HomeMy WebLinkAboutWTR2701801(2) WTR-1 W-1076
SUNSET GARDENS ABERDEEN NE & NE SUNSET BLUD ��m.Z--l�����
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FILE TITLE W Tp�- 1
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Miller National Tide insunae Compa y '"'t t'au atsatvto roe nc...t
Filed to Rmord at Requeat of �t
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p; BILL OF SALE v "'"
N KNOW ALL MEN OV THESE PRESENTS, Thal ✓ """"�•y
f2
County of
I.,and in Imsidtra front of the sum of Bey' .Slate of Washington,the part of first part.
tT Z
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I--[-]money of the United Sulu of America,to / {, D an
�rF in fiend by/[ ��
t,Ra
the pall a( the second part, the rtteipt whereof is hereby acknowledged. doo
bargain,sill aN deliver umo the yid art o I the he by these presents grant.second part,the following described permnal property now
Ioca:aC at loaf yafC�Ia(yt/ ,¢yli✓E—
a2 In the City Of County of
_OO and State of Wnhingtto.wir. y�
GG}lTiti�y.L«" �GaY.0 � a.aaP .�Z�Ctli�—<�saz �f+/
fe/�6S.1xa�....J �d`CtG'G'X'" � ���-�+a•alti./, Cam— � .c✓
(W-1076)
TO HAVE AND TO HOLD the same to the said part of the wood pert administrator, and assigns fonver. And said hero, esecuurt.
nttutora,administrator$,covmanl parr of the first part, for heirs,
executors, administrator,and assi and 4u'e to and with the raid part of the second part,
gill, that said part of the first art
Property.floods and chattels and be p uwhat of the said
$.ill wvnnt and defend the sale hereby move right and lull authority to tell tee same,and that
eseculors,a�ministraton and aadgm,6aimt all pmae lod evesaiJ part of the second put,
claim the same, rY Mrmn or parsons,whumaoever,lawfully claiming Or to
IN WITNESS WHEREOF,The said part of the first p t-ha bneunb$tt and seal this day of / hand
Isaws)
(u.u)
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(aaat)
STATE OF WASHINGTON,
County of V-t }te.
Do this day pengnWy.apfuered-4elore me
to m, known to bj'tN i d acknowledged
( .\ � ,'gr�Iy the Me eacribed in and who uecutM the within and foregoing instrument. aiN
users surd (7 free and volunury It and d,,4 for the
GIVEN un�ar ray hYBwow (I u(Il this day of Sa ati 06c/
EG�• .1f
L Cr V"S\�df T' 7>�pJ NMary Pallas s aN/er etc Aue of WuN,rgren,
�a'+we. auWng a1
wHfN aCeOaCee R[NIW 1Q •"•'M--. �.[.�' W- i .
lNflu a.nmed!.kkpim t'Nt UTILITIES T77
12 �Nb+fvr' fs r•7r7
.
M AN � EASEMEN
aWAMa r
THIS INSTRUMENT,made this 4te day of felA1'JAhY 19 91 ,
by and between and
$Ly'iT QARL N I IMM, PARTN"e-RSRIP and
and
and
hereinafter called "Grantor(s)", and the City of Renton, a Municipal Corporation of King
County.Washington,hereinafter called 'Grantec
WITNESSETH:
That said Grantor(s), for and in consideration of the sum of $ !O&x
paid by Grantee, and other valuable consideration, do by these presents, grant, bargain,
sell, convey, and warrant unto the said Grantee, its successors and assigns, an easement
for public utilities (including water and sewer) with necessary appurtenances over,
through, across and upon the following described property in King County, Wa•hington,
more particularly described as follows:
rr-1 See Exhibit"A" Attached
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Together with a temporary construction casement described as follows:
8
Said temporary construction easement shall remain in force during construction and until
such time as the utilities and appurtenances have been accepted for the operation and
maintenance by the Grantee.
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Ong P4OVoedl/v-.53y' a0. y9.1�
Said heretofore mentioned Grantee, its successors or assigns, shall have the right,
without prior notice or proceeding at law, at such times as may be necessary to alter
upon said above described property for the purpose of constructing, maintaining,
repairing, altering or reconstructing said utilities, or making any connections
therewith, without incurring any legal ouligations in liability therefore, provided, that
such construction, maintaining, mpamng. altering or reconstruction of said utilities
shall be accomplished in such a manner that the private i,aprovements existing in the
right(s)-of-way shall not be disturbed or damaged, they will be replaced in as good a
condition as they were immediately before the property was entered upon by the Grantor.
The Grantor shall fully use and enjoy the aforedescribed premises, including the right to
retain the right to use the surface of said right-of-way if such use does not interfere
with installation and maintenance of the utilities. However, the Grantor shall not erect
buildings or structures over, under or across the right-of-way during the existence of
such utilities.
This easement, shall be a covenant running with the land and shall be binding on the
Grantor, his successors, heirs and assigns. Grantors covenant that they are the lawful
owners of the above properties and that they have a good lawful right to execute this
agreement.
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STATE OF W ASHINGTON)
) SS
COUNTY OF KING )
1, the undersigned, notary public in-ppd for the State of Washington, herebycertify
that on this day of =fLft V personally appeared
before ms
and
and_
and -
5 ba
and� 4e .1dF '.to ins known to be individual(s)described in and who
exedue th g Strmnent, and acknowledged that Sig �..�
14 s t A ."o free and voluntary act and deed
for fps Me in mentioned.
O
ryttFO
N tary Public in and for the State y, /
Washington,residing at `f
DODDS ENGINEERS,INC.
BELLEVUE,WA 98007
Sunset Gardens
DEI Project Nc. 89140
January 18, 1991
Page 1 of 2
EXHIBIT "A"
Preliminary Water Easement
A strip of land of varying widths over portions of Tracts 9 and 10, Harries Garden Home
Tracts, according to the plat recorded in Volume 34 of Plats, page 39, in King County,
Washington, said strip of land being 15.00 feet in width, having 7.50 feet on each side
of the following described centerline:
Commencing a: the northeast corner of said Lot 10; thence SOO'59'02"R', along the east
line of said lot, a distance of 41.40 feet to the TR JE POINT OF BEGINNING of the herein
described centerline; thence N89'32'27"W 8.00 feet to a point hereinafter referred to as
point "A"; thence continuing N89'32'27"W 94.73 feet; thence S88'43'07"W 5.00 feet to a
point hereinafter referred to as point "B'; thence continuing S88'43'07"W 2.30 feet to a
point hereinafter referred to as point "C"; thence continuing S88'43'07"W 68.72 feet;
thence N88'36'31"W 6.21 feet to a point hereinafter referred to as point "D"; thence
continuing N88'36'31"W 14.10 feet to a point hereinafter referred to as point "E"; thence
continuing N88'36'31"W 4.40 feet; thence S43'15'38"W 34.30 feet to a point hereinafter
referred to as point "F"; thence continuing S43'15'38"W 21.40 feet to a point hereinafter
referred to as point "G"; thence continuing S43'15'38"W 11.86 feet; thence S88'22'11"W
2.70 feet to a point hereinafter referred to as point "H"; thence continuing S88'22'11"W
115.05 feet to a point hereinafter referred to as point "1'; thence continuing
S88'22'11"W 12.30 feet; thence SOO'28'39"E 24.00 feet; thence S13'43'41"E 58.16 feet;
thence SOO'59'02"W 13.66 feet to a point hereinafter referred to as point "J"; thence
continuing SOO'59'02"W 5.00 feet to the south line of said Lot 9;
t`
CD
And BEGINNING at aforesaid point "E"; thence NO1'23'29"E 45.21 feet to the north line of
u) said Lot 10;
CV
And BEGINNING at aforesaid point"F"; thence S46'44'22"E 6.241 feet; thence SOO'17'45"W
58.10 feet;
ON
And BEGINNING at aforesaid point "I"; thence NO1'37'49"W 17.00 feet to the terminus of
the herein described centerline.
Said strip of land shall be 10.00 feet in width, having 5.00 feet on each side of the
following described centerlines:
And BEGINNING at aforesaid point "A"; thence SOO'59'02"W, parallel with the east line of
said Lot 10; a distance of 17.00 feet;
And BEGINNING at aforesaid point"B"; thence S01'16'53"E 19.00 feet;
And BEGINNING at aforesaid point "C"; thence NOl'16'53"W 25.00 feet; S? pp
89140PREWTREZMNT P \
Printed -01/21/1991 ' q 3
/�l/A
DODDS ENGINEERS,INC.
BELLEVUE,WA 98007
Sunset Gardens
DEI Project No. 89140
January 18, 1991
Page 2 of 2
And BEGINNING at aforesaid point"D'; thence SO1'23'29"W 18.00 feet;
And BEGINNING at aforesaid point"G"; thence N46'44'22"W 15.63 feet:
And BEGINNING at aforesaid point"H"; thence NO1'37'49"W 19.43 feet;
And BEGINNING at aforesaid point"J'; hence N89'00'59"W,parallel with the south line of
said Lot 9; a distance of 21.50 feet to the terminus of the herein described centerline.
The sidelines of said strip shall be extended or shortened, as required, to terminate at
angle points and the margins of said Lots 9 and 10.
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89140PREWTREZMNT
Printed-01121/1991
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COST DATA AND INVENTORY
SUBJECT: CITY PROJECT NUMBERS: W-
NAME OF PROJECT ST-
J� - 2 -y1
TO: Ci7Y OF RENTON FROM: �RuS
UTILITIES DIVISION --
200 MILL AVENUE SOUTH L' p
RENTON, WA 98055 J �`"
6" +t 23�e/ "�
�AQiw [J u/µ gqD T "7
DATE:
a
Per your request, the following Information is furnished concerning costs for improvements installed for
the above referenced project.
WATER SYSTEM,
Lendth Size Type
L.F. OF Y" .D,T WATERMAIN ows%-4'
L.F. OF 8 '2_7 _ WATERMAIN OFFS^je
S3 L.F. OF u ' dq WATERMAIN 0. 3,7'W
4 Y — L.F. OF j J WATERMAIN
4 EACH OF d'� GATE VALVES o"a, L-¢.
EACH OF — — ^ GATE VALVES O+a-5,%e
EACH OF ^ GATE VALVES 0. 5;-Ae
ore S, `� SUBTOTAL $ ��1 ' 0—
EACH OF FIRE HYDRAN ASSEMBLIES $ 2�p
(COST OF FIRE HYDRANTS MUST BE LISTED SEPARATELY).
TOTAL COST FOR WATER SYSTEM $ 17 o0
SANITARY SEWER SYSTEM; -c- —
Length Size Type
L.F. OF — ^ py4- SEWER MAIN
L.F. OF SEWER MAIN
L.F. OF SEWER MAIN
_ EACH OF DIAMETER MANHOLES
TOTAi COST FOR SANITARY SEWER SYSTEM $ /3/F. yp
STORM DRAINAGE SYSTEM; 04, h
Length Size i, Type
_ L F. OF Z N_/Z STORM LINE
L.F. OF STORM LINE
L.F. OF STORM LINE
EA. OF STORM INLET
_--L-- EA' OF " STORM CATCHBASIN
EA. OF STORM CATCHBASIN
TOTAL COST FOR STORM DRAINAGE SYSTEM $ 6f/r --.)O
( TREE IMPROVEMENTS; (Including Curb, Gutter, Sidewalk, Asphalt Pavement and S LI g
Street htlnpJ-
5 —�--r--
TOTAL COST FOR STREET IMPROVEMENTS
J.
(SI(jNATURE)
v (SIGNATORY MUST BE AUTHORIZED AGENT OR
f0i OWNER OF SUBJECT DEVELOPMENT)
L�
BOND NO. 450419
MAINTENANCE BOND
KNOW ALL MEN BY THESE. PRESENTS; That we DERUS DEVELOf+rT'JT CIDPWJY
as Principal, and INO INaR EE C(PPM1Y a corporation
organized and existing under the Laws of the State of kkgJJNSTCN
Surety are held and firmly bound unto
C"%N e� �WTON
as Obligee, in the total sum of TYA THAW FIVE VAfdW NIPS MD 36/100
($ 2,509.36 ) Dollars, for the payment of 'which, well and truly
to be made, the executors, administrators, successors and assigns, jointly
and severally, firmly by these presents:
for Sunset Garden Condominium Sewer, Water 6r Street Lighting{ !r- -OwA-14&40
NOW, THEREFORE, THE CONDITION OF THIS OBLIGATION IS SUCH, That if the
Principal shall maintain and remedy said work free frcm defects in
materials and workmanship for a period of ONE year(s) following
completion, then this obligation shall be void; otherwise it shall remain
in full force and effect.
SIGNED, SEALED AND DATED this 161N_ day of prr,"R 19 ram.
OERUS DEWLORW APMM
BY
gY ElIZ62ETH T1J(`,4L
ATTUREY IN FACT
V ICTNome Office:
Limited 1213 Valley Street
CONTRACTORS BONDING Power of Attorne P O.Box 9271
AND INSURANCE COMPANY Y Seattle, p27t
6)622-706M3
KNQN ALL MEN By THESE PRESENTS a et CONTRACTORS BONDM AND PEIR NY INGE COMPANY,a Fappsrys sa ldanpyyrlpyprrhll�aa AbalYWp1G11191Me
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Poeera Alta aaNnbfreYeand[~
MVFNi.w"Y M ILLL�ryy 1992}ty�yt♦•iN1L 'ne
MCEPoI WuSOBpOPl h ,
BOND NO. 4x0419
MAINTENANCE BOND
KNOW ALL MEN BY THESE PRESENTS; That we DERUS DEVELOMIT CONPMIY
as Principal, and CWW70RS PMM [N&1RMlCE CUPMIY a corporation
organized and existing under the Laws of the State of WkliINGT(YJ
Surety are held and firmly bound unto �]
C�hl o� 1CWTeN
6
as Obligee, i.n the total sum of T60 TO SMll FIE H 4HDD NINE MO 36/100
($ 2,509.36 ) Dollars, for the payment of which, well and truly
to be made, the executors, administrators, successors and assigns, jointly
and severally, firmly by these presents:
for Sunset Garden Condominium Sewer. Water 6 Street Lighting
NOW, THEREFORE, THE CONDITION OF THIS OBLIGATION IS SUCH, That if the
Principal shall maintain and remedy said work free from defects in
materials and workmanship for a period of ONE year(s) following
completion, then this obligation shall be void; otherwise it shall remain
in Lull force and effect.
SIGNED, SEALED AND DATED this 15TH day of SEPTRin 1992
DERUS DEVELOR W 964W
BY)(— Z AZ
fenrF (YT9enN
BY ELIZABETH iUrY.
ATMRNEY IN FACT
Home Office:
L/ IC Limited 1213 Valley Street
CONTRACTORS BONDING Power of Attorney PO Box 9271
AND INSURANCE COMPANY Seattle,WA 98199-o271
(206)622-7053
KNOW ALL MEN BY THESE PRESENTS EItl COMPACTORS gory,,,,AND INSURANCF COMPANY a u;avatrn odY agani�eG ai.c e.rslry urke. IM revs pl the Shre d Wasr.nlfn aM IW Wp
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b h auMGmy n pause 131 eOPwa,Mre.I,Wmrinecl o aW WeG.,re pmbsmanLre crap pry^Nm aalasl aY M aroeG 350D,000.Md 151 a GYIM eorlW M eAcsedg,a Daa eun
d aSo.NMG
RESOLVED FURTHER eW E1.17ASEM AC PORT"LsgblNCpoex aW adnorry mnyreaGMeapanapbpenalcore sabrMm ft K WgIa:eabalberryeadnan MnaFee9N
M Mea xa any car a aetll,aemrb aewmy.recerveG as deanva sa vMy N ae Cm as an iMucerom ro.be
RESOLVED FURTHERMa eW Wa " Ma SWM"a eW Ca fro camp 1M-aW"and eAeFe rless a ed AV09-V oresdaearsnarty LmgeG PGNm d Aft r csNreW
GMegemG more YAawg Dasau,maa9'ruadartyd,N .Sw roDoreore«m*Fr"m lesoedS e.N .EdOrty mG elNce fmftldNN hftnd rKa Ab sanSq L UM
Seodary d eie Conpany:CIUWSJ FeWoa.Janel K Lomas.Sloven A Gd�M6 Jemler FW MKMa S PngM.EGO.SKoertaar.fnM Danacn,Wormy K$rnmm and ShKy L MN
RESOLVED FURTHER out ec sqM %Ia6,e g xlataeon Mal me Pp d AMKrsy a 03 m bce aM~)d h Pmi0enl.Ndary Punac and person c&bfp q aline"aM
Mw.9rergss aM M NrypreN aM IbM7 feeq ap,aareg pn airy LmPaO Ppay d AtlpMyfOnlamvy My and tla Ipregpaq IMWppn mry pe py saRvnb
HESO(VED FURTHER WPM""aEoverMmaGaaa yY WbCOMRACTORSSONDMGAND WSURANCE COMPANY arehosar
P+DerseOeG
INYa1NESSWHEREOF.CDNTRACTORSOONO,,GAFAWSURANCECOMPMIYNsrausenM e"md Dearpne Do Prevh IaMAScvryp mmia ne Mrebaauapm520VrEayd Mgrri,
1992
CONT CTORS BONDING AND INSURANCE COMPANY ��.wrsrsy
SYpM,INC`r'Ir
— — =a`I SEAL =f
WssA01IA1 fs,a1lrM 4rrI +S 1979 c;
STAff,F WAffia6TON-GOUMtYOFIM6 ..
Q11i2,gliFtlMl9,gt rFR,ptAalFll,op),,WSTFVENA GANNES,M meAnorm m a Ma Pr9arWnld me CrapMalmn Wl NanaO Me IYegoap LNUIM Pveard AnprNy ygµVegwNCgpEaMn
UMa01UsaAAkMybM MrewlsaFnhry adenG OMGd eMOnGrpnralron.b Ma uN6 Ntl WAsma Meson menbasG,cram nor sMbG Maine IsaunraHearo aAecuN,s sad LalabG Pear
aAN1aMy.
M WITNESS WHEREOF.I hove Mreunb ea my M:d aM aKlaaG r:n jseal Ire Gar aid veer F.W adwe rAN^
NATA�4
10
web d reNWq sree .. '+""Ymo N,�rtj'
SONDIN aevquabalamrydInc eoaned DmKsasa CONTRACipRSRONDING ANU INSUIUNGE(%,`LNPANr,Mraaywrera,asanWaoNwwgme 5aawrytl CDNTRACigIS
BO & AANDND INSURNlCE CONPANv
Powa a ,n+d nx cow enG brepangc aIlia,InN and wrrxi N6rd,sO^9nM Porn pl AIbMyWrppy btlOanYarry.Md Goa Mreq Ae,rullfy,W AN atl
+norreY N MA n brae and e,e[I
GIVENer .VA of BELLM VASHINUCN.__..es— 16TH ----.----------rya._ 'PJQ R_-. 199?
P„aEPol a;Usoe �zo9
CONSTRUCTION FIELD SERVICES iG�C
TFMPORN�OCCUPANCY INSPECTION REPORT
DATE: October 21, 1992
TO: UTILITY SYSTEMS
[ J STORM - RON STRAKA _
[ ] SEWER - DAVE CHRISTENSEN
[ J(] WATER - ABDOUL GAFOUR
[ ] PLAN REVIEW - NEIL WATTS ���'
[ ] CONSTRUCTION SVCS - PINKhAM/KOKKO
[ J TRANSPORTATION SVCS - CLINT MORGAN CT ign?
[ ] LANDSCAPE/ZONING - BOB ARTHUR
[ J BUILDING FINAL - CITY OF R_NTON
[ ] FIRE PREVENTION -COREY THOMAS Engineering Dept.
FROM: CONSTRUCTION FIELD SERVICES-
SUBJECT: Sunset Garden Ltd PERMIT NO. : B-16442 Thru B-16447
949 Aberdeen Avenue Northeast TYPE BUSINES
The subject project is nearing completion. Please investigate your area of
responsibility and indicate below either your acceptance or non-acceptance.
Please return this form by October 28, 1992 in urder that a permanent
Certificate of Occupancy ma ued. If no comments are received by the
above date, the temporary permanent ertificate will be issued.
TO: CONSTRUCTION FIELD SERVICES DATE (c L(112_
FROM: Wkiao' 4K km
This project is approved by this department subject to the following
corrections: (Note: see copy of 90 day requirements attached)
NON-LIFE SAFETY ITEMS LIFE SAFETY ITEMS
►14N1�i I W1W 6
DO YOU HAVE ANY OBJECTION TO ISSUANCE OF A TEMPORARY ERMANEN CERTIFICATE
OF OCCUPANCY? (IF YOU HAVE LISTED ANY LIFE SAFETY ITE K "YES". )
[ ] YES ( ] NO JJ
�u0pw. 6*4,0--
Authoriz d Signature
p3:finlocc
9Y8- 376 2
CA�t fH4rr
� r kowGM••O w- 1076
AUTHORIZATION OF SPECIAL BILLING
DATE.-
PROJECT NAME: 7 U t`f 5 — T S
PROJECT NUMBER: VJ - /o 7 G
WORK ORDER NO_• �67 I a
It is the intent of this letter 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
("" 17'Y or AF/YMN cy�+ rr-le �r?F �/vN c17�Ns�
W,47F-P LrNF CoNNF- I°i� l71! YFST i
BILLING TO BE SENT
'wgxer 6A n* NA[n+tscrritr�
/IY : 0 na�rcey 6.c.
Name: --
p p� J
YOU WILL BE BILLED TIME AND MATERIAL Addr -f f`�P S�
FOR ANY WORK DONE BY CITY STAFF TO S.�A4WN,F lJ�l
REPAIR DAMAGES in,. ---
Acts
Phone No_
Ow veloper, Co tractor or
thorized Agent
CONSTRUCTION FIELD SERVICES W_1076
FINAL OCCUPANCY INSPECTION REPORT ( Aec
DATE: July 8, 1992
TO: UTILITY SYSTEMS
[ ] STORM - ROD STRAKA
[ ] SEWER - DAVE CHRISTENSEN
[ ) WATER - ABDOUL GAFOUR
( ] ELAN REVIEW - TOM KRESS
( ] CONSTRUCTION SVCS - PINKHAM/KOKKO
[ ] TRANSPORTATION SVCS - CLINT MORGAN
( ] LANDSCA E ZONING - BOB ARTHUR
[ ) BUILDING FINAL - KEN BINDARA
[ ] FIRE PREVENTION=GARY GOTTI
FROM:_CONSTRUCTION FIELD SERVICES—
SUBJECT:Sunset Garden Ltd PERMIT NO. :B-16442 Thru 5-16447
949 Aberdeen Avenue Northeast TYPE BUSINES_R-1
The subject project is nearing completion. Please investigate your area of
responsibility and indicate below either your acceptance or non-acceptance.
Please return this form by July 1 1992 in order that a pe manent
certificate of Occupancy may be issued. If no comments are received by the
above date, the permanent certificate will be issued.
TO: CONSTRUCTION FIELD SERVICES DATE Sian( G1 1Agt, t
FROM: W W*
This project is approved by this department subject to the following
corrections: (Note: see copy of 90 day requirements attached)
®�ti]k11 NON-LIFE SAFETY ITEMS I LIFE SAFETY ITEMS
l^ 74ONit '*,nS60 bzew-00 tME't'n d tei O lf64L Oescel new Zmft o 'Pa-6uA�.l
D%kWW9A me Wnem.uNf . C0w4"m. fMMr la(tclwt_
C.6 _ ,_... a. Nkmwlru g—°�=.�— �� —T•—Mews Of Aw
.r
DO YOU HAVE ANY OBJECTION TO ?SSUANCE OF A PERMANENT CERTIFICATE OF #
OCCUPANCY? (IF YOU HAVE LISTED ANY LIFE SAFETY ITEMS, MARK "YES". ) p
[ >(] YES [ ] NO
�hfou/L'
Authorize? Signature
03:f inlocc
J
CITY OF RENTON
Jl PUBLIC WORKS DEPARTMENT
•"' Design/Utility Engineering .
BACKFLOW PREVENTION DEVICE
REPORTING AND TESTING INSTRUCTIONS
All Backflow Prevention Devices installed are requ;-ed, by W..:hington
State Law (RCW 42.20.050.83-19-002/WAC 248-54-195), to be tested on
installation, and annually there after. Testing must be done by a
Tester certified by the State of Washington Department of Social and
Health Services, a list of whom may be obtained from this office.
Please complete the bottom of this form, and return it to the Utility
Engineering Department at 200 Mill Ave S, Renton Wa. 98055, together
with the completed Test Form(s) attached, when the required device(s)
have been installed.
OWNERS MAILING INFORMATION
OWNERS NAME:
MAILING ADDRESS: 00
/3DT� 4 „c Uf Sudf Z!D
93,•Il WCA. 9 B Ou P—
DEVICE LOCATION INFORMATION
STREET ADDRESS:
DEVICE LOCATION;:,,�Is �^ F �i!➢� n
CONTACT PERSON: '(A
PHONE NUMBER: AF_4 - U D L Ti ' PROTECTION ZONE*:
DATE INSTALL ED:, 2_/_Lg , USER CODE*:_-
+Directions to the device on the premises.(eg. Second floor utility room
(Pm 209) next to elevator).
*To be completed by Utilities Personnel
200 Mill Avenue South - Renton. W"ngton 98055 - (206) 235-2631
PUBLIC WORKS DEPARTMENT
o p DESIGN/UTILITY ENGINEERING • 235-2631
MUNICIPAL BUILDING 200 MILL AVE.SO. RE NTON,WA-H.98055
t3ACKFLOW DEVICE TEST REPORT
o.r.cr renfaf q ewrr'�s O `1 O 6
ffeflla wNrwea
S Tw, e�" G ard' cwt
gteal�apog3s
P..
a«��rz 1 f �l � �{ v I�c u61� �' �e r �t (lc✓t�
_ awr
..
7C VA
UM enai}Ata At tW oFtaar IMf5311Pa OItpP aCJfp a graea v[
l!S LRS
I
CH116 VALVE NO.t CHEC%VALVE KO.2 DIFFERENTIAL PRESSURE RELIEF VALVE
❑ 1. Leaked .... .... ❑ 1. Opened at lbs.
INITIAL 1. Leaked ...................... reduced Pessur11
...........
TEST ...... 2. Did not open ................. ❑
3. Closed Hgnl ................. 2. Clmed light............
Gleaned ... ❑ Cleaned........................ ❑ Cleaned........................ ❑
...........I...
Replaced: Replaced. Replaced[ ❑
D,ed ... ..... ❑ Disc ..................... ❑ Disc.upper ................. ❑
Spr�n DiaC brats..................
Spnnq.................. ... ❑ 9...................... ❑ Spring...................... ❑
RGurde ......................
E ❑ Pm roamer ........_. Oupnraglt4W�
Pin numM "" ❑
P ❑
❑ Hinge Pn................... Upper ...................
A Ninge Pn................... ❑ ❑
ISol ❑ Seat........................ Lp�er...................
❑ DNonngm.smaY
S Oiaphragm. ............... ❑ ................... ❑
Omer,deacnb............... Omer.OeavfM Upped.............. ❑ ❑
Specar.braK ...............
Dlnef.Eefcripe.............. ❑
FINAL ❑ Opened at Itaa
TEST
Closed light.................... n Gmed Hqn..................... reduced presawe
Mmarki
THE ASO EPORT IS CERTIFIED TO SE TRUE
Irlt MPdtf rO hSrfO
Pf r•�ntO e• G
Public Works Department
DESIGN/UTILITY ENGINEERING ...r'�°�
200 Mill Avenue South FfiCu cu. — n.n
Renton, Washington 98055 /�, 3
�! ~r CITY OF RENTON
PUBLIC WORKS DEPAR-,MENT
Design/Utility Engineering .
BACKFLO,1 PREVENTION DEVICE
REPORTING AND TESTING INSTRUCTIONS
All Backfl ow Prevention Devices installed are required, by Washington
State Law (RCW 42.20.050.83-19-002/WAC 248-54-195), to be tested on
installation, and annually there after. Testing must be done by a
Tester certified by the State of Washington Department of Social and
Health Services, a list of whom may be obtained from this office.
Please complete the bottom of this form, and return it to the Utility
Engineering Department at 200 Mill Ave S, Renton Wa. 98055, together
with the completed Test Form(s) attached, when the required device(s)
have been installed.
OWNERS MAILING INFORMATION
OWNERS NAME:
MAILING ADDRESS:
DEVICE LOCATION INFORMATION
STREET ADDRESS:
DEVICE LOCATION`:
CONTACT PERSON:
PHONE NUMBER: PROTECTION ZONE*:
DATE INSTALLED:_J_/� USER CODE*:,
Directions to the device on the premises. (eg. Second floor utility room
(Rm 209) next to elevator).
*To be completed by Utilities Personnel
200 Mill Avenue South - Renton. Washington 98055 - (206) 235-2631
J PUBLIC WORKS DEPARTMENT
" = F DESIGN/UTILITY ENGINEERING
q • 235-2631
•'o sa rE„d'� MUNICIPAL BUILDING 300MILLAVE.SO. RENTON,WASH.98055
BACKFLOW DEVICE TEST REPORT
Ae COMit Me. yrKi PeeKlr/� - 7b(t' co.. cf nn..a
«.waNllttr E i l l t� [a(_C J`. < (`
�.)e A �
Tn I-r LICu
state
1M M414Ma,I fWE Cf 1(SI yy11(ppe I IeMEI'y VµVa
410 DS, tE3
lE3
CHECK VALVE no.I CHECK VALVE NO.2 DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL 1. Leaded ...................... ❑ a. Lashed ...................... O 1. Opened ai RIS.
TEST .educed P"UWe j
2. Closed light.................. E. C$D W EEM.................. 2. Did not awn ................. ❑
Cleaned........................ ❑ Cleaned........................ ❑ Cleaned........................ ❑
Replaced: Replaced: Repla<h:
Oise........................ ❑ onc........................ ❑ Disc.uPCw ................. ❑
Spring...................... ❑ Spring...................... ❑ Disc.lo.n.................. ❑
RGuide ............... ❑ Gcide ...................... [,
............ YI
E ..... Spring.......... ❑
PPin ryVinK ................. ❑ Pin retainer................. ❑ Diaphragm.Large
A Hinge pn............... ... ❑ Ming It pin................... ❑ Upow................... ❑
1 Some ❑
3 oiapnragm.................. ❑ Oiaohragin.................. ❑ omchragm-smAll
Other,describe.............. ❑ Other.detcnbe.............. ❑ Uppw................... ❑
Lo.w ................... ❑
SwCw.I.in ............... ❑
Other.describe.............. ❑
FINAL OOened et RJL
TESTClosed light.................... ❑ Closed hot.................... ❑
Iedpnd Drown
Qecdletc 00C)GC) 3
THE ABOVE R PORT 13 CERTIFIED TO RE TRUE
MirMW iitlOrir to asiffo•
�l
MP, aC
Public Works Department
DESIGN/UTILITY ENGINEERING
200 Mill Avenue South
Renton, Washington 98055
i�t ►�- CITY OF RENTON
PUBLIC WORKS DEPARTMENT
Design/Utility Engineering
BACKFLOW PREVENTION DEVICE
REPORTING AND TESTING INSTRUCTIONS
All Backflow Prevention Devices installed are required, by Washington
State Law (RCW 42.20.050.83-19-002/WAC 248-54-195), to be tested on
installation, and annually there after. Testing must be done by a
Tester certified by the State of Washington Department of Social and
Health Services, a list of whom may be obtained from this office.
Please complete the bottom of this form, and return it to the Utility
Engineering Department at 200 Mill Ave S, Renton Wa. 98055, together
with the completed Test Form(s) attached, when the required device(s)
have been installed.
OWNERS MAILING INFORMATION
OWNERS NAME:_c D /t�
MAILING ADDRE',S: ;1. 2=UO /
DEVICE LOCATION INFORMATION
STREETADDRESS:
DEVICE LOCATION': Soj714, f wrrc. c
CONTACT PERSON:
PHONE NUMBER: 19(hc( PROTECTION ZONE*:__
DATt INSTALL ED:i/_,(0I USER CODE:_
Directions to the device on the premises.(eg. Second floor utility room
(Rm 209) next to elevator).
To be completed by Utilities Personnel
200 Mill Avenue South - Renton. Washington 98055 - (206) 235-2631
- �~ PUBLIC WORKS DEPARTMENT
4
t DESIGN/UTILITY ENGINEERING 9 235-2631
MUNICIPAL BUILDING 200 MILL AVE.SO. RENTON,WASH.9E055
'ro ev�C
EIACKFLOW DEVICE TEST REPORT
AG count ft. O�I.CI M�1fOe (I�74 L. M n-�` CO�r.<\ np�(
it//� eGC ton60
LtI pt 6c,'J P.,.f
10"I r avtea C
^�_ sta w s.r.
7v C.0 f� r C C) t ' e&U
a Ma Al naae OF test tea 0110a YPOilrwat entee vary[
l �V SJ S 1 LES _ LBS.
CHECX VALVE 140.1 CHECX VALVE NO.2 DIFFERENTIAL PRESSURE RELIEF VALVE
1. Leaked ❑ i. Leaked ...................... ❑ 1. Opened at IES
j va r • redueed pressure
T ❑
2. Closed light.................. 2. Gored NgN.................. 2. Did not open .................
Cleaned........................ ❑ Cleaned........................ ❑ Cleaned........................ ❑
ReP4cw: 'leplaced: FePlaced.
Oise ....................... ❑ Onc ....................... ❑ one..Do. ................. ❑
Spnng ❑ Spnnq I.................... ❑ Disc rower.................. ❑
RG.41 ❑ Guide ...................... ❑ Sonng...................... ❑
E n retainer .................
P PI ❑ Pin numer................. 0 Oapnragm,4r9
AHinge Pn................... ❑ H.nge pm................... ❑ Uope,................... ❑
1 Seat ❑
R ❑ Seat ❑ Lower...................
SDiapnra9rn.................. ❑ O..Q",.qm.................. ❑ Duonragm.small
Other.desen0e.............. ❑ Other.desss............... ❑ Look, ................... ❑
Ldwar ................... ❑
Soaco.lower ............... ❑
Other.desenW.............. ❑
FINAL Closed Opened at___IOL
TESTOa Tight.................... ❑ Gosea agnt.................... reduced oras"Wo
RemarkT
THE ABOVE ORT IS CERTIFIEEO TO ESE TRUE
MtIMW Men11t 10 R \Ob .../ V
"
.' p J
Public Works Department
DESIGN/UTILITY ENGINEERING """ar a'
200 Mill Avenue South
Renton, Washington 98055
(�f 7
s I
1 / I
!£
1
r
Suny�,T a//!/, .{/C
SJ11ET GAZT) l 4 " l0'7(o
9v 9 f3T3rZ�frJ �C�E
l0- 3-9/
�'re8$ �,Cbin
UULjl-
10
STA o+ iB =
Ai�Z9bCZ N AVC AIE
J. BRIERE CONSTFUCTION, INC.
23205 SE 192nd St.
MAPLE VALLEY, WA. 98C38
N(206) 432-7582 office
#(206) 432-2833 fax
FAX TRANSMISSION
SENT TO: �I T-
DATE:
NUMBER OF PAGES WITTH -OVER SHEET: —
ANY PROBLEMS WITH TRANSMISSION PLEASE CALL (206) 432-75 2
ti Of ks IT
PUBLIC WORKS DEPARTMENT
O
,
DESIGN/UTILITY ENGINEERING E 235-2637
MUNICIPAL BUILDING 200 MILL AVE.SO. RENTON.WASH.99055
ho,vat.
BACKFLOW DEVICE TEST REPORT
1<[Ovnl Ma. --- --�.C+ rin{Or �COr•{[+ .'..Or[
nml 01 IRA Ws!5
•IRM�Ii.O f\1
.a•+ro1 a Dint[
Lie-
U'I MIfSWf..t••[Or 1Ia1 65vM oso%-:aoY rwsl c«t4 vYv(
ou as
CHECK VALVE N0.I I _ CHECK VALVE NO.7 OIFFERENIIAL PRESSURE RELIEF VALVE
T Leaked r. Opened al _IDS
t leafed .....................
I
NITIAL � reduced D'tiswe
❑ 2 Closed ISM.................. ❑ E Dm nol open ....., .......... D
Cleaned ............:... .. ._. ❑
CHs,,e0 ... _.. ......... Cleaned........................ReplaceC Replaced Replaced
... .., _... O,s< ....................... Onc.uDDe. .....
1. .. O
O,sc
S9rmp..._ SCr,np_.................... D.u.town......L.._...... fl
R I Guide l� I Gu1dr L BCnnp...... _.�.........
C I Pin k!,:,v, .. _ ri I r.r.yu...r .. (✓ I D,e 9n•apm.large l
P r-� D Upper ....... ........... ❑
M npe r•n
Seal Seal. ._... towel .. ❑
R
S par^a5m _... Darn apm... .. ❑ ONDMapm fmaN ❑
Omp.tlrfu.De........ ❑ Omer.etfcrrDe.... UpDel..... .. ❑ ... ...
. Lora .......'I............ ❑
Spacer.lower ❑ y
Other.describe.............. ❑ 175)
FINAL yyLL,r Opened ar IDF
TEST
Closed ripM.................... /Oh Closed NBN................... reduced wesswe
Aemada -THE ABOVE REPORT IS CERTIr IEO TO BE TRUE
',Wlu•trod 10
r
Public Works DepatImtln
DESIGNIUTILITY ENGINEERING "" ""e% .�
200 N101 Avenue South
Renton, Washington 93055
I
�s.
a• p1, R'.I.�
E:1=►l7. PUBLIC WORKS DEPARTMENT " .
f F DESIGN/UTILITY ENGINEERING 235.2631
MUNICIPAL BUILDING 700 MILL AVE.SO. RENTON.WASH.98055
BACKFLOW DEVICE TEST REPORT
All..m No. cow l.cI etAtpi
w.Y<or nl Yn[s
N.
ap . 31
4 N Y
10Crlqu Or Dlv ( + 6
L.+1 re1aSWp. ew63Y4 Oeoa.puss nest e..RavgY(
_ 80 OS r Les Les
CHECK VALVE NO.1 CHECK VALVE NO.2 DIFFERENTIAL PRESSURE AELIEF VALVE
INIIIAL I Leaked ...................... ❑ 1. Leaked ...................... ❑ 1. Opened at _to$
redYced p�esmw
1E5T
2 Closed b9hl .... ...._....... 2 Closed nple .................. 2 D.d no,open ................. ❑
Cleaned ..._........___. ❑ Cleaned......... ............ Cleaned........................ ❑
Replaced ................. ❑ Rer Dna Replaced
.... ❑ Dn<.upDv ..... ❑
Sponf..................._ ❑ Osc.IQ.e... .. . ❑
R GY.de .... ......... .. GNdf _ .__.. ❑ Srong.....
_... n
E I Pm•aa.np .. .. rr1�--i11 I Fir.relsn.r- ... ❑ D�a:nrapm.lelpe ..
A I Nm9e Pm '. ............. ll H.n9e r.n ... ❑ LIPPer .............. .... ❑
R sea, Seat ❑ LP.er ............... . ❑.... . ............S 0."hragm ....... ❑ OurnrAgm _. ❑ D-aphugm.anlao
Onyl.deacr.bl... ...... ❑ Omn.desenbe ........... ❑ Upp.. ................... ❑
to..er ................... ❑
Spam.bwer ............... ❑
Omn,detpnbe.............. ❑
FINAL OPlntd at lbs.
TEST Closed tight.................... Obaea bfM.................... ❑
I ed YC ed prlstY't
RtmvLt
THE As V POR115 CERIMLEDTONE1RUE_ —_
1NIVer.grpwl t0 to
�1
1� 1�Public VI'orks DepartmentDESIGN/UTILITY ENGINEERING200 Mill Avenue SouthRenton, Washington 98055
C'L•S
y c's PUBLIC WORKS DEPARTMENT
?, c DESIGN/UTILITY ENGINEERING 235-2637
r " MUNICIPAL BUILDING 200 MILL AVE.SO. RENTON.WASH.99055
� �rtJ Sfr+1V`e
BACKFLOW DEVICE TEST REPORT
Acc.en% No. 0nuc+ r(nson con•o rvro.rr
1 wu!w nnrugR
�GC I Cons+
sim¢r •o css
( (oc 0;Eyre( `1
tn/
CNrrF(swP[•++n•e a!nsl tssVM ono:-:4lssrMs+enta.v.wt
lB5
CHECK VALVE NO.1 CHECK VALVE NO.2 DIFFERENTIA,PRESSURE RELIEF VALVE
INITIAL t Leased ..._................. t Leased ...................... 1. Opened at Ibs.
reduced Dreaswe
LEST ❑ 2 Closed I; n ❑
7 Closed Ugn( ..........._._.. 9 1 .................. ❑ 7 Dm not oxen .................
Cleaned........................ Cleaned ........................ Cleaned ........................ ❑
Replaced . Replaced . ... Replaced. ......O-sc ............. ........ Orsc .................. D�sc.pppe. ...........
❑
S"'mg...................... Epnng .................... Disc.lo.e. ................. ❑
R I G.-de ...................... ❑ GOrde _....... ❑ SCnng...... ............... ❑
CI Pin gomer ...... ......_.. [.I Rn rclau.rr ._....... ..... ❑ Draonnom.large
i ^^ ❑
l I Hrn9e prn................... Ll Hinge Drn............. ... ❑ UDDer ...................
1 Seal Seal ........ Low
R ...................... e. ...... ............. ❑
S Darnragm.................. ❑ Darnragm.. ..._.. .... ❑ Drapn.agm.small
Olney.describe.............. ❑ Ome+.de>cnbe..__.. .... ❑ UpDet ................... ❑
Lewer ................... ❑
Spacer.tower ............... ❑
Olher.deselibe.............. ❑
FINAL Closed light............. 9 (�("y Opened el Ibs
TEST Closed(� m........_........' reduced wassure
Remads
THE ABOVE REPORI IS CERIUIED 70 BE TRUE
of 1 Van e(rOnl 10 +
atr+ O B.
Public Works Department 1 ��
DESIGN/UTILITY ENGINEERING "'•`+`51e'
200 Mill Avenue South
Renton, Washington 98055 'I�+"" "— "•+` —
GwS .v
♦ OF RF.TA r
fi } 7.. PUBLIC WORKS DEPARTMENT
DESIGN/UTILITY ENGINEERING t 235-2631
MUNICIPAL BUILDING 200 MILL AVE.SO. RENTON•WASH.98055
BACKFLGW DEVICE TEST REPORT
--�p.I•cr ranso• IcTorruu .� (
Ac<ounl XO. I p
u.uf Or rw(ui515
SI IIVK1.00R55
soc•tro,or o�fL/(,( r f F
J n T OT I a� umri Y�nJ /(�N��I weC y+
01 u41
(((('�'''�'���//��))�[���� .�� �"'-U !O (ssvw owo:swass nwv c.(c•vly(
u'�I rwe55�w— (ll nu(Or IIsr
CBS
CNECK VALVE NO.T CHECK VALVE NO.2 DIFFERENTIAL PRESSURE RELIEF VALVE
1. Leased ...................... ❑ I Leased ...................... ❑ T. O reduced Dre TSmt lbs.
INITIAL ❑
TEST ...... 2 Closed bgnt.................. 2 DItl not open .................
2 Clpsetl IigM ............
Cleaned........... ❑ Cleaned........................ ❑ Cleaned........................ ❑
Replaced
Replaced
Replaced.
❑
� O'sc................... .... ❑ C.sc .................. ❑ Du<.upper .................
❑ D'sc.lcwsl.................. ❑
R I Gmde ...................... ❑ Gmoe ........ ........... ❑ Spnng......................
iE I Fm Ictarner ..... ❑ I Lin glans' ❑ D'aphldgm,
PA I teal........................ ❑
...................... ❑❑ DlapMer .l amlpaf
wnpe Pm................ wnge pm . UGpe. d
❑
Seal ... . wg . s .... ........
RS Ora:nlagm. . ❑ D,aphragm ❑❑
Omlr.dlEcuba.............. ❑ Omer.Oescnbf.............. 0 Upper ...................
Spacer.lower ............... ❑
Other.describe.............. ❑
FINAL Opened at Cps
TEST
Closed ught.............. ❑ CIDStd bqM.................... ❑ educed p.115u1e
Rema'"
THE ABOV PORT IS CERTIFIED TO BE TRUE _—
A(1uRn nleOwl 10 1 511 p e
a(*• o
Public Works Department
DESIGN/UTILITY ENGINEERING
200 Mill Avenue South
Renton, Washington 98055 rr�.l.��.1.,•t,n n•II
PUBLIC ENGINEERING DIVISION DEPARTMENT
W'� �-7 12 /
CITY OF RENTON, WAS14INGTON w— 1076
1 PERMIT
APPLICATION ONLY - UNTIL VALIDATED I NUMBER p -76
�i ' N e� T C��' 1)hl✓V�,L.z�,.rre) �i�.er.✓e�/1Se1.t�
Rorer `' Location of Work
Address
Z"t ZDL 6alJ-yGG9 1PX AturR a 3t19a0-ecss . 3 11440- 0060
q u 4/4 V4 2 '7 F_F_ i3 F 1-01-V
INSPECTIONS FEES /a A N
r/`^� CONSTRUCTION Sanitary Sewer/Storm Water Permits
Right-of-Way Construction �'��_•^���
PERMIT Right-of-Way Inspection Fees j1 Ltz�
1 No CO $ t7 (Public Right-of-way) Water Inspection/Approval Fee
Special Utility Connection Fee, Water 41f
FFRMI h In Water Latecomer Fee C7
Cr Special Assessment District, Water
I lif -0 Date Issued
Sewer Inspection/Approval Fees FhL1.
�'N 4-. CI CC — — Special Utility Connection Fee, Sewer
E<piration Date Sewer Latecomer Fee A
AN(A of C30N S. Special Assessment District, Sewer C
�. Sfihi' Iv�C�:noly Z ' . Ne
Reference Data - gi(yQ /S GRRDsNI Special Deposit, Private Latecomer �^
—"�' c,� Special Deposit, Cash Bond t O _
MF 6L L_ TOTAL FEE r 29 6
RF_C ft -G f.�'a ��OvNITS fin FAl I I
Description of Work
and Number of Feet illATEQ LlN&SY SFwF g .5I3JXj!� WAZE4
- 076
Contractor Business
ARIMFO QjT•OIIS License
Address / RQD. L1� 000 Bond
1��l
Telephon
RE+NMU- WA IIQSE 4�z- �i,/ 5'
IT IF UNDERSTOOD THAT THE CITY OF RENTON 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 MU BE DONE BY A
LICENSED, BONDED CONTRACTOR. LOCATE UTILITIES BEFORE 'eXCAVA
CALL 235-2b31 FOR INSPECTION.
Call between 8 AM and 9 AM for APPLICArTf
inspection in afternoon; call
before 12 Noon the day before
for inspection in morning. PUBLIC WORKS DIRECTOR
SPECIFY TIME FOR INSPECTION.
CALL 235-2620 for street signs CALL BEFORE YOU DIG BY
and lighting. 48-HOUR LOCATORS /
1-800-424-5555
CITY OF RENTON
MEMORANDUM
DATE: January 16,1992
TO: Water Project File W-1076
FROM: Abdoul Gafour p
i
SUBJECT: Water Meters Service Orders for:Sunset Gardens Condominiums
949 Aberdeen Avenue NE
Special Utility Connections fees for Water were paid under P-7686 on March 4,1991 ..'.'
Domestic Water Meters !!!
S.O.# Meter Size Costs
Bldg.A 2771 1-1/2 in. $.300.00
Bldg B 2770 2 in. S370.00 1{{{
Bldg C 2769 2 in. $370.00
Bldg D 2768 2 in. $370.00.
Bldg E 2767 2 in. $370.00
Bldg F 2766 1-1/2 in.
Landscape Irrigation Meter
All Bldg's 2705 2 in. $370.00
Fire Protection Meter
All Bldg's 2764 3/4 in.by-pass No charge
on 4 inch Fire Main
All meters are"Drop-lti only.(By-pass meter for fire line was supplied and installed by contractor)
Work Order No. 87127 Function No.5.5%for 1-1/2 in drop-in meters,No.5566 for 2 in.drop-in meters,
and No.5536 for Fire protection by-pass meter.
N .
T D r6 fna/ tvrlkihro�g��
WAS flO,Ibu Tcr u o„ Ne-wl�
1hS T Ai I t 7, LA*{-L-ti
-7'o Sv.,sB 7
.4&;WD/c-rn
.. .Qt�'7frn S7=nAl+tD �oaciflc-r<.e.+$
/�0 �actc�•nc.eS fiv..,d
M
{ ) STATE OF WASHINGTON
\� DEPARtMENT OF HEALTH
WATER BACTERIOLOGICAL ANALYSIS
SAY^!E CU'
It Instructions are not followed sample will be releeeD.
DATE COLLECTED TIrE COLLECTED COUNTY NAME
MONTH WY YEAR
C PM
HYPE OF SYSTEM IF PUBLIC SYSTEM,COMPLETE'
0 PUBLIC I.D.No. CHICLE CLASS
❑ INDIVIDUAL ' / 8 5 0 �. 2 3 e
NAME OF SYSTEM
�(A )j �
I On F1 ItoE'er
SPECIFIC LDCAi N MERE SAMPLE COLLECTELISYAEMQYNERr MUT NWEN�D NO
M u1eMn 1i A.eM1.y W, ranwM /�
SAMPLE COLLECTED BY:dMlnal
Ili/� (.'J ,
JURCE TYPE
L7 SURFACE ❑WELL ❑ SPRING ❑PURCHASED ,COMBINATION
W OTHER
SE ryD REPORT jp:rvnm Full H7.AabMA arq zm CPPFI _
)T,i C o
.AN",- G-GsytiaisC�—
1 -
Kc;a4vI W"HINCTON
TYPE OF SAMPLE
1.6 DRINKINGWATER ❑ CM��MteD lResiOuaf_TOtel_Fieel
chM:N IrAatmenl—fl. ❑ Filtered
❑ UOlreabdor Other
2. ❑ RAW SOURCE WATER
3. 50 NEW CONSTRUCTION or REPAIRS
❑ OTHER(SWHVI,
COMPLETE IF THIS SAMPLE IS A CHECK SAMPLE
FIEVS.US LAB NO
?REVIOUS SAMPLE COLLECTION DATE
REMARKS:
LABORATORY RESULTS ow LAB USE oum
MPN-COLIFORM $TO PLATE COUNT SAMPLE NOT TESTED
BECAUSE'
MORN DILUTION TEST UNSUITABLE ❑ Sample Too Old
A—; `I T, ❑ COrNlVant GMRNHI ❑ Not in Proper Container
MP COLIFORM
2. ❑ TNTC ❑ pm..d Gant lnl"RNIN n
t .. /10D ProritMd—Pleaae Read
FECAL COLIFORIfT
3. ❑ ELOW DaMIa Instructions on Form
❑ MPIY'E}MF ,. ❑ ❑
�lO aM
FON DRMIKKIO WATER SAMPLES ONLY,THESE RESULTS ARE:
SATISFACTORY ❑UNSATISFACTORY
SEE REVERSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS
"ONO DATE.TIME RECEIVED— RECEIVED BY
� ,�< ,
DATE REPO O IAaORATORY
RELIARKS
DC43C62 (REV.IM
WATER SUPPLIER COPY F.
i
N.ITICE OF NEW FIRE HYDRANT IN-SERVICE
NAME OF DEVELCIPPMENT ` c. RDE AuS
ADDRESS A.) _
INSTALLATION CONTRACTOR �%bc It It E Crv�iT n�c T.
WATER PROJECT NO. _ 'w - 1151 (o
MIMBER OF HYDRANTS Th rEE
HYDRANT LOCATIONS (FOR FIRE DEPT. USE ONLY)
1. STA +yD 2il RT HYDRANT NO.
2. S7A za 89 N7 " QT
3. _5L 4f M � 1�-s It
5. w-Jo 76
6. --2,r-
INSPECTOR