HomeMy WebLinkAboutSHANGRI-LA LT 13Shangri La
Estates
Block 1
Lot 13
#020 043 31
Municipality of Anchorage
Development Services Department S_---"' - '''°
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 Page 1 of
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: SW0`30`346 PID Number:, 020-04,3-31
Nome:
MARK ENYEART Wastewater System: · New [] Upgrade
Address:
4000 EAST 80TH AVE. * ANCHORAGE, AK * 99507 ABSORPTION FIELD
Phone: No. of Bedrooms:
(907) `349-8095 4 · Deep Trench I-I Shallow Trench I-I Bed I-IMound BOther
1.2 OPD/$q. Ft.
Block: Lot: Subdivision: Depl~ ~o pipe bottom from orynol grade: Gravel depth beneath plpe:
1 13 SHANGRI LA ESTATES 2.5 ~ 0.5
Township: _ Range: _ Section: _ Flll added ab<we odglnal grade: Gravel length:
SEE DWG. ~ 2 @ 50 (100 TOTAL)
WELL: [] New [] Upgrade 5.0 2 5+
ClaulficatJon (Private, KB,C): Total ~ Caeed To: Total obeorpUon or~: Pipe material:
/ ,. ~ 500 so. ~. D 3034/ F-810
Drfllen Date Drilled: StaUc War L~v$1-. In~.alle~. Date Inatalled:
n. C&N CONSTRUCTION 8/28-9/10/2005
cP.~ ~ ~ TANK
SEPARATION DISTAN C ES · Septic [] Holding ri S.T,E.,P, r-I Other
T~o Septic Absorption Uft Holding Public/Private Manufacturer:. Capoclt~ in gollorm:
Tank Reld StoUon Tank s,,,r u,,, ANCHORAGE TANK 1250
Well 100'+ 100'+ - - 25'+ Mate~: STEEL Number of oomlx~rtmenb: 2
Surface Water ~00'+ ~00'+ - - - LIFT STATION
Foundation 5'+ 10'+ -- -- -- 'Pump on' level at: ~" High water alarm at:
Out'lain Drain ~ NI~NE KNOW~ . /Pump Make~l~6'~,: l a.~o, Irmp.cUorm performed by:.
Remarks: BENCH MARK
L~catJon and D#crlpflom
BO'ITOM OF TANK
ENGINEER'S SEA~I
Inspections performed by: AKWWC, INC. Dates: 1st. 8/28/200`3 ~?.~..::'i:4 ~)'l~/~i~; '..?~
Development ~ ervices Department Approval .~'.~.~.... ~
R~viewed
and
PERMIT NUMBER:
-.-, ;: . 25, SLOPE/SNOW ~0~0E
/
....
ALASIL& WATER & WASTEWATER C.J.G.
'='======~'=~=~'==~"=' CONSULTANTS, INC. ~
3701 E, TUDOR ROZ~D, SUITE I01 · ANCHOR/~GE, AK 99507 · PHONE ((}07)337-6179 · FAX ((}07)338-3Zt.6 1"=40'
PREPARED FOR: PHONE NUMBER: PAGE NUMBER:
MARK ENYEART (907) 349-8095 2 OF
LEOAL DESCRIPTION:
SHANGRI LA ESTATES SUBDIVISION; LOT 15, BLOCK 1
~T'fPE OF WORK:
AS-BUILT DRAWING OF NEW SEPTIC SYSTEM
A B
ST1 6B.90 134.10
s'r2 74.59 ,37.59
DBL1 76.01 38.53
DBI.~ 76.84 39.22
FS 77.61 40.13
C01 113.53 65.05
MT1 112.57 64.25
C02 60.7,3 58.10
MT2 61,45 57.20
C0`3 73.69 74.61
M'r3 74.70 74.13
C04 J 120.91 82.62
MT4 119.92 82.47
PERMIT NUMBER:
~o~o~ AS- BUILT D RAWIN G
..... 020-045-5~
O~[ = 112.2+
TOP 0~ T~K AT _ /
IN~ - 108.18 ~ ~ / = ~TOP OF T~K AT
~ ~~ - 108.16
- -~ ' ~ INSU~ON
AT/ N~ 1250 GABON
~ OF BUNO SEPTIC TANK
O~ - 107.36
. RL~ F~RIC ~
~L~ F~RIC
~~ ~:0~.~~' BOSOM OF ~mCH
.
= 96.96 (Am.)~
~ I~ OF PIPE
= 97.4~ (AVCO
~ ~ R~ E~A~ON OF BOSOM OF
~/28/2oo~
.................. CONSULTANTS, INC. ~ .... s~:
5701 E. TUDOR RO~D. SUITE 101 * ANCHORAGE. AK 99507 * PHONE (907)357~17g * FAX (907)558-5ZL6 N.T.S. '///~ ·
PREPPED FOR: PHONE NUMBS: PAGE NUMBS:
MARK ENYEART (907) 349-8095
~,ss..'
SHANGRI ~ ESIATES SUBDIVISION; LOI 13, BLOCK 1
~E or WORK: ~., ..... '
PROFILE AS-BUILT DRAWING OF SEPTIC SYSTEM
Mayor
Permit Number: #SW Date of Issue: Parcel Identification Number:
Date Started: 6-19-02 Date Completed: 6-20-02 Is well located at approved permit location? [] Yes []
Legal Description: .Sh~n.qri La Estates BIk 1 Lf 13 ~
Property Owner Name & Address: Anchorage Development & ConstruCtion, LLC
Anchorage, Alaska
No
Borehole Data: Depth (ft)
Soil Type, Thickness & Water Strata From To
stick-up 0 2
silty cobbly gravel 2 10
Bedrock 10 307
gravelly silt
Jrt20 w~ Intermittent fractures
tr...hroughout with main source
32 40
Method of Drilling [] air rotary [] cable tool
Casing type: steel
Wall Thickness: .250 inches
Diameter: 6 inches Depth: 2_~0 feet
Liner Type: ~
Diameter: ~ inches Depth: ~
Casing stickup above ground: _2 feet
feet
Static water level (from ground level): 20 feet
Pumping level: 307 feet after
_2 hours pumping 20+ gpm
Recovery Rate: 20,+ gpm
Method of Testing: airlift
Well Intake Opening Type:
[] Open End [] Open Hole
[] Screened Start ~ feet
[] Perforations Start~ feet
Stopped ~ feet
Stopped ~ feet
Grout Type: Bentonite granules Volume: I bg
Depth: StartO feet Stopped: feet
Pump: Intake Depth ~ feet
Pump size __ hp Brand Name
Well Disinfected Upon Completion? [~ Yes [-'[ No
Method of Disinfection: chlorine tablets
Comments:
Well Driller:
Alpine Drilling & Enterprises
PO Box 110496
Anchorage Alaska 99511
AttentiOn: The well driller shall provide a well log to thc property owner within 30 days of completion and the property
MUN/CIPALITY OF ANCHORAGE
Deve/opment Services Department
On-Site Water & H/astewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-790.4
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Initial
Date Issued: Sep 02, 2003
Expiration Date: Sep 01, 2004
Permit Number: SW030346
Legal Description:! Shah~ri-La Lot 13'
Design Engineer: 0041 AK Water & Wastewater Consultanl
Owner Name: Mark W. Enyeart
Owner Address: 4000 East 80th Avenue Total Bedrooms: 4
Anchorage, AK 99507-
Parcel ID: 020-043-31
Site Address: Unknown
Lot Size: 48223 SQ. FT.
Permit Bedrooms: 4
This permit is for the construction of:
r~ 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.
Received By: /'"~'~/>~( ;;/~'~ ~~iJ!
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
Parcel I.D.
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Q? o-Oq .5- 5i
Permit Number
Property owner(s) MARK W. ENYF..ART
Day phone 349-8095
Mailing address (1) 4000 EAST 80TH AVENUE * ANCHORAGE. AK
Mailing address (2)
Legal description (Lot, Block & Sub'd.)
Zip Code 99507
LOT 13. ~SHANGRI--LA ~ SUBDIVISION
Legal description (Section, Township & Range)
Lot Size L~ ~ ~ "~'~'Z~ Acres/Sq.Ft.
Number of Bedrooms
THIS APPLICATION IS FOR:
Sewer Only [] Well Only []
Sewer and Well [--] Water Storage r-']
Sewer Upgrade D
THIS PROPERTY CONTAINS:
Hot Tub [~] Jacuzzi BI
Swimming Pool E] Water Softening Unit D
Therapy Pool D
I certify that the above information is correct. I fudher certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal codes.
ALASKA WATER & WASTEWATER CONSULTANTS, INC.
Date of Payment:
Receipt Number: L.~
Waiver Fees;
Date of Payment:
Receipt Number:
ALASIG WATER & WASTEWATER
.-.,,-~.-~ ~a~..,-.-,~ CONSULTANTS. INC.
August 15, 2003
Municipality of Anchorage
Development Service Department
Building Safety Division
On-Site Water & Wastewater Program
P.O. Box 196650
Anchorage, Alaska 99519-6650
Ref: Proposed Septic Upgrade for Lot 13, Block 1; Shangri La Estates Subdivision
To whom it may concern:
The proposed 4 bedroom house will be served by an existing private well and proposed septic
system. Several test holes were excavated on the property. The drainfield will be designed
around the 30 foot radii of our test holes. We proposing that a 1250 gallon septic tank and dual 5-
wide type drainfields be installed. Comments regarding the design are summarized as follows:
1. SOILS: See the attached logs which shows the soil classifications, groundwater monitorin~
and the percolation test results. It is our opinion that an application rate of 1.2 gallons/day/ft
should be used.
2. TRENCH DESIGN:
a. Percolation Rate: <1 minutes/inch
b. Proposed Application Rate: 1.2gallons/day/fi2
c. Number of Bedrooms: 4
d. Design Flow: 600 gallons per day
e. Minimum Absorption Area: 500 fl2
f. Total Depth: 3.0 feet (max.)
g. Effective Depth: 0.5
h. Width: 5 feet
i. Reduction Factor: N/A
j. Minimum Length: 2 ~ 50 feet long each (100 feet total length)
k Effective absorption area = 500 fl~
3. SURFACE WATERS: There are no surface waters within 100 feet of the proposed septic
system.
4. TOPOGRAPHY: The area for the proposed drainfields is a 20-25 percent slope running
approximately southeast to northwest; in short, there are no slope concerns.
3701 E. Tudor Road, Suite 101 * Anchorage, AK 99507
Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: akwwc.com
We are unaware of any adverse impacts this installation would have on adjacent wells or septic
systems. If yo[~ have any questions, please contact us at 337-6179. Thank you for your
assistance.
Sincerely,
.! .E., M.S.
NOTE: A site plan drawing, a design drawing, two soils logs, and a 7 page construction
specification letter which are all part of the design package for this septic system.
3701 E. Tudor Road, Suite 101 * Anchorage, AK 99507
Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: akwwc,com
SANDPIPER DRIVE
SHANGRI-LA ESTATES S/D; ~m
LOT 9, BL~K 1, ~ ~ LOT 10, BLOCK 1~/D;
LOT 11, BLOCK
. .,
I I ~ I
~ . / ~ ~ ~~oo'
------~ .... T------ " '
....... ~ ......... ~ · ~~~ .... ~--~~~
x ~ .... _~ ..... 7 ...... [ -~- ~ -~
, ................ ~---~ .....
............ ~_~ ~
-~ -~'
/ / . ~/ I ~~1 ~T 12, B~CK 1,
S~R~-~ ~A~ S/D; / x-
LOT 14, BLOCK 1, /
X mT 20, BroCK
X /
,',,,~ / /
DA~
."
AIASI~ WATER & WST~WlTU~ =~.c.~.o. ~>~.~ ~ ~
~~ CONSULTANTS, INC.
PR~ FOR PHONE NUMBS: PAGE NUMBS:
~,..~ ~ ~...
MARK W. ENYEART 549-8095 1 OF 2
~ D~CRI~ON:
SHANGRI-~ ESTATES SUBDIVISION; LOT 15, BLOCK 1, ~h~Z"~..
~i[. ~ '. ........
~E OF WORK:
SITE P~N FOR PROPOSED SEPTIC SYSTEM -,~ .......
/
PO~~
PRO hi p~kT
~-PROPOSED DRAINFIELDS. EXCAVATE: TWO
~/ TRENCHES THAT ARE ,3 FEET DEEP
· ~MAXlMUM BY 5 FEET WIDE BY 50 FEET
[ / I /I DRAINROCK. IN~'T;~J~. TRENCHES
~ ' I II PARALLEL TO SLOPE CONTOURS. _
........ _¢_
........ / ...... I-
~,, ALTERNATE SITE WILL / ,/. // r
REQUIRE THE USE OF / / /
X ~ ~v~,~TEx --' /.TH~ .-L~.-~f
~ ~ ~ ~'"'~.--- ~'"' ~'~ ~,_.~,/~ ~ ~ ~INSTALL DOUBLE
If \ -~/ SUBDIVISmON ~'"////~ h
,,1J) -~/ ~/'//// ~4 BEDROOM
' %ES.[,LLNO '"'°/\ i~
! {~oPE~ow S~O~OE ~SE. ENT
/ //
/ _ ~/_ .,,
..~ - /
DATE:
~ 8/15/200~
DPAWN BY:
.............. C.J.G.
ALASIC& WATER & W. ASTEWATER sc~:
_TS I ==,..==~ "
PREPARED FOR; PHONE NUMBER; PAOE NUMBER: "F~I
MARK W. ENYEART 349-8095 2 OF 2
LEGAL DESCRIPTION;
SHANGRI-LA ESTATES SUBDIVISION; LOT 13, BLOCK 1, II. '.,
DESIGN FOR PROPOSED SEPTIC SYSTEM UPGRABE
AI.~SKA WATER & wASTEWATER
'=' : · , CONSULTANTS, INC.,
3701 r' TUDOR ROAD, SUITE '101 ANCHORAGE, .AK. 90507 · PHONE: (gOT~537-B17g · FAX: (g07.~.%.~]-324~ · WEBSiTF~ okw~c.con'
~LOG - PERCOLATION TEST
LEGAL DESCRIPTION: SFIAN(~ RI LA ESTATES SUBDIVISION; LOT 13, BLOCK 1,
PERFORMED FOR: MARK W. ENYEART DATE' 8/11/2003
ORGANICS/LOAM
ITEST HOLE #1I
GP/SP
GM
BEDROCK
.SOIL CLASSIFICATIONS
GW ~ ORG
SP Ifil
GIrl CL
GC OL
SW HH
SP CH
SIft OH
SC
DEPTH TO
GROUNDWATER DATE
DRY 'B/11/2003
p~.'~ ~/~o/~,~
DATE READING CLOCK NET TIIfiEWATER LEVEL NET DROP
T,,..,.
PERCOLATION RATE <1 (MIN./INCH) PERC. HOLE DIA. 6 (INCHES
TEST RUN BETWEEN 2.5 FT. AND 3.0 FT,
A FOUR HOUR PRESOAK WAS PERFORHED: [] YES
SOILS LOGGED BY: RYAN SMITH PERCOLATION TEST pERFORMED BY:
COIfiIfiENTS: ' THE INSITU SANDY SOILS WILL ACT AS A SAND FILTER.
[] NO
JOE MARCHETTI
PERFORMED BY AKWWC, INC. I, JEFFREY A. GARNESS, CERTIFY THAT THIS WA~ PERFORMED IN ACCORDANCE
WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE: ~ ll~'l¢3
f /
ALAS~ WATER & WASTEWATER ,~-'~'~Y' "'
..... ......
LEG~ D~CRIP~ON: s~ RI ~ E~A~ :SUBDMSION; LOt 13, BLOCK 1, ~0~o~"'~ JE-~7955 .."
PERFORMED FOR: ~RK W. ~ DA~: 8/1¥2003 q~h~e?~"k [ .-'";~
ORGANICS/LOAM
EPTH ~
f~~]~ ITEST HOLE ~21
[~q SOIL C~SSIFICATIONS ~ I ~
~ ..... : ~ ................. 7 .......... T ...... .
:~,...~.~ , . ~ ........................................
4qlOll~ll ~ c ~ OL -- .
II~11 N II 'GROUNDWATER ~-~ { , 'z I L
I1~11 ~ II , _~~-~-//-~-~SlTE p~l
~o~~"°c~ = ~: ..' / ~-=~oo, L
I I ~.~ ,~,..~ ~ c~oc~ NET T~HE W~T~ ~EVE~ ~ET D~O~
~ ~ ~ ~'~ I~'''~ T~HE (H~NUTES) ~E~D~N~ O~CHES~
17~ I
I j TEST RUN BETWEEN 3.0 FT. AND 3.5 FT.
~o~ ~ ~o~..o~. ~.~o~ ~ ;~o~.~:' ~; I.o
SOILS LOGGED BY: RYAN SM~ PERCOLATION TEST PERFORHED BY: JOE M~CH~I
COMMENTS:
PERFORMED BY AK~C, INC. I, JEFFR~ A. GARNESS, CERTI~ THAT THIS W~ P~RFORMED IN ACCORDANCE
WffH ALL ~A~ AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE:
DEPTH TO
GROUNDWATER DATE
DRY 8/11/2003
20441 I'°TARi%{IGAN BLVD.
SOILS FERCOLATION TEST
Ford
Lot/3 Shan~rfla
Date Peffonned:~
TS~T HOLE # oo12
{Feet)
10-
'l
;SEE ATTACI::ID SITE FIAN
FOR HOLE LOCATION
Was Ground w~ater e~c~nt'~x~? NO
11-
12-
14-
15-
16-
17-
~ %o wa~ aR:ex mca~toring? NA
Date? 08/14/00
Reading Dam GroSS N~ EW=pth ~o Net '
T'm~e 2-~me Water ·
1 S/10/~ 1L~ - 9" -
3 ' [ 1L~ - 9' .
4 { 1!~!! 5~ 314/16' 52/16'
I
5 ~ . { l~ - 9' .. -
6 [ ll:~ 5~ 315/16' 51/16'
7 ' 11~8 - 9~ '
8 11~ ~ g 41/I6' 4
11 ~ ~ ' - ~ '
19-
2O-
PRIOR TO TP. ST
Kenneth M..Duf~, certify that this test was performeclin accordance~ with all State and 2vftmicipal guide2in~ in
eH~'t on this da~.
George P. Wuerch,
Mayor
April 15, 2003
Municipality of Anch0rage
Building S,-uCcty Division
.Anchorage Development & Construction
9441 Abbott Loop Rd.
Anchorage AK 99507
Anchorage
..Ali.America City
2002
Subject:
On-Site Water and/or Wastewater Permit.
Permit Number: SW020087
t2~Legal Description: propos.ed' Shangri-La BloCk'l LOt 13.,
Dear Anchorage Development & Construction:
An On-Site Water/Wastewater Permit, number SW020087, issued by this office for a single-family
system, will expire on May 1, 2003. This permit was valid for 365 calendar.days.
If this was a well permit and the well has been drilled, a well log must be sent to this office for
documentation of the installation and to cio'se the permit.
If this permit was for a wastewater disposal system, an original as-built inspection report must be sent to
this office for review, approval and documentation. 'This as-built inspection report must be signed by
the licensed Professional Engineer who inspected the installation of the system. As-built inspection
reports are required to be submitted within 30 days of the completion of the system.
If no system was installed under this permit, and you' are still planning to install a well or wastewater
disposal system, a new permit must be obtained from this office. A new permit fora second year ma~,
be issued for a fee orS100.00 if the renewal application is received on or before the expiration date of
the original permit. .
When applying for a new permit, the fees are: $400.00 for a wastewater permit and $150.00 for a well
permit.
If you have any questions, please call this office at 343-7904. .. .. - .~
Jam/6fi Cross, P.E.
Mah'ager
On-Site Water and Wastewater Program
Enc: Copy of permit
P.O. Box 196650 ·Anchoragc, Alaska 99519-6650 ° T¢lcphonc: (907) 343-8301 ° Fax: (907) 343-8200
4700 South Bragaw Strcct· Anchoragc, Alaska 99507
http://www.ci.anchoragc.ak.us
MUNICIPALITY OF ANCHORA GE
Development Services Department
On-Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WATER SUPPLY PERMIT
Initial
Date Issued: May 01,2002
Expiration Date: May 01,2003
Permit Number: SW020087
Legal Description: HORACETR 3B
Design Engineer: 0000 None Required
Owner Name: Anchorage Development & Construction
Owner Address: 9441 Abbott Loop Rd.
Anchorage, AK 99507-
Parcel ID: 020-043-12
Site Address:
Lot Size: 54450 SQ. FT.
Total Bedrooms: 0 Permit Bedrooms: 0
This permit is for the construction of:
[-'-I Disposal Field [] Septic Tank
[~] Holding Tank r-~ Privy
[] Private Well
[--I 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.
'[.hj.~i;]p_e_r~!t.. ii.~'.f~ r.. pr.o_ pS. ~ed.:s~a..ngr!:La.. Block ! :: ~.o_~_ .1. 3.:i; ~
Received By:
Issued By:
Date:~Z
· 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. ? ~O..~ -
Oo~ o -o,--/~ - t I
Mailing address (1)
Legal description (Section, Township & Range)
Lot Size I, ~.5~ Acres/8~l=t.
5-~/ 4 5.o ~ ,
THIS APPLICATION IS FOR:
Sewer Only r"l
Sewer and Well D
Sewer Upgrade D
Permit Number SW02 0087 .
Day phone
Number of Bedrooms
Well Only
Water Storage
THIS PROPERTY CONTAINS:
Hot Tub D Jacuzzi D
Swimming Pool D Water Softening Unit D
Therapy Pool r'-]
i certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
(Signature of p~operty owner or authorized agent)
I
Permit Fees: /~_~.
Date of Payment:
Receipt Number: / f~) ~'-/'7/
(Rev. 12/00)
Waiver Fees:
Date of Payment:
Receipt Number:
PAD
1110,0
.0o0
2O