HomeMy WebLinkAboutWTR2702823 WTR-27-2823
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WATER PROJECT FILE
MOHLAND POST OFFICE(NE ITN ST)
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Laucks Testing Laboratories, Inc. Laucks Testing Laboratories, Inc.
.,, 940 S.Harney Seattle.WA 98109 940 5 HaF•uw Seattle,WA 90108
WATER BACTERIOLOGICAL ANALYSIS WATER BACTERIOLOGICAL ANALYSIS
SAMPLE COLLECTION:READ INSTRUCTIONS ON BACK OF GOLDENROD COPY SAMPLE COLLECTION READ INSTRUCTIONS ON BACK OF GOLDENROD COP`
If inetruetlons are not followed.sample will be rejected. It instmctbns am not followed.sample will be reje iad,
DATE COLLECTED TIW COUNTY NAMI DATE COLLECTED n COL�LCgp COUNTY NAME
MONTH MY WAR -1_ MONTH DAY YEAR .�pS IS�L.
(Yj ❑AM PM �A�✓_C - C� C7 _AM 2�1L �/
(ET IFF E OF S STEM IF PUBLIC SYSTEM.COMPLETE: , TYPE CA SYSTEM IF PUBLIC SYSTEM.COMpt ETE. ��
W PUBLIC i RIPUKIC ww�DLLee
❑INCINOuAI I.D.No. Cn BROUP ❑INDIVIDUAL I.D.Na / C CtFT�LLF OBROLA
t.r..aw t.arraaW nr wa+rt..e.a.I 111��� �!`.ok
NNE OF SYSTEM J NAME OF SYSTEM
%J. 1r/ I- f .f /11f n -,t 4, L34. CL-� _
Jn
sPEcsICLOCA11011WHERESINPUEOWAM TELEPIIONENO 9Ploicio Aatfas EWLLF�W TELEPIIONENO --
c L O 5-Tk xllz, C a .
1r/ DA
SA Ltt�6a� F %r-
EVEMNB I
COLLECTED BY:plan* SYSTEE- RANNI.:mam") OSY Normal SYSTEM OMMERMIGAL fNama)
80URCF TYPE L GROUND WATER UNDER UERCE SOURCE TYPE GROUND WATER UNDER UENCE
❑SURFACE PIMau w ❑SPRING ❑PURCIMBED a❑COMWAAM' ❑SURFACE 51 WELL% ❑SPRING 0 PURCMABEO y❑COMBpMTs
�'�y MC) NTERM WOTHER WELL flELO -NMRM oroTHER
SSIE.FKI PORT lO'(P1Y1t FUN FFl1e�rIaa,,Addlaas and Z4Co� �' ND T F��yn Name.AWaap a,le A
; ✓. bvY .P iS/m/!if AbtCi a7 A;:, f\f N1 M.•
TYPE OF SAMPLE Idwck only ona k1 Baa cOaarad 1`:f! OF SAMPLFIUback onN wr In ft,m',m,)
MINK ROUTINE
WATT R I[.,�Chlovrwlwf lRewdual total I rm•1 CJ DRINROUK WATER �1 Chlamaten(Fim,". TUL,I 1 r.•
cheek(mnnrwnt �1 arM chmi k Vealmint [ 1 Filtr—
Eat ❑lMinratM aFre✓V^ala
L]REPEAT SAMPLE _.__..-__ ❑RFPEIT SAMPLE
Pnvlcua cdlbnn plaaence - __ PnVmua coYfUrm prim.. Lap a._ _
CITY
❑RAW SOURCE WATER SILTY RAW SOURCE WATER pppppyyyyy���''���''���
TE ❑Fit Glenn ❑ $mRcf a TIE C A"."
Nf'.W CONSTRUCTION a REPAIR$ NEW CONS1Rl1CTl(N a HEfWIiiS
1 r]] 7 ❑Pa(af Ca1BNm � � �ll cool,.r
❑OTHER ISpaclNl _. �.'_(,f `— ❑]OTHER
I�S»�rlN�lREMARKS �
L1tji*it
I.d..7•��,+A G�C'�T_5 - 1i"
it"UK em)ONNWA WX M Nuave SAS Use ONLY)BNNKM tNA71R FirmllT1
❑UNSATISFACTOITt,CaaNmw luasea ❑SATISFACTORY ❑UNSATISFACTORY.Coafama paaMN []SATISFACTORY
CoYfarma abaan Colnarm Obtain,
E]E.OaY Patient E.Call sbMn1 REPEAT ❑E.COY Iaaaatd []EGO. apaanl
REOUMD SAMPLES ❑Faed IaaaMa ❑fawl apwnt REQUIRED SAMPL ❑F"Ewrnt ❑F-W abiwo
OTMM LASORATONY FAMLLTS --... _ OTTMII LABOIMTOM$**AT&
TOTAL OMWORM 1100 mI E,COLD /100 ML TOTAL CZ1OFMA 1100 ml E.COLT A MOM
FECAL COL.FORM _../tG)W PLATE COUNT Ina FECAL COLIFORM /100 mi PLATE COUNT /ml
ANOTHER SAMPLE REQUIRED ANOTHER SAMPLE REQUIRED
SAMPLE NOI TT.STED BECAUSE- TFSI UNSUIIABI F RF.CAUI l SAMPLE NOT TESTED BECAUSE TEST UNSUITABLE BECAUSE
❑S.PM too oM []ConMleltl growth ❑Sample loo old ❑ConManl gown
❑Wrond'.u'NY [1 TNIC ❑WrapcwnayeN ❑TNTC
❑h—rno-I—, []Tartar ,ufore ❑hKonlplata Nrm ❑Tlapd cuea,a
❑ ❑E-ii dWn. ❑ _.._.- _ _ ❑Eacaaa datas
BBB RBYBME SWE OF OMM COPY FOR GXPLANATM of RE LI Ts ME NRKME OW OF GREEN COPY FOR_BXPLAMnM OF MIWLTB
WM1 000,% MIT 7"WrIFIVTEI NEff Nit H, to LID It Oaalsl MTE.TIMERECEMD RECFNEDa
tl l
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aAIE NFMTFO lA9(NWY(wv DALE RFPDRIEU lA{aaMtDav
wwlwa MMWF
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Laucics Testing Laboratories, Inc.
960 S.Harney Seattle,WA 96108
WATER BACTMOLOGICAL ANALYSIS
SAMPLE COLLECTION:READ INSTRUCTIONS ON BACK Of GOLDENROD COPY
N Inotnoot""m m m t W 10"AhI aamPla WRI pa r*IW*d.
DATE COLLECTED I TI COLLECgp CDUNTv NAME
MpITM MY YEAR iapilii—TYPE Oi SYSTEM 6 PUBLIC SYBTYM,COMRETE:
�PIXp IC
❑IN 1 I. Np. -7 / C LE GROUPirvw N
NAME OF SYSTEM (
I Y
SP[CIF1L TELEPHONE NO.
V , EVENING 1
D BY:INamal SYSTEM OWNETVMOR.:(No"
SOURCE TYPE GROUNDWATER UNDER SUREA(�' 11 LUENCE
C7 SURFACE WELL a ❑SPRING ❑PURCHASED b❑WAlMAATIGN
WELLFIELD INTERTIE warwR
SI ND EPOR T Fyy N u w A"
TYPE OF SAMPLEIoMck Doty oM M SMa"Imm)
El ROUTINE
OR KIM! NC'WATER Q mat (HOWUN:
CMCk IWelmMt ❑Fft
❑REPEAT SIMPLE ❑1A111aalatl of
Prw'our conkum p,akarlq Lap a _
❑RAW SOURCE WATER Souea S o
KNEW CONSTRUCTION aREFIAIRS S
n Cdxn
❑OTHER ISDac'Iq'1
REMARISS
RM UK ONLY)DRIN M V AIU FAWATe -
❑UNSATISFACTORY,CdEaan p,aaatx ❑SATIBFACIppY,
REPEAT ❑IT Cok W111I ❑E.Cak eGYK80
CtXMar,l,a aMam
fta=m ❑powwi~,t [IFkal WUM
A
OTHM LABORAT01W REMlLTa
TOIALCOLIFOpM ..-. 1100.1 E.COLI !' itOp Ml
FECAL COlIFORM _ .nT" PLATECOUNT, _.AW
ANOTHER SAMPLE REOLAIIE'O
SAMPLE NO'TESTED BECAUSE. TEST UNSUITABLE RECAUST
❑Sal 1016 too old ❑CunRLwIt Erovnn
❑WYaq<aVama ❑TNTC
❑11vot„p4to loran ❑Tunw cuAun
❑_..___. ❑Exim ii tlktm
SEE REVERSE SIDE OF GREEN COPY FOp EXPIANATTpN W pESUITS
LA9 NO 0OKeTeI L
LIME RFC"o ,RECRVF.o ev
MIT"PMTEo tASORpWY
i
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aau x+os N,ev wi
WATER SUPPLIER LOPY
Laucks Testing Laboratories, Inc.
'^•. 940 S.Harney Seame,WA 98108
WATER BACTERIOLOGICAL ANALYSIS
SAMPLE COLLECTION READ INSTRUCTIONS ON BACK OF GOLDENROD CUPY
M Instructions am not followed,esmple win be reiscted.
DATE COLLLCILD TIMECOLL CTEO COUNry MONM OAv YrAR TI +!7^�
i �co ❑AM PM
TYPE OF S TEM IF PUBLIC SYSTEM COMPLETE:
PUBLIC
❑INDMOWL L •RS• CISM,E6ROUP
n.M.u+rr r MMnc i A-- 8
NAM€OF S$YSTEM ) --
SPECIFIC
TELY@PHdiE 40.
'¢ -LLT®tEM.INpO SY'Ys oYyNEnnADRh ORDIM WATER UNDER SURFACE LUERCE
[)SURFACE CjnYELL FIELD L-1 SPRI,, ❑I URCH,SED w KTN
INTERTIE Q BoMBMT POAT TO. _
_ n OTHER
-
`'- IPmt FuM Fyme,AeAesa And
ZIP
<l.,
IAn.nmae r -rS(,
TYPE OF SAMPLE fcM,k onty onA In ml,cdumll
❑ROUTINE
DRINKING WATER ❑Colon,yePa IAxxiOual. T n,I Fryl
chFck IpInwnl L terW
❑RE PEAT SAMPLE Eat pp
Provroue cdaorm weuercx �V... s
Iat
CITY
❑RAW SOURCE WATER s ❑1 TOMI Coliryrm
NEW CONSTRUCTION w REPAIRS r7 C��❑ �,J ecN CdNrnn OTHER ISSpw,f l F
IW Use ONLY)UIMWMW INATOL R&T
LINSATISFACTOW CaMbn pp "m C7��TORy,REPEAT ❑E.Coh present ❑E.Coh Mfenl
ejaga
REOUIREDES ❑Fecsl pM'enl ❑Fscol sMsnt
_7�O"IR—LAMNCHRA .1�Y RESmm
TOTAL COL60RMf'T npDm E COLIA 1100ML _....
FECAL CCY IFORM__- Moo" PIATE COUNT_-. nM
ANOTHER SAMPLE REOURED -
SAMPLE NOT TESTED BECAUSE TEST UNSUITABLE BECALM
❑Sllmple t-w u ConMrenl r mh
❑W v v psmsatsr TNrC.
I �IntWnPlnl.Mrm r❑r,,nppKt nullun
LJ Esegs Csana
Sf L HI ye.AS!910F.OF GREEN LOPY•DR E%PLANATION OF RE0 UE
-..en Ho vlumis, an nME Plcr�vFn
P!clNrn ey
14rE Rltytgrrn UAIXUt(Kly
nF W1Mx I
V(Y,>m WiIIEv ayi
WATER SUPPLIER COPY
lhJ? 74& fKi
1UF,ecQ.S Lu�eS o�p C �lU���c3`��� �5�3 �✓
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PROJECT NAME: /;! r - S )OJ f
ALIAS:
CONTRACTOR(IF KNOWN):
PROJECT NUMBER: it//r'
WORK ORDER NUMBMb
STATE CONST.REPORT
SIGNED BY:
YEAR PROJECT TAKEN INTO PLANT;
RECORDED BILL OF SALE:
RECORDED EASEMENT:
COST DATA INVENTORY: PIPE S_ Hl DRANT S
BACKFLOW TESTS: Y N
PURITY TEST: no.taken Tat No(a)_`F)T tt
PRESSURE TEST:
f'�1tc.T MANAIsGpe.:
0.
s®^�°�a
y'
Short Plat' R__ )
REQUEST FOR PROTECT M Prelim Not (PPII )
CAG 0 )
To: Technical Services Date WON1It`7 F) S GreenN
From: Plan Review/Project Manager p�yt r t�Qti/
Project Name '—'� ley�.IlQ_-- C/dQ<CA.. It4 .yam
ULI 00 elan roan)
Circle Site of Waterline: 10" 12" Circle One: ew or Extension
Circle Site of Sewerline: 8" 10" 12" Circle One: New or Extension
Circle Sire of Stormline: /12" 15- 24" Circle One: Ne or Extension
Address or Street Name(s) �' 4�r��(�
Dvlpr/Conttractor/Owner/Cnslt : ZLZ�Q & 5
A V O nnw41 CJ o emmaca
t.a.�Q L"
Check each discipline involved in Project Ltr Drwg N of sheets per dis ?line
f ✓ ✓
V Trans•Storm Rye
(aaadray/0eaioate) (Ott alv.unpmvemenuxlndudebuln none)
(mduda TFSC aheeu)
� Transportation tiiaw„adonav,r,<nuaon,uahcny
O Wastewater O O
d
�/' S.niury tewv Hain Cmclude buin name) `
Water (Atai�u,uJ.u,H)dMu) PI-1-Lo--�
(Include mmpedn a Hodmnul co Shmu)
❑ Surace Water ❑ O
Improvements (CLP Y7)in-l"Wba+inna ,)
TAD- a►U • ;�5?l3 R �S,a
TS Use Only TRLI • r 11 7$ - —
wtR �7-a It! a3 W AU-4
()LP a7— �JI3 Lu CuL onzq