HomeMy WebLinkAboutCLOUD 9 LOT 2
Cloud 9
Lot 2
#020-161-30
$/(8/� 0 z -5 -
(Rev 05/02/18)
Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3
ON-SITE
WASTEWATER INSPECTION REPORT
Permit Number: OSP221334
PID Number: 020-161-30
Dwelling: n Single Family (SF)
❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: no New ❑ Upgrade
Name
Mark Philips
ABSORPTION FIELD
❑Deep Trench Q Wide Trench El Bed ❑Mound
Site Address
7990 Paine Rd
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
(907)227-0492
Four(4)
6.0 GPD/SF
3.5 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
3.0 Ft.
Gravel depth beneath pipe
0.Ft.
Subdivision
Block Lot
Cloud 9
2
Fill added above original grade
1.0 Ft.
Gravel length
20 Ft.
Township Range Section
Gravel width
5.0 Ft.
Beds: Number of Lines
N/A
Distance between lines
N/A Ft.
SEPARATION
DISTANCES
To
Septic
Absorption
Holding
Lift Station
Sewer
Total absorption area
100
Number of trenches
One(1)
Dist. between trenches
N/A
From
Tank
Field
Tank
Line
Ft'-
Ft.
Well
>50'
>50'
N/A N/A
>25'
TANK El Septic [:1S.T.E.P. F71 Holding Other
Manufacturer
Advantex
Capacity
1500 Gal.
Surface Water
>100,
> 100'
N/A N/A
Material
Plastic
Number of compartments
Two(2)
Lot Line
>5'
>10'
N/A N/A
NA
Foundation
>1 0'
>1 0'
N/A N/A
LIFT STATIONManuffacctturer�
Capacity
Remarks AWWTS
+
Gr-e-Cl£o oa r d5
R.
2-5-0 Pei rj. Gal.
Alarm location
Electrical installed by
Near FC®
Frontier Electric
PIPE MATERIAL House to tank D3034Tank to D3034
drainfield
Installer
MKS Excavation
Drainfield D3034 CO/MTD3034
Inspector B Schiller
BENCH MARK (Assumed elevation) 100 ft
Inspection 1- 9/27/23
9/28/23
Location and description
dates:
2°d
Top of flashing @ A
3rd
4m
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
Conditional Approval:
Date
Aw
AVI
49
Septic SySte
Approved
Date 2 2�(Z
�� °SenO 2592i1ier °
�'�� ° .. 1/9/25Aw
_
Note: this approval d s not include well permit requirements.
°
-
(Rev 05/02/18)
20' SLOPE EASEMENT
NEW 20' LONG X 5' WIDE
0.5' EFFECTIVE DEPTH
ABSORPTION TRENCH
Benjamin Schiller
CE 12592R
E
GISTEREDPROFE S S I O N A L E N GINEER
1"=50'
NEW 1500-GAL CAT III
ADVANTEX TANK W/
AX-20 TREATMENT POD
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEANOUT
FS - FLOW SPLITTER VALVE
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
LEGEND
PERMIT # OSP221334 PID # 020-161-30
CLOUD 9, LOT 2
A B
FCO 27.0
MH 43.4
POD 46.9
A
B
CO1 60.6
MT1 59.3
CO2 72.5
MT2 73.0
13.3
20.5
22.0
32.9
33.0
51.9
51.4FEET
0 50 100
2/11/25
10' T&E EASEMENT
10' T&E EASEMENT
3' SECTION LINE EASEMENT
TH#1 TH#7 NEW WELL W/
50' RADIUS
PLAN AS-BUILT
4-BDRM HOME
CO1MT1
MT2
CO2
MH
FCO
ALTERNATE SITE
GRAVEL
D
R
I
V
E
W
A
Y
GRAVEL PAD
POD BM
CLOUD 9, LOT 2
PERMIT # OSP221334
PID # 020-161-30
�- <- N CV
O I— I— O
U� 101.0 FINISH GRADE 100.0 ORIGINAL GRADE 2 v
97.0 DRAINFIELD ROCK 97.0
96.5 96.5
MOA APPROVED SAND
94.5.. 94.5
-- 20' NO GROUNDWATER 8/12/22
fXGINEE0.ING
PROFILE AS -BUILT
(NO SCALE)
°F Ate
"lir. 47H
Benja in Schiller
PF CE 12592119/2025
•moi
lh�_PROFESSIO; _ 4
MUNICIPALITY OF ANCHORAGE
Development Services Department � � - Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
Well Log
Permit Number: # osp221334 Date of Issue: 9/29/22 Parcel Identification Number:
Date Started: 6/23/23 Date Completed: 6/28/23 Is well located at approved permit location? Yes 01 No ❑
Legal Description: CLOUD 9 LOT 2 G:3440
Property Owner Name & Address: Brad Luckenbill
7990 PAINE RD, Anchorage
Borehole Data: Depth (ft)
Soil Type, Thickness & Water Strata From To
Casing Stick Up
0
2
Fill
2
10
Silt & Gravel
10
15
Silt W/ Broken Rock
15
55
Soft Bedrock
55
70
Bedrock
70
400
Water Sample Results:
Arsenic: _/V 0 ug/L
Nitrates: J. 56 mg/L
Total Coliform Bacteria: colonies/100mL
Method of Drilling FN� air rotary ❑ cable tool
Casing type: Steel
Wall Thickness: •25 inches
Diameter:6 inches Depth: 80 feet
Liner Type:
Diameter: inches Depth: feet
Casing stickup above ground: 2 feet
Static water level (from ground level): 91 feet
Pumping level: feet after
hours pumping gpm
Recovery Rate: wpm
Method of Testing. airlift
❑
Open End
F1 Open Hole
❑
Screened
Start feet
Stopped feet
❑
Perforations
Start feet
Stopped feet
olume:
Start
Well Disinfected Upon Completion? Yes No
Method of Disinfection: tabs Comments:
Well Driller: Johnny Kay
Company: Hefty Drilling Inc.
Mailing Address: Anch AK 99511
Attention: The well driller shall provide a well log to the
On-site Water and Wastewater Section within 30 days of
completion.
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
X�
Pump Installation Log
osp221334 9 29 22
Well Drilling Permit Number: Date of Issue: - -
Parcel Identification Number: - -
Legal Description
CLOUD 9 LOT 2 G:3440
Block
Lot
2
Property Owner Name & Address:
Brad Luckenbill
7990 Paine Rd.
Anchorage, AK
Pump Installation Date: 2 -11 -24
370
Pump Intake Depth Below Top of Well Casing: feet
Grundfos
Pump Manufacturer's Name:
5SQE 15-450
Pump Model•
1.5
Pump Size: hp
10
Pitless Adapter Burial Depth: feet
Campbell B10 Type
Pitless Adapter Manufacturer's Name:
Unknown
Pitless Adapter Installer:
Well Disinfected Upon Completion? ® Yes ❑ No
Method of Disinfection: Tabs
Comments:
Dylan Kay
Pump Installer Name:
Hefty Drilling, Inc.
Company:
P.O. Box 112130
Mailing Address:
Anchorage AK 99511
City: State: Zip:
Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation.
N 00°19'02" E 613.50'
N 09°00'08" E 452.78'
N 51°59'34" E 271.05'
S 89°45'32" E 263.00'
LOT 1B
LOT 5
LOT 4
LOT 3
LOT 2
CLOUD 9
SUBDIVISION
PLAT NO. 2008-91
259,838 SF.FT.
5.96 ACRES
10' T&E ESMT
10' T&E ESMT
10' T&E ESMT
3' SECTION LINE ESMT
20' SLOPE ESMT
30'
S 89°45'32" E 409.12'
16.0'
SHARED ACCESS
AGREEMENT
2023-026156-0
SOLAR
PANELS
CONEX
SHED
4'X6'
EE
GM
S
PAINE ROAD
30'
92.4'
40
1
.
9
'
17
2
.
3
'
251.8'
SEWER
LIFT 1
0
0
'
W
2 STORY
HOUSE
WELL
LEGEND
GAS METER
VENT/CLEANOUT
SEWER MANHOLE
ELECTRIC SWITCH CABINET
W
GM
FUEL TANK
S
E
FENCE
EDGE OF GRAVEL
RETAINING WALL
CULVERT
STAIRSEE
GM
16.0'
8.0'44.0'
86.0'40.0'
4.0'
20.0'54.0'24.0'
4.0'
16.0'
DECK
PORCH
10'X6'
2 STORY HOUSE
Stacy M. Wessel
No. 107877REGISTEREDPROFESSIONALLANDSURVEYOR
100'0'100'
BUILDING DIMENSIONS 1"=50'
01-23-25
I HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY OF THE FOLLOWING
DESCRIBED PROPERTY:
LOT 2, CLOUD 9 SUBDIVISION, PLAT NO. 2008-91
LOCATED WITHIN THE ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT
THE VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN THE PROPERTY
LINES AND NO VISIBLE ENCROACHMENTS EXIST OTHER THAN NOTED.
DATED AT ANCHORAGE, ALASKA THIS 23RD DAY OF JANUARY 2025.
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
hftp://www.muni.org/onsite
On -Site Water & Wastewater System Permit
Permit Number: OSP221334
Work Type: WellSeptic Initial
Tax Code Number: 02016130000
Site Legal Address: CLOUD 9 LOT 2 G:3440
Site Mailing Address: 7990 PAINE RD, Anchorage
Owner: CLOUD 9 ALASKA LLC 50% &
Design Engineer: FORGE ENGINEERING
This permit is for the construction of:
Effective Date:
Expiration Date:
111cnt
X0�:;
rJ, n
Uepartment
Lot Size in Sq Ft:
Total Bedrooms:
9/29/202 2-
2/22'/
2/22'/ 0 3
V?- 5/'za 2-3
J
259838
Q Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy 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
Veronica Pope
FGE 2022.09.29
Received By: "
Date:
Issued By: Date: Z-Fo Z Z
4
MUHMPI UTY OF AFgC HORAGE
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. 020-161-30
Property owner(s) Cloud 9 Alaska LLC (Mark Phillips) Day phone (907) 227-0492
Mailing address 645 G St #100-181, Anchorage, AK 99501
Site address NHN Paine Rd, Anchorage, AK 99516
Legal description (Sub'd., Block & Lot) Cloud 9, Lot 2
Legal description (Township, Range & Section)
Lot Size 259,838 Sq. Ft. Number of Bedrooms 4
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑x
Initial ❑x
Single Family (SF)
❑x
(w/wo ADU)
Septic Tank
Fx-1
Upgrade ElDuplex
(D)
ElHolding
Tank
ElRenewal
ElMultiple
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: g z`52C)
Date of Payment: azzZ/27-
Receipt Number: D26ng
PermitNo.
Permit App_::-: ,'-.,:c;
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
September 24, 2022
MOA Development Services, On-Site Water & Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
Subject: Cloud 9 L2- NHN Paine Rd
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 a new well and septic system. The
attached site plan identifies the location of the home as well as the proposed well, 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.
Contours are shown on the site plan showing the grade and direction of flow. This property slopes
up from the road fairly consistently at 30-40%, although it gets steeper as it rises. Past the home
the slopes approach 50%. There are no slopes greater than 46% within 100’ downslope of the
proposed system, and we have attached a profile demonstrating that the design meets the steep
slope provisions of the code and will not cause effluent to daylight. Stormwater drainage will not
impact this septic system. The new trenches 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 6’ 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,
Benjamin Schiller, PE
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221334, Curtis Townsend, 09/29/22
1575.0
1600.0
1625.0
1650.0
1675.0
1
7
0
0
.
0
1
7
2
5
.
0
17
5
0
.
0
20' LONG X 5' WIDE
0.5' EFFECTIVE DEPTH
w/ 2' SAND LINER
ABSORPTION TRENCH
MAINTAIN MIN 10' SEPARATION
FROM FOUNDATION
Benjamin Schiller
CE 12592R
EGISTEREDPROFES S I O N ALENGINEER
1"=100'
1,500-GAL CAT III ADVANTEX
FAP TANK W/ AX-20 POD
MAINTAIN 10' FROM
FOUNDATION
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEANOUT
FS - FLOW SPLITTER VALVE
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
LEGEND
CLOUD 9, LOT 2
FEET
0 100 200
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.
PAINE ROAD
4 -B DRM HOME
9/13/22
10' T&E EASEMENT
10' T&E EASEMENT
10' T&E EASEMENT20' SLOPE EASEMENT
3' SECTION LINE EASEMENT
GARAGE
TH#1
TH#7
PROPOSED WELL
15.0
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221334, Curtis Townsend, 09/29/22
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
Benjamin Schiller
CE 12592R
EGISTEREDPROFES S I O N ALENGINEER4" PERFORATED PVC (HOLES DOWN)
DRAINFIELD ROCK
5'
6"
3'
6"
DESIGN FACTORS:SYSTEM REQUIREMENTS:
600 GPD PEAK FLOW
PERK RATE: <1 MIN/IN
APPLICATION RATE: 6.0 GPD/SF
5' WIDE TRENCH SYSTEM
1500-GAL ADVANTEX TANK
BOTTOM OF TRENCH: 3.5' BELOW GRADE
FLOW LINE ELEVATION: 3.0' BELOW GRADE
TOP OF TRENCH: 0.5' ABOVE GRADE
600 GPD / 60 GPD/SF /5' WIDE *1.0 RED. FACTOR = 20 LF TRENCH REQUIRED (20 LF SPECIFIED)
9/13/22
GEOTEXTILE FABRIC
2'
MOA APPROVED FILTER SAND
CLOUD 9, LOT 2
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221334, Curtis Townsend, 09/29/22
1600.00
1605.00
1610.00
1615.00
1620.00
1625.00
1630.00
1635.00
1640.00
1645.00
1600.00
1610.00
1620.00
1630.00
1640.00
0+00.00 0+50.00 0+75.00
1"=10'
SLOPE CROSS SECTION
PRIMARY SITE
Benjamin Schiller
CE 12592R
EGISTEREDPROFES S I O N ALENGINEER8/26/2022FEET
0 10 20
CLOUD 9, LOT 2
46
%
AN
G
L
E
OF
EF
F
L
U
E
N
T
INFLU
EN
C
E FO
R
AL
T
E
R
N
A
T
E S
I
TE
46
%
AN
GL
E
OF
EF
F
L
U
EN
T
INF
L
U
EN
C
E
FO
R
PRI
M
A
R
Y
SITE
ALTERNATE SITE
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221334, Curtis Townsend, 09/29/22
LEGAL DESCRIPTION:
PERFORMED FOR:
DATE: PARCEL ID#:
SOILS LOG AND PERCOLATION TEST
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
DEPTH
(feet)
TEST HOLE 1
DATE READING START TIME NET TIME
(minutes)
DEPTH to
WATER NET DROP
PERCOLATION RATE: (MIN/INCH)
(inches)(inches)
DATE OF MONITORING
WAS WATER ENCOUNTERED?
DEPTH TO WATER AFTER MONITORING
IF YES @ WHAT DEPTH?
<1
8/5/22 1
2
3
4
5
GM (SANDY GRAVEL)
Professional Engineers Stamp:
NO
CLOUD 9 L2
8/5/22 020-161-30
MARK PHILLIPS
2:541
2
3
4
5
0
2:56
2:57
2:58
3:00
1' OB
0:18
Benjamin Schiller
CE 12592R
EGISTEREDPROFE S S I O N ALENGINEER8/19/22
PERC TEST LOCATION
TECHNICIAN: L.TIDWELL
6
-
DRY
8/12/22
COMMENTS:
6" DIAMETER TEST HOLE PRESOAKED PRIOR TO TESTING
SITE PLAN
6
USCS SOIL CLASSIFICATION WAS VISUALLY DETERMINED
0 0:17 6 6
0 0:21 6 6
0 0:30 6 6
0 0:32 6 6
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221334, Curtis Townsend, 09/29/22
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 Day of �_,, of 202,2-, by and between
Bradley D Luckenbill , 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 7990 Paine Road, Anchorage, Alaska
located at (legal description)
Cloud Nine Subdivision, Lot 2, Plat# 2008-91, Grid# SW3440 PARID: 02016130000
2. Maintenance, Repairs and Alterations.
(Owner is required to read, understand and initial each section)
qjbpI,- 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.
?,,Di,- 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
WL 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.
gy t- Owner agrees to grant the Municipality reasonable access to test and inspect the
AWWTS. The Municipality will give at least 24-hour notice.
6V I- 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.
Pift, 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: Z- 02 -2 -
Bradley D Luckenbill (print name)
STATE OF OHIO )
) ss.
COUNTY _OF__GREENE )
The foregoing instrument was acknowledged before me this day ofb
NO I ARY PUBLIC FOR Oqjdl
I
My Commission expires:
o L. GRIZZLE
-' poic, State of Ohio �/��
r G+*ec Aug. o9 2024
� pr
MUNICIPALITY:
By: (signature)
(print name)
(rev. 05/18/2018)
Date:
Title:
Page 3 of 3
