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HomeMy WebLinkAboutMAJESTIC VALLEY ESTATES BLK 2 LT 13Majestic Va'lley Estates Block 2 Lot 13 #050-731-37 Municipality of Anchorage Page I of Z DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Permit Number: 17,r.70` PID Number: D5 21 Name: J c.Octt12-1 Wastewater Wastewater System: New ❑ Upgrade Address:-;- ABSORPTION FIELD Phone: No. of Badrooma. [3 Deep Trench AS Trench ❑ Bed O Mound ❑ Other LEGAL DESCRIPTION Soil Rating: 40•4GGPD/S Total Depth from original grade: Jl Ft Lot: j... Block: Subdivision: 2 Depth 10 pipe bottom frompratle original Gravel depth beneath pipe } M k I AEFt Q• FI Township: Bangs: is Fill dded above original grade z Gravel length: r I •5;•—Z.4*' Ft Z Ft WELL: ❑New ❑Upgrade Gravel Eapib.hy,�t} Number of linea: Distance belween,rros: Ft CI mhcauon (Private. A.B.C): Total Depth: Cased To: Total absorption arae: Pipe material: �1 fj Ft Ft. SO Ft Driller. Date Drilled: Static Water Linel" Installer. Date Installed' Ft. GCG Yield:Pump Set at: Casing Height Above Ground: TANK GPM Ft Ft SEPARATION DISTANCES Xseptic ❑Holding 0S.T.E.P. To Septic Absorption Da Holdup bliNPdvate M nufacturer: Capacity in gallons: From Tank Field abtion Tank Sewer Lin» a well�4 Material: Number of Com anments: Surf eye I do'r 100' -- LIFT STATION Lot , , Size in hone: Manufacturer: Line�- Foundation I�-f I D 1 _ "Pump on" level at: "Pu el at: High water alarm at: Curtain I�OIA.� Pump Make a Model Electrical Inspections perfortned by: Drain —(�l0 Remarks: BENCH MARK Location and Description: GP GetJG. PLOOiL. 1fasln� -�-+�t•� Assumed Elevation: Ft I ov= ENGIr1kip�LL J�CP�•",,.......ea�Vs, iii ;'+�+49u► tie oil 5&S ENGINEERING 17034E le River LNig-»•»' Inspections performed by: '� coP R°aa, I�tes:ls '» '•• 2nd'=�t ... .. ». .. O K: R SHAFER ROG 1.11 No. Department of Health and Services approval „S,.••''.��e'� �Human (ai'e���:N�+ Reviewed and approved by: �� Date: 2�- _ � M-01711/91) MOA 25 Permit No.9:!�7 V�l Page 2 of ?� Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report 1-tt�trff�'1G vo�t.t�j� �st�r� Col GoZ Iota I i S.T I w Air G,52AcQE PID No.: 74'}.02 yNE1 1 tuoo c,nrt.y q• 56?tip TANS . •'ff11 Ga.r•a£ A t Ky sy �i .•• PL Cot Coy col Gaf- !�(o Gb8 r tf r y . A ••% p � ih9IL+�'v �_...__......_._ 9.1.....«... ' a ow zjS coo 03' 1 o4% +fie?^�: Rpp SHAPER 1W "1 I �l�" C^ �� No. 215 :' �• d ', r• �vf G 0�' 2� 2�° ediaF�PROFE5S1�NPs�'� 72-00 A (Re. 911) 40A 25 1 2E a V Municipallty of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG - PERCOLATION TEST PERFORMED FOR:�DATE P LEGAL 1 2 4- 5- 6- 71 5 6 7 IY . 8 13- 14- 15- 16- 17- is- 19 - 20 314151617181920 COMMENTS 9 M —0 cr T Section: WASGROUND WATER ENCOUNTERED? O IF VES, AT WHAT 1Ot.,;;rr LL DEPTH? k± E Depth to Water �Nl�1e � /� 1-•L�13 Monitoring? "`-""T — Dale: / ®mmm �ff�—v mmmm0` w«� E&M NN 0`Y/L-7ri�7�3� v��or:�s_�■�rn� c� PERCOLATION RATE (minutevinch) PERC HOLE DIAMETER TEST RUN BETWEEN FT AND 3 FT S & S ENGINEERING PERFORMED BY: -VM4 Eaule e'RTlJNR'•' 4� CERTIFY THAT THIS TESTI WAS PERFORMED IN ACCORDANCE WI1rP,1g1t 'A fE RND3 AL GUIDELINES IN EFFECT ON HIS DATE. DATE: 72-008 (Rev. U85) . E a o-; !._';OWNER OFaLAN .ADDRESS ,§LEGAL DESCRI •. ;DATE Started PERMIT NUMBER , II .vr lnyr(, w• r m.-.. a 11{w,aY'• y-3ar•yV�N•{Y-4µ+ y•'.� r^ SI � t V ''ry b!:`H 0.i YII • t rdJ! , e �` r ,. I a , +. !,T'1t,"�iJ `C!„'i"'f.0��� �':: < - ,♦C- v/ f f( 0.4,1 li /l'r "x" ", i11 >` jlr Iar R7 ;riG t,.,, rk'Ii.f y i' Z ! 't •) ..a.:,. ,' 'ooc,co aw.&w t.I•{'6 .. SUGG`IVAN W ATER;:WELLS l MT P.O. BOX 670272 CHU0IAK, ALAS KA99587.••�TELEPHONE6882759 .t 1 , r.: •i v t I\{}Y,,j. , L{� D{QJ t 10, ST/L tS . ;'^ DEJ TII OF WCLL �O t� ` 9�6 pJNOTdP'.C"/tCCtr'/�n1G�I ST, LEVEL OF WATER FT PTIOtL1d�4de-17•G (%gtcrl!� , nW F19? I- t Ended GALS PER NR �9 K}INT) OF CAST\C " l��0 � [;{,r �y • J ..++rM1. �w�)a!'iir 1 1 1: s. 1 tik:iY.rsvJ'>: �->, 4�t' 1G fit' }11 � 1-l'. � �• '`t, la •r..T�'' �•. . +.wxct .x9 •;^.-..irHi..�: 1 ,i r. L �.. -'n. 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Z+ 1•� C 'a. a"""��� aF`t) �lal i1 N K Tf '1 r" 4<�rt Ltt 1�l�. ♦2 �l a+1f. , <f laY'"9+♦t'� 7 W, l r 7 f }`fit r V .f I 1 I c 3�.t' 17 X11 `fit r 's f 7:44_, +tt!�•+'. • �-A1 a. j f v �'t ,i �41i �'l�w P-Znft -J ys}..+•7�fi-1 1l� f R, •.IS'at+2 �,ft IJr +-rl�.t f'1 •ter a r[�..:. y+'I,+l t� f' 1 ,. :. •s•1.♦ " y t'x � y1:�� at1.N f :.;>;`i n♦ 1 )r1., 1. 11r 1,. eM.•..>e Y t{. .1 ,. ,x.1�r,FL .$.}w �l f. !, t . . Kr +. ..1. '�'•L,!%�1, .'. f,r'•{LaSy„..� •4.J, sl:� IYN.•A .''1 y,l... , w' all-r�,t1 a - +',. .� tat •r <rNt+• Nt�> •� ,r ->: w ar 1... i t1 X\�'� , Y i'+{) :. ''"t lrt {...\�.. ..� �a k ,I � � t' yl �✓1 Irf.l " -t,,St lt• ?I �a DRI„LLERSWAME�+' a:a s •. 1t 1;'. 1 `. , i. • \. ,.S>!•i tdl . 1 i • a,rl PR. LLa?7 ,,t1 >.,I f MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW920049 DESIGN ENGINEER:S & S ENGINEERS OWNER NAME:STILES DAVID T & LAURIE LEE OWNER ADDRESS:3936 ROUND TOP CIRCLE ANCHORAGE, ALASKA 99504 PARCEL ID:05073137 LEGAL DESCRIPTION: MAJESTIC VALLEY ESTATES BLK 2 LT 13 LOT SIZE: 54508 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 PAGE 1 OF 1 DATE ISSUED: 4/02/92 EXPIRATION DATE: 4/02/93 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD / WELL SYSTEM 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 FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED BY: DATE: ISSUED BY: A'-� DATE: -_ x ^ 9 �� March 26, 1992 ROBERT SHAFER, P.E. ROGER SHAFER, P.E. CIVIL ENGINEERS 190 71 694-2979 FAX 694 1211 HEALTH AUTHORITY Municipality of Anchorage APPROVALS DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 L Street Anchorage, AK 99519-6650 SEWER& WATER MAIN EXTENSIONS REFERENCE: Majestic Valley Estates, Block 2, Lot 13 SEWER & WATER INSPECTION We request you issue a permit to drill a well and install a septic system to serve the proposed 3 bedroom house on the referenced property. ENGINEERING STUDIES Test holes were performed on the property on June 18, 1991. AND REPORTS The approximate location of the test holes are located on the attached site plan. The monitoring tubes within the holes were checked on June 25, 1991 and again on March 22, 1992. WELL INSPECTION This property has enough area for a septic upgrade which can & FLOW TEST p p y g p pg be seen on the attached site plan. We do not anticipate any adverse effects on neighboring properties by the installation of the proposed septic system. S17EPLANS If you have any questions, or require additional information for your review, please contact us. Sincerely, ROAD DESIGN u r Roger J. hafer, P.E. SOIL TEST RJS/lsu PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS ON SITE WASTEWATER DISPOSALSYSTEM DESIGN 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 N' 1 C n N V J h � W H Z w 2 M W 2 Q j Z3a�b-. 0 U Uvoce U g W oho a� %C A Qk 9r 0 of `.,a �g M 12, � N V J .05 wd C PERFC LEGA 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 n TEST RUN BETWEEN 3FTAND 41 FT COMMENTS- `�'I y ��I 22-�1Z, -,,-1 PERFORMEDg1y7034 Eagle River Loop Road No. 204 ttgG-River, Alaska99577 CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINEECT ON THIS DATE. DATE: 72-0081Rev. 4;851 IN Municipality of Anchorage DEPARTMENT OF HEALTH 8 HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST PERFORMED FOR:_ 1%��V 151 ����L DATE PERFORME LEGAL DESCRIPTION:y��Z t4A, IG Township, Range, Section: DEPTH A_ 1 !G '' SLOPE SITE PLAN ,QF ft) /^ "7 . 2- 3 �.0. 4 5 r" eo 6 l Q. 8- 10- 11 10 11 12- 13- 14- 2 13 14 d R rCQ�1 15 ROG �.. ... ``.S. 16- L% No f� �9 '0.. 17- AQOF ,6 1s 20 COMMENTS t1.- I - A * f4 ... 1I SHAFER . y,A A. Show TSo. ,air -E - WAS GROUND WATER ENCOUNTERED] IF VES, AT WHAT /f I DEPTH? Depth to Water Attu 1 4 I Monitoring? Cate: ®®MMM IVA n ^ N PERCOLATION RATE (/y (minutes/inch) PERC MOLE DIAMETER t TEST RUN BETWEEN FT AND FT 3.22-171 1NG PERFORMED 917034 Eagla River Loop Road No. 204 Eag • River, AJoSka V93/1 ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDEI 72-008 (Rev. 4185) CERTIFY THAT THIS TEST WAS PERFORMED IN ON THIS DATE. DATE: 59 Development Services Department Phone: (907)343-7904 On -Site Water & Wastewater Section Fax: (907)343-7997 Certificate of On -Site Systems Approval OSC251377 Parcel ID 050-731-37 Expiration Date'. Legal description MAJESTIC VALLEY ESTATES BLK 2 LT 13 Site address 26301 WHITE SPRUCE DR Current property owner(s) LOCKS JOSHUA C X The On -site system(s) is/are approved for 3 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or conditions: In October 2018, the Municipality of Anchorage (MOA) published Policy W.05 "Standard of Care Regarding the Inspection of Steel Septic Tanks when Performing COSA Inspections" If this policy is not attached to this COSA, please request a copy from the MOA On -site Section. While this policy is not codified, it does describe the process by which an engineer is to inspect a steel septic tank that is older than 30 years. The septic tank on this property is now 33 years old' however, the engineering firm that conducted this COSA inspection did not elect to follow this standard of care. The buyer is to be aware that the physical condition of the septic tank (i.e. absence of holes, leaking, or corrosion) has not been verified. By: Original Certificate Date: 8/29/2025 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 Service 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 submittal. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory Other Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 050-731-37 Complete legal description Majestic Valley Estates Block 2 Lot 13 Location (site address) 26301 White Spruce Dr. Eagle River, AK Current property owner(s) Joshua Locke Day phone 2. ON -SITE SYSTEMS SIZED FOR 3 BEDROOMS 3. TYPE OF WATER SUPPLY: ❑ Private Well serving # 1 dwelling units ❑ Other Non-public well as regulated by MOA ❑ Water Storage ❑ Community Well or Public 4. TYPE OF WASTEWATER DISPOSAL: ❑ Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: 0 Steel ❑ Plastic ❑ Concrete ❑ Fiberglass Age 33 - See advisory if steel or fiberglass older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench X 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 $ �SG Waiver Fee $ Date of Payment l )w-?� S COSA # of 2V � 7 7 Date of Payment Waiver # COSA Applicalion_Apr2025.doc COSA Checklist Legal Description: Maiestic Vallev Estates Block 2 Lot 13 Parcel ID: 050-731-37 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system _ A. WELL DATA n Well log is filed with Onsite (or attached) Date drilled 4/1992 Total depth 300 ft Cased to 62 ft ❑✓ Sanitary seal is functioning correctly n Wires are properly protected Casing height (above ground) 12* in. Date of flow test for COSA 8/8/25 Well production at time of test 5.9 gpm Water storage tank volume None gallons Well disinfected for coliform test? ❑ Yes (21 No Q Coliform bacteria is Negative Nitrate mg/L Fv1 Nitrate less than MRL (ND) Arsenic ug/L ❑J Arsenic less than MRL (ND) Collected by Arcterra Consutling Static water level at beginning of test 69 ft. Date 7/30/25 Comments *Inside well vault with drain Meets code requirements B. TANK DATA Measured operating fluid level in septic tank 49"* Date of pumping 8/5/25 ❑ Required maintenance completed, if AWWTS Comments: *tank integrity verified via camera inspection D. DISPOSAL FIELD DATA Which system tested (date installed) 7/24/1992 F/� ALL standpipes present per record drawing Total measured depth from grade 5 ft (max) Measured depth to pipe invert from grade 4 ft (min) ❑ N/A — pressurized field. R Per record drawings, field is insulated. Q 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 gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Comments/Deficiencies: COSA Checklist_May2025.docx STATION ❑ Require ntenance completed Age of lift station ryes`` Lift station material Comments: Adequacy test date 8/8/25 Results P Pass Fluid depth prior to test 0 in Water added 450 gal New fluid depth 0 in Elapsed time 10 min Final fluid depth 0 in Absorption rate 450+ gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) 6 in Effective depth used 0 in Effective depth remaining 6 in E. SEPARATION DISTANCES From Well on Lot to: (Please enter distances if less than required) Septic Tank/Lift Station on Lot > 100' ❑✓ Yes if No ft Neighboring Tank > 100' ✓❑ Yes if No ft Disposal Field on Lot > 100' ✓❑ Yes if No ft Neighboring Disposal Fields > 100' F/� Yes if No ft Sewer Line/Main > 100' F/I Yes if No ft Sewer Manhole/Cleanout > 100' 0 Yes if No ft Sewer Service/Septic Line > 25' ✓❑ Yes if No ft Holding Tank > 100' Q Yes if No ft Animal Containment > 50' Q Yes if No ft Manure/Animal Excreta Storage > 100' P� Yes if No ft ❑ N/A — Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Disposal Field(s) on Lot to: (Please enter distances if less than required) Tank to Foundation > 10' Yes if No ft Surface Water > 100'❑ Yes if No ft Field to Foundation > 10' Yes if No ft Wells on Adjacent Lots: Tank to Property Line > 5' ✓❑ Yes if No ft Wells > 100' © Yes if No ft Field to Property Line > 10' ✓❑ Yes if No ft Community Wells > 200' Yes if No ft Water Main/Service Line > 10' ✓❑ Yes if No ft F. ENGINEER'S COMMENTS 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 Arctrra Consulting Phone (907)-696-611/1 Engineer's Printed Name Kenneth Duffus Date Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the ���►s`t�1t� Cf' conditions as of the day tested. The flow and absorption rates may change due to �1 subsurface conditions that may not be observed from the surface, changes inland use, local ��#! �+�� soil characteristics, groundwater levels that may fluctuate during the year and the water i usage of the family being served by the system. The operational life of all well and septic }{" A �`d systems are subject to these various and dynamic characteristics and are outside the i control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future occupants or can ArcTerra that no unseen encroachments, deficiencies or discrepancies XEN`7EN' w 0u , *��i guarantee 1 1 E + exist. %` #+4 0 COSA Cheddist_May2025.docx !!� „��►� Septic Tank Advisory Certificate of On -Site Systems Approval # OSC251377 Subdivision: MAJESTIC VALLEY ESTATES Block:2, Lot: 13 The septic tank for this property is 33 years old. The average life of an asphalt coated steel septic tank is 20 years. Typical replacement costs are $15,000 or more, not including engineering, surveying, MOA permitting fees or site restoration. Steel septic tanks utilizing "Coal Tar Pitch" coatings are subject to corrosion as the steel reacts to water and rusts. These tanks have a finite lifespan buried in the ground. These tanks can become structurally compromised and pose a health risk. They could collapse and/or leak untreated wastewater directly into groundwater. In the interest of protecting public health and the environment, the Municipality of Anchorage Development Services Department has issued Policy W.05 Standard of Care Regarding the Inspection of Steel Septic Tanks when Performing COSA Inspection. Please request a copy of this policy from the Department if interested. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. Mailing Address P.: Q B6x 196650 * Anchorage, Alaska 99519-6650 * www rnum org MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT Policy W.05 "Standard of Care" Regarding the Inspection of Steel Septic Tanks when Performing COSA Inspections The Municipality of Anchorage, Development Services Department, On -Site Water and Wastewater Section and industry has observed that steel septic tanks utilizing "Coal Tar Pitch" coatings, such as Tnemec #46- 465, or equivalent coating systems, are subject to extensive corrosion, and in some cases are structurally compromised less than 10 years after installation. Most steel tanks using this conventional coating method are leaking and/or are structurally unsound within 15-20 years of installation. In the interest of protecting public health and the environment, effective beginning May 1 of 2019, the Municipality of Anchorage will no longer allow the installation of steel septic tanks unless they are coated (interior and exterior) with an approved polyurethane lining or "like" material approved by the Department. There are thousands of steel septic tanks currently installed in the Municipality of Anchorage. The position of the Department is that steel septic tanks, having a conventional Coal Tar Pitch coating system, over 20 years old are likely compromised to some degree. Effective October 15, 2018, it is the policy of this Department that the following "standard of care" shall apply for engineers inspecting septic systems as part of the Certificate of Onsite Systems Approval (COSA) process: • Prior to pumping the tank or after the tank has filled back up to operating level, the engineer should measure the liquid depth in the second compartment of the septic tank and note it on the COSA paperwork as a comment. • If a steel septic tank with a conventional coating is 20 to 30 years old, and the liquid level is in normal operating range (± 3 inches of manufacturer's published outlet invert elevation) the Department will issue an "Advisory Notice" with the COSA explaining that the septic tank may be approaching the end of its useful life. A liquid level below the normal operating range indicates the tank is leaking and needs to be replaced. • If a steel septic tank with a conventional coating is over 30 years old, it should be replaced or physically exposed by excavating down to the waterline along one side -wall and one end of the tank and inspecting it for holes. The inspection should be performed by a registered engineer or certified installer. If there are holes in the tank wall, water weeping from the tank wall, or other tank components are compromised, the tank needs to be replaced. If a certified installer deems the tank free of holes or other deficiencies, a registered engineer or On -site staff should be notified to allow verification of tank integrity. Results of the investigation should be noted in the comments section on the COSA form. • If during the COSA process the engineer observes a condition that would lead them to believe that the tank and/or tank components are compromised, then additional investigative work is necessary to confirm that the tank is structurally sound and watertight. In addition, if a steel septic tank with a conventional coating is over 10 years old, it should be exposed and inspected for holes at the time of construction to replace a failed drainfield. The department recommends the installation of fiberglass, plastic, concrete, or polyurethane coated steel septic tanks when site conditions allow. Although installation of conventionally coated steel septic tanks is legal until May 1, 2019, the installation of such tanks is discouraged given their short life expectancy. Ross Noffsinger, ffCtitJgSL1ilding Official Date: 10/15/18 Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519-6650 * www.muni.org MUNICIPALITY OF Development Services Department` On -Site Water & Wastewater Section Parcel I.D. 050-731-37 Certificate of On -Site Systems Approval 1. GENERAL INFORMATION Phone: 907-343-7904 Fax: 907-343-7997 Expiration Date: Complete legal description MAJESTIC VALLEY ESTATES BLK 2 LT 13 Location (site address) 26301 White Spruce Dr Current property owner(s) SEYMOUR Day phone 865-6472 Mailing address Real estate agent Sabra Day phone 865-6472 V 567 9,0- 3 2. TYPE OF DWELLING: ti Fx� Single Family (w/wo ADU) Q ❑ Duplex SEP 2 20;� ❑ Multiple Dwellings (Single Family and/or Duplex) ti h 3. NUMBER OF BEDROOMS: 3 `�� 6 8 L 9 `' 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well F -I Private Septic R Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. 5. 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 for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further 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 (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm NorthRim Eng. Phone 694-7028 Address PO Box 770724, Eagle River Engineer's Printed Name Steve Eng Date 9/26/19 rI DROG1RAM �? '61" SVT SEI>>\1�,�, 7 Original Certificate Date: 16 —) qrj The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Septic System Advisory Well Flow Advisory COSA Checklist blue sheet Nitrate Advisory Arsenic Advisory 'n Other- a,4Z }q pdyi- LAy 6. DSD SIGNATURE System #1 Approved for bedrooms a � `• System #2 Approved for o bedrooms `_ ��® �1 .,t❑ %N1. Eng ° L6 Zn I7 Conditional approval for bedrooms, with the following stipuIbfions?OFESSO' -.`�� rI DROG1RAM �? '61" SVT SEI>>\1�,�, 7 Original Certificate Date: 16 —) qrj The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Septic System Advisory Well Flow Advisory COSA Checklist blue sheet Nitrate Advisory Arsenic Advisory 'n Other- a,4Z }q pdyi- LAy Legal Description: MAJESTIC VALLEY ESTATES BLK 2 LT 13 Parcel ID: 050-731-37 If more than 1 septic system on lot: COSA Checklist # of Structure served by this system A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 4/92 Total depth 300 ft Cased to 62 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 12* in. Date of flow test for COSA 9/23/19 Static water level at beginning of test 77 ft. Comments * Inside Manhole w/Daylight Drain B. TANK DATA Age of tanks) 724192 years Tank type/material Steel Measured operating fluid level in septic tank 47 ❑ Standpipes/foundation cleanout per record drawing Date of pumping 6/17/19 D. ABSORPTION FIELD DATA 7/24/92 Which system tested (date installed) 7/24/92 ❑ ALL standpipes present per record drawing Total measured depth from grade 5. ft (max) Measured depth to pipe invert from grade 4 ft (min) ❑ N/A — pressurized field ON Monitor tubes go to bottom of effective. If not, state depth into effective Well production at time of test g+ gpm Water storage tank volume 0 gallons Well disinfected for coliform test? ❑ Yes ❑ No t(trColiform bacteria is Negative ate I,. 4�hg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) i Collected byk'i'1'` Date of Sample l+ 1 C. LIFT STATION ❑ Required maintenance completed Age of lift station new years Lift station material Steel Comments: Adequacy test date 9/23/19 Results ❑✓ Pass For 3 Fluid depth prior to test 0 Water added 450 gal New depth 5 in Elapsed time 60 min M I fl "d d th 1 bedrooms in ❑ Code -required soil cover over field Ina uI Up In OR System presoaked Absorption rate 450 gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) no date of test) Gallons introduced 2000 gallons If yes, enter date Comments/Deficiencies: COSA Checklist yellow sheet E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' ✓/ Yes Community Sewer Manhole/Cleanout > 100' F/ Yes if No ft M Yes if No ft Neighboring Tank > 100' ❑✓ Yes if No ft Private Sewer/Septic Line > 25' F71 Yes if No ft Absorption Field on Lot > 100' Q Yes if No ft Holding Tank > 100' ❑✓ Yes if No ft Neighboring Absorption Fields > 100' Yes if No Animal Containment > 50' Q Yes if No ft Q Yes if No ft if No ft F. ENGINEER'S COMMENTS Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' Yes if No ft M Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' Q✓ Yes if No ft Surface Water > 100' Yes if No ft Property Line > 5'✓Q ✓/ Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' Q✓ Yes if No ft Private Wells > 100' Q Yes if No. Water Main > 10' Q✓ Yes if No ft Community Wells > 200' Q✓ Yes if No. Water Service Line > 10' p Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ✓/ Yes if No ft If absorption field is under driveway comment below Property Line > 10' ✓Q Yes if No ft Wells on Adjacent Lots: Water Main > 10' ✓0 Yes if No ft Private Wells > 100' Yes if No Water Service Line > 10' p Yes if No ft Community Wells > 200' Yes if No Surface Water > 100'✓Q Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION 1 certify that I have determined through field inspections and reviewk of Municipal records that the above systems are in conformance with t>, MOA COSA guidelines in effect on this date. ' CSF COSA Checklist yellow sheet ft ft ft III DEVELOPMENT SERVICES DEPARTMENT On -Site Water and Wastewater Section www.muni.org/onsite Septic Tank Advisory Certificate of On -Site Systems Approval #OSC191458 Subdivision: Majestic Valley Estates Blk 2 Lot 13 Starting at 20 years of age the MOA issues Advisory's for steel septic tanks. The septic tank for this property is 27 years old. Typical replacement costs range from $8,000 to $11,000. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. This is an example of what the metal of a 20 year old steel tank MAY look like. ASBUILT SEWARD & ASSOCIATES LAND SURVEYING 694-0829 I HEREBY CERTIFY THAT i HAVE SURVEYED THE SCALES It, S©# FOLLOWING DESCRIBED PROPERTY: + OF Rt14R DATE= AND THAT NO ENCROACHMENTS EXIST EXCEPT AS y/J�JP•.•' �' S 4 INDICATED. IT IS THE RESPONSIBILITY OF THE t H` • • ! OWNER TO DETERMINE THE EXISTENCE OF ANY GRID= y•••.• •• ••••• •• ' ••••g EASEMENTS, COVENANTS, OR RESTRICTIONS WHICH DO NOT APPEAR ON THE RECORDED SUBDI- , Dv.n. Mark s.W.,a / VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD FB' t �'•.•• LS -6918 *�► ANY DATA HEREON BE USED FOR CONSTRUCTION -OF ARY LINELINES, OR FOR ESTABLISHING BOUND- DRAWN:tifi�...'' 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 of FOR A SINGLE FAMILY DWELLING Parcel I.D. �.`7t) r31� 3 HAA# n5�1�i3 Expiration Date: 1. GENERAL INFORMATION Complete legal description ., BZ Location (site address or directions) .26301 V tl117"E .9iolz Icrs hof'rile, Current Property owner(s) 04""4 Day phone SSo7 2634(232 Mailing address'"W#f7, SPZ Jc a /31?ttfC Lending agency Mailing address Real Estate Agent Mailing Address Day phone &4rri3A-tA CRr77—aVA15;tJ Day phone 4-c'%/d'6e_ PZJ4ZV7-/4L V/ -f'7' -f vTic E.W�-.2,!4a Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System TYPE OF WASTEWATER DISPOSAL: 0 Individual On-site R ❑ Individual Holding tank ❑ ❑ Community On-site. ❑ ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 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. (Certificates may be 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 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 Health Authority Approval Guidelines for this application, shows that the on- site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further 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(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Zt r IV loin Phone %!f" 70e74p Address L7, 237 PCI Pe_ Engineers Printed Name _STr_5✓E 9(/W Date SVS -As 5. DSD SIGNATURE Approved for > bedrooms. Disapproved. c OF A/_ 191Q ........... sloven WE K 6156 Conditional approval for bedrooms, with the following stipulations: Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other By: ! �.{ c n 1 �d\ 1 f .r (in Original Certificate Date: � .i (Rev OIA1) r Legal A. WELL DATA 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 Well type tp If A. B. or C provide PWSID # Date completed 4&j.Z Sanitary seal (YIN) Total depth 3!q.0 --ft. Cased to 62 n. FROM WELL LOG Date of testq� Static water level OW S n. Well production S g.p.m. WATER SAMPLE RESULTS: Parcel Ib: t eso - l31 37 Well Log (YIN) Wires properly @protected (YIN) _ C%NngW� (P/Tvw yd) `N L in. � rJ AT INSPECTION /2/OS 7-5' n. 9 g.p.m.I- Col form _(:j_colonies/100 ml. Nitrate DL mg.A. V Other bacteria _Z_ colonies/100 ml. Arsenic: mg./I. Date of sample:441—ISAOS Collected by: B. SEPTICIHOLDING TANK DATA / Tank Type/Material eft loaOi5 ErAZ Date installed 7/2 i(1 i2 Tank size Ica 0 gal. Number of Compartments _jj_ Cleanouts (YIN) V Foundation cleanout(//YIN))��T� Depression over tank (YIN) V High water alarm (YIN) Date of pumping Pumper S'&/Zn19t/ fcAmAly'ye C. ABSORPTION FIELD DATA Date installed ZZ Soil rating (g.p.d./ftp or6�) g -L System type�/f!rL.r TRdf Length /SZ n. Width S n. Gravel below pipe Total depth _,� n. Eff. absorption area 7_,I�Q ft2 Monitoring tube Depression over field Nd Date of adequacy test l OS Results (Pass/Fail)TWX For 3 bedrooms Fluid depth in absorption field before test A_ in. Water addeddsu gala' New depth in. Elapsed Time min. Final fluid depth Q in. Absorption rate >= 44SOO g.p.d. 4 - Any Any rejuvenation treatment (past 12 mo.) (YIN & type) I" - If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) 'Pump on' level at n. 'Pump otr level at High water alarm level at in. Datum Cycles tested Meets alarm & circuit re menls9 E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot t Absorption field on lot Public sewer main A r Sewer /septic service line L s t On adjacent lots /040 /11 On adjacent lots / a B ~ Public sewer manhole/cleanout AV Holding tank Nlq SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation S t Property line /a r* Absorption field Water main A//. Water service line /O r+ Surface water /00 r* Wells on adjacent lots ©orf SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line /0 11 11 Building foundation 0 Water main NIA r Water Service line /0'00 Surface water /00 �*' Driveway, parking/vehicie storage Q Curtain drain am Wells on adjacent lots !00 r F. COMMENTS tr`iyrr DC.f/n/ /NA'T,4ueA /N w&4 Pit __:;•.. t��•�. t::...; r�: G. ENGINEER'S CERTIFICATION r,�r •.•• ;, , ���:Z• 0-Z;/ I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineers Printed Name STE_/E EAJC I ye"^" w. E "a I4 Jf'.PE 6255 Date S S OS f� 9F� 1!: AC�FS�iC"' •v HAA Fee Eqw •Co Date of Payment Receipt Number (Rev. 12/01) Waiver Fee $ Date of Payment Receipt Number �G �,vrvss ,,,rl. t✓ .per N` Yr� , 1I9 �'Q • /iia w ASBUILT I HEREBY CERTIFY .THAT I HAVE SURVEYED THE FOLLOWING DESCRIBED PROPERTY: AND THAT NO ENCROACHMENTS EXIST EXCEPT AS INDICATED. IT IS THE RESPONSIBILITY OF THE OWNER TO DETERMINE THE EXISTENCE OF ANY EASEMENTS, COVENANTS, OR RESTRICTIONS WHICH DO NOT APPEAR ON THE RECORDED SUBDI- VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD ANY DATA HEREON BE USED FOR CONSTRUCTION . OF FENCE LINES, OR FOR ESTABLISHING BOUND- ARY LINES. AAI&.'s1 lwl SCALE: �._ So• DATE: GRID: FB: /off 6e DRA Nt o", L c .0;0:wqkvk%• %� pF'At:9S�♦ .te - . -�- f • �; \ � Ate; .".' ,� ,S�i.r Majestic Valley Estates, Block 2, Lot 13 Steve Eng, PE, P1 On 5/19/05 improvements were made to seal the manhole lid which contains the water well on Majestic Valley Estates, Block 2, Lot 13. A daylight drain had previously been installed in the manhole, at the direction of the MOA On -Site Program. A 11/. inch thick Butyl Tight Sealer was obtained from Hughes Supply in Anchorage. This sealer is designed to seal a manhole lid. Photographs below: Open Manhole w/ Butyl Tight Sealer Installing Butyl Tight Sealer Butyl Tight Sealer In Place Manhole Cover Sealed Into Opening i even r. Eng j ; FE 6256 a .......... .......•`� .� GiF55lC' •r' 1 if 1.' "1� ! 4 sal=+ ->••x �f I L i� ' � •� 1 - r � 1 r .�...�� - � �•' ✓=.'� moi; yr Yr i � s r .�...�� - � �•' ✓=.'� moi; yr Yr i MUNICIPALITY OFANCHORAGE • DEPARTMENT OF HEALTH 8 HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # Q 6 - 13N - 3_1 1. GENERAL INFORMATION HAA # WZ0 1T)O L1?1 Complete legal description Lot 13; Btock 2; Majutic. Valley SubdEvi6ion Location (site address or directions)—bltiU Property owner _Rglntt P0nnPha Day phone 694-9681 Mailing address PEPPERS CONSTRUCTION/P.O.. Box 771064, Eagte Riveh, Atadka 99577 Lending agency Mailing address Agent Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water 3 y Day phone Day phone NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site (XX Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-075(Aw.1/91) front MOA121 5. 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 of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I furtherverify 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 in compliance with all Municipal and State codes, ordinances, and regulations In effect on the date of this inspection. Name of Firm S & S ENGINEERING Phone 17014 Eagle River Loop Road No. 204 Address Eagl_ Riyer Alaska 99577 Engineer's signature 6. DHHS SIGNATURE Approved for .3 bedrooms. Disapproved. Conditional approval for Additional Comments A Date 1'21-9'R �. YI•�I I 4'! Z e_r1,�0} t•:. Jtf'�, .nom :.• bedrooms, with the following stipulations: Date 2 - 9-9Z The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given In paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. nan (n... iA,) 8�k MOA121 a Municipality of Anchorage ARL Department of Health & Human ServicesMW HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description-.\=!�!rt3 Parcel I.D. .tA_F_y A. WELL DATA I Well type If A, B, or C, attach ADEC letter. ADEC water system number � `a Log present Date completed Z Driller Zol'uy&-( Total depth '��� Casedto `Z 4 Casing height ��- Sanitary seal &N) 4 Wires properly protectedd N) Date of test Static water level Well flow Pump level FROM WELL LOG -1,-9Z _ 15.C> g.p.m. %3 Y__ SEPARATION DISTANCES FROM WELL TO: AT INSPECTION rn n Lp.rti.'n to �o � T L O Septic/holding tank on lot co ; On adjacent lots Absorption field on lot 1 , ; On adjacent lots Public sewer main —Public sewer manhole/cleanout— Sewer anhole/cleanout Sewer service line 2'S t�- Petroleum tank WATER SAMPLE RESULTS: Coliform b )O'" Q Nitrate tC> Other bacteria Date of sample: 1 7,1 - 93 Collected by: S & S ENGINEERING 17074 Eagle River Loop Road No. 204 B. SEPTIC/HOLDING TANK DATA Eagle River, Alaska "S77 Date Installed -7 ' 7- "t �'X-L— Tank size \bo0 Compartments Z Cleanoutsl, i'/N) Foundation cleanou (Y N) 4_ Depression II(Ya IJ High water alarm (Y& �-1 Alarm tested (Y/N) �lA Date of pumpingPumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Weil(s)onlot —on adjacent lots X055 Foundation 1A To property line to Absorptionfield Watermain/service line Surface water/drainage � o o \� 72026 (Rev. 7M) Frons CONTINUED ON BACK PAGE C. LIFT STATION Date Installed Size in gallons Vent(Y/N) High water alarm level "Pump on" levet at Meets MOA electrical codes —Manufacturer Manhole/Access (Y/N) p ofP'levelat `Cycles SEPARAT19N-MTANCE FROM LIFT STATION TO: on lot On adjacent lotsSurface water D. ABSORPTION FIELD DATA Date installed 1 ,24-9Z- Soil rating 0•L0 U -(�'" System typel�Y-A�.SFtE�.*a Length Z� Width S Gravel thickness Total depth S -Total absorption area i Loci `¢ Cleanouts present ON) Depression over field (Yb)Date of adequacy test •"� NE� Results (pass/fail) Jlti for rJ1D- bedrooms Peroxide treatment (past 12 months) (Y& If yes, give date AA SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ca On adjacent lots o tom% Property line o r To building foundation �� ►�`p To existing or abandoned system on lot Onadjacentlots 2� Cutbank Water main/service line o�� Surface water o o 04- Driveway, parking/vehicle storage area S D0c- Curtain drain '%Ab E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effecty lVR,"tjof this Inspection. = L OF-AGgmtt 5 S 5 ENGINEERING c '•>.�j ~•. 9 0 s o: Signature 17034 Eagle River Loop Road No. 204 P`t ?;� .i , y ti R mA �Iv River, Alaska 99577Z f �•• q Iu.� e. N.I N�1 •1•M• Engineer's Name e' Date ,27-� 3 t' 'HAFErt • W p v fir'^: 'Ip• •• i, v iROFESSl4yr,A+."' HAA Fee $ /ly Waiver.Fee: $ Date of Payment - Z-7- n Date of Payment Receipt Number 4- Receipt Number 72-M (R.. "I) 6"k MOA 21