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HomeMy WebLinkAboutRABBIT CREEK VIEW & HEIGHTS BLK 8H LT 7AOnsite File Rabbit Creek View & Heights Block 8H Lot 7A #020-561-49 kmev uoiuZi its Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP231267 PID Number: 020-561-49 Dwelling: X Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑1 New ❑ Upgrade Name Home Renewal Company LLC ABSORPTION FIELD ❑ Deep Trench ❑■ Wide Trench ❑ Bed X Mound Site Address 8236 Byron Drive ❑ Other Phone Number of Bedrooms Soil Rating depth from original grade 2.0 GPD/SF JTotal 1.0 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 0.5 Ft. Gravel depth beneath pipe 0.5 Ft. Subdivision Block Lot Rabbit Creek View and Heights 8H 7A Fill added above original grade 2.3 Ft. Gravel length 50.0 Ft. Township Range Section Gravel width 5.0 Ft. Beds: Number of Lines NA Distance between lines NA Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line 250 Ftz 1 NA Ft. Well 68.9 96.8 67.3 NA 25'+ TANK ❑ Septic 9 S.T.E.P. ❑ Holding ❑ Other Manufacturer Anchorage Tank Capacity 1,500 Gal. Surface Water 100'+ 100'+ 100+ NA Material Number of compartments Lot Line 51+ 51+ 5'+ NA NA Steel 2 Foundation 10'+ 10'+ 10'+ NA LIFT STATION Manufacturer Capacity Remarks Orenco 250 Gal. Alarm location House Electrical installed by Solid Ground Installer PIPE MATERIAL House to tank 3034 Tank to drainfield 3034 Northern Excavating Drainfield 3034 CO/NIT3034 Inspector PES BENCH MARK (Assumed elevation) 100 ft Inspeection vt 7/20/2023 8/17/2023 Location and description 3d 8/18/2023 2nd 4th 9/24/2023 Nearest Deck Corner ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional Approval: Date Pi•••..,. AM :* .. .. ...... "$even annowe CE 8149 •'•.,10-6-23.••• ...... Septic System Approved Date 9 2� z' Note: this approval does not include well permit requirements. kmev uoiuZi its :z m m 0^^ -� ci m � � �� -L IBJ 7J 70-j:z-170m -0 -71 U)r70rz1pocIn0� c �ro-1 0M D ;�zz z o mm�z cf) z z m O z O c C z m* m > D m mul 70 m r -D z m m O O ® O O 0 . U 0cn 0 w TUBE 1 --I -P, (::: 0 c Ico ;z DU) = 1Z 70 70(D mDO F'l Z FOUNDATION C � CLEAN OUT m N Dx N N O � O N N 0c)NCP O (Ji m �0 O W n 01 CD N N N = U) C-0� a � N Co N � N F D Co Cn 00 cn 00 / O N D N CD CA N — � I 0-) U1 O J c0 /. I Amo >m� CA(DUJ O J 07 A 07 O O O ® O O 0 . U 0cn 0 w TUBE 1 --I -P, (::: 0 c Ico ;z DU) = 1Z 70 70(D mDO F'l Z FOUNDATION U) -71 F- z U) r Dr O�Cp m DU CLEAN OUT m Om.O- DM70 m �m zmm0 Dx U =� Nc� O m N O � O N N 0c)NCP (Ji m �0 O W n � � O Q cf) U) LT 1 . m m-0 m O = U) C-0� a � � O O Cn 0 m F 0 A-�Dz�DOzom O [1I CP X Z O / O N D / IMONITOR / Ca X—�_ I -0 � � I E- DN COD /. I Amo >m� o A lFTI 70 > Z D O m o m MONITOR TUBE O O ® O O 0 . 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BOX 1807 PALMER,, AK 9645 PHONE (907) 745-8200 FAX (907) 745-8201 I a3 7 REVISIONS O a7 7Z RECORD DRAWING ` o 0 SCALE 1 „ - 50' D cf) W _m / r l� -70/ zm N O/ 1 m �D F _ \ O [1I CP X Z O / O N D / r c- D 0 / Ca X—�_ I -0 � � I E- DN COD /. I Amo >m� o �mm m lFTI 70 > Z D O m o m \w\ w _ Z Z U)\ D \ D F- F- r F- F- O m O (n CD < \ CD Q U O O �ou O 17 o - z m mi m m Dz F- �m O 1,:�E O r x GOco /'oo 7 M 0 (7 J �• �53�\a D / PANNONE ENG SVC LLC g(C.1. 1088) P.O. BOX 1807 PALMER,, AK 9645 PHONE (907) 745-8200 FAX (907) 745-8201 I a3 7 REVISIONS O a7 7Z RECORD DRAWING ` o 0 SCALE 1 „ - 50' r m F / r l� DRAWN LJC/DRM 3 3 1 \ �D 71 x Dm< �mz � -< � . D 0 m \ z 1 49 NOTES: PANNONE ENG SVC LLC g(C.1. 1088) P.O. BOX 1807 PALMER,, AK 9645 PHONE (907) 745-8200 FAX (907) 745-8201 pF *: 4Q ISL :* • • ......• ..meven anrio�a CE 8149 10/6/23..--OSP231267 REVISIONS DATE 10/6/2023 RECORD DRAWING SCALE 1 „ - 50' RABBIT CREEK VIEW & HEIGHTS BOCK 8H LOT 7A BOYLE RONALD A JR SITE: NSN BYRON DRIVE ANCHORAGE, AK P.I.D. NO 020-561-49 DRAWN LJC/DRM SITE PLAN PERMIT NO. SHEET 2 OF 2 Certified Drilling Log OWNER OF LAND: Ronald Boyle ADDRESS: 8236 Byron Drive Anchorage, AK 99516 LEGAL DESCRIPTION Rabbit Creek V&H B8H L7A DATE: 7-25-23 PERMIT NUMBER: OSP221248 DATE OF ISSUE: 7/25/22 TAX IDENTIFICATION NUMBER 02056149000 Is well located at approved permit location: Yes No Method of Drilling: air rotary cable tool Depth of Well: 120’ Casing Type: Steel Wall thickness .250 inches Diameter: 6 inches, depth 114 feet Liner type Static Water Level: Flowing feet Recovery Rate 5 gpm gph Method of Testing Air Well Intake Opening Type: open end open hole Screened Start feet Stopped Perforations Start feet Stopped Grout Type: Bentonite Volume: 50 lbs Depth: from 2 feet, to 42 feet Well Disinfected Upon Completion: yes no Method of Disinfection: Chlorine 50 PPM Comments: Bore Hole Data Depth From To 0 2 Casing Stickup 2 4 Overburden 4 29 Tight Silty Sand & Gravel 29 39 Silty Sand & Gravel 39 110 Hardpan 110 120 Tight Silty Sand & Gravel Drillers Name: Cole Sullivan ATTENTION: It is the responsibility of the property owner to submit a copy of the well log to the proper authority. Municipality of Anchorage: Department of Health & Human Services and/or Department of Environmental Conservation. MatSu Borough: Department of Environmental Conservation. Well Drilling Permit Number: SW Parcel Identification Number: R Doc co dry BILL R. COLE ��► ULLIVAN WATER WELLS P.O. Box 670269, Chugiak, AK 99567 688-2759 www.suilivanwaterwells.com Pump Installation Log 22 I'Lq S Date of Issue `7! 2_16 fZ2 Legal Description Property Owner Name & Address I wii i-rr� V�\4'' iCk\ ror� Dr. Pump Installation Date: '�:'o /9 3 Pump Intake Depth Below Top of Well Casing: 7C)t Pump manufacturer's Name: �r y� �L� ✓\ Pump Model: i Q �'� �C, �( --93C) Pump Size: 1/0, Pitless Adapter Burial Depth: i 16 Pitless Adapter Installer: �Kktk�v^ Disinfected Upon Completion? ® yes Method of Disinfection: Chlorine 50 PPM Comments: Pitless Manufacturer: p Pump Installers Name: Sullivan Water Wells feet X feet Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation. .00 AT HORA i AS—BUILT OF: RABBIT CREEK VIEW & HGTS REPEAT LOT 7A BLOCK 8H PLAT 2004-91 SURVEY CERTIFICATE: I, John L. Schuller, Have conducted a physical survey of this property as shown on this drawing and that the improvements situated hereon are within the property lines and no enchroachments exist other than noted. Under no circumstance shoul4 any information on this drawing be used for construction of fences, structures, improvements, or for establishing boundary lines. EXCLUSION NOTES: It is the owners responsibility to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. WORK ORDER NUMBER: DATE: SCALE:E-MAIL: AUG 24, 2023 1 "=40' schuller@ak.net 23— 01 8 DRAWN BY: CHECKED BY GRID NUMBER: BOOK AGE: JLS SW3341 230256 * ^ FND 5/8 " REBAR �t 1 AMW OFA \0 %, V 1� �" t' s[i)? LA Nto � i C) - 49TH1 'A........ ..........z ;OHN L. SCHULLER.• 0 LS--10408ele AAW o f e fl1 �- .e.• 1.831. Talkeetna Street Anchorage, .Alaska 99508 (907) 227-1455 office (907) 274--4992 f ax MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Water & Wastewater System Permit Permit Number: OSP231267 Work Type: WellSeptic Renewal Effective Date: Expiration Date: Tax Code Number: 02056149000 Site Legal Address: RABBIT CREEK VIEW & HEIGHTS BLK 8H LT7A G:3341 Site Mailing Address: 8236 BYRON DR, Anchorage Owner: HOME RENEWAL COMPANY LLC Design Engineer: PANNONE ENGINEERING SERVICES This permit is for the construction of: Q Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy Z�Zcnt Department 8/16/2023 8/15/2024 Lot Size in Sq Ft: 32600 Total Bedrooms: 3 Q Private Well ❑ Water Storage All construction shall 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 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 (24/7). 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 Received By: S v�� 1 " ` S Date: Issued By: Date: t 6 -Zo 13 MUHMPAUN OF HCH ORAGE 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. 020-561-49 Property owners) Ronald A Boyle Jr Day phone Mailing address Site address NSN Byron Drive Legal description (Sub'd., Block & Lot) Rabbit Creek View & Heights Block 8H Lot 7A Legal description (Township, Range & Section) Lot Size 32,600 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (N all that apply) Absorption Field ❑X Initial ❑ Single Family (SF) ❑X Septic Tank 1KUpgrade ElDuplex (w/wo AD U) (D) El Tank El Renewal M Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑X 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: Z -� Z Waiver Fees: Date of Payment: Receipt Number: Permit No. Permit App_'-'-'- :-'.,:c.; Date of Payment: Receipt Number: Waiver No. ti° • �°Jill . Steven R. Pannone, Principal Registered Professional Engineer E-mail: steve@panengak.com DATE 8/16/23 Subject: Expired On -Site Water and Wastewater Permit Permit Renewal Request Permit Number: OSP221248 Legal Description: RCVH B8H L7A Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPUANC OSP231267, Curtis Townsend, 08/16 This is a request to renew the permit for the above mentioned lot. All site conditions remain the same. The construction still will not affect the health, safety, or development of the surrounding lots. Sincerely, Steven R. Pannone, PE, F. ASCE Owner/Civil Engineer Mailing: P.O. Box 1807, Palmer, Al( 99645-1807 Telephone: (907) 745-8200 FAX: (907) 745-8201 MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program pOBox |9GG5O478DElmore Road Anchorage, Alaska 8001e-snso px '7904 Fax: (eur)a4a'Toy7 - nnp:xwmw.mun/.urgmnn/m ° On -Site Water & Wastewater System Permit Permit Number: OSP221248 Effective Date: 7/25/2022 Work Type: VVe|Sop8c|nitia| Expiration Date: 7/25/2023 Tax Code Number: 02056149000 Site Legal Address: RABBIT CREEK VIEW & HEIGHTS 8LK 8HLT7A G3341 Site Mailing Address: O238BYRONDR, Anchorage Owner: BOYLERONALD AJR Lot Size in Sq Ft: 32600 Design Engineer: PANNONEENGINEERING SERVICES Total Bedrooms: 3 Disposal Field R1 Septic Tank [] Holding Tank [] Privy Private Well [] Water Storage . . . . . All construction shall beinaccordance with: 1. The attached approved design. 2. All requirements specified inAnchorage Municipal code Chapters 15.55 and 15G5and the State ofAlaska Wastewater Disposal Regulations (18AAC72)and Drinking Water Regulations (1 8AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the DevelopmentServiceoDepadmentperAMC15-65 Provide notification by calling (907) 343-7904 (24/7).4. From October 1StoApril 15, a subsurface soil absorption system under construction during freezing weather shall beeither: a. Opened and Closed onthe same day, or b. Covered, sealed, and heated to prevent freezing Received By: Issued By: MUNICIPALITY ANCHORAGE r ` v Community Development DepartmentM 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. 020-561-49 Property owner(s) Ronald A Bo Mailing address Site address NSN Byron Drive e Jr Day phone Legal description (Sub'd., Block & Lot) Rabbit Creek View & Heights Block 8H Lot 7A Legal description (Township, Range & Section) Lot Size 32,600 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS'AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑X Initial I—XI Single Family (SF) 0 Septic Tank 0 Upgrade ❑ (w/wo AD U) Holding Tank El Renewal Renewal ❑ (D) ❑ Privy ❑ Multiple Dwellings ❑ (SF and/or D) Private Well ❑X 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: # E o�2 V Waiver Fees: Date of Payment: 7 'T% .2 © Date of Payment: - Receipt Number: Receipt Number: Permit No. Q S Pia y Waiver No. Permit App__- : :'-r Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221248, Deb Wockenfuss, 07/25/22 F=31 Tank Bouyancy Check RANNONE ENGINEERING SERVICES. LLC Job Name: Rabbit Creek View & Heights Block 8H Lot L7A Subject: Septic Tank Bouyancy Check Job Number: 12022.06.30 Originator: luc I Checker: ----j Septic Tank ASSUMPTIONS SITE PARAMETERS 1. No angle of repose on backfill material Weight of Water E:=62.4lb/ft' 2. 100 lb/ft' backfill material Weight of Soil 10E� Ib/ft-Tank Bury Depth =4 ft TANK DIMENSIONS Diameter of Tank 5=3 ft Radius of Tank 2=6 7 ft Length of Tank E=ft Area of Tank 22.31 ft, Volume of Tank 379.31 ft' Weight of Tank I b Manholes r ------------ I Yes Percentage of Tank in Groundwater BOUYANT FORCES (weight of the displaced water) 23669 Ib UP RESISTING FORCES (weight of soil & tank) Volume of Manholes 22 W Volume of Soil 295 ft, (Volume of Soil over Tank minus Volume of Manholes) 29514 Ib DOWN NET FORCE ON TANK E5845 Ib Design OK -A� c- cl 1A le G 6. Z 5 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221248, Deb Wockenfuss, 07/25/22 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221248, Deb Wockenfuss, 07/25/22 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221248, Deb Wockenfuss, 07/25/22 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 'L9 Day of w+ r of 2023 , by and between t v�l+S UW -40-f-?— , 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: I . Advanced Wastewater Treatment Systems The Municipality grants permission to the Owner to utilize and operate an Advanced Wastewater Treatment System (AWWTS), described asyntx located at (legal description)���� RABBIT CREEK VIEW & HEIGHTS BLK 8H LT7A 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). '�L 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 I 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. 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 shalt 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. S. 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. 05x'1812018) Page 2 of 3 OWNER: By: (signature) Date: Zql2J R-k"40,ft_ (print name) -1 STATE OF ALASKA )ss. THIRD JUDICIAL DISTRICT ev The foregoing instrument w day of �,,,kkn ledged before me this 20?3. by Ww c NOTARY PUBLIC FOR ALASKA A� My Commission expires: 0Qaa-a))& MUNICIPALITY By: (signature) 7-0 tlr-5F,--O print name) (rev. 05118/2018) j) )%b OF N\ - Date: Title: V(C— Page 3 of 3 MUNICIPALITY OF ANCHORAGE Development Services Department T Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Parcel I.D. 020-561-49 Certificate of On -Site Systems Approval Expiration Date: Legal description RABBIT CREEK VIEW & HEIGHTS BLK 8H LT7A Site address 8236 BYRON DR Anchorage AK 99516 Current property owner(s) HOME RENEWAL COMPANY X The On-site system(s) is/are approved for 3 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: VA Original Certificate Date: `' Z 3 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject systems) 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 Absorption Field Advisory Tank Age Advisory Other Well Flow Advisory Nitrate Advisory Arsenic Advisory COSA Approval_June 2022 MUHMPAUT Development Services Department On -Site Water & Wastewater Section ANCHORAGE R Us H Phone: 907-343-7904 Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 020-561-49 Complete legal description RABBIT CRFEEK VIEW AND HEIGHTS B8H L7A Location (site address) 8236 BYRON DR Current property owner(s) Dmitry Vakulich 2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS Day phone 3. TYPE OF WATER SUPPLY: 0 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 NEW - See advisory if steel older than 20 years 6. ABSORPTION FIELD: 0 AWWTS ❑ Bed ❑ Deep Trench 0 Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: Q 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 $ 120 Waiver Fee $ Date of Payment Date of Payment COSA # 0_5 C 22>� `57 Waiver # COSA Application—June 2022 907-745-8200