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CITY OF PORT ANGELES
DEPARTMENT OF PUBLIC WORKS
. . . INSPECTION REPORT . . . . . . . .
REQUE6" t' r:
Date - -"'7 - C I
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)
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Phone No
Permit No
Sewer Foundation Framing Chimney Plumbing Final Sewer Excav Other (., ,(J .c{~ J"'--
INSPECTION NOTES
Inspected Date
Remarks
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RESTORATION REQUIRED
YES
/
NOV
SURFACE RESTORATION
SURFACE TYPE 0 Unimproved 0 Gravel
[] Repaired by City
[] Repaired by Permittee
o No Damage Found
o Asphalt 0 PCC
~l Qrder #
COMPLETE
o INCOMPLETE
o Other
>)0 :/ 0
(Continue on reverse side if necessary)
STREET SUPERINTENDENT
(DATE)
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Public Works Department ~- lAiF#SO<{..o
\Vater Distribution Repair Report
DATE REPORTED
?DLjD
t =- 7--6}
I Crew
IWork Order No:
7/t/
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EMERGENCY 0 ROUTINE 0 OTIZEN COMPLAINT /
LEAKAGE SURVEY 0 OTHER 0
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CONDITION
REPAIR LOCATION
ADDRESS
TIME.
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a...(. tll C- SIZE.
-( )rA.M. OP.M.
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~
DATE OF REPAIR.
TYPE OF MAIN
DEPTH OF MAIN
CLOSEST VALVE DEPTH.
COMPONENT REP AlRED:
MAIN JOINT 0 CIR. BREAK 0 SPLIT BELL. 0 LONG BREAK 0
HOLE 0 CLAMP 0 OTHER /
SERVICE. TAP 0 CORP STOP 0 PIPE ~URB STOP 0 FITTING 0
METER SETfER 0 METER 0
LINE VALVE. FLANGE NUTS/BOL TS 0 STEM 0 BONNET 0
HYDRANT BRANCH 0 VALVE 0 BARREL 0
OTHER.
COMPONENTS OF REPAIR. CLAMPO DRESSERO OTHER
SITE CONDITION GRAVEL 0 ASPHALT 0 SIDEWALK 0 CURB 0
TOP SOIL AREA b{ SOIL TYPE
CUTS ASPHALT CUT _FI' CUR.B CUT _FI' SIDEWALK_FT
DRIVEWAY CUT _FT
MAIN CONDITION INTERNAL LINING TUBERCULATION-MINOR 0 SEVERE 0
EXTERNAL CORROSION LOCALIZED 0 EXTENSIVE 0
CHLORINE RESIDUAL SAMPLE t 1-1 P.P.M.
WATEROFF FROM 7..>>AM. TO C; 1'1 M.
M.TO
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FROM
APPARENT CAUSE OF LEAK.