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HomeMy WebLinkAboutTIMBER RIDGE #1 BLK 3 LT 9Timber Ridge #1 Lot 9 Block 3 #050-321-39 Municipality of Anchorage Page 1 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: SW980464 PID Number: 050-321 -39 Michael & Suzanne Kelley Wastewater System: [] New [] Upgrade Address: ~.0. Box 91091 Anch., AK 99509 ABSORPTION FIELD Phone: [ NO. of Bedrooms: 272-2911 Four ( 4 ) [3 DeepTrench ~] Shallow Trench [] Bed [] Mound [] Other Total Depth from original grade: LEGAL DESCRIPTION Soil Rating: . 6' GPD/Sq. Ft. 6.5 Subdi ~sion: Depth to pipe bottom from cfi inal grade: Gravel depth beneath pipe Lot: 9 Bl°ck:3 Timber Ridge No. I 2. ~ Ft. Ft. Township: I Range: I Section: Fill added above original grade: Gravel length: I I .5 - I Ft. 100 Ft. Number of lines: I Dist~ncelt)e2~een I~n es: WELL: ~Y--New [] Upgrade Gravel width: 5 Ft. 2 Ft. Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material: Private 400 Ft. 240.4~t. 1 ,000:; SO. Ft ASTM D3034 PVC .r...r: %aF~')d~ 9 ;,atic Water Level:Installer: Da~e/~t~ll;d~ 4 / 9 9 M-W Drilling 234 Ft. Bailey' s Backhoe Y,e,d: 1.8 GPM IP"mps''t: Ft. Ic~s."gHei~5^~'eer°~od:Ft. ,TANK SEPARATION DISTANCES x~Septic [] Holding [] S.T.E.P. To Septic Absorption Lift Holding ~bllc/Prlvate Manufacturer: Capacity in gallons: From Tank Fiel~ Station Tartk SewerLines Anchorage Tank I , 250 Well- ~!100 ' > 100 ' N/A N/A ~.25 I Material: Number of Compartments: Steel Two su~ce >100' >100' N/A N/A N/A LIFT STATION - ~/n Water Lot Size in gallons: [ Manufacture~ Line >5~ >10' N/A N/A N/A 1 >5' >10' N/A N/A N/A 'Pump on" level at: [ "Pump of P level at: I High water alarm ~t: Foundation CurtainDrain None [oted ~n Lot >umpMake&Mode[ [ Electdcallnspecti(~nsperformed by: Remarks: 2" Insulation Over Entire BENCH MARK Location and Description: Drainage Trench Area. Concrete Footing For Northernmost Deck Support In Back. [Assumed Eiev~t~)°n': 0 ' Fi, MEA Dates:l st 9/23/99 Inspections performed by: 2nd. 9/24/99 DePartment of Health and Human Services approval ¢~. 4~..41 /~"'%' ' Reviewed and approved by: te:~ 72~313 (Rev. 9/91) MOA 25 Municipality of Anchorage Page 2 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, AK 99519-6650 343-4744 On-Site Wastewater Disposal System or Well Inspection Report Permit Number SW980464 PID No. 050-321-39 Four Bedroom. House PLAN AS, SCALE 1" = 50' Municipality of Anchorage Page 3 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, AK 99519-6650 343-4744 On-Site Wastewater Disposal System or Well Inspection Report Permit .Number SW980464 PID No. 050-321-39 ¢/ I 2'1 7,,,5' I , - ' ' r3 ~ 91 .7 ~ 2" Direct Bury ~nsulation 84.8 76.5 7 50' 2" Direct Bury Insulation ..... ," ~ ........ ~ ...... r ........ :~ z... Drain fie ld Rock ~~1~ 50' 4~7',; PRO.FILE AS-BUILT HORIZONTAL SCALE 1" = 10' NO VERTICAL SCALE Jan-24-O0 10:49A THE THOMAS CO. INC. 694-5202 M-W DRILLING, Inc. ?'" P.O, Box 110378 · 10330 Old Seward H~§hway (907) 34~1-e$35 ANCHORAGE, ALASKA 99511 P.02 DRILLI L'qCI, OwRer ,.MIKE AND/OR SUZANNE KELLY UseofWe]] DOMESTIC Location (address of: Township, Range, Section, if known; or distance main road LOT 9, BLOCK 3, TIMBER RIDGE S/D #1 EAGLE RIVER, ALASKA Size of casinf 6~' Static water level 2 3 4 Scz~en ( ); Depth of Hole 490' leer Casedto 240.48 feet . ft. (s~q~ (b~low) land surfaco. Finish of well (check one) Perforated ( ). open end ( X ); De.crlbe screen or l:~erforation · I' NA Well Pumping test at 1 . 8 ga]~on~ /)er ~ (minute) for ] .~ 5 of drawdown from static hvel. Date of eompletion 17. MARC}{ 1999 hours with., 166 ~ft. Depth in feet from ~round surface 0 _TO 2 2 __TO 92 92 ~TO. 108 108 TO. 220 269 ,,TO 326 .TO. 326 .TO 400 TO TO_ TO _ TO. TO WELL LOC) Giv~ detaih of formations penetrated, size of n'~aterlal, color and hardness CASING STICK UP GRAVEL: BROWN, SILTY, COBBLY CLAY: GRAVELLY, SILTY GRAVEL: BROWN, COBBLY, SILTY BEDROCK: SILTSTONE ARGILLiTE AS ABOVE; FRACTURE ZONE, WET ~EDROCK; SILTSTONE ARGILLITE WITH SMALL WATER IN SPORADIC FRACTURES AS ABOVe: DARKER GREY SEAPS Received Time hn.24. I]:02AM ~-cusro~m MUNICIPALITY OF ANCHORAGE Deparfment of Health and Human Services On-Site Services Program 825 L Street, Room 502 P.O. Box 196650, Anchorage, AK 99519~6650 (907) 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM ! WATER SUPPLY PERMIT Initial Date Issued: Dec 10, 1998 Expiration Date: Dec 10, 1999 Permit Number: SW980464 Legal Description: TIMBER RIDGE #1 BLK 3 LT 9 Design Engineer: 0014 Anderson Engineering Owner Name: MICHAEL & SUZANNE KELLEY Owner Address: P.O. BOX 91091 ANCHORAGE , AK 99509- Parcel ID: 050-321-39 Site Address: Lot Size: 89420 SQ. FT. Total Bedrooms: 4 Permit Bedrooms: 4 This permit is for the construction of: [] Disposal Field [] SepticTank [] Holding Tank [] Privy [] Private Well [] Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ). 3. The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling (907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received B.y~ _ ,~ ~--~_.:~ issued By: ~~' Date:/2 - lO- ?6' November 23, 1998 Municipality of Anchorage Department of Heath & Human Services 825 "L" Street Anchorage, AK 99502-0650 Subject: Lot 9, Block 3, Timber Ridge Subdivision No. 1 Septic System Design Impacts to Adjacent Properties Dear Onsite Services Engineer: The owner of Lot 9, Block 3, Timber Ridge Subdivision No. I intends to construct a four bedroom home on the lot. We are therefore requesting a permit to construct a well and septic system to serve the home. The location of the new system and the well are shown on the attached Site Plan. Design information and documentation is also provided for your review. The testholes placed on the property revealed silty sands and gravels which percolated at a rate between 24 and 30 minutes per inch. No groundwater was noted during the testhole excavation nor was any found during the following monitoring period. We have therefore designed the primary and alternate systems to be a 5' wide shallow trench with 4' of gravel beneath the distribution pipe. The trench will be a total of 100' in length with two laterals. A flow splitter valve will be installed to assure equal flow to each trench. The total depth of the trenches will be 6' to 7'. The lot slopes gradually from Canyon View Drive in the area of the proposed systems for nearly 50'. It then drops off at a rate between 10 to 15%. The trenches will be placed across the slope. The slope from east to west in the area of the trenches is between 2% and 5%. The house will be constructed on the knoll just off the road and the septic system below near the southerly midsection of the lot. Lot 9, Block 3, Timber Ridge No. 1 November 23, 1998 Page Two If the system is constructed as designed the following statements apply: The system, if constructed as designed, will have no adverse impact on the wells in the area or those to be constructed in the future. The system, if constructed as designed, will have no adverse impact on existing septic systems in the area or those to be constructed in the future. The system, if constructed as designed, will have no adverse impact on reserved space, either surface or subsurface, on any lots located in the area. The system, if constructed as designed, will have no adverse impact on drainage patterns in the area. The current drainage pattern will be maintained. Sincerely, Michael E. Anderson, P.E. Attachments 58'$0'T 50.00 /8 /4 THIS PROJECT- AREA MAP NOTE: systems in the.area~ 130.35 Well Power Pole ~? 1,250~G~ SepticN Tank Overhead Power Line 20' utility Easement SITE PLAN scALE 1"= 50' LOT 9, BLOCK 3, TIMBER RIDGE NO. I DESIGN FACTORS: SYSTEM REQUIREMENTS: Four Bedroom Home Perc. Rate: 30 Min./Inch Application Rate: .6 GPD/SF 5' Wide Trench System 1,250 Gallon Septic Tank 4' Drainfield Rock 4 Bedrooms X 150 GPD / .6 GPD/SF = 1,000 SF of Absorption Area 1,000 SF/5 LF (Width) X .5 (Red. Factor) = 100 LF Trench Length Therefore: Construct a 5' Wide Absorption Trench System With Two Laterals Each 50' in Length with 4' of Drainfield Rock Beneath the Lateral. Distribution Pipe in Trench Placed at 2' Below Original Ground Surface. Flow Splitter Valve Required at Location Shown. Mound Over Trenches to Provide 3' of Cover or Provide 2" of Direct Bury Insulation. Natural Backfill 6II ~4" PVC (Holes Down) -Drainfield Rock NOTE: TYPICAL WIDE TRENCH SECTION (NO SCALE) Grade Area Over Trench to Drain Away. Minimum 3' of Cover over Septic System. Minimum 10' Separation From Lot Line. Minimum 4' Separation From Groundwater. PERFORMED FOR; LEGA 1 2 ::.':'.'i 8-_. 10- 11 12 13 16 17- 18- 19- 20 COMMENTS Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST Michael & Su'zanne Kelley DESCRIPTION: Lot 9 ~ Block 3, Timber Ridge No. Township, Range, Section: 1 SLOPE roTS PLAN WAS GROUND WATER ENCOUNTERED? , NO PERCOLATION RATE ~ ~ (m,nuteshnch) PERC HOLE DIAMETER PERFORMED BY: A F[~ ~m ] a I '~V~.~,~. ~,~.d~J~RTiF~Y ACCORDANCE WITH ALL STATE AND MUNiCiPAL GUiDELiNES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) WAS PERFORMED IN Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES .825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED ~OR: Michael & Suzanne Kelley LE6A[ DESCRI~ION: Lot 9 r Block 3t Timber Ridge No. 1 DATE PER: Township, Range, Section: SLOPE SITE PLAN 2- 3 4- 10 11 12- 13- 14 15 16 17 18- 19- 20- COMMENTS WAS GROUND WATER ENCOUNTERED? NO IF YES, AT WHAT DEPTH? ~ 0rr-o ~4 O ~ Hone n..~l~ 11/23/9~ i I i PERCOLATION RATE ~ tm,nutes/mcn) PERC HOLE DIAMETER TEST RUN 8ETWEEN ~" FT AND ~ FT ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION AND MATERIAL SPECIFICATIONS SUBJECT: LOT 9, BLOCK 3, TIMBER RIDGE SUBDIVISION NO. 1 GENERAL: The scope of this project includes the construction of 2 new 50' long X 5' wide X 4' effective depth absorption trenches at the location shown on the site plan. A flow splitter valve will be required to assure equal flow to each trench. The project also includes the procurement and placement of a new 1,250 gallon septic tank. Total depth of the trenches shall be 6' beneath the existing ground surface. Mounding will be required over the trenches to provide a minimum of 3' of protective cover. Construction shall be in accordance with the approved site plan, design drawings, Municipal Permit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. The Contractor shall be responsible for obtaining all underground utility locates and for the layout of the septic system and verification of the location of all lot lines. Unless specifically agreed otherwise, the contractor shall be responsible for final grading areas subsequently depressed from soil settling. Property owner shall be responsible for revegetation of affected areas unless specifically agreed otherwise. Contractors installing wastewater disposal systems must be certified by the Municipal Department of Health and Human Services for system installations. Owners installing their own systems must receive prior approval from D.H.H.S. before beginning system installation. SEPTIC TANK INSTALLATION A new 1,250 gallon septic tank must be procured from an approved source and installed at the location shown on the Site Plan. Lot 9, Block 3, Timber Ridge No. 1 November 23, 1998 Page Two A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. 3. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. 4. All standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 5. Tanks installed without 4' of cover shall have a minimum of 2" of direct burial insulation. A foundation cleanout shall be installed one to four feet from the building foundation. Two cleanouts are required between the tank and the drainfield. 7. Final grading over the tank shall be such that a positive slope exists away from the septic tank. DRAINFIELD CONSTRUCTION: The drainfield shall be constructed to the dimensions shown on the design. The bottom of the trench shall be within 2" of level. Distribution piping must be placed level with perforations down atop a level bed of drainfield rock. Rock should then be placed over the pipe to provide a minimum of 2" of cover. 3. A silt barrier or geotextile fabric must be placed between the drainfield rock and the natural soil backfill. Monitor tubes must be 4" in diameter and installed at the locations shown on the design. The portion below ground must be perforated. Lot 9, Block 3, Timber Ridge No. 1 November 23, 1998 Page Three Contractor shall verify the septic tank and drainfield are a minimum 100' away from any private water wells in the area, 150' from a Class "C" Well or 200' from any community well. Direct bury insulation must be placed over the distribution system if less than 3' of backfill depth is available. Finish grade over the trench must be mounded to prevent settlement or depressions. 7. Grade area surrounding the absorption trenches to drain away. A minimum 2' of accepting soil is required below the drainfield rock for a 5' wide trench. Contractor shall verify this condition prior to placement of the rock. All pockets of unacceptable materials must be removed and replaced. MATERIAL SPECIFICATIONS: 1. Septic tanks must be constructed by a Municipally approved septic tank manufacturer. 2. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Cast Iron (perforated and solid), ASTM D3034 or P.V.C. (perforated and solid), ASTM F810 or H.D.P.E. (perforated, but not solid) and ASTM D2662 or A.B.S. (perforated and solid). 3. Insuiation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Co. Styrofoam HI or equal). 4. Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). Lot 9, Block 3, Timber Ridge No. 1 November 23, 1998 Page Four 5. A permeable geotextile fabric (Typar, Mirafi or equal) must be installed between the final drain rock layer and the native soil layer. 6. All drain rock shall be .5" to 2.5" in diameter with less than 3% passing the #200 sieve. INSPECTIONS: A minimum of two inspections are required by Municipal Ordinance. These inspections must be conducted under the supervision of a professional engineer registered in the State of Alaska. The first inspection must be conducted after the excavation of trenches, beds or pits and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled. The second inspection must be conducted after the placement of the geotextile fabric, gravel, distribution piping, standpipes, cleanouts and insulation. No backfill should be in place at the time of inspection. Contractor shall provide a copy of all field survey layout and construction notes for use in preparing the certified as-built of the completed system. 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 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Lot 9, Block 3r Timber Ridge No. 1 Location (site address or directions) Canyon View Drive & Golden Ea~le Drive Property owner Michael & Suzanne Kelley Day phone 272-291 1 Mailing address P.O. Box 91091 Anchorage, AK 99509 . Lending agency Mailin. g address Day phone ' Day phone Agent Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: Four (4) TYPE OF WATER SUPPLY: Individual well XXX 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 XXX Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. l/91) Front MOA#21 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 Anderson Engineering Phone 522-7773 Address P.O. Box 240773 Anchorage, AK 99524 Engineeffssignature ~ ~'~¢'~'"'""~ Date 1./PR/f~(~ DHHS SIGNATURE Approved for /_gL. Disapproved. Conditional approval for bedrooms. 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 pu rchssers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DH HS do not conduct inspe~:tions or analyze data before s certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Legal Description: Lot A.' WELL DATA Well type Private Log present (Y/N) Total depth 400 ' Sanitary seal (Y/N) Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform 0 Date o[ sample: 1/25/00 B. SEPTIC/HOLDING TANK DATA Date installed 9/23/99 Foundation cteanout (Y/N) Date of Pumping New C. ABSORPTION FIELD DATA Date installed 9 / 24 / 99 Length 100 ' Width Health Authority Approval Checklist 9, Block 3, Timber Ridge PamelI.D.: Number 1 050-321-39 if A, B, or C, attach ADEC letter. ADEC water system number Y Date completed 3 / 1 7 / 99 Cased to 240 o 48 ' Y FROM WELL LOG 3/17/99 234' 1.8 g.p.m. Casing height (above ground) Wires properly protected (Y/N) AT INSPECTION >2' Y g.p.m. Nitrate Y-~ ~ 6/ ~//_ Other bacteria 0 Colle~edby: MEA Tank size 1 , 250 Number of Compartments 2 Cleanouts (Y/N)__ Y Depression (Y/N) N High water alarm (Y/N) N Pumper Construction Y Soil rating (g.p.d./fF orfF/bdrm) .6 System type 5 ' Wide Trench 5 ' Gravel thickness below pipe 4 ' Total depth 8 ' Effective absorption area 1 , 000 SFMonitoringTube present (Y/N) Y Date of adequacy test New Cons t o Results (Pass/Fail) Fluid depth in absorption field before test (in.); Fluid depth (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) 72-026 (Rev. 3/96)* N Immediately after Absorption rate -- If yes, give date Depression overfield (y/N) N For .bedrooms gal. water added (in.): g.p.d. D. LIFT STATION - None on Lot Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at* "Pump off" level at* High water alarm level at* *Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot > 100 ' >100' Absorption field on 1ct Public sewer main N/A Sewer/septic service line > 2 5 ' On adjacent lots > 100 ' On adjacent lots > 100 ' Public sewer manhole/cleanout N / A Lift station N/A >5' Wells on adjacent lots SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation > 5 ' Property line > 5 ' Absorption field Water main/service line > 1 0 ' Surface water/drainage >_kl/l.0 ' >100' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line __ > 10 ' Surface water > 100 ' Curtain drain N~na Building foundation > 10 ' Water main/service tine > 1 ~) Driveway, parldng/vehicle storage area ~ 5 (] ' ,~n T.~- Wells on ar]jacent lots ~ 1 00 ' F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal r in conformance with MOA HAA guidelin/e,~ in effect on this date. Signature ~ ~ ~ Engineer's Name Mi mhm~l R. At~r]~'-~nn, Date 1 /28/00 Date of Payment Receipt Number Waiver Fee $ Data of Payment Receipt Number 72-026 (Rev. 3/96)* Laboratory Analysis Report CT&£ RtL# Client Nume Projec! Client Sample Ordered By PWS~ S. amplc Rcmerks 1000310001 Anderson Engi~c~ffng Lot 9 ~lock.3 Tm~bet Rid§~ Lot 9 Block 3 Timber Kidge Drinking Water Clien! PO# Printed Datefl'imc 02/01/2000 8:$g Collected Date/Time 01f25/2000 13:B0 Rccelved DatefTime 01/25/2000 15:35 Technical Director S~ephen C. £dc Released By~ iii .0 01/25/00 It~p Received Time Feb. 9:0gAB O~-Ol-O0 08:04 FROB-CTE ENViRO~NTAL 5615301 T-5~6 P,0z/oZ ~-IU~ CT&E Environmental Services Inc. Drinking Water Analysis Report'for Total Colifomx Bacteria ^,cho~,so. ^~ eas, a.~eos Tel: (~7) 562-23~3 ~ ~$TRUCTION$ ON ~E~E $IDE ~EFO~ COLLEClING SAMP~ lax [~71651-5~1 MuST BE COMPLET~ ~Y WAlK 9UPPLIER TO BE COMPL~ l ~u BY L&BO~TORY PUBLIC WATER SYS.TEM LD. ~ PRAVAT£ WATER SYSTEM SAMPLE DA'I'E: SAMPLE TYPE: Q Reptaz Sample (fur ruutl~e ~amplo · wi~h lab re~ ~o. ) Q Speci~ Pu~ose Year · SAMPLE LOCATION · . ---?~</, ,,.','~ ~.¢~'~ = Treate~ Water ysls shows This Warm' SAMPLE to be: Surfs fa~or/ Unsafisf~ S~le ovm 30 hou~ ~ld, S~]c ~ I~g m ~m; ~le should nor ~ OV~ A,~aiyti~d Met~ ~mlm~e filtrr ~a MMO-MUG Rcs~Jt' 1000310 .n [~k~ Jun Dam: ....... 12 D~: Com~en~; BACTIiRIOLOGICAL WATER ANALYSIS RECORD F. Col{ ~ Coloal~','l 0~ mi -- 'BOB COLIFIRM. Colffor1~/lO0 fnJ Receive4 Ti~e Feb. I. 9:O~Ag