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THE TABLELANDS BLK 4 LT 6
The Tablelands Block 4 Lot 6 #051-801-14 Municipality of Anchorage Page 1 of 4 Development Services Department On -Site Water and Wastewater Program 4700 South Bragaw Street P.O. Box 196650 Anchorage, AK 9951"650 www.U.anchorage.ak.us (907) 343-7904 ONSITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number. SW040500 PID Number. 051-801.14 S inell Homes Wastewater System: New Actrua 1900 W. Northern LI hts Ste. 200 Anch., AK 99517 ABSORPTION FIELD 344-5678 our 5' Wide Trench LEGAL DESCRIPTION Tac Degh kanap+W ,*0. .45 cPaTP 6 Ft. Block to S m &,on losptn to pp bonuo Iran ageW Vac* Gca mpb bem itn pipe 4 6 The Tablelands 2 Ft. 4 Ft. TowNep Rvps Seam Fs amen *Igen mpuW vacs Great Lwvp 1-3 Ft. 136 Ft. Well: AWWUWaterSystem r..e.I.Aan 5 N,.mly a w. 4 o,wc. esl.a.n w.. 10' Ft. ClaaMlraam (PraM.. A, e, Q T" Dwft TaZ sb—pl n*a "L Ww Ft. Ft 1,360 Fe ASTM 3034 PVC Onllar Dal* DM W Sulo Wwar Laval kwll a kmuaiw Ft Pisano's Dirtworks 2115.1712005 v,eb P„aps«.t cum Albv u,r TANK GPM FI. FI SEPARATION DISTANCES 'Septic To Septic Absorption Lift Holding uaioprivate y From Tank Field Station Tank s,,wune Anchorage Tank 1,250 Weil >200' >200' N/A NIA >25' a Steel Two (2) sMraoewate, >100, >100, NIA NIA LIFT STATION — NONE ON LOT Law >5' >10, N/A WA C' Faabrvl >5' >10, N/A WA wv cw .e ` a a al b b in None Noted t Pump IMa MmN M'" Irupur WM by CM DWI R"°`tte BENCH MARK ree now Spitter valves Placed to Assure Lven now. o�w Finished Floor. 100.0 FL Engineer's Stamp Inspections performed by: T. Kimbrough Dates: 1" 2/15/2005 4911, ��"-"_ 2nd 211681712005 0 ...... .' usQ-:, Department of Health and Human Services approval ���VICIIAR C AVCf nSON y,� . IX � 01 —eL-06 ♦ �J4 No Cf -4381 r •44��+fp �' �: ° ��` and approved by: Date: �P mReviewed 4aa��5;'•�. Municipality of Anchorage Page 4 of 4 DEVEOPMENT SERVICES DEPARTMENT 4700 South Bragaw Street Anchorage, AK. 99519-6655 - 343-7904 On -Site Wastewater Disposal System or Well Inspection Report I-1'Il(i� >tIM,AS7I;&4Ti'i1_i*i4#] PID No. 051-801-14 n v U S U ROFILE AS -BUILT $cola: 1" - 10' �! 49th IAEL E. ANDERSON No, CE- 381 / Municipality of Anchorage DEVEOPMENTSERVICES DEPARTMENT 4700 South Bragaw Street Anchorage, AK. 99519-6655 - 343-7904 On -Site Wastewater Disposal System or Well Inspection Report Permit Number. SWO4050D TBM Page 3 of 4 PID No. 051-801-14 W U i in N U L n n 97.50 Cu 2 Fabric Bralnfleld Rock Fabrlc Ilralnfleld Rock II --80.2 PRO/FILE AS -BUILT Scale: 1' - 10• GO U T U 98.82 98.46 TO;•` r 49th E ANM RSOI Permit Number SW040500 Municipality of Anchorage Page 2 of 4 OEVEOPMENT SERVICES DEPARTMENT 4700 South Bragaw Street Anchorage, AK. 99519-6655 - 3417904 On -Site Wastewater Disposal System or Well Inspection Report PID No. 051-801-14 2004-25 THE TABLELANDS SUBDIVISION LOT 6, BLOCK 4 40,000 S.F. / 1 ; 4iI1 0 try° cRr / 1 ?V0. . e* / oR a /t�Q o� Alt. Site 'r*`rr Four Bedr 7A7dvantex Home S sietment �9a J• / A / W D, 0.3 A e oz r, CS_ZU e ' / ea z „h 221— Cz Dl u4 66s / • u zzr Aa z• ci6001 1]T U 63O 619 W7 21 S 41 r e1w 297 157 Cl 71 634 .66' S Ba•Ja;9 F Jr�S4 H OF Al'Ahij, r 2 1 49th '• rr /.....A.......n... .. ...t.....r y��.... '= PLAN AS -BUILT �jNO \\\1....,•.'�SCALE 1' = 50' MUNICIPALITY OF ANCHORAGE Development Services Department Onsite Water 8 Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Initial Date Issued: Dec 22, 2004 Expiration Date: Dec 22, 2005 Permit Number: SW040500 Parcel ID: 051.801-14 Legal Description:ITHE TABLELANDS SUBDIVISION BLOCK 4 LOT 6"! Design Engineer: 0014 Anderson Engineering Owner Name: SPINELL HOMES, INC Owner Address: 22950 WHISPERING BIRCH DRIVE CHUGIAK , AK 99567 - Site Address: 22950 WHISPERING BIRCH DRIVE Lot Size: 40000 SO. FT. Total Bedrooms: 4 Permit Bedrooms: 4 This permit Is for the construction of: Q✓ Disposal Field [D Septic Tank Holding Tank [:] Privy Private Well ❑ Water Storage All construction must be In accordance with: 1. The attached approved design. 2. All requirements specked 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. Municipality of Anchorage Development Services Department j Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw SL 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 Parcell.D. 14 Permit Number SW Property owner(s) Soinell Homes, Inc. Day phone 3445678 Mailing address (1)1900 W. Northern Lights, Suite 200 Anchorage, AK 99517 Mailing address (2) &'194 6b Whispering Birch Drive Zip Code 4qg57o_4- Legal description (Lot, Block & Sub'd.) _Lot 6, Block 4. Tablelands Subdivision Legal description (Section, Township & Range) Lot Size 40,000 SF Acres/Sq.Ft. THIS APPLICATION IS FOR: Number of Bedrooms Four (4) Sewer Only ® Well Only ❑ Sewer and Well ❑ Water Storage ❑ Sewer Upgrade ❑ Hot Tub ❑ Jacuzzi ❑ Swimming Pool ❑ Water Softening Unit ❑ Therapy Pool ❑ 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 property owner or authorized agent) 444 tr Permit Fees: - Waiver Fees: Date of Payment /Z— /5'- 05/ Date of Payment Receipt Number. fil -12q 1 Receipt Number. (Rev. 12/00) ANDERSON ENGINEERING P.O. BOX 240773 ANCHORAGE, AK 99524 522-7773 522-6779 FAX December 14, 2004 Municipality of Anchorage Development Services Department On -Site Water and Wastewater Program 4700 South Bragaw Street Anchorage, AK 99519-6650 Subject: Lot 6, Block 4, Tablelands Subdivision Septic System Design and Permit Application Impacts to Adjacent Properties Dear Onsite Services Engineer: The owner of Lot 6, Block 4, Tablelands Subdivision intends to construct a new four- bedroom home on the lot. We are therefore requesting a permit be issued for the construction of a new septic system to serve the new home. The subdivision is currently served by a community water system. No conflicts exist with adjacent septic systems or wells and the proposed septic system on this lot. The attached Site Plan and backup documentation identify the location and configuration of the proposed septic system and alternate site. The current drainage pattern is identified on the Site Plan. The drainage pattern will be maintained after development of this lot is complete. Test holes recently placed on the lot indicated silty sand and gravel in the area of the absorption trenches. The accepting soils were tested and found to have a percolation rate of 31 to 60 minutes per inch. The system is designed with an application rate of .45 GPD/SF. No groundwater was found in either test hole during placement and none was found during the monitoring period. Our design includes the placement of a new 1,500 -gallon septic tank along with 4 - 34' long by 5' wide by 4' effective depth absorption trenches to collect and treat the sewage generated in the house. The bottom of the trench will be 6' below the surface. The distribution pipe will be 2' below the surface. A flow splitter valve will be placed to assure even flow to each trench. A minimum of 3' of cover will be placed atop the trenches and a minimum of 4' of cover will be placed atop the new septic tank. The ground surface on the lot slopes at grades from west to east as shown on the Site Plan. The absorption trenches will be constructed parallel with the slope of the ground surface as much as possible in conformance with Municipal requirements. The new Lot 6, Block 4, Tablelands Subdivision December 14, 2004 Page Two septic system will be constructed a minimum of 10' from the water service proposed for the lot and on adjacent lots. It will also be constructed a minimum of 100' from any surface water 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. 2. 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. 3. 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. 4. 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 LOT 6, BLOCK 4, TABLELANDS SUBDIVISION DESIGN FACTORS: SYSTEM REQUIREMENTS: Four Bedroom House 5' Wide Trench System Perc. Rate: 31-60 MinJlnch 1,500 Gallon Septic Tank Application Rate: .45 GPD/SF 4' Drainfield Rock 4 Bedrooms X 150 GPD/.45 GPD/SF (Application Rate) = 1,333.3 SF Absorption Area 1,333.3 SF/5 SF " .5 (Red. Factor) =133.3 LF Trench Length THEREFORE: Construct 4 - 34' Long x 5' Wide x 4' Effective Depth Absorption Trenches. Flow Line Elevation in Trenches to be 2' Below Original Ground Surface. Total Depth to be 6' Below Existing Ground. Provide 4' Cover Over Septic Tank and 3' Cover Over Trenches. Place 3 Flow Splitter Valve to Insure Even Flow to Each Trench. Natural Backfill 1'6" 3' Cover Over Trench Geotextile Fabric 6" I U 4" Perforated t PVC (Holes Down) 4'0" 1 1 ,> —r Drainfield Rock 5' TYPICAL 5' WIDE TRENCH SECTION (NO SCALE) J NOTE: Grade Area Over Trench to Drain Away. Minimum 6' Separation From Bedrock. :... Minimum 4' Separation From Groundwater. Poo... Minimum 100' Separation From Wells in the Area. "1� Minimum 10' Separation From Water Services. Minimum 100' Separation From Surface Water or Streams. �#,, N�L E. ANDERSON No. cEAM LOT 6, BLOCK 4, TABLELANDS SUBDIVISION ALTERNATE SITE DESIGN FACTORS: SYSTEM REQUIREMENTS: Four Bedroom House 5' Wide Trench System Perc. Rate: 31-60 Min./Inch 4 Bedroom Advantex Treatment System Application Rate: 2 GPD/SF 4' Drainfield Rock 4 Bedrooms X 150 GPD/2 GPD/SF (Application Rate) = 300 SF Absorption Area 300 SF/5 SF • .5 (Red. Factor) = 30 LF Trench Length THEREFORE: Construct a 30' Long x 5' Wide x 4' Effective Depth Absorption Trench. Flow Line Elevation in Trenches to be 2' Below Original Ground Surface. Total Depth to be 6' Below Existing Ground. Provide 4' Cover Over Septic Tank and 3' Cover Over Trench. Natural Backfill 1'6" 3' Cover Over Trench Geotextile Fabric 6" 1 U 4" Perforated PVC (Holes Down) 4-0-1 1' Drainfield Rock 5' TYPICAL 5' WIDE TRENCH SECTION (NO SCALE) j Jg NOTE: Grade Area Over Trench to Drain Away. Ca Minimum 6' Separation From Bedrock. ■.. ; Minimum 4' Separation From Groundwater. 0 Minimum 100' Separation From Wells in the Area. 0 Minimum 10' Separation From Water Services. 00 Minimum 100' Separation From Surface Water or Streams. �##, MICHAEL E. ANXMIC No. CEAm! MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT 4700 SOUTH BRAGAW STREET ANCHORAGE, AK 99519-6650 DEPTI I OCCO %] G SOILS LOG - PERCOLATION TEST LEGAL DESCRIPTION: LOT 6, BLOCK 4, THE TABLELANDS S/D PERFORMED FOR, SPINELL HOMES DATE: 11/19/2004 PROJECT No • M04I06 PARCEL ID,#• TECHNICIAN: T. L. KIMBROUGH TEST HOLE # 1 MEDIUM COMPACTED 6 SILTY SANDS W/GRAVELS SOME COBBLES TO 10' 7 SP -GM 11 nex 17 SLOPE KL F- MMRSUN No. CE -4981 "4 SITE PAN CURBKEY 02 T81 SFF FUTURE A0,RI111 T DATE READING GROSS TIME (MINUTES) NET TIME (MINUTES) D yATER F (INCHES) NET DROP I (INCHES) 11/19 TEST HOLE PRESOAKED PRIOR TO TESTING: 1 10:40 12.0" 2 11:10 30 11.06"1.94" 3 11:40 30 10.19" .87" 4 12:10 30 9.3" .87" 5 12:40 30 8.56" .75" 6 1:10 30 7.81" .75" PERCOLATION RATE 40 (MIN/INCFI) PERC. HOLE DIA. 6 CINCHES) TEST RUN BETWEEN. 4 FT. and--5_F-r. WAS GROUND WATER ENCOUNTERED? NO IF YES @ WFIAT DEPTIF) DEPTH OF WATER AFTER MONITORING: NONE DATE OF MONITORING: 12/13/2004 COMMENTS: NO IMPERMEABLE LAYERS ENCOUNTERED. TEST HOLE PRE SOAKED PRIOR TO TEST. TEST PERFORMED BY VETECH ENGINEERING TECHNICAL SERVICE. 1, MICHAEL E. ANDERSON CERTIFY THAT THIS WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPLE GUIDELINES IN EFFECT ON THIS DATE: / T. - 114 - pie MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT 4700 SOUTH BRAGAW STREET ANCHORAGE, AK 99519-6650 SOILS LOG - PERCOLATION TEST LEGAL DESCRIPTION: LOT 6, BLOCK 4, THE TABLELANDS S/D PERFORMED FOR- SPINELL HOMES DATE: 11/19/2004 PROJECT No • M04106 PARCEL ID4- TECHNICIAN: T. L. KIMBROUGH DrPni TEST HOLE # 2 Occt) I 2 3 READING OB/OG NET TIMEJ (MINUTES) 4 NET DRQP I (INCHES) 11/19 5 1 10:30 MEDIUM COMPACTED 6 SILTY SANDS W/GRAVELS 7 2 SOME COBBLES TO 10' 30 10.875" SP -GM 8 3 9 12.0" 10- 011121314 11- 11:30 30 12- 1.125' 13- 5 11:30 14- 12.0" BOH 51617 15- 6 12:00 16- 11.0" 1.0" 17J 18 19 4V 49th Nz c w DERSM No, CE -4381 / SITE PAN CURBKEY TH2 o T81 SFE FUTURE ASflUILT 0% DATE READING GROSS TIME (MINUTES) NET TIMEJ (MINUTES) DE PTH O ) F (INCHES) NET DRQP I (INCHES) 11/19 TEST HOLE PRESOAKED PRIOR TO TESTING: 1 10:30 12.0" 2 11:00 30 10.875" 1.125" 3 11:00 12.0" 4 11:30 30 10.875" 1.125' 5 11:30 12.0" 6 12:00 30 11.0" 1.0" PERCOLATION RATE -30 (MM/INCFI) PERC. HOLE DIA. 6 (INCHES) TEST RUN BETWEEN•`FT. and--5—FT. WAS GROUND WATER ENCOUNTERED? NO IF YES @ WIIAT DEPTII'? DEPTH OF WATER AFTER MONITORING: NONE DATE OF MONITORING: 12/13/2004 COMMENTS: NO IMPERMEABLE LAYERS ENCOUNTERED. TEST HOLE PRE SOAKED PRIOR TO TEST. TEST PERFORMED BY VETECII ENGINEERING TECHNICAL SERVICE. 1, MICHAEL E. ANDERSON CERTIFY THAT THIS WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPLE GUIDELINES IN EFFECT ON THIS DATE: /Z -/Y, o •/ ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION AND MATERIAL SPECIFICATIONS SUBJECT: LOT 6, BLOCK 4, TABLELANDS SUBDIVISION GENERAL: 1. The scope of this project includes the procurement and placement of a new 1,500 -gallon septic tank at the location shown on the Site Plan. Work also includes the construction of four new 34' long X 5' wide X 4' effective depth absorption trenches at the location also shown on the Site Plan. The distribution line in the trenches will be placed at 2' below the existing ground surface. Total depth of the trenches will be 6' below the existing ground surface. Three Zabel Flow Splitter Valves must be placed to insure even flow to each trench. A separation distance of 200' from any well and 100' between the septic tank and absorption trench and any surface water must also be maintained. A minimum of 3' of fill is required over the absorption trenches and 4' over the septic tank. In lieu of the required fill 2" of insulation and 2' of fill may be placed. 2. Construction shall be in accordance with the approved site plan, design drawings, Municipal Permit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. 3. The Contractor shall be responsible for obtaining all underground utility locates and for the layout of the septic system and verification of the location of all lot lines. The Contractor must also verify the location of wells in the area and assure that the separation distances are met. 4. Unless specifically agreed otherwise, the contractor shall be responsible for final grading areas subsequently depressed from soil settling. Property owner shall be responsible for revegetation of affected areas unless specifically agreed otherwise. 5. Contractors installing wastewater disposal systems must be certified by the Municipal Department of Health and Human Services for system installations. Owners installing their own systems must receive prior approval from D.H.H.S. before beginning system installation. SEPTIC TANK INSTALLATION A new 1,500 -gallon septic tank must be procured from an approved source and installed at the location shown. 2. A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. Lot 6, Block 4, Tablelands December 14, 2004 Page 2 of 3 3. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. 4. All standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 5. Tanks installed without 4' of cover shall have a minimum of 2" of direct burial insulation. 6. A foundation cleanout shall be installed one to four feet from the building foundation. Two cleanouts are required between the tank and the drainfield. 7. Final grading over the tank shall be such that a positive slope exists away from the septic tank. DRAINFIELD CONSTRUCTION: 1. The drainfield shall be constructed to the dimensions shown on the design. The bottom of the trench shall be within 2" of level. 2. Distribution piping must be placed level with perforations down atop a level bed of drainfield rock. Rock should then be placed over the pipe to provide a minimum of 2" of cover. 3. A silt barrier or geotextile fabric must be placed between the drainfield rock and the natural soil backfill. 4. Monitor tubes must be 4" in diameter and installed at the locations shown on the design. The portion below ground must be perforated. 5. Contractor shall verify the septic tank and drainfield are a minimum 100' away from any private water wells in the area, 150' from a Class "C" Well or 200' from any community well. 6. Direct bury insulation must be placed over the distribution system if less than 3' of backfill depth is available. Finish grade over the trench must be mounded to prevent settlement or depressions. 7. Grade area surrounding the absorption trench to drain away. 8. A minimum 2' of accepting soil is required below the drainfield rock for a 5' wide trench. Contractor shall verify this condition prior to placement of the rock. All pockets of unacceptable materials must be removed and replaced. Lot 6, Block 4, Tablelands December 14, 2004 Page 3 of 3 MATERIAL SPECIFICATIONS: Septic tanks must be constructed by a Municipally approved septic tank manufacturer. 2. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Cast Iron (perforated and solid), ASTM D3034 or P.V.C. (perforated and solid), ASTM F810 or H.D.P.E. (perforated, but not solid) and ASTM D2662 or A.B.S. (perforated and solid). 3. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Co. Styrofoam HI or equal). 4. Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Femco, or equal). 5. A permeable geotextile fabric (Typar, Mirafi or equal) must be installed between the final drain rock layer and the native soil layer. 6. All drain rock shall be .5" to 2.5" in diameter with less than 3% passing the #200 sieve. INSPECTIONS: Municipal Ordinance requires a minimum of two inspections. These inspections must be conducted under the supervision of a professional engineer registered in the State of Alaska. The first inspection must be conducted after the excavation of trenches, beds or pits and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled. The second inspection must be conducted after the placement of the geotextile fabric, gravel, distribution piping, standpipes, cleanouts and insulation. No ball should be in place at the time of inspection. Contractor shall provide a copy of all field survey layout and construction notes for use in preparing the certified as -built of the completed system. ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION AND MATERIAL SPECIFICATIONS SUBJECT: LOT 6, BLOCK 4, TABLELANDS SUBDIVISION (ALTERNATE SITE) GENERAL: 1. The scope of this project includes the procurement and placement of a new Four Bedroom Advantex Treatment System with an AX -20 -Mode 1a 40x94 Pod to serve the new home on the lot. System will be placed at the location shown on the Site Plan. The new septic system also includes the construction of a new 30' long X 5' wide X 4' effective depth absorption trench at the location also shown on the Site Plan and at the configuration shown. The distribution line in the trench will be placed 2' below the existing ground surface. The total depth of the bed will be 6' below the surface. The new system must be placed a minimum of 200' from the wells in the area and 100' from any surface water located near or on the lot. 2. Construction shall be in accordance with the approved site plan, design drawings, Municipal Permit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. 3. The Contractor shall be responsible for obtaining all underground utility locates and for the layout of the septic system and verification of the location of all lot lines. 4. Unless specifically agreed otherwise, the contractor shall be responsible for final grading areas subsequently depressed from soil settling. Property owner shall be responsible for revegetation of affected areas unless specifically agreed otherwise. 5. Contractors installing wastewater disposal systems must be certified by the Municipal Department of Health and Human Services for system installations. Owners installing their own systems must receive prior approval from D.H.H.S. before beginning system installation. SEPTIC TANK INSTALLATION The Advantex Treatment System must be installed in conformance with specifications and regulations furnished by the manufacturer, Anchorage Tank and Orenco Systems Incorporated. No variances from the manufacturer's specifications will be allowed without permission from the manufacturer and Municipal representatives. Lot 6, Block 4, Tablelands December 14, 2004 Page 2 of 4 2. A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. 3. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. 4. All standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 5. Tanks installed without 4' of cover shall have a minimum of 2" of direct burial insulation. 6. A foundation cleanout shall be installed one to four feet from the building foundation. Two cleanouts are required between the tank and the drainfield. 7. Final grading over the tank shall be such that a positive slope exists away from the septic tank. DRAINFIELD CONSTRUCTION: 1. The drainfield shall be constructed to the dimensions shown on the design. The bottom of the bed shall be within 2" of level. 2. Distribution piping must be placed level with perforations down atop a level bed of drainfield rock. Rock should then be placed over the pipe to provide a minimum of 2" of cover. 3. A silt barrier or geotextile fabric must be placed between the drainfield rock and the natural soil backfill. 4. Monitor tubes must be 4" in diameter and installed at the locations shown on the design. The portion below ground must be perforated. 5. Contractor shall verify the septic tank and drainfield are a minimum 100' away from any private water wells in the area, 150' from a Class "C" Well or 200' from any community well. 6. Direct bury insulation must be placed over the distribution system if less than 3' of backfill depth is available. Finish grade over the trench must be mounded to prevent settlement or depressions. 7. Grade area surrounding the absorption trench to drain away. 8. A minimum 2' of accepting soil is required below the drainfield rock for a 5' wide trench. Contractor shall verify this condition prior to placement of the rock. All pockets of unacceptable materials must be removed and replaced. Lot 6, Block 4, Tablelands December 14, 2004 Page 3 of 4 MATERIAL SPECIFICATIONS: 1. Septic tanks must be constructed by a municipally approved septic tank manufacturer. 2. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Cast Iron (perforated and solid), ASTM D3034 or P.V.C. (perforated and solid), ASTM F810 or H.D.P.E. (perforated, but not solid) and ASTM D2662 or A.B.S. (perforated and solid). 3. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Co. Styrofoam HI or equal). 4. Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Femco, or equal). 5. A permeable geotextile fabric (Typar, Mirafi or equal) must be installed between the final drain rock layer and the native soil layer. 6. All drain rock shall be .5" to 2.5" in diameter with less than 3% passing the #200 sieve. SAND GRADATION: 1. Sand used to level the new absorption bed must have the following gradation: 50% Passed the No. 4 Sieve 2% Passed the No. 100 Sieve 1% Passed the No. 200 Sieve 2. The sand source must be approved prior to use. INSPECTIONS: Municipal Ordinance requires a minimum of two inspections. These inspections must be conducted under the supervision of a professional engineer registered in the State of Alaska. The first inspection must be conducted after the excavation of trenches, beds or pits and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled. The second inspection must be conducted after the placement of the geotextile fabric, gravel, distribution piping, standpipes, cleanouts and insulation. No backfill should be in place at the time of inspection. Lot 6, Block 4, Tablelands December 14, 2004 Page 4 of 4 Contractor shall provide a copy of all field survey layout and construction notes for use in preparing the certified as -built of the completed system. MUNICIPALITY OF ANCHORAGE • r Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section 7) Fax: 907-343-7997 Certificate of On-Site Systems Approval Parcel I.D. 051-801-14 Expiration Date: 1-1 -2,- 26Z0 1. GENERAL INFORMATION Complete legal description The Tablelands, Block 4, Lot 6 Location (site address) 22950 Whispering Birch Drive Chugiak, AK Current property owner(s) Brian Rogers & Amanda Richmond Day phone (907) 268-9761 Mailing address 25731 Denaina Drive, Eagle River, AK 99577 Real estate agent Day phone 2. TYPE OF DWELLING: H Single Family (w/wo ADU) Duplex Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ❑ Private Septic H Water Storage ❑ Holding Tank LJ Community Well n Community Public Water System H Public Sewer L Waiver request for Distance Received by: Date: COSA to be released to the engineer.unless otherwise requested by the engineer. COSA Fee $ S50- b'o Waiver Fee $ Date of Payment l I t t l U L 9 Date of Payment Receipt Number © o 0(l) Receipt Number COSA# Q S G L-l P `i Waiver# P 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 Forge Engineering Phone 907-522-7773 Address 1399 W. 34th Ave Suite 101, Anchorage AK 99503 Engineer's Printed Name Michael E. Anderson, P.E. Date 7/11/19 Ari ;....................'4:7 w 49th • 6. DSD SIGNATURE :' �,"'j p '.` 0 • .111 System #1 Approved for 4 bedrooms �V MICHAEL E ANDERSON� i : 4 . �1 -a., No. CE-4381 •..._. System #2 Approved for bedrooms •j��� ..,, 7/11/19 N••.••'���: Disapproved c�I l.FESS\c�4'.� Conditional approval for bedrooms, with the following stipulations: GROUTY(op op .��# , G r- � O -SirF R Sr wgSTF�,AND ToPR0�So GRyMER z,?CD `F 0 i �sFKVICE`'� �\, ,Ills. -- cidA Br-- ( 1---..._ — Original Certificate Date: 7— I (c, 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 Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet COSA Checklist Legal Description: The Tablelands, Block 4, Lot 6 Parcel ID: 051-801-14 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) Well production at time of test gpm Date drilled Water storage tank volume gallons Total depth ft Well disinfected for coliform test? ❑ Yes ❑ No Cased to ft ❑ Coliform bacteria is Negative ❑ Sanitary seal is functioning correctly Nitrate mg/L ❑ Nitrate less than MRL (ND) ❑Wires are properly protected Arsenic ug/L D Arsenic less than MRL(ND) Casing height(above ground) in. Collected by Date of flow test for COSA Date of Sample Static water level at beginning of test ft. Comments AWWU PUBLIC WATER SYSTEM B. TANK DATA C. LIFT STATION Age of tank(s) 13 years ❑ Required maintenance completed Tank type/material SEPTIC/STEEL Age of lift station years Measured operating fluid level in septic tank 49" Lift station material ❑■ Standpipes/foundation cleanout per record drawing Comments: Date of pumping 4/2/19 D. ABSORPTION FIELD DATA TRENCH Which system tested (date installed) 2006 Adequacy test date 6/26/19 ❑Q ALL standpipes present per record drawing Results ✓❑Pass For 4 bedrooms Total measured depth from grade ft(max) Fluid depth prior to test in Measured depth to pipe invert from grade ** ft(min) Water added 774 gal ❑ N/A—pressurized field New depth ** in ❑ Monitor tubes go to bottom of effective. If not, state Elapsed time 1440 min depth into effective #2-3.3' #4-1.5' ** 10 Code-required soil cover over field Final fluid depth in Absorption rate 600+ gpd 0 System presoaked (Required if vacant for greater than 30 days prior to Any rejuvenation treatment(past 12 months) None date of test) Gallons introduced 2000 gallons If yes, enter date Comments/Deficiencies:There are 4 trenches."See comments below. 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' Community Sewer Manhole/Cleanout> 100' 0 Yes if No ft 0✓ Yes if No ft Neighboring Tank > 100' 0 Yes if No ft Private Sewer/Septic Line >25' 0 Yes if No ft Absorption Field on Lot> 100' Q Yes if No ft Holding Tank > 100' 0 Yes if No ft Neighboring Absorption Fields> 100' Animal Containment> 50' 0 Yes if No ft Q Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' 0 Yes if No ft ✓0 Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' 0 Yes if No ft Surface Water> 100' 0 Yes if No ft Property Line > 5' 0 Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' 0 Yes if No ft Private Wells > 100' 0 Yes if No ft Water Main > 10' ✓0 Yes if No ft Community Wells> 200' 0 Yes if No ft Water Service Line > 10' 0 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' p Yes if No ft If absorption field is under driveway comment below Property Line > 10' 0 Yes if No ft Wells on Adjacent Lots: Water Main > 10' 0 Yes if No ft Private Wells > 100' p✓ Yes if No ft Water Service Line > 10' 0 Yes if No ft Community Wells> 200' ID Yes if No ft Surface Water> 100' 0 Yes if No ft F. ENGINEER'S COMMENTS Trench 1:MT 9.7',CO 5.6'Liquid start: 13".End 17". 1440 min:6". Trench 2:MT 8.7'CO 5.4'Liquid start: 13",End 14.5.", 1440m:7". Trench 3:MT 8.4'CO 4.4'Liquid start: 18" End:25.5", 1440m: 23".Trench 4: MT 5.9'CO 4.4'Liquid start:0"End 2", 1440m 0", G. ENGINEER'S CERTIFICATION .��'►��' mits, • �� r. "Y I certify that 1 have determined through field inspections and review =4%ic>,._ow. ".....•••• .j+ of Municipal records that the above systems are in conformance with „ 1,.. • MOA COSA guidelines in effect on this date. i 4 ii 49th ..j.--- N, '1.4- t .,... 0..N.....N...SYN•••”••.M.M. N.. *.S li VA,MICHAEL E. ANDERSON '� 0II 1 S's No. CE-4381 �'• . i,.... d�.� '•..• 7/11/19 ..•' �, " COSA Checklist yellow sheet ♦.. . �•.e""'..... P� �� 44OFESS\C'� ♦. 4 it 111%Will , • Municipality of Anchorage On -Site Water and Wastewater Program (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcell.D. 051-801-14 1. GENERAL INFORMATION Expiration Date: Complete legal description THE TABLELANDS BLOCK 4 LOT 6 Location (site address) 22950 WHISPERING BIRCH DRIVE CHUGIAK. AK 99567 Current Property owner(s) O VESTER JR & LAURA CASH Day phone Mailing address Real Estate Agent 2263 ROCKY MOUNTAIN AVE. #2 LOVELAND CO 80538 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ❑ Individual Individual Water Storage ❑ Holding Tank ❑ Community Class _ Well ❑ Community ❑ Public Water System ® Public Sewer ❑ WaiverNariance request for: Received by f --J Date. _ COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ K"10 Date of Payment v Receipt Number 0b5a�/ COSA #_ 0JCI3111-I (g7 Waiver Fee $ Date of Payment Receipt Number Waiver # 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. Name of Firm ARCTERRA CONSULTING, INC. Phone 868-3791 Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577 Engineer's Printed Name KENNETH M. DUFFUS Date _ 3122113 Engineers 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 conditions as of the day tested. The flow and absorption rates may change due to 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 usage of the family being served by the system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the 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 guarantee that no unseen fid' encroachments, deficiencies or discrepancies exist. 6. DSD SIGNATURE Ill '," role System #1 Approved for bedrooms. System #2 Approved for bedrooms. x'111 Disapproved. Conditional approval for bedrooms, with the following stipulations: By: Original Certificate Date: Th uniIGp y nchoraDevelopment 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 engineers work. ATTACHMENTS: COSA Checklist X Septic System Advisory Well Flow Advisory COSH blue sheet 10-10 iZdo Nitrate Advisory sem_ Arsenic Advisory . Other If more than 1 septic system is on the lot: COSA Checklist # _of _ Structure served by this system _ Certificate of On -Site Systems Approval Checklist Legal Description: THE TABLELANDS, BLOCK 4 LOT 6 Parcel ID: 051.801.14 A. WELL DATA — PUBLIC WATER Well type If A, B. or C provide PWSID # _ Well Log (Y/N) Date completed Sanitary seal (Y/N) Y Wires properly protected (Y/N) Total depth _ft. Cased to _ft. Casing height (above ground) _in. FROM WELL LOG AT INSPECTION Date of test Static water level Well production 9-10 M. g.p.m. WATER SAMPLE RESULTS: Coliform —colonies/100 mL Nitrate _ mg/L Arsenic: _ ug/L Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC / STEEL Date installed 211512005 Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (YIN) N High water alarm (Y/N) N Date of pumping 311812013 Pumper SANITARY C. ABSORPTION FIELD DATA Date installed 2115/2005 Soil rating (g.p.d./f:2 or f?/bdrm) 0.45 System type SHALLOW TRENCH Length 136 ft. Width 5 ft. Gravel below pipe 4 ft. Total depth 9_6 ft. (Measured 3/19/13) Eff. absorption area 1360 ft Monitoring tube Y Depression over field N Date of adequacy test 3119113 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test 3.3 & 8 in. Water added 380.200 & 400 gal. New depth 20.19 & 23 in. Elapsed Time: 1290 min. Final Fluid depth Z9 & 11 in. Absorption rate >= 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date D. LIFT STATION Date installed "Pump on" level at _ in. Datum Size in gallons "Pump off' level at —in. Cycles tested E. SEPARATION DISTANCES - PUBLIC WATER WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot Public sewer main Sewer /septic service line Animal containment areas SEPTIC/HOLDING TANK ON LOT TO Manhole/Access (Y/N) High water alarm level at Meets alarm & circuit requirements? On adjacent lots On adjacent lots Public sewer manhole/cleanout Holding tank Manure/animal excrete storage areas Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main 104 Water service line 10'+ Surface water 100'+ Wells on adjacent lots 200'+ ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main 104 Water Service line 10'+ Surface water 1004 Driveway, parking/vehicle storage 10'+ Curtain drain 50'+(NONEKNOWN) Wells on adjacent lots 200'+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of determined through field inspections and review of Municipal records that inspections and review of Municipal records that the above systems are in Municipal records that the above systems are in conformance with MOA above systems are in conformance with MOA COSA guidelines in effect on conformance with MOA COSA guidelines in effect on this date. COSA guidelines in effect on this date. on this date. Engineer's Printed Name KENNETH M. DUFFUS Date 112812013 COSA brown sheet 10-10-12.doc in. Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw SL P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 JCERTIFICATE OF HEALTH AUTHORITY i- joda HeenaroeZ Aol?it ( a APPROVAL RFOR A SINGLE FAMILY DWELLING Parcell.D. 051-601.14 HAA #_ n5r1U45 Expiration Date: 9 — Z — O 6o 1. GENERAL INFORMATION Complete legal description Lot 6. Block 4. The Tablelands Subdivision Location (site address or directions) 22950 Whispering Birch Drive Current Property owner(s) Spinelt Homes, Inc. Day phone 344-5678 Mailing address Lending agency Mailing address Real Estate Agent Mailing Address 1900 Northem Uahts Blvd Anchorage AK 99517 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 Four 4 Day phone Day phone TYPE OF WASTEWATER DISPOSAL: ❑ Individual On-site ED ❑ 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 5 by an independent professional civil engineer registered in the Slate 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. (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 Anderson Enalneerina Phone 522.7773 Address P.O. Box 240773 Anchoraae. AK 99524 Engineer's Printed Name Michael E. Anderson, P.E. Date 91112005 f 49th 5. DSD SIGNATURE 0 , -% CHA° r. �EtSON 0 No. cr.-43M �+ Approved for —�—L— bedrooms. pie `^.� st•o•�+ f Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments "z ' WATER AND m: Attachments: HAA Checklist X Maintenance Agreements Septic System Advisory Supplemental Engineer's Report Well Flow Advisory Other By: Gam. Original Certificate Date: 9 ' oZ ' 0 .J Municipality of Anchorage ' Development Services Department Building Safety Division On.Slte Water & Wastewater Program 4700 South Bragew SL P.O. Box 198050 Anchorage, AK 99519-850 www.d.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST ._ .i. •, il' 1 IP 111 •1 A. WELL DATA wen type Date completed _ If A, B, or C provide PWSID 8 _ Well Log (YIN) Sanitary seat (Y/N) — Total depth fL Cased to fL FROM WELL LOO Data of test Static water level it. Well production 9— p.m-WATER SAMPLE RESULTS: Cdltomr coloniesl100 m1. Nitrate mg.A. Date of sample: Collected by: B. SEPTICIHOLDINO TANK DATA Tank Type/Material—Beftooel Tank atza 1250 gal. Foundation deanout (Y/N) X Date of pumping C. ABSORPTION FIELD DATA Number of Compartments j Depression over tank (YIN) jl '7 .• 14141. 71 •L Wires properly protecW (YIN) Casing height (above ground) in. AT INSPECTION it. g.p.m. Other bacteria Date Installed VISMS Cleanouts (Y/N) Y colontes/100 ml. High water alarm (YIN) ;KIJo Date Installed V15=5 Soil rating (g.p.d./fe or fe/bdrm) .45 Gpprp System type S Wide Shallow Trench Length 138 fl. Width 3 R (travel below pipe 4 R Total depth LQ R Eff. absorption area 1.380 ftr Mondming tube.Y Depression over field 11 Date of adequacy test Results (Pass/Falq For _ bedrooms Fluid depth in absorption field before test _ in. Water added_ gal. New depth_ In. Elapsed Tune: _ min. Final fluid depth _ in. Absorption rata >= g.p.d. Any rejuvenation treatment (past 12 mo.) (YM & type) _N If yes, give date D. UFT STATION Data Installed `Pump on' ksvel at _ in. Datum E. SEPARATION DISTANCES Size In gallons Manhole/Access (Y/N) 'Pump air level at _ in. High water alarm Wel at in. Cycles tested Meets alarm b Bradt rogrdremw ta7 SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankAift station on lot WA Absorption flekl on lot WA Public sewer main WA On adjacent lots WA On adjacent lots WA Public sewer manhole/cleanout WA Sewer /septic service tine NIA Holding tank 1UA SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO: Building foundation >S Property line >fE Absorption flekt >S Water main Mi Water service line >11Y Surface water MW Wefts on adjacent Iota >-2W SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line >1g' Building foundation Mir Water main >M' Water Service line MIr Surface water >W Driveway, pgftlg, rehide storage a5_ Curtain drain None Noted Wells on adjacent lots V_ F. COMMENTS G. ENGINEER'S CERTIFICATION I car* that I have determined through field kmperdlons and a� review of Munlaipai records that the above systems are in 49th confomrance with MOA HAA guldens in effect on dds date. _ I .................. NZCVZ . L ANDERM Engineer's Printed Name Michael E Anderson P.E. `e4 4 No. a-4381 + Date gni 05•4i �Aa"...... 1� ! HAA Fee $ .9 S7 t Si71r Q .S F; Date of Payment 9-1- O5' Receipt Number "34Jt c0( (Rev. 12M) Waterer Fee $ Date of Payment Receipt Number m § z k � \\\\§\\\/ �Z�2�2�9M/ \\oZi —0iArn em z� mKon oco_4oE�MCA §§§ m==mom c®nm 0�n) 2�2m§�§orn §2q§e§me0� #;u#g§) «006KI6 o/_ mman oo(A0Z on i ,�$@oq�2 §# ;D =: = o �\\§\§rn o\®\ £z%< QPM r-\)§§ o-0zm a : )v\��0§ m >. ) m � I � D CC) r— m Z\ Df U2 12