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Home My WebLink About1600 S O - Building JI 0" r: . ", . N~ 04330 "'\: C> -. APPLICATION FOR PERMIT It> ~ OWNE';;:/l1~ 73LA_e -' j LOT BLOCK5t- i 00 (Print Name) /I 1/ 1?>r:A ~ JOB ADDRESS {5 :;;./ /<;?t7v , SUBDIVISION / \ t> hereby makes application for the fOIIoWi.,J, c:: 1. 2. Work to be completed by (date) Location of work: Outside Inside traveled roadway (if within traveled roadway, complete items 3, 4 & 5) Value of work to be performed (If over $2,000, complete item 6) Contractor name OR Performance Bond Amount I~~ Proof of insurance 0 ST ~ Work $2,000, and less: $50,000 personal iniury, $100.000 per incident, $20,000 pro~erty Work $2,000 and more: $200,000 personal injury, $500,000 per incident, $100.000 property Permittee understands that no street may be ciosed to traffic unless approved by the City Engineer and Chief of Police and notifications given to the Chief of Fire Department. may be closed to traffic from llo l:h ~ /2;1:1-, I 3. 4. 5. 6. (street) to ~ty Engineer f.J)~ qnMMENTS/COND~TIO~S l:~51()t:!d~'rD~/~c2t?!4!!iJt!e~~ 10 \ l7\~ ~ -n J //.9-8 0/& -r'tJoi!!!.- S'd.walk..m~ ~ 0 \l ~ 0 r C{ Cu.rb/Gutter ,.... . ............... ...... 60.00 ~)_'4\)~;; \);;- /).Ja:~...e.-l/~U ~. g::.~~;~'~.rt .....:::::g:~ ~ q. \ (\l'(~ g ~ =to ke v-U..u-J a>-J ~- San"T 1~~~;r~~~i :::::::::::::::::::::: 80.00 \ ~. ~ (/J ~ II WATER MAiN (J) ~: ~~~r:~~~:~~) SEW 5. ~p.. SANITARY ER (includes W/M removal) /1 STORM DRAIN 6. Secondary Sewer Treatment HO r T/If? TELECABLE Ch.-d-O-<J e...(.~torm DrainAssessment .....m.....m............ ....m......m..... ;::;11 lmil/II TELEPHONE UG ,. Tap ..................................... UTI L1TY POLE 2. C.B. . ~W;h:~ ffhe~~.pe~r" ?2}2:.reed by::;,:~.;s Waterte~:: ::::" ..... t ,7v'~f'j?c;i .rmleM 3. Commercial deposit o e apPIlCflnt from any liability or reepon.lbilityfor any accident, Iou or damage to (Based on estimate 1~=$1,OOO.00 deposit) ..... 1381'SOM; or property, happening or occurring a. the proximate result of any work 250 00 undeltfl'lWn un6erthe termeo' thi.applicatlon and the permit or pennitawhich may be 4. Hot tap ....................................... ................... . granted in reaponee thereto, and that all of aid Ilabilitlee are hereby auumed by the 5. Fire Hydrant install (deposit) ................... :;~; X J;rLed:x. PJ-~ ~~~:nentm~":~~~~~~~~~":~H~~ Telephone No. Non-traveled.. .................. 160.00 Curb removal ........................... .................. 160.00 Mailing Address Chief of Pollee Fire Chief ol) V ")1~~ .............125.00 ....................40.00 ................... 475.00 ................... SOO.OO Thiaeertifi" thai the above named appIic"nt is lIIan1ed the permita 10 do the """,k d&&cribed in end lor the purpose shO'M'l in the appIicatiCl'l. Each penn~ iSlIIanted wbject to the terms 01 fle ag'''''''''1 contained in the Mid apphcation ands.ubjecllo the prOVlfllOlls of the code of the City a! POl't A.ngeltM.. and nothing permitted her8Under shall be deemed 10 overtide the provi&ions 01 al)' applicable law of the Cil)'. Stale or Federal Gowmnant Permit total ... Restoration total........ TOTAL ... Receipt No issued b 24 HOUR MINIMUM NOTICE REQUIRED PRIOR TO SERVICE OR INSPECTION Call 48 Hours Before You Dig: 1.800-424-5555 Work Order No. P.O. No. Warrant No. Rnance - Amount deposited ..................................... $ Receipt No. PUBLIC WORKS W& ~ 1 g Refund amount due ................................... $ WORK ORDER # ~ Additional amount due.City ........................ $ . PERMIT. N~ 04330 INSPECTOR'S COPY - white AP~CANT'S COPY- pink. OFFICE COPY - ~ary ...v _ . _. '_,1./? _ /1, . . PonP,int, Ino.5I92 ~ ..720/0 pu i.-?~~?~ K~~= 710531 Cost of repair (W/O #) ............................... $ . CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS . . . . . . . . . . . INSPECTION REPORT. . . REQUEST: A "-- ~ Date 11/;1-) I'/? Time -3 :>~ Received by \ // /1 Location of Work to be inspected () '<;T Name of person requesting inspection \>,,~ rf\~:.~~ Address of person requesting inspection Phone No. ~ Type of Inspection (circle appropriate one): Permit No. ~ ~~Foundation Framing Chimney Plumbing Final Sewer Excav. Other ::!.!;I~:~OT~~.bI4?-aJ~im. 1ft- BV~~ Remarks: (' 0 "'" ? I o""1P -p / / ' /~ o-""A /ib:- (phone, person) . 1( RESTORATION REQUIRE, fv r!L- ES NO 'rt ~ '" c.;\'l \1) . I Cl-'f 1 G \ _ -0 V 17/cJPQ.\ )( o. c. ~ III " / ~ t ~ ~L- ~ 18~ SURFACE RESTORATION: SURFACE TYPE: 0 Unimproved 0 Gravel 0 Asphalt ~~ ~ -('\ ~ ~ \\'\ OPCC o Other o Repaired by City o Repaired by Permittee o No Damage Found Work Order # o COMPLETE o INCOMPLETE (Continue on reverse side if necessary) STREET_SU~ERINTENDENT /n4TFI .. CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS . . . . . . . . INSPECTION REPORT . . . . . . . . 0\r REQUEST: Date /Z - J - t.f?- Time I Z,' :> 0 r. ./Vl. Received by 7/2 e /J 114 (phone. person) , c- d.J 5'~ Location of Work to be inspected / cJ -~ 'i" 0 Name of person requesting inspection .J /~"l Fo .Do e Ie c~ Address of person requesting inspection SELdER 7ft!" Phone No. t:Y-i- / G:J ~ Inspection (circle appropriate onel: Permit No. 4-3;? 0 6 Foundation Framing Chimney Plumbing Final Sewer Excav. Other ~ 5' (, 4- d' INSPECTION NOTES: Inspected: Date /2 - .s - r Z- Time /.':J' tJ f? JYI . By Remarks: ;\1J4 D E 7/:t,p oN /tJ" 1,-v.C'. j"Gf.uE"/Z:" jV!/4 IN S/tJ/,,- jv1;d tuH'I /Yr--/ USED lof-G 1/71'=- SA!:>!:> /1= , , J, ? 17 <;"/:J qfZ 7.5- I rOle> N/?'W .J'c;e,j//CI~ . ( " " ~ ~ . , I , -{~f "l 40u to- /' N \ (,"fF':V".~,.. 1;./ / ~I (( " \:) ) .--- 'tl ~ I J>-i:..~ sT ~ RESTORATION REQUiRED...... YES X. NO ~ SURFACE RESTORATION: SURFACE TYPE: 0 Unimproved )Q:Gravel o Repaired by City o Repaired by Permittee o No Damage Found o Asphalt 0 PCC Work Order # o COMPLETE o INCOMPLETE o Other (Continue on reverse side if necessary) STREET SUI'F;RINTr=Nnr=NT fnA.T.&:' - . CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS . . . . . . INSPECTION REPORT. . . . . . REQUEST: Date /'Z--/cr-9 ~ Time e.f: >0' /',.<-1 Received by (phone. person) "'.... ~O"" Location of Work to be inspected / 8 - ~ f~ ~ .E?~. Name of person requesting inspection Address of person requesting inspection v ~. _ Phone No. Type of Inspection (circle appropriate one): Permit No. Sewer Foundation Framing Chimney Plumbing Final Sewer Excav. Other INSPECTION NOTES: Inspected: Date /'Z--/6'-9z...- Time c.j: J 0 .l""'rt1By ICN J~~ , Remarks: ~~~;-A:::> r:o/ $/ ~.o .oFffY ~/'rlZ.&1' sz:-( (-V ~ / ~ ~ :; r; ;R/ to (~F n:Ite. "-Ar6hr~ r-J ~ Cri-YA-nrl 6- ~6- 7#E:- d~ Jjpc- . -::f'b ~r F/~ la'!;:=:. 7ZJCA7 ~ S"OrV'~ A-f-L, ~ - ~ ~ -r;et..e 6' ~- C-(/ , RESTORATION REQUIRED. . . . .. YES NO SURFACE RESTORATION: SURFACE TYPE: 0 Unimproved OGravel o Asphalt OPCC o Other o Repaired by City o Repaired by Permittee o No Damage Found Work Order # o COMPLETE o INCOMPLETE (Continue on reverse side if necessary) STREET SUPERINTENDENT (DATE) CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS . . . . . . . . . . . INSPECTION REPORT. . . . . . . . . . . REQUEST: . Date Time Received by (phone, person) /1 ~I Location of Work to be inspected () ()r./ o!- -'V /~ Name of person requesting inspection Address of person requesting inspection Phone No. Type of Inspection (circle appropriate one): Permit No. Sewer Foundation Framing Chimney Plumbing Final Sewer Excav. Other ;6 0C tJr ~~ 7f!?,cj 7b v RESTORATION REQUIRED. . . . .. YES NO SURFACE RESTORATION: SURFACE TYPE: 0 Unimproved OGravel 0 Asphalt 0 PCC o Other o Repaired by City o Repaired by Permittee o No Damage Found Work Order # o COMPLETE o INCOMPLETE (Continue on reverse side if necessary) _SJREET_SU~ERINTENDENT_-_ln4T~\-- - CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS . . . . . . INSPECTION REPORT. . . . . . --- Time 3 ~ Location of Work to be inspected Name of person requesting inspection Address of person requesting inspection Type of Inspection (circle appropriate one): C~;oundation Framing Chimney Plumbing Final _____ J ~~ INSPECTION NOTES: ~ /~ Inspected: ,Date /~ 4,,9-- Time Remarks: ,(::>>"""1> I-,,~ . . REQUEST: si Date JI / ~ '1;;- I - 'Ii 1~ Received by ~ / ' (phone, person) '1.P1 1/ LL ,OS1 /~-tI- "* /B~ Phone No. Permit No. Sewer Excav. Other B~ By '--1~_ NO X RESTORATION REQUiRED...... YES ~1/f'U~ I~ ' ~ rt0 j t- J \ :0 '~ ~ by c7ry )s-f )t..~Je..a.l Vi ~L J 6 -c!c- SURFACE RESTORATION: SURFACE TYPE: 0 Unimproved 0 Gravel 0 Asphalt 0 pcc o Repaired by City o Repaired by Permittee o No Damage Found o Other Work Order # o COMPLETE o INCOMPLETE f'.- "~~/~ I~~ (Continue on reverse side if necessary) .. $TREET_SUI!ERINTENnI'NT 'DA:n:\ CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS . . . . . INSPECTION REPORT. . . . . . . . . . REQUEST: Date / Z - / - 72- Time /Z.''JiJ I?/fi. .-- . Received by /f:'EN 1J4 (phone. person) Location of Work to be inspected /P ~ ~ dd Name of person requesting inspection ' } / /V[ f3 Po c kj..-=- R- Address of person requesting inspection S:fftJE: f!. I/-l 'P Type of Inspection (circle appropriate one): e Foundation Framing Chimney Plumbing Final Phone No. l~'f, ,- / c, .3 Permit No. 4320 '5f& Sewer Excav. Other :3 C, 1-C. INSPECTION NOTES: Inspected: Date /2 -1- '1 z... Time 1.' 5'0 /'1//1. By Remarks: M J4 DE 7A f' (fAr / tJ " r: J/, cf. 1--1/4 /p / c . c,' PiZ'?-,. M-I if S"F6 to 1<- C; 7i::-E !:PI D D/r=: FIR ,.vEw .s'eRI//d I': J(~. ,9 f'c I S/ L7/-- /If:dw!l y ) \\- . \ ~ . \ \ - ~l '() " , '1.. I cf'f{ 51 " , RESTORATION REQUIRED . . . . .. YES Y NO SURFACE RESTORATION: ' SURFACE TYPE:~nimproved !<GraVel o Repaired by City o Repaired by Permittee o No Damage Found o Asphalt 0 PCC Work Order # o COMPLETE o INCOMPLETE o Other (Continue on reverse side if necessarvl STREET SUPERINTENDENT (DATEI REQUEST: /4. Date II ?' , Location of Work to be inspected Name of person requesting inspection Address of person requesting inspection Type of Inspection (circle appropriate one): CS;~Foundation Framing Chimney ~T10N NOTES, d I Inspected: Date I ~ tf;}- Remarks: CC>""'f Lete::: . CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS . . . . . . INSPECTION REPORT. . . . . . /' -3 .:>-::) ~f Time --r;-::;:.; / I /&V _# /rr Received by (phone, person) 1101/ Sf' I Phone No. Permit No. Plumbing Final Sewer Excav. Other y(~ ~/!!l- By =-ud- Time t RESTORATION REQUIRED . . . . .. YES NO ex I f{~ SURFACE RESTORATION: SURFACE TYPE: 0 Unimproved 0 Gravel 0 Asphalt 0 PCC o Other o Repaired by City o Repaired by Permittee o No Damage Found Work Order # o COMPLETE o INCOMPLETE (Continue on reverse side if necessary) _ .STREET_SU~ERINTENDENT fnAIl=l__ CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS . . . . . INSPECTION REPORT. . . . . . REQUEST: Date 12 - Z - cr 2- Time rZ::JtI)f frI' --" Received by / P F /II J A (phone. person) Location of Work to be inspected /(f ~ P () ff Name of person requesting inspection J J:vr f::O d d (l~ k: I~/L Address of person requesting inspection _rEttlt3"~ --;/:lP Phone No. /YX 1- Ie, J' ~spection (circle appropriate one): Permit No. 47 sO L/roundation Framing Chimney Plumbing Final Sewer Excav. Other 564-7 INSPECTION NOTES: Inspected: Date 12 - 2 - 9'"Z-- Time /.' 70 /l, iff. By j I ~ . Remarks: M.Hf,>k ",7UO oN" /()"SEaJ6~ MItI:V /7,6h <,;,!('pl(?' .F/aj=- MI ctll/cJ:!1 TAJ~)iq11~6 /(jX<;, 770-10.. SA{JD (r:;: nk'. A/L-::'c.J JI7Rt//d:li- RESTORATION REQUiRED...... YES ,X NO ~) ~ " ~ .... C-1! '0 /([,6 r\ ~ ~ \: , /~ / -... SURFACE RESTORATION: SURFACE TYPE: 0 Unimproved ,lQ'GraVel o Repaired by City o Repaired by Permittee o No Damage Found o Asphalt 0 PCC Work Order # o COMPLETE o INCOMPLETE o Other (Continue on reverse side if necessary) STREET SUPERINTENDENT....- _ _ {DATEI . / . , ~ j \,11 , vr rvn I I-\NUt:Lt:>:), WA::iMINli I UN (/ TREASURER'S OFFICE _.-= F 321 E. FIFTH int 457-0411 P.O. BOX 1150 DATE OF RECEIPT, --A----3 -- 3.. "J 2--.- RECEIVm OF ----D.~~ - ( ~<L S-o -f;: fr 5 " =- NO_ Credit 10 Acct. of IN PAYMENT OF AMOUNT - <;" ""'"c.... ,"Yuro . .\)..., /1<(1 Current --:; ..e..e... LCJ/O 1 Exoens8 0 '"8 Pari< (;;~I}Yr~ ' ~ 4- :::> a..; Cemetery Police Convention 2 Center 3 Street Arterial 4 Street Revenue 5 Sharing 6 light - . 7 SewerfWater 8 Solid Waste 9 Equipment Rental Off Street 10 Parl<lng Flremens 11 Pension 12 Cemetery Endowment LI. 13 Guaranty 14 Self Ins. 1978 G.O. 15 Bd.. Investment 18 Portfolio 17 LI.D.S. 18 Utilities - ~~Jl<l'lt c- 4 0 53_Qt REC.'O.BY ;;t~ II TOTAL 7..-0 I () PAYM'T. OD .- -_.- . - ---- ... . . '" C' PORT ~Iv, .... _,,=~ G'<: ()~~7=:~~(~ '" ..-~ --_.~ _ :tt~~.~~ ~ F;;;;?'. .- MEMORANDUM 321 E. FIFTH ST. P. O. BOX 1150 PORT ANGELES. WASIIINGTON 96362 PHONE (206) 457-0411 FAX (206) 452-0353 '" .6 'VeL Ie vf)"'''' January II, 1993 TO: TRENIA FUNSTON, ENGR. TECH. FROM: RON JOHNSON, ENGR. SPEC. RE: , .~ ,~ ~ ~ ~I INSPECTION DEPOSIT FOR PEACHTREE ESTATES The construction inspection deposit to be collected with the issuance of the right of way and utility construction permits for Peachtree Estates is $4,100.00. This is an estimate and will be adjusted based on the actual inspection hours. Inspection Estimate: I. Curb & gutter 2800 l.f. = 9 day x 2 hr = 300 ft p/day 2. Sidewalk 500 l.f. = 3.3 days x 2 hr = 150 ft p/day 3. Sanitary Sewer Pipe 1400 l.f. = 5.6 days x 3 hr = 250 ft p/day 4. S.S. Manholes 6 each x 2 hr = 5. Storm Drain Pipe 2100 l.f. = 8.4 days x 2 hr = 250 ft p/day 6. Storm drain Structures 14 each x .5 hr = 7. Watermains 18.00 hr. 7.00 hI. ~ ~ ~.~ ~ ~ ~ ), " l~ . j 16.80 hI. 12.00 hI. 16.80 hI. 7.00 hI. 1950 l.f. = 3.9 days x 2.5 hr = 9.75 hI. 500 ft p/day 8. CSTC & AC Paving 3 days Total Use Construction Inspection @ $28.53 p/hr x 112 hrs = Estimate for Phase I inspection not paid Administration City Engineer @ $29.91 p/hr x 10 hrs = Total Estimate Peachtree.RWJ A ~ .c /'rOO 'it?tJ~ II"" /~ ~.5r /5 ~.s~~ 24.00 hrs. 111.35 ] ]2.00 hrs. $3,200.00 600.00 300.00 $4,100.00 * ~~.. < Ii. PUBLIC WORKS CONSTRUCTION rIil and RIGHT-OF-WA Y PERMITS .. City Phone: 206-457-0411, ex!. 124 . .>r"UCANT/OWNER~h7tl;1I7 f?,-z;u tJ __ ADDRESS OF JOB: 10 ~ /61 u. 2t /~ APPUCANT ADDRESS: PHONE ::2:5007 LEGAL OF JOB: 'J?p ~ ~~ (2 WORK IS 0 OUTSIDE or 0 INSIDE OF TRAVELED ROAD VALUE OF WORK Is:l Lot ~ 'ill 9/(rr~r'Vts~~d'~wav and is equal to or less than $2.000, then permit may be issued to other than licensed and bonded contractor.) .PERWT 00083 PLANS REQUIRED 0 YES 0 NO CONTRACTOR: PERFORMANCE BOND REQUIRED 0 YES 0 NO AMOUNT: $ PROOF OF INSURANCE: 0 Work $2.000 or leSs: $50,000 personal injury. $100,000 per incident, $20,000 property o Work over $2,000: $200,000 personal injury, $500,000 per incident. $100,000 propel1Y o Right of Way Use: $300,000 personal injury, $300,000 per incident, $100,000 propel1Y DATES FOR START & FINISH Permittee UDderstanda that no street may be closed to traffic unless approved by the City Engineer and Chief of Police in advaoce of the clOSllIe; that there is a 24 hour minimum notice prior to inspection. and to call 48 hours before digging to: 1-800-424-5555. Ia. .. . t1ldlllftSlaaoltWI,.....Il.~....\lrU.llppibs...lbIQyolPlxt~_..oll!.~ot~UalJbe....batmlilMlDu.~l'TaD~1IIIbWIyot......ibil.ity for..,.8Cddca.._CII'dam.,to~arpn:lpOft)', ~orocr;urrlquu.prcai:Im~ftlINit oI~ -.twdcl\&laI.....,tm ICmaoluw .~IKatimU'ld \h: I'Crmit OI'pcrmi,-....nicbmay be ~ ia ra_ u..-._m.&Uol..ad 1IabI.1lLio....r...t.y__ by lZliaapp~. Signed: DATE: ..... = ~ Rl:n'o I I I I I lYPI! FEE PAID TYPE FEE REQ'O PAID lJOKT OF WAY EXCAV. "'JIl ~,EWER tSFRI (6" 10 PtL. 6'a4" ....00 SIIlEW"v '-JIl. SAN. SEWER tun.'. lit ~I ~.OO ...,"""" 1125.00 SAN SEWER. tL FR' . ADD. UNIT ".00 DllVEWA Y Sl2HlO SAN SEWER OTHERS . MiDool7j,OO; SO.(X)jlll Ma-S750 lOOOCDotl$O.OO2j e1<Za& D'NY C\1Lyarr ,,_............ "'JIl SEWER TAP- BY CITY NO S12HXl>1JlXl.00 WYE/MANHOLE TAP mEETCllT.1laIIlon&icI:I SD.oo -M lql4~J SEWER CAPfWATER METER sm.oo REMOVAL OTHER RJOilT OF WAY WOIlK ....00 LllfO~~ ALTERATIONI SJO.oo REPAIR TO SE'NER FIIUlHYDRANr DEPOSIT Z'5MIJ.l STORM ORArN TAP 512J,OO 11 RE!. WATER SERVICE I" X SI8" $350.00 hl~ :3;;<' r::o-" l~DnPE' EACH 5<1),00 lE3. WATER SDV1CE I" X )(4" SJ7'-CO . . 5" ?''ftl P S<ll0,OOin 561HO",,--oOc Ii I\R ASSESS. lE3. WATER S"'"VICE ,- X I" '-.00 . ,j,,, (J R S, 0 . CHARGE 5nHXlfE'WM COMW, WATD. SERVICE '" - S1,OXl t1. t~ : MU.WA:A DR. S ESS. 5150,00 IE'NM ~':-I~~ u ...., -J&!:. - e>l. ~;ToFMy~~ WATER SERVICE - 0TlIER ESTIMATE VARIES S~. 5100 WAT'D. SYS. DEV. CHARGE 1730.00 I'EWM TOTAU . . .~ na.~ Ihal.u. abcMIMIDd~ ia IN.IlIIlId~ pcrmiw \0 00...... "'<11" ac.crib:l4in&ad for liD put'p<>>O ~ aD liD IPPliOllion. EacbpomulII lnnIal"utlJlCCl10 l1-.. "'...... oflho. "r.ftlCITCa. calLIinod aD lb: "Wlicau...., Illd"""" 10 1bo,...,..;Aca cllbo City 01 Port Anp_ MIftic:ip&J C~_ .,<-.hint Ill'rmiUedbl...mr u-.ll i&deema:I lO",,"1"r'Ido! Iho. pmv;.K:no oJ"", Ipplicablir 11..- oflb: Cil', CCU'lI~, 51-1'" ~"'. D. COMMENTS/CONDITIONS: V::Yn . - // {7 \ W//n C>~ L3t/r-J~r 0}"rpe r;d e-. _.urn o InstalI 0 Repair :5 T I"H / ./ '/" f ~~iC./" - -DWatermain (/d-//" /~/91 /701 I?b?/ ./7/ C Saaitary Sewer ....... Ho- -I4P @ /~ ~ z.' 8; . '//~g)oD C Storm Drain v AJI, / I . ,/ ~ec-::d. CUadcrgroundTelephone1Elec'trical /A./STnL.L- /B't:IJ ;;. Z3(/~/~rsTr._ yO '1)3 (12193) RECEIPT # ex. ISSUED B~ DATE: T (fi2 ~J('i}~/600~bRKORDERNO' "'- meier-so/? i?u71v:... db_~ 00083 INS~OR'S COPY---WHrrE_APPLlCANT:S.COPY___PINK_0FF1CE-COPY. CANARY PERl\1lT (OL ':3{POC/ to ')f4vL../~~ wA- ?CJ3c) .;KMIT TOTALS $ INSPECTION FEES $ I ~ "ORT "1,1,1 o _ . Q~ .....4. /,. ''< .... 4' ~,~..... <f'. o .. I/l ~~~~, ,~, .. .. -'.,' ~ ;;.;;:r .-,' . ",..,",f",.t ft&" ':;',~~"'~ ~ CITY OF PORT ANGELES ---- "'~: .o~"" U8LIC WO~'f: 321 E. FIFTH' P.O. BOX 1150 PHONE (3601 457.0411 PORT ANGELES. WASHINGTON 98362-3206 FAX: (3601 452-0353 October 25, 1996 Pacific Ventures Limited 9721 45th Ave. N.E. Seattle, WA 98115 RE: Utility fees for Eagle's Lair Subdivision Dear Mr. Bergsma Per our 'conversation I have compiled Eagle's Lair Subdivision. the utility fees r ~/ {pO associated with the Lts 1-6 along West 16th Street: All water service lines with boxes are to property 'line. Fees for drop in water meter $125.00 each lot. The water main was installed by private contractor. Sanitary sewer connection ~+ ~OO sanitary system user fee each lot. ~ ;2/&0 - Lts 7-13 along Butler Street: All water service lines with boxes are to property line. Fees for drop in water meter $442.86 each lot. The service lines were installed by City forces, partial payment previously made toward construction made by owner. Sanitary sewer connection $80.00 + $410.00 sanitary system user fee. Lts 14-26 Delores Place: bl-OIO - All water meters are installed and paid. Sanitary sewer connection $80.00 + $410.00. Lts 27-32 no" Street: t?-/ (PO - All lots will require new service lines / with meters. Existing lines on property do not have corp stops, so crew will need to go back to the main in no" Street. Fees for each lot will be $550.00. Sanitary sewer connection $80.00 + $410.00. Because of previous quotes to the developer of this subdivision the sanitary system user fee mentioned above applies to this subdivision only, the fees have since been restructured and increased. Upon application for building public works permits please bring this information with you. If you have any additional questions, feel free to contact me at 417-4807. Siqcerely, .~ JJ>1f-_l4L-- 'G-if~~~{O'L- Trenia Funston Engineering Permit Specialist . - , PUBILlC WORKS & R/W PERMIT D Attached Notes OWNER/APPLICANT Issued: 1 1 Permit No: Work Order: o PROPERTY LOCATION 0001000-0000 PROJECT INFO Work is: Lot: Subdivision: Parcel No: Block: 2 '- Eagles Lair ~ Long Legal Value Work: $0.00 Plans Required: Start Date: 1 1 Finish Date: 1 1 Contractor: 0001000-0000 Performance Bond Required: Amount: $0.00 Proof of Insurance: Work to Perform: ~ Install ~ Sanitary Sewer ~ Mise o Repair ~ Storm Drain ~ Watermain 0 Underground Tele/Elec PROJECT NOTES All water service lines with boxes are to property line. Fees for drop in w/m $150.00 Its 1-6. Sanitary sewerconncetion $95.00 + $745.00 FEES ASSESSMENT 1.) RIWExcav: $0.00 15.) Other San Sewer: $0.00 2.) Sidewalk: $0.00 16.) Sew Tap Wye/Man Tap: $0.00 3.) Curb/Gutter: $0.00 17.) Sew Cap/W/M Removal: $0.00 4.) Driveway: $145.00 18.) Alter Repair Sewer: $0.00 5.) Dwy Culvert: $0.00 19.) Storm Drain: $0.00 6.) Street Cut: $0.00 20.) Catch Basin per ea: $0.00 7.) Other RIW: $0.00 21.) Sewer System Dev: $745.00 8.) Fire Hydrant: $0.00 22.) Milwaukee Dr. Sew Ass: $0.00 9.) Res Water Serv: 5/8" $150.00 23.) RIW Use Perm: $0.00 10.) Comm Water Serv: $0.00 24.) Admin Cost (D.R.A) $0.00 11.) Other Water Service: $0.00 25.) ORA $0.00 12. )Water System Dev: $1,025.00 26.) Mise: $0.00 13.) San Sewer SFR: $95.00 TOTAL FEE: $2,160.00 14.) San Sewer MFR: $0.00 add unit: 0 Amount Paid: $0.00 Receipt No: Inspection Fee: $0.00 Balance Due: $2,160.00 {)J /&~ ~ 6-rS /-(p PEACH TREE ESTATES . PERMIT #083 W/O 167 $2500.00 FIRE HYD PAID 11/29/94 REC #/594/ INSTALLRD ~ $750.00 APPLIED TOWARD WATER METERS ON BUTLER oJ7STREET REC # 605 C($4A2.8.6zX-'Z.)] STILL DUE EACH METER u. W/O 175, J. 100 1719 & 1723 BUTLER, W/O 177, 1707 & 1713 BUTLER, W/O 180, 1619 & ~ Lf1'rl~ ~~~:~;~~iI~~~.181, 1611 BUTLER SVC LINES INSTALLED TO S<t.(\.Se-w ~b gfl A o oiL-up 41o~ $100.00 PAID 11/29/94 REC # 594 BACTERIAL TEST J WATER MAIN 18TH & "0" & DELORES PLACE. PAID FOR ALL J? SVC/METERS ON DELORES (13) DIG TO CORP/SET METERS. $250.00 PAID 12/3/94 REC # 605 HOT TAP MAIN 16TH & ~ BUTLER STREET. WAS IT DONE? PERMIT # 4330 fq $40.00 PAID 11/25/92 REC # 38979 WORK IN R/W $375.00 PAID 11/25/92 REC # 38979 (3) TAPS SAN. SEWEIV "0" STREET. LATERALS TO PROPERTY LINE ON "0" *WHEN SSO(?< STRUCTURES CONSTRUCTED ON LOTS $~O.OO + $,UO,OO DUE EACH. WlA'\ $2010.00 PAID 3/3/92 INSPECTION DEPOSIT REC # 4053Qi . . v II zsv- $400.00 PAID 1/28/93 WORK IN R/W INSPECTION drupi Y\ DEPOSIT REC # 39069 $829.06 PAID 1/30/95 REC #/j0719/c W/O 1442) STORM DRAINAGE REPAIR $400.13 PAID 1/30/95 REC # CITi# 195000012o!STORM --. ---~ -_._--~--~----------- ~_._-_.- -.----.--..--- - --~ -- ~ -. ._~ -~~~ _ /1-- _Z_~ -_.__--=~Zril~- -l::{,_ ..-=..~~ ~~.--=..~- :-~=~~_ -_ _-~_-~~~=~~-~~~~~?~r~~~;---~~..~-:~-- ___ __.__.~_~_~t2_~~__~o_:-+__ -- - --- ------.-----------.-- - .._._-- ~ -_._--- - ---- --- - - --~------ ---_. ------- - ---_.- - - -- --- -- u_ _ n ~~._ ._______-..~, - .-~----. ..!-cJf.-. ~.----':-_.- n -----~---'2~/.3------..-l?u:ry~A-y/.:f_.-------m - -- ------,---- -----,------ ----- ----- --------- {--. .--- _____~-~---~.-~ _~-~-~-ht--.- -----f2~- ~a02t:tJL~~~~- ~--- -----------~~~-,~ -~-44Z----. -.----~lt/i/-.~---g't)--7------------.~-------'- - -'" -----;~---.----.---.--- :;;-B-- ----,~--- / ~-~---------~ ==~~~a:LL~~~-~-~~.=~~>~~~~-;~--,-~~ _ ~--kAj22tLZw.L---Z~ ~__ -..- -- - - ----j~-:;-:-:----:---; .' 7/71---- -- ------.!..ft-- ~~-_---~~~---~C2--t- T~2-... ~~~==~~~_:...: /' '- - ~ -----~ ..---- -===-~ __:1 ~~~-~~-~:.~;itl.~~==~-== -~~-= ~-===-~-?ill ~..=~~&fi_ 1------. .'~~~'.f~-~~~ --7v-~/P4U-4U)- -- · . 2i'!;2:,.,~~ --------- ---O~()~t.).- ------ . --- -- ~~~-----A_(J/tI--~---W_ ~2F,4--Z~ -------~=~ ,~ --~"-~=d;:;f.-=--=-=:~::==~~-:-~.~====:~--.-.-~-:.- , - ~ '~.~==~=-~:~~--- ---- ----------- _.- _:~==::=~~==,--. - ~ ~ORT "'.... ~ O~Q~ ~ (~ " 1/1 rrtF- r.. L- p-- "5ll' .o~/i) Ulll./C WO~'+' Jtt/JU ~,~ ,Coer; CITY OF PORT ANGELES 321 E. FIFTH' PO BOX 1150 PHONE (206) 457-0411 PORT ANGELES. WASHINGTON 98362 FAX, (2061 452-0353 February 9, 1994 Land Title Company 402 S..Lincoln street Port Angeles, WA 98362 . RE: Milwaukee Drive Sewer Latecomer's Fee Land Title File Dear Michelle: The latecomer's fee established by Ordinance No. 2618 will affect only those properties that connect to the sewer line placed in Milwaukee Drive from 10th street to 18th street. . If a property has, or will have, a working septic system and does not intend to connect to said sewer system, there will be no monies due the City. The latecomer's fee will only be due if and when a property is connected to the sewer system. (See section 1, Ordinance 2618.) This ordinance will be out by time in ten (10) years from November 16, 1990 (see section 6, Ordinance 2618). The City of Port Angeles, Washington, hereby acknowledges that Lot 2, Short Plat 77-12-13 (2903 W. 18th street) is released from the Milwaukee Drive trunk sewer connection charge until the owner of said lot requests or is required to connect to the City 's sanitary sewer. Upon said request, the latecomer fee will be assessed along with interest and any other normal connection fees related to the type of construction. If you have any additional questions or comments, please call Trenia Funston at 457-0411, ext. 124, or myself. Jac N Pittis, P.E. Director of Public Works cc: Trenia Funston JNP: pr Disk: [94-2] LandTitle.JNP File: Address Form: LateC.LTR "t I I ~, . f:{:1..0 JlN;;j is: \."?'''' I '! I'" <n , '\ ''':',' " ~';.1 t,ll! "1 l~H : .....j. :~ ~: I Vl >1 ~, , ~ F lj !i' l~,,~ " t I I :J . " ,CL ''- I,~ -+- - ~ SIXTEENTH STREET N56. 4~/OO.\I 575,00 or ~ n ~___-.y-____ ____460.00____ ('"' "65,00 82,50 T 82.50 T 82.50 T - 8250 - -or- - - - ... t 1 :(tJ I I . 65,00" I 1 /&OStJvf/erl Z.2TfiZ;;Ji:o I ZSZbwl&tl::.1 Z5ZDWI(,o'!b.:ZS-IZ,cU1Li't>. I ;2504CJI~~t 10hj(pO~ Ig' ~ 0 - Ighlr..nr!2- Ig;l7.liPD'lE 1!'2-I&00'. 11Z110092 I o 6 ci...s 0 '4 . - 3 C?: 2 10 1 0 " :~~L~":'~~"~ \ID~~fV:'('ksiy @5g}) ': t - 85,00.J.- ' . ~-f20,1ib ," + . - 1- /v,il&i"Y -. ' 160,00 --, OlD: 120.00 - -100,00' :- IlL I~ 1:ZI'fD~ Ig ~ ' 1~321 SQ, ~T, I g g liP/? S D" I liil ~ Ig 1 'f"" /t'/t6 . /. 13;gili FT, R ~fZ&jf ~ ~: I IV 1 I ".... ,J"Il/o.'!!3-' I:;) :;0/21 ~ ~ t _ _ _ _ _ I 15 i?~, ~~~l l;g ~ I J- 120.00 -'I 01 :>, '/5(;/ I~ 0 I tJ 1 /(/;/Ci/hrTMI15;;jI/Wj)d," OlDl 1" ~ ---- 1-., go Ig 4: lI7~~lo ~I 19,' ",. , 151 100.00 --y. v>., I~'~ 'fj;/{pD ,gi1(...l~ 1~~02;~ 9,060 ,I:. I /tJZOS''o" 1 , 571 ~8i'" I' L ~zJ so. FT. ;;; g 1 I~~E". gl _. 1~ 1,1) c.-t:-'..........- '1 ~~ _ _ _ _ .J 10 '" I 31 ~ I~-; ;:2~O--=--cd.>n' 'l II @iV: . 10 t70&,p,~ .31 Ti, ';51 !7o<jL1JL4->..,." - - - - - ~ O~I 9 l:ril 18 I 100.00 cilr--. . r--. / 5/1 /) 10 "'I ~/ I I 9,167 SO, FT, 9,000 SO. FT'I' I 70Z () I~ <n Si" .765' 30 g g I f2f60'2E g ~ .t- _ _ _ I ? ) g 23 I ci 30 ci I 1 120.00 ';, I. ~~ I 1705~ '" I ~'\ '" I Ig!707~11 oll,;;cio~fffi~;' .;>'~ 1 ~ I I~ I:Z;IPQoo.E.- ;1 ~ 1 d 17 0" :ri .5 q" '-- - - - - ~~~I ~'1~O- " I 100,00 I "777 I'" ~ Q I I /7IOS'O'" I t _ - - - ' ' I . if><7) HI 0 9,000 SO. FT'I ,j zk60 00 1 120.00 I ~~oo ci 2 2! I r.p - ~ I 10/713~,' I 1 ;''''/7//4 ~I@. ~I l:ri t2/Mit':' I ~ I 9,000 S9JL.....g ~';U!/O,' I 5Pl I " (/_____-~). I "I Ii( ~1ri '" 7-1'2 ~I) L - -- j j. ( '77 f( I J710.oI-4cu.o" 1, I I 100.00,,- 1 120,00' - T 120,00 I 9,000 SO, FT,I I /7/(P so' I I /7/'1&;zlt.v I I /7P~...i4-- . g 25 I g IYZu,50"'-"gl Ig .,;",/ftO- 1 gl 9,000SO"FT, g ~/7 ',",.em,;" ~ I 28 ~I I~ 1',;-. ~ 1 ~11c 15,,0''\. ~ 7idl/!ooo"T I@ i" I ~~Z: 1 S&Cr ZH ~; L____ i t - ~1200O' - '--t2'Q'OO [.f .0 I 1 100.00 .VJ I' ' tw. tr-fC I d . I . 0!72?~11 1/;7;Jd~ 0 g9,414SQ,n. 1/7;<15001 l.lJ \;;j 'Ii 01 {0,(14 so, FT, ;;j 1ri 26 I 0 I ;;j ~ ~ I'" c1z/ 1~ ~ ~11p:.g~. c>-cJ '" .30 1'30 "/7~C23 0L&~ ~ I t~5: 40 :'\ .t ~., 15151 Orb7 572. 1,5151 580) t liJ ,~~O__, I OQ ,001 I ~ 3" r<. rt l'."e.. 0 .00 1 16 0- - - - ~ no,...,Zl,''1wlB'2:' Ifl .0 (") 305.00 ~ 270.00 ,. -i!J. ~ S56.4S'0()~E 575.00 STREET EIGHTEENTH ~, ~. I , , " " c , 1 ~ STATE OF WASHINGTON OEPARTMENT OF HEALTH WATER BACTERIOLOGICAL ANALYSIS SAMPlE COllECTION: READ INSTRUCTIONS ON BACK OF GOLDENROD COPY It Inatructlona a,. not followed, umple will be re)ected. DATE COlLECTED TIME COlLECTED COUNTY NAME MONTH DAY YEAR /.,.... 11/ ;<;,/ 7'-/ ~'~ C'-- """'\'--'--'\1-\ TYPE OF SYSTEM IF PUBLIC SYSTEM, COMPLETE: l]PUBLlC ~ CIR~GROUP o INDIVlDUAl 11.0, No.1 fc 'is ~ ~ 00. W B (se","onIy1residllnCe) lAME OF ~STEM ~), \'. " ... _ \ -~\ .-.. ~ -\ 0 'I. ~.-- \ t..2-. ':::~ . ~_--' ,PECIFIC LOCATION WHERE SAMPlE COllECTED TELEPHONE NO. \.::..:'---\ I. ',--J',' ~ - ~,;- DAY(l .j ! '7--'~ f J t -~... .'-,1 \ _.~ EVENING ( ) ;AMPLE COlLECTED BY: (Name) SYSTEM OWNERlMGR.: (Name) -, (2.. r ,'__ '__,,- ~.' . ""r, ~,- ,:.c_.__. \- Vr-. _~<_ ~r. IOURCE TYPE 0 GROUND WATER UNDER SURFACE INFWENCE ] SURFACE IY' WELL or 0 SPRING 0 PURCHASED or 0 COMBINATION o WELL FIELD INTERnE or OTHER iEND REPORT TO: (Print Fun Name. Address and Zip Code) ~. . -:.:.r-.. , \ \ \ - ' --- ~ \, ~ '. WASH...arOl\l -. lYPE OF SAMPLE (check only one in this column) ~ ROUTINE ~:l Chlorinated (ReSidual: TotaI_ Free) """1lRINKING WATER - check treatment )' Filtered o Un...tedor01her o REPEAT SAMPLE Previous coliform presence Lab If Date -iw SOURCE WATER Source If ~ EW CONSTRUCTION or REPAIRS [ THER (Specify) 1EMARKS: IT] o Total Co,"orm o Fecal CoI~orm (LAB USE ONLY) DRINKING WATER RESULTS __ O UNSATISFACTORY Colifonns present 0 SATISFACTORY, , CoIiforms absent REPEAT 0 E. Coli present 0 E. Coli absent ~~~~~~ 0 Fecal present 0 Fecal absent OTHER LABORATORY RESULTS TOTAl COLIFORM -0- 1100 ml E. COU _ l100ml FECAl COLIFORM 1100 ml PLATE COUNT Iml ANOTHERSAMPLEREQURED SAMPLE NOT TESTED BECAUSE: o Sample too old o Wrong container o Inoomplete tonn o TEST UNSUITABLE BECAUSE: o Confluent growth OmTC o Turbid culture o Excess debris SEE REVERSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS LAB NO. (7 DIGITS) DATE, TIME RECEIVED RECEIVED BY ,1Jo- DATE REPORTED LABORATORY; III;; r 1,-/1 IEMARKS OH)06-()()2(REV 4'92) , ~ STATE OF WASHINGTON DEPARTMENT OF HEALTH WATER BACTERIOLOGICAL ANALYSIS SAMPlE COllECTION: READ INSTRUCTIONS ON BACK OF GOLDENROD COPY It lnetructlona aN not followed, aample will be rejected. , , DATE COlLECTED TIME COlLECTED COUNTY NAME t.IONTH DAY YEAR R-' -. .- II / "- -It,t Cd AM , OPM-~- TYPE OF SYSTEM IF PUBLIC SYSTEM, COMPLETE: 'Ii(! PUBUC ITIIITJ- ~. ' o INDIVlDUAl ItD, No,J.~ "; , " , . <SMYeSorwy11l1S1denee) f _' ., . _ \1 ... CIRClE GROUP A' B NAME OF SYSTEM "..-,- --\ SPECIFIC LOCATION WHERE SAMPlE ~CTED . ::; , " TELEPHONE NO. DAY.." ) / 1- " 'I '* ...t....~ " . ,- ..\ "( ., (. -\- J SAMPLE COlLECTED BY: (Name) EVENING ( ) SYSTEM OWNERlMGR.: (Name) ,.-, -, i__ , L.. Ii \ (.-' '"!>-.J. _,'.-.-.- ,,( . ~ t..'-_:: I ). SOURCE TYPE 0 GROUND WATER UNDER SURFACE INFLUENCE O SURFACE NI WELL 0' 0 SPRING 0 PURCHASED or 0 COMBINATION ~ELl FIElD INTERTlE orOTHER SEND REPORT TO: (Print Full Name, Address and Zip Code) ~~.'_ t'T- ~ \ " . I\,_ \ Tl~.., ... \ WASHINGTON TYPE OF SAMPlE (check only one in this column) o ROUTINE 0 Chlorineted (Re~dual: Total F...) DRINKING WATER 0 - - check treab11ent t Filtered o Untreated or Other o REPEAT SAMPLE Previous coliform presence Lab. Date ~RAW SOURCE WATER Source . ~ NEW CONSTRUCTION or REPAIRS THER (Speofy) IT] D Total Coliform o Fecal Colffonn REMARKS: (LAB USE DNLY) DRINKING WATER RESULTS o UNSATISFACTORY, CoI~s Il'esent o SATISFACTORY, Coliforms abSent REPEAT o E. Coli present o E. Coli absent SAMPLES o Fecal present o Fecal absent REQUIRED OTHER LABORATORY RESULTS TOTAl COLIFORM ...a. /100 ml E. COLl _ l100ml FECAl. COLIFORM 1100ml PLATE COUNT Iml ANOTHERSAMPLEREQURED SAMPLE NOT TESTED BECAUSE: TEST UNSUITABLE BECAUSE: o Semple too old o Confluent growth o Wrong container o TNTC o Incomplete form o TurbidculbJre 0 o Excess debris SEE REVERSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS LAB NO. (7 DIGITS) DATE, TIME RECEIVED RECEIVED BY q ,y{)-)~J r, /1-.2 DATE REPORTED LABORATORY; ./ (; tI"4z;:: /1 ";9 I'll REMARKS r>oH V\l-M'> 'A~ &1ll'>' 1~/ 70 CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS . . . . . . . INSPECTION REPORT. . . . . . . . REQUEST: Date Time Received by (phone, person) Location of Work to be inspected ~"oh Tvee. Name of person requesting inspection Address of person requesting inspection Type of Inspection (circle appropriate one): Sewer FoundatiOn Framing Chimney Plumbing Final C sTsTes Phone No. Permit No. Sewer Excav:(~~ INSPECTION NOTES: Inspected: Date 6--t..( -9.3 Remarks: ---r; / ~ 1 ib //'!'" T S S I,'..,pc, BT<,. Time ,4 II( BY::- ---{ A J re: ~-"t cl ) /, _ '7c-_ proc.1!'. ",-i-(!<I;. 0>"\ IJ//L ""d I h'(', RESTORATION REQUiRED...... YES NO SURFACE RESTORATION: SURFACE TYPE: 0 Unimproved OGravel o Asphalt OPCC o Other o Repaired by City o Repaired by Permittee o No Damage Found Work Order # o COMPLETE o INCOMPLETE (Continue on reverse side if necessary) STREET SUPERINTENDENT (DATEI Date Time Received by (phone. person) CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS . . . . . . INSPECTION REPORT. . . . . . . . . . . REQUEST: 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 jgD- 'f ~;zc{, " o ., { r...e Phone No. Permit No. Fina~wer ExcaV Other /,D h..., INSPECTION NOTES: I Inspected: Date .3 -I 7 - <1 ~ Time ? /'J/I By ~ Remarks: ~b.sN!!>"lJ~,.,J 1'.....\,."Io.....J-<.I....., r.....oc..@'.,..Jl..&..rt"~ ~<; ~v-e.~ 'l.AJ.:;z.~ 1-;Z)/1~7 ~.pI..\..pV p'r..o -ILI.-<-r AP f'u...I-t!-4! .....gc " P,--'-e..d.'-'<.~s :J ~c~~~b'-e- r. r __' I 7;;. ~F-"'.J ~~..J.. +..... ''''V' "'I &-e<.v~...' p '/~' -1- /"t;y.5//->/)V ""1/'7.;ci -rh...."'.. 'j t. -Pr...... 4/-1 - Je7 sT;Q,"j hi f' 76 i y=J~ . RESTORATION REQUiRED...... YES NO SURFACE RESTORATION: SURFACE TYPE: 0 Unimproved OGravel o Asphalt OPCC o Other o Repaired by City o Repaired by Permittee o No Damage Found Work Order # o COMPLETE o INCOMPLETE (Continllp. on rp-vp.r::>e 5irle if np.(,,:p.~~i1"vl <::TQJ:J:T C:l Inr:O"'lTr:",nCI\IT Ino.TF:1 CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS . . . . . . INSPECTION REPORT. . . . . . REQUEST: Date Time 9 z-- !;O . . . . . Received by (phone. person) ) g 8- ( "0 '/ Pe.a r Cl Tr.... 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 Final Phone No. Permit No. Sewer Excav. <Q~ /,Sh~. INSPECTION NOTES: Inspected: Date 3 -/ I -"13 Time Remarks: ;;;/~.J 70 r-D",-tmc7-',r ...L.~+ rn.......I"lJ/u'+r:Joo1 if' ~JtJ, tr.(JJ'11 nv-al"" ~t-l ,.e:c, I I ~ t.Ll_t4D. _-=.r9~ .0 .,..,..., , W/I- . /-} WI By c:.--u. d 'f-h'ru.r bfoc.-i<.. ""..,1 ~dd:",,?, ~e'r !.lIlt.. .~~+Rlj::1-t;~.... Irr/ . RESTORATION REQUiRED...... YES NO SURFACE RESTORATION: SURFACE TYPE: 0 Unimproved 0 Gravel 0 Asphalt 0 PCC o Repaired by City o Repaired by Permittee o No Damage Found o Other Work Order # o COMPLETE o INCOMPLETE (Continue on reverse side if necessary) c;TRFFT c;llPFRINTFNnFNT mATFI II CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS . . . . . . INSPECTION REPORT, . . . . . REQUEST: Date 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): Phone No. Permit No. Sewer Foundation Framing Chimney Plumbing Final Sewer Excav. Other INSPECTION NOTES: "Fi:.ae-h Tree.- E s-fo, fes 9' ;2..-"30 Inspected: Date 1.;L-?-'72- Time 3 PM BYf: A'A4 Rem~rks: A1;r ",,;-t/, /rJ4f R,h~",- c< l)-4n JYJ~,..,..;son 0 n .:1';0 - cL""<<,,J , / /1' /, ' Il1s/JPL.711111 tJl Or6/~c--r - (PUJPr-' u.J;z-te~, M:::J/J'TC c! h6l'Jk-UD5 . r1(1.n~c:.lk / " U . ~/ ' / ,'" I ,sf -r...sf< t-eQ..,~d ' "/hPI I "d,caled rheJ ''''''...-fed rl-u e, f,; 7. ; "'SlX?c.-r-- I' / ' 6 I" -rhf'IV n".., e<-7, I v RESTORATION REQUiRED...... YES NO SURFACE RESTORATION: SURFACE TYPE: 0 Unimproved OGravel o Asphalt OPCC o Other o Repaired by City o Repaired by Permittee o No Damage Found Work Order # o COMPLETE o INCOMPLETE Ir:....n'ti.,,,............. .."..n.."''' ,,:;,..1... if ....,..,..,..<::..:-1,.,,\ ........r-r:CT..... '.~-r"''''''''''''''''''''''''''- ~ / / ~EQUEST: I / Date CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS , . . . . , INSPECTION REPORT. . . . . . Time Received by (phone, person) . :.tJ.- I II...., Y Location of Work to be inspected /.>? ~ '--" Name of person requesting inspection PeA L h Tyr' €'_ Address of person requesting inspection Type of Inspection (circle appropriate one): Phone No. Sewer Foundiltion Framing Chimney Plumbing I I.... Permit No. Final ~~er Exi:a~Other INSPECTION NOTES: Inspected: Date 3-tD -9~ Time 4111 Remarks: ---;;;/k"'d T;, r-~M~r*" ",b.~r ~"R/:t; N..l1rJ rD_~13r-r;-;::n p~.oC"DrJLI~c;. - "bSel'"'lIll{;"'IJ", I , ;:z c.e<2o"TRl:, Ie.. . +0'- fire ~wey- !tHe -1/'7 OJ len" I r. fA. I - J D - r.:l,. a ....... A _ B~#- ,.,1' b,,~)d',/I >YI~,~/s 11f'..-:t'I~ b of-/' wc-re ,~ dd/, ;'1;'" I~ e RESTORATION REQUiRED...... YES NO SURFACE RESTORATION: SURFACE TYPE: 0 Unimproved DGravel 0 Asphalt 0 PCC o Other o Repaired by City o Repaired by Permittee o No Damage Found Work Order # o COMPLETE o INCOMPLETE (Continue on reverse side if necessary) STREET SI JPFRINTFNnFNT (ntiT~\ CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS . . . . . . INSPECTION REPORT. . . . . . REQUEST: Date 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): 8 ~h ...( '10" 1\ = f -r E t -+- " I '- c _ {efl~h ,yee S <lIes /VJa T P~IreE"_ Sewer Foundation Framing Chimney Plumbing Final Test INSPECTION NOTES: Inspected: Date 5-17- 9 =s Remarks: C hec-~d N {(> S Time P n1 c-e.vtiE r I, 'Yle.5. By ~ ...; / is - I ::> "" " Yl 0 K . c;;~ n . , 0" S1~ I, ':>hrs RESTORATION REQUIRED . . . . .. YES NO SURFACE RESTORATION: SURFACE TYPE: 0 Unimproved DGravel 0 Asphalt 0 PCC o Other o Repaired by City o Repaired by Permittee o No Damage Found Work Order # o COMPLETE o INCOMPLETE (Continue on reverse side if necessary) STREET SUPERINTENDENT IDATEI___ CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS . . . . . . INSPECTION REPORT. . . . . . REQUEST: Date ";/ - ;) '-/ - 9 -'3 Time " Received by (phone, person) (/1},/ " /~ .~ _ 0 / /1 'I T/- 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 Final "Jt;e ) c:' reo e Phone No. Permit No. Sewer Excav. ~ 0..1/;- '----"" / INSPECTION NOTES: Inspected: Date 5 - ::>4 .- '7 .J Time Remarks: "j:;'esSurtl 7-;.. "Te rJ n~ LAI ""j).Jcre_q La...,p (J,?""yc_h 'Tree d f- ;;LIO I b<. +'" ,- / '_'- ._A _ .;) _ > 1'''' 1,1 /",,;1 A/11 c_--cu-J ,.., ,7;;.(k_! /I"J By ,~l '"l-r~r Y1-1 ,.7, n E " t~ -t:".S' -06 rJ,.",,, 1 L """--0-:: L.... \:7 ~.' 7;':' <:../e...J J .1 I") n::_~<;s-'t.{re e , RESTORATION REQUiRED...... YES ::,.. iI\ '<1 -'- " ----- ~ .~ -S [\::l ~ c 1/, /0/ -- NO ~ ~ ....-/ \l SURFACE RESTORATION: SURFACE TYPE: 0 Unimproved OGravel 0 Asphalt 0 PCC o Repaired by City o Repaired by Permittee o No Damage Found o Other Work Order # o COMPLETE o INCOMPLETE (Continue on reverse side if necessary) STREET SUPERINTENDENT (DATEI CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS . . . . . INSPECTION REPORT. . . . . . REQUEST: Date "-1-;2//-7'3 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 1/" v~ ' " J) G / 1. -I ';) f Ii 'l f' I p- -e f. Phone No. Permit No. Sewer Excav, ~ Final V l"-..! L- , Ti:..:~T INSPECTION NOTES: J-1-1 .7/,..-\ By c_~~ " VI <""~ '-r~7 ! /(~J. ~ n Inspected: Date c5 - ;;J..Go ~ <7.3 Time e M . -;:> Remarks: . t 02 5'$. ur-e h,. ,--re < j n CL-0 '-^' ""Ie r ,. (')" 0 T, C',.. c ,~ ( .\' '0.. -:t;, /t.. i.'c-- Q~ -;:L It.) / b ."f'o " J. . ,u2 (,"17 ( --r;" d~ J I ~.')"" ;"1"7 I V1 , " ',-tf. "'6 <::; i ~i' n I ;",:/ C.e7 rt. 7- I ~l r.-. P , I V1 P r-e SS4. rf' RESTORATION REQUIRED I / i'0---- . NO A l~-.- YES (~--J l,," /r 1" ' '<I /(;'7'1,--- _.__-1-.LJ_ -- ! SURFACE RESTORATION: SURFACE TYPE: [] Unimproved DGravel 0 Asphalt 0 PCC o Other [] Repaired by City [] Repaired by Permittee [] No Damage Found Work Order # o COMPLETE o INCOMPLETE (Continue on reverse side if neccss;}rv) ~TP:FFT <::;\ IPt:Pl!\ITI=r'dnl=I\tT (r-,J\TF1 CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS . . . . . . INSPECTION REPORT. . . . . . ~ REQUEST: Date Time Received by (phone, person) 7). 11 u Location of Work to be inspected /t:. - <~i-:- () /lJ ,,6'uTZ...E-.e Name of person requesting inspection /'1 ff-7 / ,P'~ Address of person requesting inspection Type of Inspection (circle appropriate one): I rsv /'7i..- p /3u~ - /6 - 7Z> /~ - 1 Phone No. Permit No. Sewer Foundation Framing Chimney Plumbing Final Sewer Excav. Other INSPECTION NOTES: Inspected: Date 12--2:3-'75. Time 9:- By R~ J~.,~/ Remarks: 7iPC4:7 Mn-n- 70 /"tAI<::& V'/C-r ~L;6 Ante; 6~ ;8~ A-:5 c5~. Ak= ~ /"JE ~ C-< /"7h rC--O .LiAr/-= ~ 5 /..v ~~ g../ /'Vll!h-/. /z--Z,7-9:5 / z.--z:.8- '7 --S - /O:~o A--t.. N~4t5- ~ d>~ ~e:! ~ ~ RESTORATION REQUiRED...... YES NO ~>J"-rf?1Jc.G- ~&-{}::-~ W-zp f1 LOw . /'-., ", 1- b -I- 1- i\ ~ ~ ....- (gO'!"Y) f/t--T /~c.c:. ~ ~ ~ .s: r~ 6/1U:..,S H D 'I SURFACE RESTORATION: SURFACE TYPE: 0 Unimproved OGravel OAsphalt OPCC o Other o Repaired by City o Repaired by Permittee o No Damage Found Work Order # o COMPLETE o INCOMPLETE (Continue on reverse side if necessary) STREET.S.U~ERINTENDENT_-.. _lnATI'.I___ CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS . . . . INSPECTION REPORT . . . REQUEST: Date Time Received by (phone, person) /A.. ~ ' I 'f Location of Work to be inspected / b -.' 0 6 -.;-:- Name of person requesting inspection /1'1 ~ P~~E Address of person requesting inspection Phone No. Type of Inspection (circle appropriate one): Permit No. B Foundation Framing Chimney Plumbing Final Sewer Excav. Other INSPECTION NOTES: Inspected: Date ";~/;3- '1..3 Time /~: - By .KbV ;;~Sa-...t Remarks: ~ tJh4.v.6- P1(cA1/~ O~ '77D ~p ~ ~ ~ /:5 n;,/? "54-,...,,.;;;::;Z: J"'e.wJZ5?, .67{ 1A4VA-r7~ /.5 I 7 ~ p.r;- ~ ~CA? Pl~ /I/o ~e- IS Tt!7 ~~ ~ PicCri-V..t:P~ 2"i-.aif- l,c /"/'5 Nt17 J~ R'6 " ~~ r~""'H't5", nn::-.c7 .Pk.c--r ~ ~ A- ~ t?""~ b.C- p<f'~ HL-L '-C/7 -rU $1"bVP ~-n; RESTORATION REQUIRED . . . . .. YES NO ~ A7(??/JF. ~--C-- ~ 5 M>7"'E- / 5 / / / ,F/~ f/ " U--"'H ~"- : ( r SURFACE RESTORATION: SURFACE TYPE: 0 Unimproved o Gravel OAsphalt OPCC o Other o Repaired by City o Repaired by Permittee o No Damage Found Work Order # o COMPLETE o INCOMPLETE (Continue on reverse side if necessary) STREET. SUPERINTENDENT _. _IDATEI. CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS . . . . . . . INSPECTION REPORT. . . . . . REQUEST: Date ,&-8 - If t.f Time 8: ,3D A1.-v\ Received by fi:'LAi.J/L u..) (phone. person) I Location of Work to be inspected /1-1 'i ~ 1'1-2.3 2, LA_+- LL,-"L Name of person requesting inspection a, ~~"c;~R;lt.~ Address of person requesting inspection I t~ i (3:' {co f' p. F'iHe.ty Type of Inspection (circle appropriate one): Phone No. / (e,.C;- Permit No. 008 3 Sewer Foundation Framing Chimney Plumbing Final Sewer Excav. Other ~c ~ 3SS"2.0 Dw, :2.eo I INSPECTION NOTES: Inspected: Date 1'2-- p;.qf Remarks: \\.ls-h.J1....-.J f),J:tt..l('J \ Time 3; 3c;1f U1 0~ 1")'-041" I,J~, By p" 'B.-J....1L.feM ~-,Uj,.(I....-s \ ~I.P"'J..' La t ~ I 2- ~\)./~ ~ (I 't-I'l B",~L"t.) \ ~ 1 r1 tP.E 3 - rf: . . x - S'f' - -, 3' T . ~ 61., Lot 'V I ~ <l: -.,.. (li~3 i3~ ') ~p AQ. - v / B~ ~iltc-e---I- RESTORATION REQUiRED...... YES NO V SURFACE RESTORATION: SURFACE TYPE: ~ Unimproved OGravel o Asphalt OPCC o Other o Repaired by City o Repaired by Permittee o No Damage Found Work Order # l:fe;;- o COMPLETE o INCOMPLETE (Continue on reverse side if necessary) STREET SUPERINTENOENT_:\_IDATEL . v , CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS . . . . . . INSPECTION REPORT. . . . . . . . REQUEST: Date I 7.- ~ q - q '-f Time 10,'(/0 Itwt Received by r:'lttlrlJt- W (phone..(!erson) Location of Work to be inspected 11- 0 7- i 1"1- 13 D t.uf Lee. , Name of person requesting inspection ~, Beu I--,t.Rre-~ Address of person requesting inspection 11- ~ ~ ..~ I eM p. <(.j....b \ Type of Inspection (circle appropriate one): 5-1. (h~l~ A.l:>b/~Ju) Phone No. / t,S- Permit No. 083 Sewer Foundation Framing Chimney Plumbing Final Sewer Excav. Other ?,-Cr!, 'If. 35"'52-0 'tWo 2.00 ( INSPECTION NOTES: Inspected: 'Date \ 'V-q - qL/- Remarks: .3c. u <. n U e-b IJ ~ Time t-J:3 0 f WI By i3, i3i:--v/::;~FOr.e.D I "'f..sle" IAJIt;---kct. :s.a.uiC€5 (.2) o..J~ . . "fJ l2<'~ -~ ~ \-:fD~ 51' $ IA'lo I- X p~: 3' ft i~l~ "*' \ J-OT II B~' l 18e~, RESTORATION REQUIRED . . . . .. YES NO ,/ SURFACE RESTORATION: SURFACE TYPE: Iii Unimproved 0 Gravel 0 Asphalt 0 PCC o Other o Repaired by City o Repaired by Permittee o No Damage Found Work Order # 1-=1-1- ~ COMPLETE o INCOMPLETE (Continue on reverse side if necessary) 5.TREET SUPERINTENPENT_~__ _IPATEI CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS . . . . . . INSPECTION REPORT. . . REQUEST: Date /?- - 1"3 - q..f Time f'3: 00 o4vv1 Received by ~14J1c- L"..) (phone. .[!ersonL Location of Work to be inspected J 1,0 (q ~ I 1-0 I '5 ~ f Le--e... l2oJ, Name of person requesting inspection i?" l">E\JE: ~4='a R-D Address of person requesting inspection I:}-lt- sl'B' (f't?"'-p. Yl4-le/)) Phone No. / ?, ~- Type of Inspection (circle appropriate one): Permit No. (\fI, 3 Sewer Foundation Framing Chimney Plumbing Final Sewer Excav. Other Ac.c.# 3S:5-~ Dw, zoo I INSPECTION NOTES: Inspected: Date '2 - ,::,:> - q L/. Remarks: :r J.);:,U!..LCD (). - I Y-.5/g " +-\:: Ii\..-U:' Time 2', 00 of)lM . (...]<AJ~IL ,5,...,-;l_t.Jt'C.::,-:=' By ,B, ~__-U.<--rL-.(;L/') UC\ W\.L..-h-o.,a... c:. M- ":-t A :-<. RESTORATION REQUIRED. . . . .. YES NO ,/ -W\IoI'\ Lot I> 6 ffi. SLrr 3 - 1."1!i:~ >\'.- - La+- to- 9 .:.' - n-ol r-- ( 1 381' \ / ~ 'IV I(If . ~~), ~ 8"~ < - "l--o I S.f2. ~{.. SURFACE RESTORATION: SURFACE TYPE: [B'Unimproved 0 Gravel 0 Asphalt 0 PCC o Other o Repaired by City o Repaired by Permittee o No Damage Found Work Order # /80 G COMPLETE o INCOMPLETE (Continue on reverse side if necessary) S:fREET_SUP.ERINIENDENI tn.4.TI='__ 'I CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS . . . . . . INSPECTION REPORT. . . . . . REQUEST: Date Time Received by (phone. person) Location of Work to be inspected <0" sf. /?,,,,r /, -;;e ,t;~iej;;~ GS-Oq ') Name of person requesting inspection J#,>v,~~'" - 'Hiree Address of person requesting inspection Phone No. Type of Inspection (circle appropriate one): Permit No. Sewer Foundation Framing Chimney Plumbing Final Sewer Excav. Other INSPECTION NOTES: Inspected: Date -'j- 1.3 - q .~ Time j {':36 ?1 BYcl~ Remarks: C...;:t.... ~ '" ;:-r;::t j, :'1 .-:1-1 ,,' "{j)" sf. f-'~ '-. Y1e~ ?r6~Po:-rl'h-;~. IA{7:~~F/;~t;;~(. c_:::;.,;~; ;:;:;~t S' ....-, VI ~ 'A..Il'~,V ~, t. C"..eVlr_.:rt-;-;,;1 RESTORATION REQUiRED...... YES NO SURFACE RESTORATION: SURFACE TYPE: 0 Unimproved DGravel OAsphalt OPCC o Other o Repaired by City o Repaired by Permittee o No Damage Found Work Order # o COMPLETE o INCOMPLETE ~, (Continue on reverse side if necessary) STREET SUPERINTENDENT (DATEI v CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS . . . . . . INSPECTION REPORT. . . . . . REQUEST: Date Time Received by (phone. person) ~ / Location of Work to be inspected /8 - ~ 0 ,$/~ Name of person requesting inspection Address of person requesting inspection Type of Inspection (circle appropriate one): r'~e:-E- tS6.J'7'1-r:l'S 5 Phone No. Permit No. Sewer Foundation Framing Chimney Plumbing Final Sewer Excav. Other INSPECTION NOTES: (""'?ts" "",,I'" ) Inspected: Date ~-z:8-9:5 Time / /: - By ~ ~s'.-"..,,/ Remarks: ~ &~/ ""ttPr 11"'~.;;e: Ae~ c>rr"'~ />-1 ,H. (:;- /4 --n:u:- ,~~. /1h::4:l ~ 7ZJ 0wEe A-c--c ~ c5T"6:'-//Nr<Y(, ~ ~)-r- ~ ~E<.d .L.It:X~ /hIo /~ ~.lhN'?- t6A-:ee-/~&-$' kKl>-U>--to 7AtF, /"7.H d2 /(p'!J...,.: i IILl': ~ OrbL/ ~ (..U77--c/U? ~ (~CTF / r- 771104\/, ~ RESTORATION REQUIRED . . . . .. YES NO SURFACE RESTORATION: SURFACE TYPE: D Unimproved D Gravel D Asphalt D PCC D Other D Repaired by City D Repaired by Permittee D No Damage Found Work Order # D COMPLETE D INCOMPLETE (Continue on reverse side if necessary) STREET SUPERINTENDENT (DATE) r CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS . . . . . . INSPECTION REPORT. . . . . . REQUEST: Date 11--( - q 4- Time I :00 PM . Received by PI?,IH-tK-- W. (phone. person) Location of Work to be inspected U. €. ('areLJo-~_ 0 C I t'3 ~,.!I &-I-L~'lL Name of person requesting inspection P,. i3,""-,I....~f-FO ce..{) t -t<t: I,." / \ 6. Address of person requesting inspection 1+-,....." 1'2, /~.... 1'0.. VMI\ Phone No. I r ... 1/' I Type of Inspection (circle appropriate one): Permit No. Sewer Foundation Framing Chimney Plumbing Final Sewer Excav. Other ~c, ~ .3S82..0 i;) c.O. - 30() 1- INSPECTION NOTES: Inspected: Date 12.. 2..-tjt.l Time 4: 00 IWI By 8. 'i3b-U;;"-/2.(;.."ei) Remarks: t u,sft4..{I,--D 1J/"c-uJ b" h'.e.~-' Hu....1 /tA-of-(..3' .~fj""L b~..f...\Jc~O 1.1.."A.e.I4./.k A J,j.,...It.t/A..J".f- iJlAi'Je"-' I . I I ' ~ ~l.I.~"Je, ~, , ~~ 4- 8" A-c.. f,f/ -) j \ t 1'.\ / 8 ~ $#t~-f- I . RESTORATION REQUiRED...... YES NO V SURFACE RESTORATION: SURFACE TYPE: ~Unimproved OGravel o Asphalt OPCC o Other o Repaired by City o Repaired by Permittee o No Damage Found II or Work Order # _ I:>...J o COMPLETE o INCOMPLETE IContinue on reverse side if necessary) STREET !iJJPERINJ:ENDENT . .__IDATEI_._ v CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS . . . . . . INSPECTION REPORT. . . . . . REQUEST: Date I 2- ~ I <-I ~ q '-f Time r3 :~O A-t.-v\ Received by Pt..A-w1:.. U (phone, person) Location of Work to be inspected I&'I I '6 (."f L/,,7€- :sf.. Name of person requesting inspection ,~. ?'~J <-'I) k RJ), t'~ , "K" / , ~ \ Address of person requesting inspection I~, - 6- ( r (I"f'f). y"A-tel) . " .. Type of Inspection (circle appropriate one): Phone No. I b "1 Permit No. () ~ 3 Sewer Foundation Framing Chimney Plumbing Final Sewer Excav. Other /\Ce. II 3S~-2 0 (:)u.J. 2(1':> I INSPECTION NOTES: Inspected: Date I ~ - t</-- r; if Remarks:X/Vs'f>:!.-LC""-,, ~ ...-u) -kvl ~ -1-,: YVl-e:: Time I.' 3 d tlJU/l By B. H f=7 k-XL -t".eI'J I ~ ~ /AJ J{--7L ~6--n__th'ct-- - U(') 1/v1t-~_ kLJ.. I &./$ $A-~f:;~-f- -d -d I .,j, 181- " Ii '" 1 , ~ '1.'p~. -D. La i *"1- ~ bo' /fotJ \ \f.+' \ v.l<... .It. <b !if RESTORATION REQUIRED. . . . .. YES NO V"" SURFACE RESTORATION: SURFACE TYPE: 52 Unimproved DGravel o Repaired by City o Repaired by Permittee o No Damage Found D Asphalt D PCC 0 Other Work Order # _I ~ l o COMPLETE D INCOMPLETE (Continue on reverse side if necessary) .STREET.SUI?ERINTFNnFNT . __/nATC'_ --.. STATE OF WASHINGTON DEPARTMENT OF HEALTH WATER BACTERIOLOGICAL ANALYSIS SAMPLE COLLECTION: READ INSTRUCTIONS ON BACK OF GOLDENROD COpy It Instructions s,., not followed, umplo will be teJected. DATE COLLECTED TIME COLLECTED COUNTY NAME MONTH I . DAY". YEAR 0"1 :~ '7 ;;. (0 jr/::5' --'- KlAM DpM t.__ '- , ~.~ , ' , TYPE OF SYSTEM IF PUBllC SYSTEM, COMPLETE: &:I. PUBLIC DillIIJ CIRCLE GROUP o INDIVIDUAL 11.0, No,1 ' ('l: . h A B (serves only 1 residence) NAME OF SYSTEM .- C. \ ~ () ',- ~C,\ ".'- \ \i-J' '__ SPECIFIC LOCATION WHERE SAMPLE COlLECTED TELEPHONE NO, I~:~ ":0 p~""-\\T\'-""~ y:::,,_, " EVENING ( ) SAMPLE COLLECTED BY: (Name) liYSTEM OWNERlMGR,: (Name) ,f,/-'lJ " , ,'"",- '. (.:." \ ''''''-~' SOURCE TYPE 0 GROUND WATER UNDER SURFACE INFLUENCE o SURFACE 171 WELL Of 0 SPRING 0 PURCHASED Of 0 COMBINATION ~WELL FIELD INTERnE or ornER &END REP.ORT TO: (Print Full Name, Address and rip Code) \'-': ..... i' ; (, ';i..~"" .'\-' \\ (,),,> {\'.j, ~,~ " WASHINGTON rYPE OF SAMPLE (check only 000 in this column) Q ~~1J~'h WATER 0 Chlorinated (Residual: _ TotalJ Free) check treatment I 0 Fihered o Un_led Of Other tJ REPEAT SAMPLE Previous coliform presence Lab, Dais o RAW SOURCE WATER Source. [I] rn o NEW CONSTRUCTION or REPAJRS D OTHER (Specify) REMARKS: o Total Coliform o Fecal Coliform (LAB USE ONLY) DRINKING WATER RESULTS --,-- - o UNSATISFACTORY, Coliforms present o SATISFACTORY, Coliforms absent REPEAT o E. Coli present o E. Coli absent SAMPL'ES REQUIRED I o Fecal present o Fe<:al absenl OTHER LABORATORY RESULTS -..- TOTAL COUFORM..Q /100 ml E. COLI _ /100ml FECAL COLIFORM _ /100 ml PLATE COUNT _ _~~ Iml --.-.-- ANOTHER SAMPLE REOURED SAMPLE NOTTESTED BECAUSE TEST UNSUITABLE BECAUSE: o Sample too old o Confluent growth o Wrong container o TNTC o In<:omp~te 1000 I o Turbidcullure 0 . o Excess debris lAB NO. (7 DIGITS) SEE REVERSE SIDE OF GREEN COpy FOR EXPLANATION OF RESULTS DATE, TIME RECEIVED RECEIVED BY q()Q- It) ~ lABORATORY: c1;)t.". REMARKS DOH~;> !f:lFV 4"0;>\