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CITY OF PORT ANGELES
DEPARTMENT OF PUBLIC WORKS
. . . . . . . . . . . INSPECTION REPORT. . . . . . . . . . .
REQUEST ~
Date 1.2. - y; - ~ 1
f'~
Time
Received by
(phone, person)
location of Work to be inspected
Name of person requesting inspection
Address of person requesting inspection
Type of Inspection (circle appropriate one)
Sewer Foundation Framing Chimney Plumbing
y ~( #51-
('( .u I (jl (0 C""T
l1 ~ i: Phone No
Permit No
Final Sewer Excav Other ~
J06
INSPECTION NOTES
Inspected
Remarks
Time By
C__t-R-e(:;');+!- I::n~/~/ i;:;j
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Date
I '1~;
.
RESTORATION REQUIRED
./'
NO ~
.. YES
~
l'
c(
~
,;;'( C-y
r )3' < 1
SURFACE RESTORATION
SURFACE TYPE D Unimproved D Gravel
D Repaired by City
[] Repaired by Permittee
[] No Damage Found
D Asphalt D PCC / D Other
Work Order # ,) J 3 /
,
~PlETE
D INCOMPLETE
1
1)(
~
(Continue on reverse side if necessary)
STREET SUPERINTENDENT
(DATE)
CIty of Port Angeles
Public Works Department
Water Distribution Repair Report
IWork Order No
CONDITION
L ;f,. ':)3 I I Crew 1 ( Y
r'?
1:Z- ~-D?
EMERGENCY 0 ROUTINE 0 CITIZEN COMPLAINT V
LEAKAGE SURVEY 0 OTHER 0
) J.... - <g -0; TIME ~ }QA.M. OP.M.
r ADDRESS J 60 l( 5.( If ( S+
DATE REPORTED
DATE OF REPAIR.
REPAIR LOCATION
TYPE OF MAIN
~'~ C~
J(
SIZE
....
DEPTH OF MAIN
CLOSEST VALVE DEPTH.
COMPONENT REPAIRED. /
MAIN JOINT 0 CIR BREAK ~ SPLIT BELL 0 LONG BREAK 0
HOLE 0 CLAMP 0 OTHER
SERVICE TAP 0 CORP STOP 0 PIPE 0 CURB STOP 0 FIITING 0
METER SETTER 0 METER 0
LINE VALVE FLANGE NUTS/BOL TS 0 STEM 0 BONNET 0
HYDRANT BRANCH 0 VAL VE 0 BARREL 0
OTHER. /
COMPONENTS OF REFAIR. CLAMP~SSERD OTHER
SITE CONDITION GRA VEL 0 ASPHALT 0 SIDEWALK 0 CURB 0
TOP SOIL AREA 0 SOIL TYPE
CUTS ASPHALT CUT _FT CURB CUT _FT SIDEW ALK _FT
DRIVEWAY CUT _FT
MAIN CONDITION INTERNAL LINING TUBERCULATION-MINOR 0 SEVERE 0
EXTERNAL CORROSION LOCALIZED 0 EXTENSIVE 0
CHLORINE RESIDUAL SAMPLE i~) ( P.P.M.
WATER OFF FROM 1:,t M. TO -!!/..ff M.
FROM
M.TO
M.
APPARENT CAUSE OF LEAK.
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