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HomeMy WebLinkAboutCALKINS LT 1C. aA nci, Sla LDT PARCEL � gVK 050- Z//- zo - np GREi, �"'1 ANCHORAGE AREA BORO(*"''H Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME George Ballentine MAILING ADDRESS BOX 457, Anch.,99510 PHONE LOCATION Crestview! and Bonnie Way LEGAL DESCRIPTION Lot 1, Calkins Sub. SEPTIC TANK: U.L.N 175020 DISTANCE NUMBER OF FROM WELL MANUFACTURER Steel Fab. MATERIAL Steel COMPARTMENTS 1 INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY 1000 GALLONS. SEEPAGE PIT: NUMBER OF PITS 1 . DIAMETER 86' OR WIDTH _18', LENGTH 25'. DEPTH 61 LINING MATERIAL Log CRIB SIZE: DIAMETER8L DEPTH 61 DISTANCE FROM: WELL 100 BUILDING FOUNDATION 15� NEAREST LOT LINE 20� TOTAL EFFECTIVE ABSORPTION A EA (WALL AREA) 516 SQ FT ADDITIONAL ABSORPTION WELL: TYPE Drilled CONSTRUCTION Standard DEPTH DISTANCE FROM: BUILDING NEAREST NEAREST SEPTIC SEEPAGE FOUNDATION 50, LOT LINE 101 SEWER LINE 50, TANK 80' SYSTEM loo CESSPOOL APPROVED DISTANCES: , OTHER SOURCES DISAPPROVED REMARKS INSTALLED BY: Ballentine PIPE MATERIAL: Cast Iron LOT SLOPE: REMARKS: Form No. En -031 I s d 2 V DIAGRAM OF SYSTEM DATE 0111Y 97 3 9n APPROVED r L �^ c O r � V 10 V V 3�— • an 1 / M -qt,4 1S? U 7 DATE 0111Y 97 3 9n APPROVED .... INTER -OFFICE • ' ANDUM j F . GREATER ANCHORAGE AREA BOROUGH FROM: DEPARTMENT: 1Q! /' SUBJECT: �_- a 7SI INITIATED BY:. ' .).... SS _IGfCl�Nd/ DATE OF MEMO:^AD _%Z _DATE ANSWER TO: DEPARTMENT: _��arvN._i�%6 REQUESTED: RECEIVER: -At Edeejv_ _ _ REQUESTED ACTION SCHEDULE MESSAGE: e pr REPLY: FOR INFORMATION ONLY _! -� - PREPARE BACK-UP INFORMATION^� tri FOR IMMEDIATE ACTION C; CALL ME BEFORE YOU ANSWER i FOR YOUR CONSIDERATION C NEED YOUR RECOMMENDATION C: OTHER MESSAGE: e pr REPLY: n pso�,, zo MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL���^ OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date N4/L 76' yyy7 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) 2. TYPE OF RESIDENCE Single -Family Multi -Family ❑ Other Number of Bedrooms 7WIf r� 3. WATER SUPPLY Individual Well Community O Public O Note: If communitywell system• must havewritten confirmation from the State Department of Environmental Conservation attesting to the legality and status. • w 4. SEWAGE DISPOSAL L"Nc7`rL ; SFi4- CcJS�G L:Z7is/LJ Onsite 9 Public af Community ❑ Holding Tank 1 / 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 72.025 (11/84) 4,?7 `1-1 "t AC�i,yS S,l3//ib'�5iciy �'.¢GL.L %Zic%4/L Location (address or directions) 1 r.,!Ajrrt csr C2R5�i�i�w /Jf��vr �t/fi/� �illtrit's1� �'d. (b) (c) Applicant Name wNN Telephone: Home 671.1" `/ Z5',%� Business.277_-746 �Z ��h'rlFr lClr/?:2 -77 Applicant Address jy�� � Applicant is (check one): Lending Institution ❑ ; Owner/builder; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution Address Telephone (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: AAZZje-4,6 L„c 2. TYPE OF RESIDENCE Single -Family Multi -Family ❑ Other Number of Bedrooms 7WIf r� 3. WATER SUPPLY Individual Well Community O Public O Note: If communitywell system• must havewritten confirmation from the State Department of Environmental Conservation attesting to the legality and status. • w 4. SEWAGE DISPOSAL L"Nc7`rL ; SFi4- CcJS�G L:Z7is/LJ Onsite 9 Public af Community ❑ Holding Tank 1 / 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 72.025 (11/84) 5. ENGINEERING FIRM PROVIDiA INSPECTIONS, TESTS, FILE SEARCH, (nA 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 a 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 757477 /MC Telephone Address - PO, 47,y G 7/oZl 9 CeVa6ll4e Ikl Date GONG IT1OOVA L- 6. DHEP APPROVAL /`I .' =Fee 00 ..l,.�........... STEV_—N E. FLCDIV 0•9� O pglne"erfSeal Q ' Approved for 44"^ bedrooms by ekl� 'Q Date -2 —S 0; - Approved Disapproved Conditional Terms of Conditional Approval 45_4.:=~U-4 �" �S ' cc;`t"O' -/ -/&=, �"6 /' � . ss...«r• G P.1"C � TL SdLv C� "C' /.�f-a.i- f-laa..ti �Ti...w s. /Sr :'t0f GwKKttTG.Q '�. �'G SC+Jtti. nai Ml .0 CAUTION •�� va. to.� h'o..r sA4 h1*1 •S 7�w.•lr. K_ 7"Q c1o•.��/y "C' w¢ . 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 (1 IM) MUNICIPAL" OF ANCWOR. =_ MUNICIPALITY OF ANCHORAGE (MOA)' r.WiltONMENTAL SERVICES DIVISION HEALTH AUTHORITY APPROVAL (HAA) MAR 2 U 1987 CHECKLIST FEBRUARY 1984 RECEIVED Legal Description: ��`�AL�c iN 5 5ve IFAG Ls Q r t'� A. WELL DATA Well Classification �2rv� fi,£ If A, B, C. D.E.C. Approved (Y/N) �— Well Log Present (Y/N) _y Date Completed /I ff /7 11 YieldOM- Total Depth I'XT Cased to 2/0 Depth of Grouting IV A, Static Water Level 185-' Pump Set At A / u Casing Height Above Ground 1 Sanitary Seal on Casing (Y/N) Y Electrical Wiring in Conduit (Y/N) Y Depression Around Wellhead (Y/N) Separation Distances from Well: / To Septic/Holding Tank on Lot g� ;On Adjoining Lots To Nearest Edge of Absorption Field on Lot !b0 ; On Adjoining Lots 1 50'Z 26.5 To Nearest Public Sewer Line 3B To Nearest Public Sewer Cleanout/Manhole 6q -f To Nearest Sewer Service Line on Lot y 44 Water Sample Collected by 30/4H -09 -" 4 5 ; Date 3 - `- a-�7 Water Sample Test Results 574%;S FAc-foe,Y Comments W..11 -�w f a,«..1,�/� cry.c.xf,o.. ✓��..•iv i - t wees w..•W..L ! APoc, SM B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes (Y/N) Depression over Tank (Y/N) Size '` No. of Compartments Air -tight Caps (Y/N) Foundation Cleanout (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 Comments Page 1 of 2 72-026(11/84) Date Last Pumped ;for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field _ To Stream, Pond, Lake, or Major Drainage 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 D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) _ 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) — Dimensions Manhole/Access (Y/N) _ "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA •• Check Permitted Bedroom Rating Against HAA Request •• I certify that I hav hecked, verif`ie�%� conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed : 442 `� Date �.aG& 7 Company 54--r–llve MOA No. Receipt No. 001 00/� ®r A`Q�Ct Date of Payment 3' a2 0- p 7 _� cor �'. Engineer's Seat Amount: $ 16 4 .'" �: C.�`' � :! ;, \ a sees* r' �s c� 7 , • STCVLN L. F'LOUIN Page Pa 2of2 • 9 1� n '. azoo.s 0 72-026 (11,84) n, S.R. 1 Box 2570 Chugiak, AK 99567 March 19, 1987 Municipality of Anchorage Department of Health and Environmental Protection 825 L Street Anchorage, AK 99501 RE: Lot 01 Caulkins Subdivison Eagle River, AK This property abuts an existing public sanitary sewer system. The owner of this lot has a standard septic system, however, he plans to connect to the sewer system late this spring. He is therefore, requesting a conditional health authority approval to obtain refiancing of his home. H.A.A. information regarding the well is attached. Sincerely, Steven Flodin C.E. 4209 Enclosures CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. TELEPHONE (907) 562.2343 5633 B Street �z Anchorage, Alaska 99518 lora `Pow pp�ckWWpp "'°" "• Drinking Water Analysis Report fbr Totlal Coliform. Bacteria TO BE COMPLETED BY WATER SUPPLIERII TO BE COMPLETED BY LABORATORY ❑ PUBLIC WATER SYSTEM I.D.N PRIVATE WATER SYSTEM �'o h h 3� r� -�' �s 9 rasa Name / Phone No. n 92 j �` WA r ii Ofr,, rA /C l' . Mailing Adoress /� 7`� L p City L...' � /� j vc r i�/l Stale l Zip 7Code SAMPLE DATE: ETM I` —�--t� Mil l / I Mo. Day Year SAMPLE TYPE: ❑ Routine ❑ Check Sample (for routine sample with lab rel. no. ) ❑ Treated Water ❑ Special Purpose ,}< Untreated Water SAMPLE Time Collected NO. I LOCATION Collected By An 2 l 3 4 1 1 51 1 READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Analysis shows this Water SAMPLE to be. 14 Satisfactory ❑ 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 delivery mail. Date Received 3 — y'SN7 Time Received 1001 Analytical Method: Membrane Filter No. of colonies/100 ml. Lab Ref. No. Result' Analyst G U m LUJ CD U m l l m BACTERIOLOGICAL WATER ANALYSIS RECORD Membrane Filter. Direct Count Verification: LTB B Coilforml100m1 Final Membrane Filt R ulls Coilform1100ml Reported By Date O ZAS f/e7 Time: ��� a.m. p.m. TNTC = Too Numberous To Count OB = Other Bacteria M -W DRILLING, Ina n P. O. Boz 4-1728 • 2811 Dawson A C 907-279-1741 ANCHORAGE, ALASKA 99509 DRILLING LOG TO Well OwneV-11 7:-_ P Use of Well n•,.. Location (address of: Township, Range, Section, if known; or distance main road 11! R11r 7. N19 -4"o 1014! T, a!».� Ai ai Size of casing F ' nepth of Hole_=I-feet Cased to feet Static water level 1 Pn ft:' (abUe) (below) land surface.Finish of well (check one) open end (` X - Screen ( ); Perforated .Describe screen or perforation Sone Well pumping test 'at-tTgallons per (1}gyr) (minute) for�ours witla�6ar of drawdown from static level.... i ; :; •' `:•' Date of completion }g e g 712 WELL LOG .. t Depth in feet from -.. . . . - ground surface . Give details of formations penetrated, size of material, color and hardness TO 3t eq lt� - ll' Cr- a is de_} --L1--TO 16 - TO L "G "SIU7 1 =old "Wre , ..:��-:� •tom �, �":`". �T—TO �'1° .. :C;F¢i: 69��• -Mitis eeeaelentl betti•4art - O _ —TO- -TO— Wayne E. L'estber Wayne TO —TO— O .TO —TO- O -TO— TO TO- TO 3 3 — Contractor b O 6 6 BILL SHEFFIELD, GOVERNOR DEPT. OF ENVIRONMENTAL CONSERVATION Telephone: 1907! Address: ANCHORAGE/WESTERN DISTRICT OFFICE 437 'E' STREET, SUITE 303 ANCHORAGE, ALASKA 99501 274-2533 "NICIPAUTY OF ANCmORAGE October 11, 1985ivi'� ONMEONTA<EPROTECTION MAR 2 Triad Engineering DECEIVED 6937 Old Seward Highway Anchorage, Alaska 99502 ATTN: David A. Grenter, P.E. SUBJECT: Horizontal Separation Waiver between Private Well and Sewer Line, Spruceridge West S/0, Eagle River, Alaska (8521—WA-191) Your letter of October 49 1985 Dear Mr. Grenier: I have reviewed the as—built information on the subject project. I am in.agreement that an.additional casing is not necessary for the private well. The project is hereby approved. Sincerely, S even 'W. Eng, P.E. GADL� ,c� '7119inee: SUE/msm s r� n 0 MIJNICIPAL17y of ANCHORAGE Clpr. CF HEALT g ENVIRONMEpTAI PROJECTION 84-182-D October 4, 1985 MAR RECEIVED Department of Environmental Conservation 437 East Street - Suite 200 Anchorage, Alaska 99501 Attontloli: . Mr. Steve Eng, P.E. District Engineer Subject: Horizontal Separation Waiver Between Private Well and Sower Line, Sprucoridge West Subdivlson, Eagle Rlver,.Alaska 8521 -WA -191 Dear Mr. Eng, On June 27, 1985, a waiver for the above mentioned project was granted based upon the construction requirements set forth In our Juno 19, 1985 letter. An additional item of driving a larger casing around the existing private well casings to a depth of 1 1/2 times the depth of the sewer trench was required. The sanitary sewer line has-been installed and asbuilt drawings have been prepared. The Anchorage Water b Wastewater Utility has inspected the line and will accept.the line for maintenance upon completion of a few minor items. The installation of the casing around the private welis•has not been completed at this time. Discussions with the owner, contractor and review of this requirement has resulted In a request to your office to consider removal of this condition. Driving of a casing around an existing casing would be vary difficult. Tho first problem would be gaining access and permission from`the property owner to accomplish this task. Secondly, prior to driving of the casing, the contractor would l's have to dig down and disconnect the•servlce line from the pltless adaptor and electrical lines to the pump. This would q disturb tha surrounding ground and may create more of a potential problem than the'casing Is trying to prevent. We feel I} that with the approved design and the stops that were taken during the construction of line, the potential of contamination of the wells Is extremely low. u 85-182-0 Pago2 r^1 Attached are copies of the asbullt drawings and along with compaction tests taken In the sewer trench. Shown on the asbullts is an additional private well which was located during construction on Lot 1, Calkin Subdivision to be within the minimum separation distance. Heat shrink wraps around all pipe Joints were installed from the existing manhole to manhole 1 as well as from manhole 1 to manhole 4. Also note that 8" Toes with blind flanges were installed In manholes 2, 3 & 4 rather than wyos. This was approved and accepted by AWWU. We request that you consider the deletion of the requirement for casing of the wells for the reasons stated above. If we can provide any additlo Information for your review, please call. Sincer y, David A. Grenior, P.E. attachments c I I I,..,..__ ...._._.m__ ... _...........,._.... ............... �_. __.,—....._.»- ------ MUNICIPALITY OF ANCHORAGE Eiw;. P.:.. ,.1,tL :.IC N DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION / 825 L Street - Anchorage, Alaska 99501 EAR 2 ENVIRONMENTAL ENGINEERING DIVISION Telephone 2644720 RECEIVED NUMBER OF BEDROOMS IM SINGLE FAMILY REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will pot be processed. Please allow ten (10) devs for processing. 1. PROPERTY OWNER J"of/,v 'E. .V-;�,WE3* ❑ MULTIPLE FAMILY PHONE 9.2s2 MAILING ADDRESS DO ESSpp `� &y //0 goN,V/E W,43-�, .674CI-AE �11E.e, - A. 9y' ?% PROPERTY RESIDENT (If different from above) ' ATTACH WELL LOG. A well log is required for all wells drilled PHONE Z. BUYER o41//,D SZ4 TTY `%�,e, , ❑ PUBLIC UTILITY 33 7-/7,C 2 - MAILING ADDRESS MAILING 41? © E. 43 S LENDING INSTITUTIONPHONE SC�v,C/TY� /Acif/e "If individual/on-site, give installation date ❑ PUBLIC UTILITY MAILING ADDRESS /O// F. 4. REALTOR/AGENT SUN Rent -rt' 1AIC, PHONE MAILIN ADDRESS. 5. LEGAL DESCRIPTION /� LOT / 1. /t/S STREET LOCATION / eox. , ,v w- GQES T V i EkJ �1 6. TYPE OF RESIDENCE NUMBER OF BEDROOMS IM SINGLE FAMILY ❑ One ❑ Four ❑ Other OZ Two ❑ Five ❑ MULTIPLE FAMILY ❑ Three ❑ Six 7. WATER SUPPLY ® INDIVIDUAL' ' ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) & SEWAGE DISPOSAL SYSTEM ® INDIVIDUAL/ON-SITE" "If individual/on-site, give installation date ❑ PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED /781 �aifl - Ga fAG �S�M AS,, t r- THIS SIDE FOR OFFICIAL USE ONLY INSPECTION APPOINTMENTS DATE RECEIVED TIME TIME TIME DATE DATE DA INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON-SITE 13 PUBLIC UTILITY Connection Verified PERMIT NUMBER DATEINSTALLED INSTALLER ❑Septic Tank or ❑ Holding Tank Size: If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS [S APPROVED FOR _ BEDROOMS ❑ CONPITIONAL APPROVAL (letter must accompany certificate) SAPPROVED DATE BY Title LEGAL DESCRIPTION 72-010 (Rev. 3/78) S&S ENGINEER16.G MECHANICAL ENGINEER MCILMICAL ENGINEERS ;CIVIL ENGINEER ; DAVID SLENKAMP CIVIL ENGINEERS ROBERT A. S11AFEI 694-9055 SRB 196X Eagle River, Alaska 99577 654-2979 MUNICIPALITY OF ANCHORAGE Tr, R j DEPT. G (:j ION, APR l ` April 3; 1979 REG[ jLI v E® REF: Lot 1, Caulkins Subdivision, Eagle River, Alaska. Sun Realty ATTN: Earl Ellis P.O. Box 1201 Eagle River, Alaska 99577 . A sewer system adequacy -test was performed on 31 March and 1 April 1979 for the three bedroom residence located on the referenced property. The septic tank was pumped and verified to have a capacity of 1,000 gallons. The seepage pit was charged with 1;000 gallons of water and in accordance with measurements taken at the end of 24 hours, percula- tion had caused the removal of approximately 1,118 gallons or 373 gallons per bedroom. As a result of the above survey and test, it can be concluded that the sewer system (septic tank and seepage pit) serving the referenced property is -adequate. OB T A. HAF P.E. CF: Mr. John James Box 110 Bonnie Way Eagle River, Alaska Security Pacific Mortgage Company» E OF q� 1011 E. Tudor Road, #190 p �P�.••"'°'"•ti.~ S •+ a 9 •, Anchorage, Alaska /municipality of Anchorage, x Dept of health & Environmental 'rot x ago*,,, �'!' "`•"" " ' r' Ribero A. S It it % Nu. 1457 ,•"4z.,'�' CNEUMAL a GEOLOGICAL LASORMRM OF AL."ICk INC. roo7) si�14 P.O. BOX 4-1276 ANCHORAGE, ALASKA 99509 4649 BUSINESS PARK BLVD. Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY PUBLIC WATER SYSTELABORATORY: I.D. NO. .v' NAME. ., Publk Water *stem Name I` Y9 ADDRESS Mailing Address L� 0 CITY City0 State Zip Code Date Received � �D SAMPLE DATE: C� ®� �®p0 Mo. Day Year Time Received SAMPLE TYPE: Analytical Method: ❑ Routine ❑ Check Sample (for routine sample ❑ Fermentation Tube with lab ref. no. ) ❑ Treated Water Kj Membrane Filter O Special Purpose ❑ Untreated Water SAMPLE Time Collected NO. LOCATION Collected By a.m. L-1 C „� I �-�--�- Time Received 2 Presumptive l Oml 1 oml 1 oml l Oml 1 oml 3 24 Hours 48 Hours 4 Conflrmato!y 24 Hours 5 READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Form No. 18-310 (3.78) 19 Lab Ref. No. Result' Analyst op L I [Q] I i m m �I ---J..M No. of eolonlw 110o ml. er No. of ►will" pori ons. 06.1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD Rev. 1978 Date Collected Source a.m. Date Received Time Received p.m. Lab. No. Presumptive l Oml 1 oml 1 oml l Oml 1 oml 1.0 ml 0.1 ml 24 Hours 48 Hours Conflrmato!y 24 Hours 48 Hours EMB Broth 24 hours: Broth 48 hours: Multiple Tube Report: 10ml Tubes Poslti"/Total 10ml Portions Membrane Filter: Direct Count Collform/100rrml Verification: LTB BGB Final Membrane FII r co orm/looms 1 Reported By Date p.m. Yr vTlt I Yu 0=i:? J9''7 X) OT Ni -10T A'COAJ Y T I J El=i E).miT : b o ri P? 1.1 lr-) i t I Jc�lz,iA *11U009 oLl Agr'l d ---J *'c!"q 0"1-'Oq 10 0.1 1. Am DC f lorv,b:lo OA S I i J R. El T AV,' 42' C "a T S J 7, r","� D C. OT !'4- T P, Y Iii i A OULOO. clqr'1-1;0 griluol 1i1) 0 b^I-;onT cn Aoi d,l ji4i,"f lolf-W b9ii,31inu 7 vaoq'.Uci Islooc"3 Ll y3 bA1J^no0 1401 'AO 3J CN t L 0;1003ri 21?YJA9lA (d) OWL .vatl CVOITOURT-`ill GAAP. 1^11V.2 �W—'1)3jj07 t5" -';;'Ortel 0;1 rrloJ ov, O.S j .,,.c b"' ')1y r. -.IT l,nL.C) If .'.1 2w0" Z-� ril m- 3 211i A 1!':,^,( CVOITOURT-`ill GAAP. 1^11V.2 �W—'1)3jj07 t5" -';;'Ortel 0;1 rrloJ