HomeMy WebLinkAboutWILD IRIS LT 4Wild Iris
Lot 4
#015-141-72
Municipality of Anchorage Page
Development Services Department
On-Site Water and Wastewater Program
4700 South Bragaw Street
Poe. Box 196650 Anchorage, AK 99519-6650
www. ci.anchorage.ak.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: SW030091 PID Number: 015-141-72
,am.: Wastewater System: New
Northwood Homes, Inc.
Address:
P.O. Box 92301 Anch., AK 99509 ABSORPTION FIELD
Phone: . Number o~ Bedroo,~: 5' Wide Trench
694-5890. Four
Soil Rating: Total Deplh from original grade:
LEGAL DESCRIPTION 1.2GPD/Ft2 8 FI.
Block: Lot: Subdivisionl Depth to pipe bottom from original grade: Gravel depth beneath pipe:
4 Wild Iris 4 F,. 4
3'ownship: Range: Section: Fill added above original grade: Gravel Length:
0 n. 52
Gravel width: ~ NurnDer of lines: I Distance between lines:
Well: New 5 Ft.
Classification (Private, A, B, C): Total Depth: Cased to: Total absorptmn area: P~pe Material:
Private 226 n. 226 n. 520 Et' ASTIV13034 PVC
Ddtier, Cate Drilled: Static Water Level: Installer: Date Installed:
Alpine Drilling 8/6/2003 195 n. Sanders and Sanders 5/2/2003
'~e,d: ,.,rap Set a,: [ Casi., ~,~h, Above O~.nd:, TAN K
10 GPu F~.. >2 F,.
SEPARATION DISTANCES [] Septic [-I Holding [] S.T.E.P. [] Other:
To. Septic Absorption Lift Holding )ublic/Private Manulacturer; ~,apac~ty in L~allons:
~ Tank Field Station Tank Sewer Line Anchorage Tank 1,250
Material; Number of Compartments:
we, >100' >100' NIA N/A >25' Steel Two (2)
Su,aceWater >100' >100' N/A N/A %/ LIFT STATION - NONE ON LOT
Lof Un. >5' >10' NIA NIA
Foundation >5' >10' N/A N/A/ / X~ -~.mpo.-,eve, at: '~.mp ofr',eve, at:. I .,~h wa,eratarmat:
intn. In.
C,,.a~n Dra~n None Noted P..~ Make & Model Electhca, Inspections perlormed by:
Remarks: BENCH MARK
Loca[ion and Des~lp[ion;
Front Deck Northwest Corner
100.0 Ft.
Engineer's Stamp
· -,-
Inspections performed by: IVlEA Dates: 1st 512103
· [..~t. MICHAEL E. ANDERSON ~..~
Department of Health and Human Services approval ',;~: ."~-
· , ~.; No. cE-~sf ...'..~
· ,,
Reviewed and approved by: 0.~/_¢~'"..,~ ~ /z::~ Date: /O-..~,~.-C,_~ .
Municipality of Anchorage Page 2 of 3
DEVEOPMENT SERVICES DEPARTMENT
4700 South Bragaw Street Anchorage, AK, 99519-6655 - 343-7904
On-Site Wastewater Disposal System or Well Inspection Report
Permit Number: SW030091 PID No. 015-141-72
S1 15,6 24.2
S2 24.2 2,9.3
C4 39.4 45..9
M1 39.4 41.3
C5 50.7 20.,'5
Ld
._J
25'
S 89'58'39"E 114.77'
C4
TH1
Alternate
Site
¢.¢'
S1 k'~
Four
Bedroom
Home
GRAVEL DRIVE
10' T, & E. ESMT.
S 89'58'01"E 119.80'
1 12TH AVENUE
LOT 4, WILD IRIS SUBDIVISION
PLAN AS-BUILT
SCN.E 1' = 40'
..- 49th
E. ANDERSON
No. CE-4381
Municipality of Anchorage
DEVEOPMENT SERVICES DEPARTMENT
4700 South Bragaw Street Anchorage, AK. 99519-6655 - 343-7904
On-Site Wastewater Disposal System or Well Inspection Report
Permit Number: SW030091
Page 3 of 3
PID No. 0'i5-141-72
f--97,1
· /11,250 Gatton \
/ ]Sepi;Ic T(ink ~
9~.~ I ~9~.35
U
~91,7
Geo'text:Ite
I)r-o, lnFletC
87.6
5;~,
95.8
J F~lbrlc ,--. ..........
Rock
79,0
91,7
PROFILE AS-BUILT
Scale: 1" = 10'
FR× HO. : 907 34S 0202 Oct. l? 200~ 09:5~H Pi
Municipality of Anchorage
~" ~)epartrne~t of Health _and. Human Services
· 825 ' L'
P,O. B°x 196650 Anchorage, Alaska 99519-6850
Rick Mystrorn http~'/w~w.c~.anchomge.ak.u~
Meyor
Permit Number: l!SW 0200004 Date of Issue: ,~-22-03 Parcel Identification Number: 018-14'!-72
Date Started: _8-_ _4-03_ Date Completed:. ~-6-03 -- · Is well locm~ at approved p~-mit location? {~ Yes [-] No
Wild !r~s l_ot~
Northwood Homes Inc.
PO Box 92301
Ancho~ge, Alaska 99509...
Depth (ft)
Method of Drilling [] air rotary
[-1.cable tool
Casing type.-, steel
Wail Thickness: .250' inches
Diametcn _6 inches Depth: 22.6. feet
Liner Type: ~
Diameter: .... inches Depth:
Casing stickuP above ground: _2 fcct
fc~t
Static water level (from ground level): .195 feet
Pumping level: 226,feet a~.
_2 hours pumping ~0 gpm
· Recove .fy ]~te: ~0 gpm
Method of'l~esting: air/iff
Well Intake Opening Type:
[] Open End [] Open Hole
[] S~r~n~ Start .....'feet
[-[ Perforationz Start ,feet
Stopped feel
Stopped' feet
Grout Type: bentonite # 8 Volume: 1. bg
Dep~: Start _0 fe~t Stopped ? f~et
Pump: Intake Depth , feet
. .P.~_~mp size hp Brand
Well Disinfected Upon Completion? [~ Yes {-'] No
Method of Disinfection:. ,,
Comments;
Well Driller:.
Alpine Drilling& Enterprises
PO Box 110496
Anchorage Alaskd 995;I 1
Legal Description:
Property Owner i~ame & Address:
Borehole Data:
Soil Type, Th~ckn~s & Water Stra~ From To
.wlick-up 0 2
organ[cs & silt 2 3
sandy gravel 3 12
gravelly s~/t ~2 22
silt 22 55
gravelly silt '55 59
grave/ly sandy silt 59 6'4
alibi gravel 64 8f
gravelly silt 81 101.
grave/ ' ~/01 ~17
silty gravel I 17 163
gravelly silt " 763 q 85
silty cobbly gravel q85 · 792
grevelly s~ 192 220
waff r sand & gravel 220 226
Attention: Thc well driller shall provide a well log to the property owner with h~ 30 days of completion and the property
MUNICIPALITY OF ANCHORAGE
DeVe/oprnent Services Department
On-Site Water& Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM I WATER SUPPLY PERMIT
Initial
Date Issued: Apr 22, 2003
Expiration Date: Apr 21, 2004
Permit Number: SW030091
iL~g~l DeScription! Wild Iris Lot 4 ~
Design Engineer: 0014 Anderson Engineering
Owner Name: Northwood Homes Inc.
Owner Address: PO Box 92301
Anchorage, A 99509-
Parc&l ID: 015-141-72
Site Address: NHN Wild Iris Cir
Lot Size: 40596 SQ. FT.
Total Bedrooms: 4 Permit Bedrooms: 4
This permit is for the construction of:
[] Disposal Field [~ Septic Tank
~-~ Holding Tank [] Privy r~ 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 en. gineer 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.
Received By:
Issued By'
Municipality of.Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P,O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D.
Permit Number SW O.,~O q/
Properly owner(s) Northwood Homes, Inc.
Mailing address (1) P.O. Box 92301 Anchoraqe, AK 99509
Mailing address (2)
Legal description (Lot, Block & Sub'd.). Lot 4, Wild Iris Subdivision
Legal description (Section, Township & Range)
Lot Size /~//~ ~"~{~-
Day phone 694-5890
Zip Code
Acre~
THIS APPLICATION IS FOR:
Sewer Only
Sewer and Well
Sewer Upgrade
THIS PROPERTY CONTAINS:
Hot Tub
Swimming Pool
Therapy Pool
Number of Bedrooms Four (4)
r'-] Well Only []
[] Water Storage []
[-] Jacuzzi []
[-'1 Water Softening Unit []
I certify that the above information is correct. I fudher cedify that this application is being madefor a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit Fees:
Date of Payment:
Receipt Number:
(Rev. 12/00)
Waiver Fees:
Date of Payment:
Receipt Number:
ANDERSON ENGINEERING
· i P.O, BOx 240773 .:~..
ANCHORAGE' AK 99524 .'~"
· 522,7773 : ' . 522-6779 (FAX).
April 15, 2003
Municipality of Anchorage
Development Services Department
on-Site Water and Wastewater Program
4700 South Bragaw Street
Anchorage, AK 99519-6650
Subject:
Lot 4, Wild Iris Subdivision
Septic System Design and Permit Application
Impacts to Adjacent Properties
Dear Onsite Services Engineer:
The owner of Lot 4, Wild Iris Subdivision intends to construct a four-bedroom home on
the lot. We are therefore requesting a permit be issued for the construction of a new
well and septic system to serve the home. The attached Site Plan and backup
documentation identify the location of the well and configuration of the new septic
system and alternate site and the parameters used in the design. Also identified on the
plans are the test hole locations and the wells and septic systems on the surrounding
lots. Drainage arrows and spot elevations are shown indicating the current drainage
patterns. The drainage patterns will be maintained after construction.
The test holes placed near the location of the proposed absorption trench indicated
clean sands and gravels with varying amounts of silt with a percolation rate of 4minutes
per inch. No ground water was found during placement of the test holes and none
was noted dudng the monitoring pedod. We are therefore proposing to place a 1,250
gallon septic tank and a new 50' long by 5' wide by 4' effective depth absorption trench.
The total depth of the trench will be 7' below the surface with the distribution pipe at 3'
below the surface. Sufficient fill will be placed to prevent freezing of either the septic
tank or the absorption trench.
The ground surface on the lot slopes as shown on the site plan from south to north at
varying slopes. The absorption trench will be constructed parallel with the slope as
much as possible in conformance with Municipal requirements. All components of the
new septic system will be constructed a minimum of 100' from any surface water and
wells in the area.
If the system is constructed in accordance with our design the following statements
apply:
The system, if constructed as designed, will have no adverse impact on the wells
in the area or those to be constructed in the future.
Lot 4, Wild Iris
April 15, 2003
Page Two
The system, if constructed as designed, will have no adverse impact on existing
septic systems in the area or those to be constructed in the future.
The system, if constructed as designed, will have no adverse impact on reserve
space, either surface or subsurface, on any lots located in the area.
The system, if constructed as designed, will have no adverse impact on drainage
patterns in the area. The current drainage pattern will be maintained.
Sincerely,
Michael E. Anderson, P.E.
Attachments
Ld
S 89'5~3'~9"E 114.77'
23/
4~-5/8" REBAR (TYP PER PLAT)
!W;de
)epth
I~.
Proposed Well
,~ ~ ~ ~o' T. ~ E. ES~. V
'0O, S 89'58'0~"E 119.80'
,.~:....-,
SCALE 1" = 40' ~" '
'
~.~2:... ~ ..~
LOT 4, WILD IRIS SUBDIVISION
DESIGN FACTORS: SYSTEM REQUIREMENTS:
Four Bedroom House 5' Wide Trench System
Perc. Rate: 1 - 5 Min./Inch 1,250 Gallon Septic Tank
Application Rate: 1.2 GPD/SF 4' Drainfield Rock
4 Bedrooms X 150 ,G, PD/1.2 GPD/SF (Application Rate) = 500 SF Absorption Area
500 SF/5 LF (Width) .5 (Red. Factor) = 50 LF Trench Eength
THEREFORE: Construct a 50' Long x 5' Wide x 4' Effective Depth Absorption Trench.
Flow Line Elevation in Trench to be 3' Below Original Ground Surface. Total Depth to be
7' Below Existing Ground. Maintain 100' Separation From Well on Lot. Place 2' of Direct
Bury Insulation and 2' of Fill Over Absorption Trench or Provide Minimum 3' of Cover to
Prevent Freezing.
Natural
Backfill
· ,, O
Geotextile
-- Fabric
4" Perforated
PVC (Holes Down)
-- Drainfield Rock
TYPICAL 5' WIDE TRENCH SECTION
(NO SCALE)
~, %r: .... -'....~
~,.. ~.~
NOTE:
Grade Area Over Trench to Drain Away.
Minimum 6' Separation From Bedrock.
Minimum 4' Separation From Groundwater.
Minimum 100' Separation From Wells in the Area.
Minimum 100' Separation From Surface Water or Streams.
I
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8
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JvJUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTHENT/WATER AND WAS-TEWATER PROGRAH
/~700 BRAGAW STREET, ANCHORAGE, AK 99502-Ob05
SOILS LOG - PERCOLATION TEST
PROJECT #:
PERFORMED FOR: NORTHWOOD HOMES INC. DATE PERFORHED:
~.-12-03
LEGAL DESCRIPTION:
LOT/,, WILD IRIS SUBD.
TEST HOLE
PT/OL
1 SLOPE SITE PLAN
MEDIUM COMPACTED
WELL GRADED SANDS
WITH GRAVELS & LITTLE FINES - SW
o
TH 2
o
TH1
E ll2rh Avenue
* 2%
COMMENTS:
WAS GROUNDWATER
ENCOUNTERED.".) NO S
L
IF YES, WHAT DEPTH? 0
P
DEPTH OF WATER None
AFTER MONITORING: E
DATE: t,/l?/03
READING DATE GROSS NET DEPTH OF NET
TIME TIME WATER DROP
1 /,-12-0~ 10:35 8.5"
2 10:55 20 3.75" &.75"
3 10:56 8.25"
~' 11:16 20 3.5"
5 11:17 8.63"
6 11:37 20 3."/5" ~. 88"
PERC RATE: &.l MIN./INCH PERC. HOLE DIAMETER:
TEST RUN BETWEEN 5.5 FT. AND 6.5 FT.
NO IMPERMEABLES ENCOUNTERED / HOLE PRESOAKED PRIOR TO TEST
TEST PERFORMED BY: A. HARALA
I, MICHAEL E. ANDERSON, CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE
WITH ALL STATE AND MUNICIPAL GUIDELINES ON THIS DATE: ~,/1S/2003
2
3
5--
6--
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MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT/WATER AND WASTEWATER PROGRAM
/~700 BRAGAW STREET, ANCHORAGE, AK 99502-0605
SOILS LOG - PERCOLATION TEST
PROJECT #:
PERFORMED FOR: NORTHW00D HOMES INC. DATE PERFORMED:
~.-12-03
LEGAL DESCRIPTION:
LOT ~., WILD IRIS SUBD.
TEST HOLE #
PT/OL
2 SLOPE SITE PLAN
MEDIUM COMPACTED
WELL GRADED SANDS
WITH GRAVELS & LITTLE FINES - SW
o
TH2
o
TH1
E. ll2th Avenue
., 2%
COMMENTS:
WAS GROUNDWATER
ENCOUNTERED? NO S
L
IF YES, WHAT DEPTH? O
P
DEPTH OF WATER None
AFTER MONITORING: E
DATE: ~./17/03
READING DATE GROSS NET DEPTH OF NET
TIME ~:IME WATER DROP
1 z._12.03 10:56 9.375"
2 11:15 20 L.25" 5.13"
3 11:17 9..5"
~' 11:37 20 L.5" 5"
5 11:38 9.Z. 3"
6 12:08 20 t..3?S" 506"
PERC RATE: &.l MIN./INCH PERC. HOLE DIAMETER:
TEST RUN BETWEEN 55 FT. AND 6.5 .FT.
NO IMPERMEABLES ENCOUNTERED / HOLE PRESOAKED PRIOR TO TEST
TEST PERFORMED BY: A. HARALA
I, MICHAEL E. ANDERSON, CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE
WITH ALL STATE AND MUNICIPAL GUIDELINES ON THIS DATE: ~,/15/2003
MUniciPality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
· (907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
,FOR A SINGLE FAMILY DWELLING
Parcel I.D.d)15.141.72
GENERAL INFORMATION
Complete legal description
Location (site addresS; or direCtiSns)
Lot 4, Wil~l Iris Subdivision
'HAA# O ~ O ,.~- ,,'~ ,,b"-
Expiration Date:../ - 3 0 - 0/3/.-
Wild Iris Circle at East 112t~ Avenue
Current Property owner(s)
Mailing address
Northwood Homes, Inc.
P.O. Box 92301 Anchora.qe, AK 99509
Day phone 694.5890
Lending agency
Day phone
Mailing address
Real Estate Agent
., .~.'.,:. 'A~dd
":.. ~,i/l~iiling ress
· :;:" Unless otherwisg'requested, HAA will be ~eld by DSD forpickup.
NUMi3'ER OF BEDROOMS: Four (4)
-!?.'.' -:.. ! ..' ;.
3, TYPE OF WATER SUPPLY:
,. Individual Well []
· Individual Water Storage []
Community Class .. Well []
Public Water System []
Day phone
TYPE OF WASTEWATER DISPOSAL:
Individual On-site []
Individual Holding tank E]
Community On-site ' '.[]
Public Sewer D
!
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
engineer registered in.the State of Alaska. Certificates of Health Authority Approval are required for the transfer of .
title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. (Cedificates may bb reissued' for'a period of up to One year with
valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water
system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's
work.
4. STATEMENT O'F 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 Health Authority Approval Guidelines for this application, shows that the on-
site water supply and/or wastewater disposal system is(am) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein..I fudher verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the. on-site water supply and/or
wastewater disposal system is(am)in compliance with'all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm Anderson Engineering
Address P.O. Box 240773 Anchorage, AK 99524
Engineer's Printed Name Michael E. Anderson, P.E.
DSD SIGNATURE
.L~ /~pproved for
Disapproved.
Conditional approval for
bedrooms.
Phone 522.7773
'Date 10118/2003
OF z~J I lJj
............... ·
. ..............
bedrooms, with the folloWing stipulations:
:Additional Comments
By;
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental'Engineer's Report
Other
Ori'ginal Certificate Date: / 0 3 0 - 0._~
(Rev. 12/00)
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak'.us
(907) 343-7904 '
'HEALTH AUTHORITY APPROVAL CHECKLIST'
Legal iDesqription:
A. WELL DATA
Well type'Private
Date compieted 81612003
Total depth 226 ft.
Date 'of te~t
Lot 4, Wild Iris Subdivision
IfA, B, or C provide PWSID #
Parcel ID: 015-141.72
Well Log (Y/N) Y
Sanitary seal (Y/N) Y
Cased to 226 ft.
FROM WELL LOG
81612003
Wires properly protected (Y/N) Y
Casing height (above ground) >24
AT INSPECTION
in.
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform ~ colonies/lO0 mi.
Date of sample: 10/1012003
B. SEPTIC/HOLDING TANK DATA
Tank Type/,Material Septic/Steel
Tank size 1:1,250 g~il.
i'
Foundation ~Cleanout (Y/N)
Date o~' pu~ ping
C. ABSORPTION FIELD DATA
· Date installed 512/2003
Length .52 -
Total depth '_8 ft.
Date of ade~luacy test
195
10
ft.
g.p.m.
Nitrate..75 mg./1.
Collected by: MEA
Numl~er of Compartments _2
Depression over, tank (Y/N)iN
Pumper New Construction
Fluid depth in absorption field bef~)re test in.
Elapsed TIme: min. Final fluid depth
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
g.p.m.
Other bacteria. 0 colonies/100 mi.
Date installed 5/212005
Cleanouts (Y/N) Y
High water alarm (Y/N) N
-..,. Soil rating (g.p.d./ft2 or ft2/bdrm) 1.2 GPDISF System type. 5' Wide Trench
ft. Width 5 ft. Grav~l below pipe.4 ft.
Eft. absorption area 520 ft2 Monitoring tube Y, Depression over field N
Results (Pass/Fail) For bedrooms
Water added gal.. New depth in.
in. Absorption rate >= g.p.d.
N .'If yes, give date
De
LIFT STATION
Date installed
"Pump on" level at
Datum
. in.
Size in gallons
"Pump off" level at ~
Cycles tested
in.
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements? ·
in.
SEPARATION DISTANCES
sEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot >100'
Absorption field on lot >100'
Public sewer main NIA
Sewer/septic service line >25'
On adjacent lots >100'
On adjacentlots >100'
Public sewer manholelcleanout
Holding tank NIA
NIA
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation >5' Property line >5' Absorption field >5'
Water main >10' Water service line >t0' Surface water >100'
Wells on adjacent lots >100'
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line >10' Building foundation >t0' Water main >10'
Water Service line >10' Surface water >100' Driveway. parking/vehicle storage, >5'
Curtain drain None Noted Wells on adjacent lots >100'
Fo (~OMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field insl~ections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name Michael E. Anderson, P.E.
Date 1011812003
HAA Fee '$
Date of Payment
Receipt Number
(Rev. 12100)
Waiver Fee $
Date of Payment
Receipt Number