,ql,tL . ,,~;fECNON
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825LStreat-Anchorage, Alaska 99501 AUIj ? 980
ENVIRONMENTAL SANITATION DIVISION
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTION~: Completo all parts on page 1. Incomplete requests will not be processed, Please allow ten (10) days for processing.
1, PROPERTY OWNER /PHONE
MAILING ADDRESS
PROPERTY RESIDENT (If different from above)~ PHONE
2, BUYER ~ PHONE
3. LENDING ~STITUT,ON
I
LEGAL DESCRIPTION
6, TYPE OF RESIDENCE NUMBER OF,B
~ One ~ Four [~ Other
~INGLE FAMILY ~ Two E] Five
~ MULTIPLE FAMILY ~ee ~ Six
7. WAT E' I~_S UI~.EY
~ INDIVIDUAL' ' ATTACH WELL LOG. A well log is reauired for all wells drilled
[~] COMMUNITY s nce June 1975, For wells drilled prior to that date, give well
[] PUBLIC UTI LI'FY deDth (attach log f available.)
8. SEWAGE DISPOSAL SYSTEM
~ INDIVIDUAL/ON-SITE*~ YEAR ON-SITE SYSTE!M WAS INSTALLED,
~ P~UBLIC UTI LI'FY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST tJEFORE PROCESSING CAN BE INITIATED,
THIS SIDE FOR OFFICIAL USE ONLY '-
1. TYPE OF RESIDENCE
[] SINGLE FAMILY
[] MULTIPLE FAMILY
2, WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTI LITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
[~]IN DIVIDUAL/ON -SITE
[]PUBLIC UTILITY
Connection Verified
[]Septic Tank or [] Holding Tank
Size: If Tank is homemade
give dimensions:
NUMBEROFBEDROOMS
[] 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
Septic/Holding Tank
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
[] OTHER
Absorption Area Sewer Line Nearest Lot Line
5. COMMENTS
DATE
[] DISAPPROVED
(Rev, 6/79)
· CHEMICAL & GL_,~OGICAL LABORATORIES ALASKA, INC.
'
A TELEPHONE (907)-279,4014 ANCHORAGE INDUSTRIAL CENTER
274*3364 5633 B Street
/,,'"~ Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
WATER SYSTEM: f-T--l--"F--rq~
I.D. NO.
Water System Name Phone No.
Mailing Address
City State Zip Code
SAMPLE ~AT,:: F~I ~ [~
Mo, Oay Year
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref, no, )
[] Special Purpose
[] Treated Water
[] Untreated Water
SAMPLE
NO.
I
L
I
Time Collected
LOCATION Collected By
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
[] Satisfactory
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 48 hours old at examination
to indicate reliable results. Please send
new sample.
Date Received
Time Fleceived
Analytical Method:
[] Fermentation Tube
E~' Mernbrane Filter
Lab Ref. No. Result* Analyst
LJ I~
LJ F-i'3
READ NSTRUCTIONS
BEFORE
COLLECTING SAMPLE
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Collected __ Source
Lab, No,
24 Hours
_._.48 Hours ....
Rel)Orted By Date _
Collforrn/IOeml
CHEMICAL & GE~...~OGICAL LABORATORIES ~ ALASKA, E¥C.
TELEPHONE (907)-279,4014 ANCHORAGE INDUSTRIAL CENTER ~
274-3364 5633 B Street ~ ~
/-,"~.,.."~ Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
WATER SYSTEM:
I.D. NO,
Water System Name Phone No.
SAMPLE DATE
Mo. Day Year
SAMPLE TYPE:
[] Routlna
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
[] Treated Water
[] Untreated Water
SAMPLE
NO.
1
2
3
4
5
LOCATION
Time Collected
Coltected By
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
~ Satisfactory
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 48 hours old at examination
to indicate reliable results. Please send
new sample.
Date Received
Time Received
Analytical Method:
[] Fermentation Tube
~' Membrane Filter
Lab Ref. No, Result* Analyst
L I
L J
06.[220 (b)
Rev. Z978
BACTERIOLOGICAL WATER ANALYSIS RECORD
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
.__48 Houri
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3500 Tudor Road, Anchorage, Alaska 99507 279-8686
Received "--
// ,
Time of Inspection ~,'
Date of Inspectton~ ........
Aoprova] Requested By:
Address:
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
: FOR
'/ 7?, :; .,~ :~ ,~ / /.¢:¢, Phone." :1','/ ,/. /.~./' ,~ }
2. Prooertv Owner: k_ -~ ,, /
3. Legal Description: -:-~/ :/
4, Location: '; '/ /
5. Type of Facility to be Inspected:
Number of gedrooms:
We]] Data:
A. Type .__/~,
C. Construction
7. Sewage Disoosal System:
/
B. Depth__ /
D. Bacterial Analys~s__~j~,_~:~-.-?~!-'/:.~''
,,
A. Instelled~ /.,,,Z ~_~--__ B. Installer
C. Septic Tank: 1, Size -. 2. Manufacturer
D. Seepage Pit: 1. Size 2. Material
Disposal Fie]d: Total Length of Lines
8. Distances:
A, We]]. To: Septic Tank ---- , Absorption Area , Sewer Lines
/~2~ , ~',learest Lot I,tr~/'~ ,
Other
Contamination
B. Foundation to Sept'lc Tank ';, Absorotion Area
C. AbsorPtion Area to Nearest Lot Line .o
Request for Approval af Ih,,ividual Sawer & Water Facilities
Page Two
/
Approval Valid Cot One Year From Dete SiDned
Greater Anchorage A~ea ~orouDh, De~srtment of Environmental Quality
DIAGRAM OF SYSTEM
I certif,,, that the information contained in this request for approval to be a true
and accurate representet~or~ of the subject sawer and water facilities located
Signed
Date
DEP/-q'N[ENT OF HEALTH AND SOCIAL Sr"VlCES ~ ~
DIVISION OF PUBLIC HEALTH:
BACT[RIOLOGICAL WATER ANALVSIS OE ,OE
DATE
REPORT RESULTS TO
NAME
ADDRESS
ZIP
CODE
CITY
~,DDRESS
.OF SOURCE
TIME
COLLECTED
SAMPLECOLLECTEUBY
DATECOLLECTED ' :~
SampleCollecledFrom ;[] KitchenTap
[]Tile, []Fibre
[] Yes [] No
SANITARIAN'S REMARKS
Diameter of Well .Depth_ Feet,
Well Casing :
Material Diameter Depth
Length of Water Depth
Drop Pipe From Bottom= Feet.
ORs0t In in Utility
PUMP LOCATION: [] In Well [] Basement [] In Basement [] Room
On Top [] Other
[] Of Welt
PURPOSE OF EXAMINATION: Illness Suspected? []Yes []No
READ INSTRUCTIONS
06d 220 (b)
Satisfactory []Questionable []Unsatisfactory Sanitary Status·
ON
REVERSE SIDE
BEFORE
Analysie shows this Water SAMPLE to be;
FY Satisfactory [] Questionable [] Unsatisfactory.
If an "Unsatisfactory" or "Questionable" status is i0dicated above
you should take immediate action as recommended be!ow.
____ 1. Notifyconsumerswater[spolluted, Boillorchemical[y
treat this water as outlined in the enclosed leaflet
"Drink It Pure."
Increase chlorination sufficiently to meet recommended residual standaFds,
Determine source of contamination and take action necessary to maintain
Lactose Broth ' 10cc 10cc 10cc 10cc 10cc 1.0cc 0.1cc
24 hours
Brilliant Green , ,
24 hours
48 hours
EMB AGAR
--Lactose Broth, 24 hrs 48 hfs, Greta's stain
-Coliform Density (Most probable No. per 100ce,)
--MF results
-Detergent Test_
This ana[ysis indicates Coliform Organisms to be:
Date ' r ~
am
pm
COLLECTING SAMPLE
AGTERIOLOGICAL WATER ANALYSIS RECORD
a safe water supply at all times,
3, Check chlorination and other mechanical equipment, Make certain it is
. functioning properly.
__ 4. If after checkin0 equipment a disinfecting residual is not ebtainecl, please
wire this office for emergency assistance or advisory services,
__ 5. This is a surface water source and subject to pollution by man and animals.
An approved water supply source should be developed.
6. Improve your []spring (~dug well •driven well []drilled well [] cistern
7. Relocate your well to a safe location in relationship to your sewage disposal
system. [] see enclosure
-- 81 Sample too long in transit; sample should not be eyrir 48 hours old at
examination to indicate reliable results, please send new'sample.
[] Bottle Broken in transit, please send new san]pie.
9/ Contact your ne~arest [] Local Health Department or r~ Alaska
D v s on of Pubhc Health, sanitation office for bulletins, consultation and
assistance.
Lab. No. __
DATE
I)EP! ~MENT OF HEALTH AND SOCIAL Sr 'qCES
DIVISION OF PUBLIC HEALTH
BACTERIOLOGICAL WATER ANALYSIS
PUBLIC [] SEMi-PUBLIC [] INDIVIDUAL [] OTHER
REPORT RESULTS TO.
ADDRESS
CiTY P
ZiP
CODE
ADDRESS
,OFSOURCE
SAMPLE COLLECTED BY
DATE COLLECTED__
Sample Collected From [] Kitchen Tap
[] Other (List)
TIME COLLECTED~ < '
[] Bathroom Tap [] Basement Tall
Wall Casing
REAr) INSTRUCTIONS
O~N
REVERSE SIDE!
BEFORE
'COLLECTING SAMPLE
4. If after checking equipment a disinfecting res dub s not obtained, please
__ 5, This is a surface water source and subjebt to pollution by man and animals.
6. Improve your []spring []dugweH [-]driven well []drilledwell L~cistern
__ 8, S~mple too long in transit; sample sl~ould not be over 48 hours old at
Division of Public Health, sanitation office for bulletins, consultation and
SAN!TARIAN'S REMARKS
06-1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Received . ,' , ,/ Time Received ~ ~p~n ~-'ab. No,
Lactose Broth 10cc 10cc 10cc 10cc 10cc 1,0c~ O.1 cc
24 hours
48 hours 'J r ' '
Brilliant Green '
48 hours
--Lactose Broth, 24 hrs. 48 hrs. Gram's stain.
-Collform Density ' : ;- (Most probable No. per 100cc.)
-ME results__
This analysis indicates Coliform Organisms to be: Absent~ ,
Present '
am
pm
OFFICE
Records in this office indicate this WATER SUPPLY to be of:
[] Satisfactory [] Questionable [] U~saBsfactory Sanitary Status,
Analysis shows this Water SAMPLE to be:
[] Satisfactory [] Questionable [] Unsatisfactory.
Signature
06-1220 (a) Lab. No,
DATE
DEPf-'"MENT OF HEALTH AND SOCIAl, SF"qCIES
DIVISION I)F PUBLIC HEALTH
BACTERIOLO(ilCAL WATER ANALYSIS
OPFICE
R~cords in th s office indicate this WATER SUPPLY to be of:
PUBLIC [] SEMI-PUBUC [] iNDiVIDUAL [] OTHER_
~EPORT RESULTS TO
NAME
ADDRESS
CITY
ADDRESS
~_OF_ SOURCE
ZIP
CODE ,.
SAMPLE COLLECTED BY_ ; ~ r ~
~ TIME CO LLECTED~--~t Pm
DATE COLLECTED_
Well [] Dug [] Driven [] Drilled E] Bored
SOURCE: F'] Spring []Cistern [~] Other
Dug Well or Cistern Construction: Brick or
READ INSTRUCTIONS
o~
_REVERSE SIDE_
BEFORE
COLLECTING SAMPLE
[] Satisfactory E] Questionable [] Unsatisfactory Sanitary Status,
Analysis shows this Water SAMPLE to be:
[] Satisfactory (,~ ~uestionable ~] Unsatisfactory.
_ 1. Notify consumers water is polluted. 8oil or chemlcally
"Drink It Pure."
Improve your E]spring []dug well []driven well []drilled well [] cistern
;ANITARIAN'S REMARKS
[] No / ,/ /
08-1220 (bi BACTERIOLOGICAL WATER ANALYSIS RFCORD
Date R,ceiYed ,; ' ./'/~/ '?{- '~} -- Time Received C ?pm L~b. No._
Lactose Broth ? 10cc 10cc 10cc 10cc 10cc 1.0cc 0.1 cc
Brilliant Green .....
24 hours ___
48 hours
AGAR _
EMB
--Lactose Broth, 24 h~s. ) 48 hrs.__ Greta's stain __ --
-Reported by ,
This analysis indicates Coliform Organisms to