HomeMy WebLinkAboutWTR2701039 'PR-EL HOMES ANACORTES AVE NE W-1039
I m ----
BEGINNING
OF FILE
FILE TITLE W T)K�
`nl- 1039
COST DATA AND INVENTORY
SUBJECT: POUIEU. 3UILDta5 , lac. CITY PROJECT NUMBERS: W-_
SHoM. QtAr No. k.1,5 S-
NAME 0-- FARO-3EC
10: CITY OF RENTON FROM: 'Pr-It
UTILITIES DIVISION
200 MILL AVE. SO. ;9'XS-aP2. Y1^AosxINr- �'uwL.+ 7Q.
RENTON WA 98055
��QSi�11Oin!FS LJMa 'ItNc1P
DATE:
Per your request, the following information is furnished concerning costs for improve-
ments installed for the above referenced project.
i
WATER SYSTEM:
Length Size Type
L.F. OF _ WATERMAIN
L.F. OF WATERMAIN
L.F. OF " WATERMAIN
L.F. OF " WATERMAIN
_ EACH OF GATE VALVES
EACH OF GATE VALVES
EACH OF " GATE VALVES
SUBTOTAL $
EACH OF 5'/4 IOWA FIRE HYDRANT ASSEMBLIES S 3 2� 700. oD
(COST OF FIRE HYDRANTS MUST BE LISTED SEPARATELY).
TOTAL COST FOR WATER SYSTEM S
SANITARY SEWER SYSTEM:
Length Size Type
L.F. OF SEWER MAIN
L.F. OF SEWER MAIN
L.F. OF " SEWER MAIN
EACH OF bIAMETER MANHOLES
TOTAL COST FOR SANITARY SEWER SYSTEM f
STORM DRAINAGE SYSTEM:
Length Size Type
L.F. OF STORM LINE
L.F. OF " STORM LINE
L.F. OF " STORM LINE
L.F. OF STORM LINE
TOTAL COST FOR STORM DRAINAGE SYSTEM $
STREET IMPROVEMENTS: (Including Curb, Gutter, Sidewalk) s
"CeT RNMA"iN + NKf Wt* too. 00
TOTAL COST FOR STREET IMPROVEMENTS $ ',900-00
� ', 1vSIVNAIUR E)
(SIGNATORY MUST BE AUTHORIZED AGENT OR
OWNER OF SUBJECT DEVELOPMENT)
PUBLIC WORKS DEPARTMENT
BUILDING DIVISION
CITY OF RENTON, WASHINGTON
J]N�BER
T p. 1369
APPLICATION ONLY — UNTIL VALIDATED
Location of Work
Ownar KWL ICON( t)"'OtRA I INC i01U, 2004 1hn'nu(k IL)Q 5,3 .
Address p $�4
Go 6Ax 1� ��4 S4nr CxWAl DA
lts Mp�wK Ui� 9$198
FEES
INSPECTIONS Side sewer
CONSTRUCTION storm Sewer
PERMIT Right-of-Way Construction r� a
Sp. Uc111[y Conn. Fee - Water
Water Latecomer Fees a
(Public Right-of-Way) Water Insp./Approval Fees
Sp. Utili�y Conn. Fees - Sewer
Sewer Latecomer Fees -
�I Sewer Insp./Approval Fees
Date Issued Inspection Fees
Special D.:posit= - CASH BOND
Expiration Date
TOTAL FEE�YO y 11p0 a Z,9 S�1. oU
Description of work 11 4ON'�VA ML
and Number of Feet -- 'lf 4' — , I�6 f
,,.+,� .pP hl AMR+u1P uc� ipC
ti
Of Iw Mv-+^+ Business 13 3 3
Contractor � AMi g ron4F • ( r Oe I Li Ones
Bond
Address 2 1 G Z 5Ci" hu( Nf Z 4Ad
Tole hone
`lA�enA WA . 13472- x 6
IT IS UNDERSTOOD THAT OR INJU
RY RYCITY
ARIOr PERM
THE PERFO BE HRMANCELD EO SAID WORK LESS OF A' AND ALL
LIABILITY.
MAIN
ST
LICENSED,
WORK PBONDEEC WITHIN ONTRACTOR.E RIGHT-OF-WAY OR ON LOCATE UTILITIES BEFOREREK�AVATINO.BE DONE BY A
LICENSED,
CALL 235-2631 FOR INSPECTION• AFPLICANT
Call between 8 AN and 9 AM for
inspection in afternoon; call
before 12 Noon the day before PUBLIC WORKS DIRECTOR
for inspection in morning.
SPECIFY TIME FOR INSPECTION. '
CALL BEFORE YOU DIG By
CALL 235-2620 for street signs 48-HOUR LOCATORS
and lighting. 1-800-424-5555
PUBLIC WORKS DEPARTMENT
BUILDING DIV' "ION
CITY OF RENTON, WASHINGTON
APPLICATION ONLY - UNTIL VALIDATED PERMIT
Location of Work
Ow" FbIAA I'AHE (jrO AICL
AdAreae PO N ' `.` , 109 1, t::Al A
�: Me�Wf� tll� • �id14d
INSPECTIONS FFES
CONSTRUCTION Side Sewer
Storm Sewer
Right-of-Way Construction
PERMIT Sp. Utility Conn. Fee - Water
Water Latecomer Fees ,
(Public Right-of-Way) Water Insp./Approval Fees
Sp. Utility Conn. Fees - Sewer —
(I Sewer Latecomer Fees
Sewer Inep./Approval Fees
Date Issued Inspection Fees
Special De,.oeifl - CASH BOND
I g 41c) TOTAL FEE.!'',' �
Expiration Uate
Description of Work
and Number of Feet I~ �' �}Ll�.•,it'
%pP ry r•Ofa�..,
ontractall%Wr+r.•—�� ? Business
leY Tfl�af(l License
AdEreu Bond
2101 Air
Telephone
"rn/oHe
IT IS UNDERSTOOD THAT THE CITY OF RENTOr' SHALL BE HELD HARMLESS OF ANY AND ALL
LIABILITY, DAMAGE OR INJURY ARISING FROM THE PERFORMANCE OF SAID WORK.
ANY WORK PERFORMED WITHIN THE RIGHT-OF-WAY OR ON SEWER MAIN MUST BE DONE BY A
LICENSED, BONDED CONTRACTOR. LOCATE UTILITIES BEFORE EXCAVATING.
CALL 235-2631 FOR INSPECTICN.
Call between 8 AM and 9 AM for APPLICANT
inspection in afternoon, call
before 12 Noon the day before
for inspection in morning. PUBLIC WORKS DIRECTOR
SPECIFY TINE FOR INSPECTION.
CALL 235-2620 for street signs CALL BEFORE YOU DIG BY
end lighting. 48-HOUR LOCATORS
I-800-424-5555
REVIEW SHEET
PERMIT PEE AND RATES
PROJECT NAMIE�t 1 C-14,2 L.L. F lyit (l.
sl 1.r \11fIi ILST-AJc Ct-/c..y - z Ly
LOCATION, AWL 2('(%°1 ahlA Tru tJc' A E S ) 1rtc,Lj 1't.)1, t1
1. SANITARY SEWER (EACH CONNECTION) k,,KL
Residential $20.00
Commercial $50.00
Industrial $100.00
$
2. STORM SEWER IEach Connection)
Residential $20.00
Commercial $50.00
Industrial $100.00
3. RIGHT-OF-WAY CONSTRUCTION (Length)
Includes sidewalks, curbs, excavations and improvements
0 - 3: $10.00
361 - 100' $25.00
Over 1001 $50.00
$ w- 00
4. INSPECTION/APPROVAL FEES (2t of costs)
For replacements i improvements in r/w, easements on-site and off-site
Includes, Cost 2% Fee
Sanitary Sewer $ $
Water $ 11 900 . 00 $ 4 B•00
Storm Sewer $ $
S pElr
Street, Walks a Curbs $ $
2% of the first $100,000
141 of that amount over $100,000,
but less than $200,000
1t of any amount over $200,000
The applicant will be required to submit separate cost estimates for
each item of improvement, subject to approval by the Public Works
Department.
5. $1,000 Performance Bond Required Yes
IOU°�• 1u RlU ( t 2, 100) No
6. Contractor required to have current City business Yea
license? other
7. Latecomer Agreement - Water
Latecomer Agreement - Sanitary
Latecomer Agreement - Storm
0. System Development Charge - Water )A(O
System Development Charge - Sanitary
` _. 9. Special Assessment Area Charge - Water ,
Special Assessment Area Charge - Sanitary
10. Approved Water Plan ✓l its (SKftai
Approved Sanitary Plan
DSNS 1tp]IPIBtI
SLATE OF WASNINGTON �
DEPARTMENT OF SOCIAL AND HEALTH SERVICES
WATER BACTERIOLOGICAL ANALYSIS
SAMPLE COLLECTION.READ INSTRUCTIONS ON BACK Of GOLDENROD COPY
It inetrucilonS are not followed,wrople WIN be rejected
DATE COLLECTED TIME COLLECTED COUNTY NAME
MJNIN DAY / YEAR 1 IN`
I Q AM ❑ PM I� "I
TYPE OF SYSTEM IF PUBLIC SYSTEM.COMPLETE.
xtU RLs>
PUBLIC I.D. No. % i g 5 a L , ,
ClINDIVIDUAL
mA�
NAME OF SYSTEM'
C rt7 Of RENto�l
SPECIFIC LOCATION WHERE SAMPLE COt LECTFO SYSRM ONIBRIAYR NAME MIO FLEPIONE W
N.AR�a.I .MIw'•�eii RAT SLro
♦A4(Khril AT
yHAilt,m 0,4s• + s-V,,H ( ) 22K ZC46
SAMPLE GOLLECTED BY:(NO N
SOURCE TYPE
TtL COMBINATION
G SURFACE ❑WELL ❑SPRING O PURCHASED or OTHER
SE?REPORT To JW FUN NEmr,AOamA•na zIo Carol
11 / IILSON tnnit; Cron- DFPt
2 p0- VA II.L A„t �;O -Sr
r.INI(YAl _ WASHINGTON f1 to
o
TYPE OF SAMPLE
ic•..r.wn a..w.�a�N
1. DRINKING WATER ❑ CNIorinAtedlRPNldwl..__Total_Freel
,Wk 1reAtmenl--► ❑ Flllered
❑ Untmzted or OI W__
2. Cl RAW SOURCE WATER
3. NEW CONSTRUCTION 01"IMA1RS
4. 9 OTHER ISW.IIY1 _
COMPLETE IF THIS.AMPLE IS A CHECK SAMPLE
PREVIOUS IAS NO
rNEEV10U5 SAMPLE COLLECTION DATE ___
REMARKS'.
UI-1e•Lf
Wa t 5'�R3 Sl�ntlt nt _
LABORATORY RESULTS FOR LAB USE ONLY)
COUFORM STD PLATE COUNT SAMPBECAU BECAUSETESTED
MPN DILUTION IEST UNSUITABLE ❑ SamPla Ton Old
AW IM 1. ❑ Confluent<]r0M'IH ❑ Not Io ProPar Gomeme�
MF COLIFORM
Q, ❑ TNTC ❑ Provided-PII"m FERVI
lostou tIms on F m
InBlructlons on Fmm
FECAL COUFOR 3, ❑ EFca.F Debris
❑ MPN ❑ ME 4. ❑_ ❑
/100 m
FOR INKING WATER SAMPLES ONLY.THESE RESULTS ARE:
SA-,$FACTORY ❑ UNSATISFACTORY
SE 1 11'-VERSE Slot OF GREEN COPY FOR EXPLANATION OF RESULTS
"a �O OATEN DEIYBD_ RECEIVED BY
DAIERFNWLO LABORATORY
IIEMARNS
WATER SUPPLIER COPY 'P
RCITY OF UTILITIES
ENTON WORK ORDER - DISTRIBUTION DEPARTMENT
N.O
5383
PROJECT NO -AnZ _ DATE SAw 19-10-
PROJECT NAME Pumsa, NAMES
� r
FUNCTION OR DESCRIPTION OF PROJECT- wFT-fR Paahl 5AKPIE Of WEW K`IDUWT
3 wtm uIORK sY cill Ponds
BY CITY FORCES 09 CONTRACT ❑ IF CONTRACT NO.
CONTRACTOR'S NAME LANPafLL. (01E1'f
CONTRACTOR'S ADDRESS 2701- — SO" AVM Nt TAColih, USA 114-U -- j
ESTIMATED COST_--FUNDING SOURCE __ACTUALCOST -_
AGREEMENTS ❑ IF 50, NO._ _ SPECIAL BILLING IF SO,
To PoWE(L NONE Nkiwf>ps bit - 2z52$ HAR'*JE aEs PowEw
aze- zz4
COMPLETED A_/ Q ?) /)
APPROVED BY— y�(� , � 2s'1990
nr wru�wwr
AUTHORIZATION OF SPECIAL BILLING
DATE
PROJECTNAME; tOWILL NOME BUMA(A5
PROJECT NUMBER: W- 01�Z
WORK ORDER NO.: �/ ,5 p'J
It is the intent of this leas* to authorize the City of Renton to bill the undersigned for all costs
incurred relative to the above-referenced project, by the City of Renton for the following work
w�TfQ ��uei{`( Snn9tE fc.ti Nt H� t�rzntiti �=_-
BILLING TO BE SENT TO:
Aaareaa:a�5a8 Iv�we�NE View "7fL
City.Ve!>mo;tiQ s Uj A, `n'l?)
Attn: W6� �vEi�
Phone No-,
er/Developer, contract or
,Authorized Agent
Poo" • "!ME= TEL ho 45?y7 Jan 24.91 15:43 N0 .003 P.01
I OW ELL•Hows
+ •Ilir Give ibu four GMn 60w(7J F.i)xvimaf ,
"M: inMeryIiomf Ilk Budd" i
ou
02
f i � •�MI � -i �iM R':'� h
7
FAx com smur
t ATE'— / s ,
.^/ .PranN; _.`F72a.: / ,•.(r-a, i.ad/e.i.ri
1IESSAGE: .L u1 ae< ( ' A ac<..- yL}.e«
Number of Pages - Including Cover Sheet: G'
Powell Homes Office Number: 824-6224
F'na Number: 824-5797
POWELL' HOMES TEL No .8245797 Jan 24.91 15:48 No .003 P.02"-
PUBLIC WORKS DEPARTMENT
BUILDING DIVISION
CITY OF RENTON. WASHINGTON
APPLICATION ONLY - UNTIL VALIDATED I PERMIT
NLIMBn P- 73FL
of Work
h(Il
_ pb NON! Ou�tD/N6 , INC(Nt . T -- -- ---- ---
Address $1A• 6 1 I ?OIU_ Z ��e n —j�,n-r•i�:k h,I Sq , _
et.
�1s NI�WIc _— Ulf `Idl9a
INSPECTIONS FEES
CONSTRUCTION Side sewer _
Storm Sewer
PERMIT Right-of-Way Conn.
Fee -i ,I U 0
—�_ Sp. Utility Conn. Fee - '.ateF
(Public Right-of-Way) water Latecomer ►eel
water Inap./Approval m
Sp. Utility Conn. Fee, Sewer
Sewer Latecomer rose --
Sewer Inap./Approval tech
Date issued Inspection Fees —
Special Depoosit`- CASH v ND
Exp�on Date TOTAL FEE 2ya rl t�1C 2�150- rill
Uescriptien of Work I
and Number of Feet p4witt I lot 144I)VA%t SIL 61MI
�1, sr Lv �MAawn L�•• ,rP rMl�,nr�Iti
Contractor __. �.'f� F2,rra,,.M•s. Business
f�.1.'..' �, lAlifilm ink • License ( 3� 3
"�" '� I/rf . _-
Address 1. F 1 end (AL�r 1�•�U
2-16s. 15G ��t NI -
- Telephone
1lsfn%4- wn . '1R41L
^- IT IS UNDERST901) THAT THE CITY OF RYNPON SMALL BE HELD HARMU:SS OF ANY AND ALL
LIABILITY. UAMAGk OR INJURY ARISING FROM THE PERFORMANCE OF SAID WORK.
ANY WORK PERFORMED WITHIN THE RIGHT-OF-WAY OR ON SEWER MAIN MUST BE DONE BY A
LICENSED. BONDED CONTRACTOR. LOCATE UTILITIES BEFORE EXCAVATING.
CALL 235-1631 FOR INSPECTION.
Call between 8 AM and 9 AM for APPLICANT li-11-ir C C r�i.r. —i . 2 - 7
inspection in aftern9ont call
before 12 Noon the day before
for inspection in morning. PUBLIC WORKS DIRECTOR
SPkCIFY TINY. FOR INSPECTION. �
CALL 235-2620 for street signs CALL BEFORE YOU DIG BY
and lighting, 40-HOUR LOCATORS
1-800-424-5555
POWELL HONE- TEL No .8245797 ]an 24.91 15:48 No .003 P.03
City of Renton
Customer Services Division
Construction Services Section
INSPECTION NOTICE
Prior to the start of consbucliun activities, telephone:
(206) 277-5570
a ulhllnlunl of 24 hours In novnnce of letwitetl htspecium
Inspection requests lot the IWlowkry workday must be received mu later Illan 3.00 pin
llpno dialing, y,nl will let vIva n recoiled nlessaye asmily lot your alspoctlon Ieiluest. At the tune,relay yuut fiti
inclutllny the IWlowiny hilormallun:
I. Your PERMIT Nwnbei (is r uouo)or,In cases of Cliff projecl,file Project Idemillcatlon. (hlspecllulls will Itul
be scheduled without ploper I"Illthcalluo)
2 Location W,equesle(I Iny>ecllon (Stioal Addtess,Street Ittlelsactlun,etc)
a I ype of Inspection requested (coticiela ealihwoik,diahlaye,sewer,add menUnn,etc.)
4. Name of potsun to contact and day lime plm,le mmuber. -
,. Aply oximtate Ihne of ienue%led hispecllon AM or PM (bun to a vadnble wurklund,Imspecllons cannot bn
scheduled lul speceic hours The only exceptlutl Is hlspeolulls that le(juile Itle scheduling W spcdfll lasllllq
pelst.mei,obselvtny consuhylts,or 011ie,lfnle.resnaWlny Inciuls approved by the Inspeclut In advallco
hlspecllorts well be sehedufvd In ills older received to the limn of available mall huulc
Now llla ONLY exceplionlolho 24 Hour Minimum schedufhiytequlletl,enlf9lncasesol
bunnhdn Emergencies. I,I cases of It me EI lie,yellcles it),Oke,l Ofiltles,it,got 11 haltic c(a lit of pr Oble,Its, nIt'. ).
leleplronn �
(2(1G) 235.2631
and ask to speak to lite asslpnnd Inslw(•lor (by mole 4 posslbls) Au attempt will be milde
to conlact pie Illepeclor or,11 Illnt hlspect O,Is umlyaeahle,to assign all Etllnluellcy IIIspoulot to Ilalldle life plolllnlll
Note- this proctnlule Is lobe used lo„anl Flnetyeocles ONLY Yvnr hdh,la to eJequninly sc heduln yow tyle,nlions lu
nll„w tot n(lvan,^e rfaluasis dons cool consmhen all Enwtyavcyll YOU WILL BE Cl-fAIIGL•u FOIi'1I IE
1149PECIOR'S I IME IF IHIE PROBLEM IS NO AN EMErtOENCYI
gO0.00
POWELL`HOMES TEL No .S245797 Jan 24 .91 15 --
e; ._. —
�r.'i.q-AafRw.ta•_..•
— 1 N f- ULI
I
EX, 14
R/Mr //6.ld 1
1 II I
hm II ••
'11
1 W
FJ'.
I i
I 1
I
1 I� I - l+�rT�F,hlac� vna_ve'
SCALE' 27 } li (FLK Mj)
1 If I
Lr� o
I �
I / [MItNY IftMcwMi
/A 8`0, ,!C, 42
t I � •prYp - p.lp IU'
I
1 �
RECOMMIENPEO
FOR APPROVAL
1
BY _
r�,rem—
ARRp
PY.
t-i-10 �I N ,o c,1ee trlrnrf n�rrt tttr . �'
a II
4�1
R UMMENp£O o m
F R APPROVAL
i
3 l� y nIC�E.• !
RIM, /0.57
/NV, 151.38
POWELL' HOMES TEL No .824579 ' Jan 24 .91 1-� :48 No .Ocif P.05
CITY OF RENTONPUBLIC
DEPARTMENT OF PUBLIC WORKS
wur rr11 Ir1 x.a..r {tY4 to o.. I un .{ wevx.
r.ua lulls a{r wa rrG U x0olr L P YY.e•lD
laws r .Yv..ul qa wu n x w\t Fvv WN
IIYt OIG VM{ \.O 1'�/I•FO{l (DMIttOM WYOxaI
\IIX I IM 1 VDL t' fUIO 1=1N Uv p tlu\y
II Riawll� nIw two pailM f MI I I{Punrl
♦Y.1 x. 11 in F11..11PK rl\l0. OI1 YI.OYGO
`_-�f IOVK. N+111 Gb•xS(rgx 0Ia[t tOaD..r
� /`tr`7I YtDMxi aytgv fM a.YY lN�[x
•• �7 NVf IWIr .Ig1UM
1 ll1 PYO..O Ort.Y
Wtr _
10 IOU, u1t 110V YKYI t01,
10u4 i0 td Y.PI GD.
{t✓1AA '1 rar {ltrnr nd
to W. VY Y(tww UMI.
u W.
(pYAIrI 11,61.0
<AutwGll hOCrlq
(NI A0. 1t1, nw
•1• \ O I1P01 ttR Wlltl
11uK N w4U1 CO 4g100.14
{' It AN RIt. It,.t N.
Ilq Udt. IPRtx 10 nl
r I �.• 1111t If N11
.
R' t' • 1' ..W\ l{e01x t0 nt YI PO Nun r^,
GOrSNI\1t0[1 Co to NOt
f GV Ir wML. .Is+GO
".1111.11w f✓1' MO
Mute w vl•ww 10
M.tI
FIRE HYDRA 1-ASSIMILY
am
rt
:T 3
s
F1� Jz'v1
NYORANT LOCATION IN CUT OR FILL
all
FIRE HYDRANT ASSEMBLY DETAIL DATE
SKEET k X.xx
� _�IJEI _ ti�riE_ TEL No .8245797 )an 24 .91 15:48 No .003'P.06
CITY OF RENTON
�•� "}- ABDOUL GAFOUB
[eMiruct ian lMpK tur
MuelclMl Wllafnv 200 niu Evenue S',h
Imtan� Wattlglen VBOSS 27S Q671
NOTICE OF NEW FIRE HYDRANT IN-SERVICE
NAME OF DEVELOPMENT
ADDRESS
INSTALL %TION CONTRACTOR
WATER P9OJECT NO. VJ• 103
NUMBER OF HYDRANTS
HYDfUNT LOCATIONS (FOR FIRE DEPT. USE ONLY)
HYDRANT NO.
1.
2. _
3. _
4. _
5.
6.
INSPECTOR
�.._.
I
Sa I4"' s�
/---�
. o
-- o
�.
� - - -
-- o �
S �
w
CITY OF RENTON WATER DEPARTMENT
Pressure Test b Purification Test Form
PROJECT NO. J3o3' �--_�, jAd- �luc�
NAME OF PROJECT: _0�_ T � ON
PRESSURE TEST TAKEN MINUTES
AT A PRESSURE OF a04 4- PSI, FOR
TEST ACCEPTED ON I"& -46 n �+
PURIFICATION TEST TAKEN BY l 11 ON
PURIFICATION TEST RESULTS, SAMPLE NI
SAMPLE M2 _`--
SAMPLE M3 �—
PRESSURE COMPLETE AND PURITY COMPLETE
No connections to mains or meter permits slued until above box Is
checked by Inspector.
REMARKS:
i
I
I
DsRs" ,,A,",
3TATF Or wASNINOTW
DEPARTMENT DF sOCIAI AND H!AL TN SERVICES
WATER BACTERIOLOGICAL ANALYSIS
SAMPLE COLLECTION READ INSTRUCTIONS ON BACK OF GOLDENROD COPY
If Inatructlons are not followed,samole will IM releCled.
DATE COLLECTED I TIME COLLECTED I COUNTY NAME
MONIH WY YEAR
'HO
/ n 90 AM ❑ PM KIM
TYPE of SYSTEM IF PUBLIC SYSTEM,COMPLETE
PGBN0. 171
I RCLF�lA<.
O IaLIDavltwAL I.D.D.No. 7 S O L I2 a a
NP.�eW 1 AMEe�.1 _
NAME OF SYSTEM
Gift of itEm"4
SaICIFIC LOCATION WHERE SAMPLE COIILCIF SVSIEM ONNEA/MW rRME AND IELERIOM NO
IH4P. w e E+.r.1..R�.... 'R A'{
..mv,Y AT Sl10
HATMICIL AA%, t
S11M CO'rLIECTEO SV'.INyryII j
SOURCE TYPE/W� �J
❑SURFACE ❑WELL ❑ SPRING ❑PURCHASED TILCO INE14 ION
C OTHER
SEN REPORT IFIM Full NamE,AeeNER ArIE Zb CPen
grlr p REw�nM- LrTwtT F,+wE. 1w
po- HILL hub So
faff 1 WAENINOTON 98oS�
TYPE OF SAMPLE
1. U DRINKING WATER ❑ Cnlwmaled lRglMal To1M_Frnl
cwk tmlmMl—► ❑ FnMred
❑ Untmteo ar Ol",
x. ❑Q RAW SOURCE WATER
3. 1D1 NEW CONSTRUCTION�FWMMIB
4. ❑ OTHER(SWItV)
COMPLETE IF THIS SAMPLE IS A CHECK SAMPLE 1
'REVOUS LAB MI
PREVIOUS SAMPLE COLLECTION DATE
REMARKS
W2J_ag - _ 5APInt oP
LABORATORY RESULTS(FOR LAB GEE ONLY)
MPN COUFORM STD PLATE COUNT SAMPLE NOT TESTED
BECAUSE
II''''ff �mI
MPH DILUTION� san,psgicloold AN 1 U Conf�"l Gmwtn ❑ Notm Proper Conlalno,
mt
MF COLIFORM
x. ❑ TNTc ❑ Insufficient Inlarmell
ReW
ao
Prowoemo on F
InelNctiuMe on Form
FECAL couron 3. ❑ E.caee aan
❑ MIEN ❑ MF 4 ❑ ❑
nM I
FOR DRINKING WATER SAMPLES ONLY,THESE RESULTS ARE,
❑ SATISFACTORY ❑ UNSATISFACTORY
SEE REVERSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS
LAB NO DATE TIME RECEIVED— RECUVEO BY
DATE nlr RWtV LANORATOAY
LAUCKS Ti* TING LAGS
AFMA..s WIS.,�,ARNFV _
SiPr, ' .vA r
DP CENTER COPY ,•