HomeMy WebLinkAboutSHANGRI-LA ESTATES EAST BLK 1 LT 6Onsite File
Shangri-La
Estates East
Block 1
Lot 6
#020-043-47
Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP211382 PID Number: 020-043-47
Dwelling: Q Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: M New ❑ Upgrade
Name pg
Crown Pointe Homes ABSORPTION FIELD
Site Address
16290 Mountain Breeze Dr. ❑ Deep Trench 9 Wide Trench ❑ Bed ❑ Mound
Phone El Other Number of Bedrooms Soil Rating Total depth from original grade
907-229-1886 4 6.0 GPD/SF 7.5
Ft.
LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe
Subdivision Block Lot rj 0 2.5
Shangri-La Estates 1 6 Ft.Ft.
Township Range Section
Fill added above original grade Gravel length
3.2
Ft. 20.0 Ft.
Gravel width Beds: Number of Lines Distance between lines
SEPARATION DISTANCES 5.0 Ft N/A N/A
Ft.
To
Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches
From Tank Field Tank Line 156.25 Ft2 1 N/A
Ft.
Well >50' >50' N/A N/A >25' TANK ❑ Septic ❑ S.T.E.P. ❑ Holding R Other
Manufacturer Capacity
Surface Water >50' >50' N/A N/A Orenco (Advantex) 1500 Gal.
Material Number of compartments
Lot Line >5' >10' N/A N/A NA Plastic 2
Foundation > 10' >10' N/A N/A LIFT STATION
Manufacturer Capacity
Remarks
Gal.
Alarm location Electrical installed by
Installer PIPE MATERIAL House to tank D3034 drainfield Tank to
Northern Excavation D3034
Drainfield D3034 CO/MT D3034
Inspector J,Mlllette BENCH MARK (Assumed elevation) 100 ft
Inspection
dates: 1m 1/26/22 2 n 1/26/22 Location and description
3'd 1/27/22 4'h
ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp
4�s�®F
Conditional Approval:Date AMW • �Q�'i�
i49 TH
`�•-9 ��
Septic �'
p C Sy 7 Beni' eSchiller
Approved—`�' `^- —P/ �-- 2l 2 ����`-,9, • . CE 12592 , , . •��``�`�'�
Date �' _
permit requirements.
q ��1%PROFESSI4N?�
Note: this approval does not include well p.
(Rev 05/02/18)®®�®®�
SHANGRI-LA ESTATES EAST, BLOCK 1 LOT 6
PERMIT # OSP211382
PID # 020-043-47
Lpx�
01— 1"--
78.6 FINISH GRADE 75.4 ORIGINAL GRADE Ov
70.4-1 GRAINFIELD ROCK 70.4
67.9 67.9
20'
NO GROUNDWATER 9/7/21
c'4 61.4
r
1 --
OF -kv'kk
0* `49 TH
o. . .. . ......
..... . . .. .........
Benjami chiller
-BUILT
PROFILE AS CE 1 592
ec,29.2022,
I N G
:T. G I N E E R �(NO SCALE) 44-k ki "A "-' PR 0 F E S S
SHANGRI-LA ESTATES EAST, BLOCK 1 LOT 6
PERMIT # OSP211382 PID # 020-043-47
------ 1140 \
1150 ,1
1170--Z
LOT 5
1175
----� --T _
— -- 1180 / _ _ C
-- 1190
0
TH#2
1500 -GAL -
2C0 ADVANTEX TANK
MH1 • — W/ AX20 POD
oA} r,", _..
\__ 4-BDRM HOME
WELL
r R/v
ENG INE E RING
49 7H
Benja m Schiller
12� 222
PLAN AS -BUILT
0 50 100
FEET
111=50'
20' L�NG.x 5' WIDE, 2.5'
EFFECTIVE DEPTH ABSORPTION
_ j- � __TRENCH
ALTERNATE SITE:
20' LONG x 5' WIDE; 2.5'
EFFECTIVE DEPTH ABSORPTION
TREWfj
A B
FCO
5.5
50.0
MH1
23.8
58.3
2CO
30.4
62.8
C01
86.7
85.5
MT1
86.4
86.6
CO2
99.5
87.0
MT2
99.1
88.4
LEGEND
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEANOUT
FS - FLOW SPLITTER VALVE
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
MUNICIPALITY OF ANCHORAGE
r
Development Services Department A Phone: 907-343-7904
On -Site Water & Wastewater Section _4.Fax: 907-343-7997
Well Drilling Kermit Number:
Parcel Identification Number: 020 _ 043 47
Legal Description
Block I Lot
SHANGRI-LAESTATES EAST I 1 1 6
Pump Installation Date: 08 - 29 - 2022
Date of Issue:
Property Owner Name & Andress:
GROWN POINTE INC
PO BOX 192393
ANCHORAGE AK 99511.2313
Pump Intake Depth Below Top of Well Casing: 335 feet
Pump Manufacturer's Name: RELY JACKET
Pump model: 1003C11 -8S12
Pump Size: 1'40 hp
Pitless Adapter Burial Depth: 12 feet
Pitless Adapter Manufacturer's Name:. MARTI NSC. N
Pitless Adapter Installer:
Well Disinfected Upon Completion? XYes ❑ No
Method of Disinfection: PELLETS
Comments:
Pump Installer Name: _
ANCHORAGE WELL & PUMP SERVICE
Company: 7640 KING STREET
ANCHORAGE, AK 99518
Mailing Address: 907243-0740
City; State: Zip:
.attention.: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation.
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MUNICIPALITY OF ANCHORAGE
n,cnr
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
httpJlwww.muni.org/onsite v
Department
On -Site Wastewater Disposal System Permit
Permit Number: OSP211382 Effective Date: 9/2112021
Work Type: Septic Initial Expiration Date: 9121/2022
Tax Code Number: 02004347000
Site Legal Address: SHANGRI-LA ESTATES EAST BLK 1 LT 6 G.3239
Site Mailing Address: 16290 MOUNTAIN BREEZE DR, Anchorage
Owner: ANCHORAGE DEVELOPMENT & Lot Size in Sq Ft: 40180
Design Engineer: FORGE ENGINEERING Total Bedrooms: 4
This permit is for the construction of:
0 Disposal Field 0 Septic Tank ❑ Holding Tank ❑ Privy ❑ .Private Well ❑ Water Storage
All construction shall be in accordance with:
I. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (2417).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Special Provisions: A Category III Nitrogen -Reducing system is required on this property in accordance with
Plat 11-62.
Veronica Pope
GE 2021.09.21
Received By: .� . 13:24:06 -08'00'
Issued By: _41)eOC4 at',�
Date:
Date:
MUNICPALITY OF ANCHORAGE
Community Development Department ; &� Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
On -Site Water & Wastewater Program
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 020-043-47
Property owner(s) Crown Pointe Homes Day phone 907-229-1886
Mailing address P.O. Box 112313 Anchorage, AK 99511
Site address NHN Mountain Breeze Drive
Legal description (Sub'd., Block & Lot) Shangri-La Estates East B1 L6
Legal description (Township, Range & Section)
Lot Size 40,180 Sq. Ft. Number of Bedrooms 4
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(® all that apply)
Absorption Field ❑x Initial Fil Single Family (SF) ❑x
Septic Tank ZUpgrade ❑ (w/wo ADU)
Holding Tank 1-1Renewal F-1Duplex (D) ❑
Multiple Dwellings El
Privy ❑ (SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: A5 q q
Date of Payment: 9hl2oo
Receipt Number: Q 6 (2 3 6
Permit No. 05 e ) /-7� 82
Permit App_:- : .' .:c
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
September 9, 2021
MOA Development Services, On-Site Water & Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
9/9/21
Subject: Shangri-La Estates East B1L6- NHN Mountain Breeze Drive
Septic system design
Dear On-Site Services Engineer:
The owner of the above lot intends to build a 4-bedroom home on the property, so we are
submitting this permit application for the construction of the new septic system. The attached site
plan identifies the location of the home as well as the existing well, proposed septic location, and
alternate site. No conflicts exist between this proposed system and any other well or septic system ,
whether on this lot or adjacent lots.
The ground surface on the lot slopes toward the north steeply near the back of the lot. There are
slopes at the north of the lot as steep as 67% however the provided cross section profile shows that
if constructed properly this won’t cause issues with the absorption field . Stormwater drainage will
not impact this septic system. The new trench will be constructed parallel to the slope as much as
possible.
Wells on this and adjacent lots are shown. The new system will be a minimum of 50’ from all
wells and surface water, and more than 5’ away from the septic tank. The alternate site is located
more than 8’ away.
Please refer to the attached test hole logs, plan and profile pages for the septic design. If this design
is followed, there will be no adverse impacts to adjacent properties .
Sincerely,
Michael E. Anderson, PE
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211382, Rebecca Carroll, 09/21/21
1"=50'
20' LONG x 5' WIDE, 2.5'
EFFECTIVE DEPTH ABSORPTION
TRENCH
4-BDRM HOME
1500-GAL
ADVANTEX TANK
W/ AX20 POD
NOTE:
NO SURFACE WATER WITHIN 100' OF THE PROPOSED SEPTIC SYSTEM
ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS
PROPERTY ARE SHOWN. NO CONFLICTS WITH WELLS OR SEPTIC
SYSTEMS.
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEANOUT
FS - FLOW SPLITTER VALVE
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
LEGEND
SHANGRI-LA ESTATES EAST, BLOCK 1 LOT 6
MOUN
T
A
I
N
B
R
E
E
Z
E
D
R
I
VE
9/15/21 FEET
0 50 100
≥5'
SA
N
D
P
I
P
E
R
D
R
I
V
E
TH#1
TH#2
1210
1205
1200
1195
1190
1185
1180
1175
1170
1165
1160
1150
1140
1135
1145
MT
MT
COCO
FCO
2CO
ALTERNATE SITE
20' LONG x 5' WIDE, 2.5'
EFFECTIVE DEPTH ABSORPTION
TRENCH
EXISTING
WELL
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211382, Rebecca Carroll, 09/21/21
TYPICAL TRENCH SECTION
(NO SCALE)
NOTES:
1. GRADE AREA OVER TRENCH TO DRAIN AWAY
2. PROVIDE 3' OF COVER OVER TRENCHES AND 4' OVER SEPTIC TANK, OR 2'
WITH 2" OF INSULATION
3. CHECK GROUNDWATER AT TIME OF CONSTRUCTION. IF LEVEL IS HIGHER
THAN PREVIOUSLY OBSERVED, CALL ENGINEER IMMEDIATELY
4" PERFORATED PVC (HOLES DOWN)
DRAINFIELD ROCK
5'
6"
6"
4.5'
2'-6"
DESIGN FACTORS:SYSTEM REQUIREMENTS:
600 GPD PEAK FLOW
PERK RATE: 2.9 MIN/IN
APPLICATION RATE: 6 GPD/SF
5' WIDE TRENCH SYSTEM
1500 GAL ADVANTEX TANK W/ AX20 POD
BOTTOM OF TRENCH: 7.5' BELOW GRADE
FLOW LINE ELEVATION: 5' BELOW GRADE
TOP OF TRENCH: 0.5' ABOVE GRADE
600 GPD / 6 GPD/SF /5' WIDE * 0.64 RED FACTOR = 12.7 LF TRENCH REQUIRED ( 20 LF SPECIFIED)
9/15/21
SHANGRI-LA ESTATES EAST, BLOCK 1 LOT 6
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211382, Rebecca Carroll, 09/21/21
SHANGRI-LA ESTATES EAST, BLOCK 1 LOT 6
SLOPE CROSS SECTION
3216 0
FEET
EXISTING GROUND
46%
ANG
L
E OF
EFFLUE
N
T
INF
L
UEN
C
E
PROPOSED
ABSORPTION BED
~67%
~26
%
~35
%
1150'
1145'
1160'
1155'
1170'
1165'
1180'
1175'
1185'
1140'
1135'
0' 5' 10' 15' 20' 25' 30' 35' 40' 45' 50' 55' 60' 65' 70' 75' 80' 85' 90' 95' 100' 105'10' 5'
9/15/21
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211382, Rebecca Carroll, 09/21/21
LEGAL DESCRIPTION:
PERFORMED FOR:
DATE:
PARCEL ID#:
SOILS LOG AND PERCOLATION TEST
TECHNICIAN:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
DEPTH
(feet)
PROJECT No.:
TEST HOLE 1
SLOPE
SLOPE
SITE PLAN
DATE READING GROSS TIME
(minutes)
NET TIME
(minutes)
DEPTH to
WATER NET DROP
PERC. HOLE DIA. (INCHES)PERCOLATION RATE: (MIN/INCH)
TEST RUN BETWEEN: FT. and FT.
COMMENTS:
(inches)(inches)
J. Millette
DATE OF MONITORING:
WAS GROUND WATER ENCOUNTERED?
DEPTH TO WATER AFTER MONITORING:
IF YES @ WHAT DEPTH?-
<1 6
6 7
2/22
1
2
3
4
5
6
GW (3" MINUS LOOSE GRAVEL)
Professional Engineers Stamp:
1/21/21
NO
NONE
9/7/21
Shangri-La Estates East, B1 L6
2/22/21
020-043-47
Crown Pointe
13:181
2
3
4
5
6
4 0
16 / 10 0
16
13:22
13:25
13:28
13:32
13:36
OB
2:15
HARD
PAN
PERC
6 0
16
4 0
16 / 10 0
162:32 6 0
16
4 0
16 / 10 0
162:38 6 0
16
4 0
16 / 10 0
162:45 6 0
16
4 0
16 / 10 0
162:50 6 0
16
4 0
16 / 10 0
162:53 6 0
16
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211382, Rebecca Carroll, 09/21/21
LEGAL DESCRIPTION:
PERFORMED FOR:
DATE:
PARCEL ID#:
SOILS LOG AND PERCOLATION TEST
TECHNICIAN:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
DEPTH
(feet)
PROJECT No.:
TEST HOLE 2
SLOPE
SLOPE
SITE PLAN
DATE READING GROSS TIME
(minutes)
NET TIME
(minutes)
DEPTH to
WATER NET DROP
PERC. HOLE DIA. (INCHES)PERCOLATION RATE: (MIN/INCH)
TEST RUN BETWEEN: FT. and FT.
COMMENTS:
(inches)(inches)
J. Millette
DATE OF MONITORING:
WAS GROUND WATER ENCOUNTERED?
DEPTH TO WATER AFTER MONITORING:
IF YES @ WHAT DEPTH?-
2.9 6
6 7
2/22
1
2
3
4
5
6
GW (3" MINUS LOOSE GRAVEL)
Professional Engineers Stamp:
1/21/21
NO
NONE
9/7/21
Shangri-La Estates East, B1 L6
2/22/21
020-043-47
Crown Pointe
13:451
2
3
4
5
6
4 0
16 / 7 12
16
13:56
14:08
14:20
14:31
14:43
OB
10 3 12
16
4 0
16 / 7 11
1610 3 11
16
4 0
16 / 7 10
1610 3 101
6
4 0
16 / 7 8
1610 3 8
16
4 0
16 / 7 8
1610 3 8
16
4 0
16 / 7 8
1610 3 8
16
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211382, Rebecca Carroll, 09/21/21
MUNICIPALITY OF ANCHORAGE
ADVANCED WASTEWATER TREATMENT SYSTEM
MAINTENANCE AND REPAIR AGREEMENT
THIS MAINTENANCE AND REPAIR AGREEMENT, herein the "AGREEMENT" made and
entered into as of this Z( Day of Lt/ of 20 L t , by and between
911L i -e ele-e s , herein the "OWNER," and the Municipality of
Anchorage. herein the "MUNICIPALITY". in accordance with Anchorage Municipal Code
(AMC) 15.65.365. In consideration of the mutual covenants contained herein, the parties to this
Agreement agree as follows:
1. Advanced Wastewater Treatment Systems. The Municipality grants permission to the
Owner to utilize and operate an Advanced Wastewater Treatment System (AWWTS),
described as Advantex Advanced Wastewater Treatment
located at (legal description)
Shanari-La Sub. Bl L6
2. Maintenance Repairs and Alterations.
(Owner is required to read, understand and initial each section)
Throughout the term of this Agreement, the Owner shall enter into a service agreement
with an AWWTS service and maintenance provider approved by the Municipality or the
manufacturer's representative. The AWWTS shall be maintained in a satisfactory
condition capable of perfoirning as designed and producing treated septic effluent in
accordance with the equipment's approval for operation in the Municipality.
eZ-1 It shall be the responsibility of the Owner during the term of this Agreement to pay for all
repair(s), maintenance, adJustment(s), replacement costs, and inspection costs. This
includes an annual maintenance fee (typically $400 to $600).
Com- Owner agrees that only maintenance and repair personnel approved by the Municipality
or the manufacturer's representative will inspect and make any necessary maintenance,
repairs or permitted alterations to the system.
Owner acknowledges that regular maintenance of an AWWTS reduces the potential
failure of the system, which could include sewage backup and costly repairs or drainfield
replacement.
(f �IW Owner acknowledges that the Municipality may request records of maintenance and
repairs from the manufacturer's representative or ntaintenance provider.
Owner acknowledges that the fine for failing to maintain and repair an AWWTS may be
assessed in accordance with AMC 14.60.030.
Owner agrees to grant the Municipality reasonable access to test and inspect the
AWWTS. The Municipality will give at least 24-hour notice.
ellw Owner agrees that any sale or transfer of title of the property will not occur without a new
Certificate of On -Site Systems Approval,
41.' Owner agrees that the AWWTS installation and maintenance requirements as provided
by the AWWTS vendor/installer and approved by the Municipality are the governing
guidelines for the construction, maintenance and repair of the Owner's AWWTS.
ez"+ Owner agrees to maintain remote monitoring of the AWWTS as required by the
AWWTS approval.
3. Term. The term of this Agreement shall begin on the date of approval by the
Municipality to operate the installed system, or upon transfer of title, and shall continue
while the AWWTS is operational or until title is transferred.
4. Nonwaiver. The failure of the Municipality at any time to enforce a provision of this
Agreement shall in no way constitute a waiver of the provisions. nor in any way affect
the validity of the Agreement or any part hereof, or the right of the Municipality
thereafter to enforce every provision hereof.
5. Amendment. This Agreement shall only be amended by authorized representatives of
the Owner and Municipality. Any attempt to amend this agreement by either an
unauthorized representative or unauthorized means shall be void.
6. Jurisdiction: Choice of Law. Any civil action arising from this Agreement shall be
brought in the Superior Court for the Third Judicial District of the State of Alaska at
Anchorage. The laws of the State of Alaska shall govern the rights and obligations of the
parties under this Agreement.
7. Severability. Any provisions of this Agreement decreed invalid by a court of competent
jurisdiction shall not invalidate the remaining provisions of the Agreement.
irPv 6511 Rl7f)1 Stl T) . 9 _rl
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Date:
�lt -14 �qgl
Title:
On, WIRMIRI lboo 1 Wl
Mov 29 OG 04:32p Sonshine Enterprises (907) 34G-8057 p.3
ALPINE DRILLING & ENTERPRISES
Permit Number: #SWp60347 DateofIssue: f0-24-06
Date Started: 11-'¢4-06 Date Compleled: ¢¢-10-06
Legal Description:
Property Owner Name & Address:
Borehole Data:
Soft Type, Thickness & Water Strata
stick-up
gravelly silt
Bedrock
Parcel Identification Number: 020-043-13
Is wel~ located at approved permit location? [] Yes [] No
Horace Tract 2 - Shengra-La Block 2 Lot 6
Anchorage Development & Construction
9441 Abbot Loop Read
Anchorage, Alaska 99516
Depth (ft) Method of Drilling [] a~r rotary [] cable tool
From To
Casing Wpe: steel
0 3 Wall Thickness:. 250 inches
3 ¢7 Diameter: _6 inches Depth: 20 feet
17 326 Liner Type: pvc 0-40 feet
Diameter: _4 inches Depth: 4~0 feet
Casing stickup above ground: _3 feet
Static water level (from ground level): 2i fec,
Pumping level: 326 feet after
_2 hours pumping _4 gpm
Recovery. Rate: _4 gpm
Method of Testing: air
Well Intake Opening Type:
[] Open End [] Open Hole
[] Screened Start feet Stopped feet
[] Perforations Start feet Stopped feet
Grout Type: bentonite granules Volume:
Depth: Start Q feet Stopped ~ feet
Pump: Intake Depth feet
Pump size . hp Brand Name
Well Disinfected Upon Completion.'? ~ Yes ~ No
Method of Disinfection: chlorine tablets
Comments.%4nnulu,~ aro~d P VC filIed with bentonite
chips from 40'to JO'. Casing hm granules from surface to
bedrock.
Well Driller: Alpine Drilling & Enterprises
PO Box ~ ~0496
Anchorage Alaska 9951
Attention: The well driller shall provide a well log to the property owner within/30 days of completion and the property
owner or the well driller shall provide a well log to the Development Services~D'epartment within 60 days of completion.
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water B Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WATER SUPPLY PERMIT
Initial
Permit Number: SWO60345
Legal Description: HORACE TRACT 2
Design Engineer: 0060 DHI ENGINEERING
Owner Name: ANCHORAGE DEVELOPMENT & CONS
Owner Address: 9441 ABBOT LOOP ROAD
ANCHORAGE, AK 99507-4221
Date Issued: Oct 24, 2006
Expiration Date: Oct 24, 2007
Parcel ID: 020-043-13
Site Address: NHN MOUNTAIN BREEZE DRIVE
Lot Size: 1739258 SQ. FT.
Total Bedrooms: 0 Permit Bedrooms: 0
This permit is for the construction of:
❑ Disposal Field ❑ Septic Tank ❑ Holding Tank ❑ Privy ❑✓ Private Well ❑ Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations (18AAC80 ).
3. The engineer must notify DSD at least 2 hours prior to each Inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
5. The following special provisions.
-WHEN THE WELL HAS BEEN COMPLETED AND SATISFACTORY WATER PRODUCTION HAS BEEN
DETERMINED, THE WELL DRILLER SHALL PLACE AN APPROVED SANITARY SEAL ON THE WELL HEAD AND
NO PITLESS ADAPTER OR PUMP SHALL BE INSTALLED UNTIL AN APPROVED WASTEWATER DISPOSAL
SYSTEM HAS BEEN CONSTRUCTED.
Received By.
C��CIJ�yC�(,C it" Date: a %
Issued By: RIZ-_ l�l�C2/4o n Uci,�� Date:
Municipality of Anchorage
• �- Development Services Department *A.
Building Safety DivisionOn-Site Water and Wastewater Program4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
ON-SITE SEPTICIWELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 02004313 W&L-9
Propertyowner(s)Anchorage Development & Cons tructionDayphone 346-2147
Mailing address 9441 Abbott Loop Road Anch. AK Zip Code 99507-4221
Site address Zip Code
Legal description (Sub'd, Block & Lot) Horace Subdivision - Tract 2
Legal description (Township, Section & Range) N1/2 Sec 2, T 11 N, R S W, S.M.
Lot Size 001739258 Sq. Ft.
Number of Bedrooms N/A
THIS APPLICATION IS FOR (®all that apply):
THIS APPLICATION IS AN:
Absorption Field ❑
Initial
❑
Septic Tank ❑
Upgrade
❑
Holding Tank ❑
Renewal
❑
Privy ❑
Private Well
Water Storage ❑
the above information is correct. I further certify that this application is being made for a
Dwelling and isin accordance with applicable Municipal Codes.
(Signature of propertykwner or
agent)
Date of Payment:
Date of Payment:
Receipt Number: 0_95?L'� /J5- Receipt Number:
(Rev. 11/05)
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MUNICIPALITY OF F ANCHORAGE
Development Services Department :- Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 020-043-47-000
Expiration Date:
10/30/2025
Legal description SHANGRI-LAESTATES EAST BLK 1 LT 6
Site address 16290 MOUNTAIN BREEZE DR Anchorage AK 99516
Current property owner(s) VAUGHAN JOHN RAY & TARA
X The On-site system(s) is/are approved for 4 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or advisories:
Original Certificate Date: 11/19/2024
is Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory
Other
COSA ApprovaLJune 2022
MUNICIPALITY OF ANCHORAGE
f
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 020-043-47
Complete legal description Shangri-La Estates East Block 1 Lot 6
Location (Site address) 16290 Mountain Breeze Dr, Anchorage, AK 99516
Current property owner(s) Ray & Tara Vaughan Day phone
2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS
3. TYPE OF WATER SUPPLY: ■❑ Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: ■❑ Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: ❑ Steel ❑■ Plastic ❑ Concrete ❑ Fiberglass
Age 2 - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench ■❑ Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested: ❑
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $ C> S V Waiver Fee $
Date of Payment % /5 ZL Z Date of Payment
COSA # 0S C Z 7 'y � Waiver #
COSA Application—June 2022
4.20
10/30/24
N/A N/A
N/A
Benjamin Schiller, P.E.
(907) 522-7773
To: null
Page: 133 of 146 2024-07-02 21:32:49 GMT
19073086608
From: Wes Anderson
S
soon on ■■ ■E■ son ■■ ■ ■ono■ . e
■ ON ■E■IEE■■E■ NINE■ ■Nn ■■■In■ ■s ■
o
AAIvanTex® Field Maintenance Report AnchorageTank
n r,r,l L I Ir1cr%gw Finn 907-272-3543
Operator
Property owneraraching d
A+ Home Services Tech
John & Tara Vaughan
Contact Phone
Site Address (601) 880-6116
16290 Mountain Breeze Drive, Anchorage AK 99516
AX Site Ip p County ip # Pod w nTU MNL k pate of Last Inspection
AX -154769 OSP211382 ORD514082- RTU145303 0911512023
Retrieve O&M Info
Daily flow__
Recim ratio _
Timer settings:
Perform Field Sampling/Observations
NTU (15 x NTUs) pH (6-9) DO (2-6)
Nontypical Musty Earthy (J Moldy
Odor of Sample
Typical L-
Sulfide ❑ Cabbade ❑ Decay
Oily film in PVU Lyes ,"
Foam in tank ❑ yes Ir:l No
Check Control Panel
r��
Amps Discharge Amps
[t -C�
Audible and visual alarms OK
Dial tone (telemetry only) Dyes LNo
Inspect/Clean Pump System
Inspect Clean
Riser/Lid ........ ............
Splice Box .................... [:
Float Cords ................... L a
Floats ........................
Pump........................
Biotube® Filter ........... . . . — [ I
Biotube Pump Vault ............
Recirculating Splitter Valve...... .
Comments
Measure Sludge/Scum
Scum
1 S Compartment
Current
Previous
Current
Previous
2nd Compartment
Current
Previous
Current
Previous
inspect/Clean Advarl Filter
, Ins Cie>jn
Otlor. L7 yrormal []Pungent Laterals/Orificas �—
Biomat: (�t;orma] ❑Excessive I Pod Bottom
Bddging/Ponding: L None/Minor ❑Excessive Intake Vent _
inspect/Clean DIn Cl
Pump System
In t inspe ear,%
RisedLid Floats
Splice Box Pump
Float cords
Inspect/Service O erT
Components
Clea Ingpyet Cipa
Disinfection Equipment Dispersal Latemis/Orifices CbJS
Observations _.....___
Additional Services Rendered
i Cleaned textile sheets? ❑ Replaced UV items?
Replaced/Used other items?
Parts Used: W = Warranty, B = Billable (✓ appropriate selection)
W a Item Number Description
Fi / fety Inspection
SV reinstalled Ids bolted on
Manifold roconnected; flush valves closed (�... Control panel reactivated
Su ry/Recommendations
Li�tystem performing; no further action needed ❑Tank needs pumping
El Call for servifje Other?
Date
Fax completed form to 1-866-384-7404
MUNICIPALITY OF ANCHORAGE
ADVANCED WASTEWATER TREATMENT SYSTEM
MAINTENANCE AND REPAIR AGREEMENT
THIS MAINTENANCE AND REPAIR AGREEMENT, herein the "AGREEMENT" made and
entered into as of this 22 Day of January of 2025 , by and between
Jonathan Luk , herein the "OWNER," and the Municipality of
Anchorage, herein the "MUNICIPALITY", in accordance with Anchorage Municipal Code
(AMC) 15.65.365. In consideration of the mutual covenants contained herein, the parties to this
Agreement agree as follows:
1. Advanced Wastewater Treatment Systems. The Municipality grants permission to the
Owner to utilize and operate an Advanced Wastewater Treatment System (AWWTS),
described as AdvanTex Advanced Wastewater Treatment System
located at (legal description)
Shangri-La Sub. B1 L6
2. Maintenance, Repairs and Alterations.
(Owner is required to read, understand and initial each section)
Throughout the term of this Agreement, the Owner shall enter into a service agreement
with an AWWTS service and maintenance provider approved by the Municipality or the
manufacturer's representative. The AWWTS shall be maintained in a satisfactory
condition capable of performing as designed and producing treated septic effluent in
accordance with the equipment's approval for operation in the Municipality.
It shall be the responsibility of the Owner during the term of this Agreement to pay for all
repair(s), maintenance, adjustment(s), replacement costs, and inspection costs. This
includes an annual maintenance fee (typically $400 to $600).
Owner agrees that only maintenance and repair personnel approved by the Municipality
or the manufacturer's representative will inspect and make any necessary maintenance,
repairs or permitted alterations to the system.
Owner acknowledges that regular maintenance of an AWWTS reduces the potential
failure of the system, which could include sewage backup and costly repairs or drainfield
replacement.
(rev. 05/18/2018) Page 1 of 3
Owner acknowledges that the Municipality may request records of maintenance and
repairs from the manufacturer's representative or maintenance provider.
Owner acknowledges that the fine for failing to maintain and repair an AWWTS may be
assessed in accordance with AMC 14.60.030.
Owner agrees to grant the Municipality reasonable access to test and inspect the
AWWTS. The Municipality will give at least 24-hour notice.
Owner agrees that any sale or transfer of title of the property will not occur without a new
Certificate of On -Site Systems Approval.
Owner agrees that the AWWTS installation and maintenance requirements as provided
by the AWWTS vendor/installer and approved by the Municipality are the governing
guidelines for the construction, maintenance and repair of the Owner's AWWTS.
c'�L Owner agrees to maintain remote monitoring of the AWWTS as required by the
AWWTS approval.
3. Term. The term of this Agreement shall begin on the date of approval by the
Municipality to operate the installed system, or upon transfer of title, and shall continue
while the AWWTS is operational or until title is transferred.
4. Nonwaiver. The failure of the Municipality at any time to enforce a provision of this
Agreement shall in no way constitute a waiver of the provisions, nor in any way affect
the validity of the Agreement or any part hereof, or the right of the Municipality
thereafter to enforce every provision hereof.
5. Amendment. This Agreement shall only be amended by authorized representatives of
the Owner and Municipality. Any attempt to amend this agreement by either an
unauthorized representative or unauthorized means shall be void.
6. Jurisdiction: Choice of Law. Any civil action arising from this Agreement shall be
brought in the Superior Court for the Third Judicial District of the State of Alaska at
Anchorage. The laws of the State of Alaska shall govern the rights and obligations of the
parties under this Agreement.
7. Severability. Any provisions of this Agreement decreed invalid by a court of competent
jurisdiction shall not invalidate the remaining provisions of the Agreement.
(rev. 05/18/2018) Page 2 of 3
OWNER:
By: (signature) Date:l�� ✓- l2, Zo2
l' /c+)1<Lrinotn LLb� (prlilt Ilallle)
STATE OF ALASKA )
ss.
THIRD JUDICIAL DISTRICT )
The foregoln instrument was acknowledged before me this day of
203,,A -,by �tD tj Cl KI LO,
NOTARY PUBLIC_ OR AL SICK STATE OF ALASKA
My Commission expires: '� NOTARY PUBLIC ;: r;.y
.
Cherilyn Cramer
My Commission Expires July 4, 2026
gnature) Date:
int name) Title:
(rev. 05/18/2018) Page 3 of 3
U H 8 C � P LTY OF A HCHOo R ;E
Development Services Department - Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Parcel I.D. 020-043-47
Certificate of On -Site Systems Approval
Expiration Date: 3-29-2023
Legal description Shangri-La Estates East, Block 1 Lot 6
Site address 16290 Mountain Breeze Dr, Anchorage, Ak 99516
Current property owner(s) Crown Point
X The On-site system(s) is/are approved for 4 bedrooms
Conditional approval for
Comments or advisories:
bedrooms, with the following stipulations:
BY _ �/�— �r� Original Certificate Date:
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory X
Other
COSA Approval June 2022
MUNICIPALITY OF
f
Development Services Department
On -Site Water & Wastewater Section J -�
RU314
ANCHORAGE
Phone: 907-343-7904
Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 020-043-47
Complete legal description Shangri-La Estates East, Block 1 Lot 6
Location (site address) 16290 Mountain Breeze Drive, Anchorage, AK 99516
Current property owner(s) Crown Pointe, Inc
2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS
Day phone (907) 727-5259
3. TYPE OF WATER SUPPLY: ❑■ Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: ❑■ Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: ❑ Steel Plastic ❑ Concrete ❑ Fiberglass
Age < 1 yr - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench X Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested: X
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $ � / a � Waiver Fee.$
Date of Payment /91/ 9 -?_/;Z '-Z Date of Payment
COSA # 05 C a oLi J` Y Waiver #
COSA Application—June 2022
Legal Description: Shangri-La Estates East, Block 1 Lot 6 Parcel ID: 020-043-47
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system _
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled 11/16/06 Total depth 326 ft
Cased to 20 ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) 36+ in.
Date of flow test for COSA 12/6/22
Static water level at beginning of test 25.8 ft.
Comments
B. TANK DATA
Measured operating fluid level in septic tank N/A
Date of pumping NEW INSTALLATION
❑ Required maintenance completed, if AWWTS
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed) 1/27/22
❑ ALL standpipes present per record drawing
Total measured depth from grade 10.7 ft (max)
Measured depth to pipe invert from grade 8.2 ft (min)
❑ N/A — pressurized field.
❑ Per record drawings, field is insulated.
❑ Monitor tubes go to bottom of effective.
If not, state depth into effective
❑ Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced N/A gallons N/A date
Any rejuvenation treatment (past 12 months) N/A
If yes, enter date
Comments/Deficiencies:
COSA Checklist June 2022
Well production at time of test 3.4+ gpm
Water storage tank volume N/A gallons
Well disinfected for coliform test? ❑ Yes ❑ No
❑ Coliform bacteria is Negative
Nitrate 4.66 mg/L ❑ Nitrate less than MRL (ND)
Arsenic 12.4 ug/L ❑ Arsenic less than MRL (ND)
Collected by Forge Engineering
Date 12/6/22
C. LIFT STATION
uired maintenance completed
Age of lift statio years
Lift station material
Comments:
Adequacy test date NEW INSTALLATION
Results ❑ Pass
Fluihdepth prior to test in
Water\hn
New fln
ElapseFinal flnAbsorppdFIELD E
Effective depth (per record
Effective depth used
Effective depth remaining
COVERY
ngs) in
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less
than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100'
Community Sewer Manhole/Cleanout > 100'
Mw Yes
if No
ftE
Yes
if No ft
Neighboring Tank > 100' 0 Yes
if No
ft
Private Sewer/Septic Line > 25' R Yes
if No ft
Absorption Field on Lot > 100' El Yes
if No
ft
Holding Tank > 100' Fm -]Yes
if No ft
Neighboring Absorption Fields > 100'
Animal Containment > 50' Q Yes
if No ft
0 Yes
if No
ft
Community Sewer Main > 75' QYes
if No
ft
Manure/Animal Excreta Storage > 100'
� Yes
if No ft
❑ N/A — Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10' 0 Yes if No ft Surface Water > 100' n Yes if No ft
Tank to Property Line > 5'
Field to Property Line > 10'
Water Main > 10'
Water Service Line > 10'
F. ENGINEER'S COMMENTS
M Yes if No ft
0 Yes if No ft
Fol Yes if No ft
0 Yes if No ft
Wells on Adjacent Lots:
Private Wells > 100' Cj Yes if No ft
Community Wells > 200' 0 Yes if No ft
If tank or field is under driveway comment below
G. CERTIFICATION & STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm Forge Engineering Phone (907) 522-7773
Engineer's Printed Name Benjamin Schiller, P. E. Date 12/6/22
COSA Checklist—June 2022
OF `kk
Tf z
• • •� e ja §.5chiller . • .
CE 12592AWK
•�����
���F�pR4FESS10NP�'.��
Arsenic Advisory
Certificate of On -Site Systems Approval # OSC221574
Subdivision: Shangri-La Estates East Block 1 Lot 6
A water sample revealed an arsenic concentration of 12.4 micrograms per liter
(ug/Q. The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. information on arsenic is available from the On -Site Water and
Wastewater Program website (www.muni.org/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
MUNICIPALITY OF ANCHORAGE
ADVANCED WASTEWATER TREATMENT SYSTEM
MAINTENANCE AND REPAIR AGREEMENT
THIS MAINTENANCE AND REPAIR AGREEMENT, herein the "AGREEMENT" made and
entered into as of this Day of —P.2c Jv,.c- of 20221 by and between
,r
`�� �� V ,•�� %1�t� , herein the "OWNER," and the Municipality of
Anchorage, herein the "MUNICIPALITY", in accordance with Anchorage Municipal Code
(AMC) 15.65.365. In consideration of the mutual covenants contained herein, the parties to this
Agreement agree as follows:
1. Advanced Wastewater Treatment Systems. The Municipality grants permission to the
Owner to utilize and operate an Advanced Wastewater Treatment System (AWWTS),
described as Advantex Adavanced Wastewater Treatment
located at (legal description)
ShanQri-La Estates East Block 1 Lot 6
2. Maintenance, Repairs and Alterations.
(Owner is required to read, understand and initial each section)
Throughout the term of this Agreement, the Owner shall enter into a service agreement
with an AWWTS service and maintenance provider approved by the Municipality or the
manufacturer's representative. The AWWTS shall be maintained in a satisfactory
condition capable of performing as designed and producing treated septic effluent in
accordance with the equipment's approval for operation in the Municipality.
It shall be the responsibility of the Owner during the term of this Agreement to pay for all
repair(s), maintenance, adjustment(s), replacement costs, and inspection costs. This
includes an annual maintenance fee (typically $400 to $600).
Owner agrees that only maintenance and repair personnel approved by the Municipality
or the manufacturer's representative will inspect and make any necessary maintenance,
repairs or permitted alterations to the system.
Owner acknowledges that regular maintenance of an AWWTS reduces the potential
failure of the system, which could include sewage backup and costly repairs or drainfield
replacement.
(rev. 05/18/2018) Page 1 of 3
` , Owner acknowledges that the Municipality may request records of maintenance and
repairs from the manufacturer's representative or maintenance provider.
Owner acknowledges that the fine for failing to maintain and repair an AWWTS may be
assessed in accordance with AMC 14.60.030.
�'5�J Owner agrees to grant the Municipality reasonable access to test and inspect the
AWWTS. The Municipality will give at least 24-hour notice.
t % Owner agrees that any sale or transfer of title of the property will not occur without a new
Certificate of On -Site Systems Approval.
10 Owner agrees that the AWWTS installation and maintenance requirements as provided
by the AWWTS vendor/installer and approved by the Municipality are the governing
guidelines for the construction, maintenance and repair of the Owner's AWWTS.
Owner agrees to maintain remote monitoring of the AWWTS as required by the
AWWTS approval.
3. Term. The term of this Agreement shall begin on the date of approval by the
Municipality to operate the installed system, or upon transfer of title, and shall continue
while the AWWTS is operational or until title is transferred.
4. Nonwaiver. The failure of the Municipality at any time to enforce a provision of this
Agreement shall in no way constitute a waiver of the provisions, nor in any way affect
the validity of the Agreement or any part hereof, or the right of the Municipality
thereafter to enforce every provision hereof.
5. Amendment. This Agreement shall only be amended by authorized representatives of
the Owner and Municipality. Any attempt to amend this agreement by either an
unauthorized representative or unauthorized means shall be void.
6. Jurisdiction: Choice of Law. Any civil action arising from this Agreement shall be
brought in the Superior Court for the Third Judicial District of the State of Alaska at
Anchorage. The laws of the State of Alaska shall govern the rights and obligations of the
parties under this Agreement.
7. Severability. Any provisions of this Agreement decreed invalid by a court of competent
jurisdiction shall not invalidate the remaining provisions of the Agreement.
(rev. 05/18/2018) Page 2 of 3
OWNER:
By: (signature) Date: 2 2 6 0,
6 V\,.uuc k c%/\ (print name)
STATE OF ALASKA )
ss.
THIRD JUDICIAL DISTRICT )
The forego'ng instrument wa acknowledged before me thisD-� day of
20Z, by k'�k'Cj L,S,A�
ti
NOTARY PUBLIC FOR ALASKA
My Commission expires: t 1/ l,? %��� "Official Seal"
�i— Notary Public
Lakiesha Pleasant
State Of Alaska
Cnrn r:ri"ion ,1191113016L,1011, 11/13/2023
MUNICIPALITY:
By: �"'� (signature)
(print name)
Date: tP2--Z 7 2 4
Title:
(rev. 05/18/2018) Page 3 of 3