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Home My WebLink AboutRANSOM RIDGE LT 607, Municipality of Anchorage y k Development Services Department Building Safety Division <<� On-Site Water and Wastewater Program, 4700 S. Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 Page of www.ci.anchorage.ak.us (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number: SV/ 0,,LOI73 PID Number: O �ZD- 0 q.2-- I Name: '13 ly Wastewater System: YNew ❑ Upgrade Address: LIAO - ►tet �� A v — ABSORPTION FIELD Phone: Number of Bedrooms: ❑ Deep Trench ❑Shallow Trench ❑Bed Mound ❑Other. LEGAL DESCRIPTION Sail Rating: � Total Depth from original grade: GPD/Ftp Ft. Block: Lot: Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe: 4—O T N S Cl 7 — d. � Ft. C. '� Fl. Township: Range: Section: Fill added above original grade: G Gravel Length: — 7— 2 Fl. FI. Well: New [1 Upgrade Gravel width: -7 "')- Number of lines: Distance between lines: Ft. ;z Ft. Classification (Private, A, B, C): Total Depth: Cased to: Total absorption area: Pipe Material: 1 FL ` —{ D Ft. O Flt 1 S l c�wLt� C 7 J C_ Driller. ALP 'N12 Dale Drilled: 6-23-0x Static Water Level: *3 Ft. Installer. Dale Installed: -z- LYield: Yield: Pump Set at: Casing Height Above Ground: TANK t D GPM �V T r0 H Ft. FL SEPARATION DISTANCES ❑ Septic ❑ Holding ❑ S.T.E.P. other: To Septic Absorption Lift Holding Public/PrivateManufacturer. Capacity. From Tank Field Station Tank Sewer Line 13it.� C `%C 14, L• L✓`Gal• Well I L) -5 /� 6 i en Material: Number of Compartments: Surface Water It9O Io-v IVV LIFT STATION Size: Manufacturer. Lot Line Q 50 V/ (i � Gal. l � Foundation (� v n f0 A Pump on' level at: j-9... 'Pump off' level at: 1 High water alarm at: in. :5 in. 5 in. Curtain Drain 'V I N (L) `�) pgMyake 8 Model Electrical Inspections perfonnecj by: V Remarks: BENCH MARK Location and Description: G Assumed Elevation: Engin ee:l'*s'SdFi�p tir ��, .� ` ° � dna, . `� pr-• Y f: jjq lInspections performed by: Dates: 1st /y 2nd p L Development Seryipes Department Approval Nw�sMN� Reviewed and approved by: ( 1 . Date:&I (Rev. 12/00) I \ \ I 1 1 \ \ Hell \ ` ANDh I� \ I I \ (D t ) V4 TER \ \ a O 1 \ KNC/ MARX SW lxs I rrr \ 9C AD 20 FT X 70 K 92sx2o ST 9[n SAT 9f 92 I� I fi 49th f^1 '•�i \ \ f \ I Ell ilroese'swDr' . No. CC -2223 ,:' ti, ) \ '•- .. 4� \I \ I 1 � rr�ffESSI�i�� ` \ ♦ I \ I I I I \\ \�♦ \ \ Ij� I I \ \ I I 25 0 25 50 75 fro \ 150U \ \ I f I I SCALD 1' = 50 FT. \ \ \ 1 I I II I TOBBEN SPURKLAND P.E. I I RANSOM RIDGE LOT 6 I I SEP71C SYSTEM AS BUILT I 203 W 15TH. AVENUE DATE: MAY 4, 2004 ANCH. AK. 99501 BEN MAY SHEET.' 21J GRID: 3337 /on7) 970—TO19 I PERMIT # SVO20173 PID k 020-092-14 RSR00062.DVG n INSTALLATII)N L EXCAVATE A 1D' x m' x 10' DEI? ME FDR MYCLE SYSTEM Z PLACE A NIVIMM D" 4' SMD DY GRAVEL FO? LEVELING MRSE X TI[ BDTTOV X A[ EXCAVATZk CDWACT AS REQUIRED 2 PLACE 4 SWM or r x B' x e DIRECT MIAL RIGID DKStLATMV DV TLP Zr COMPACTED LEVELM CD.RS£ TO PROTECT BOTTOV Or nk-RQASS TAHL TAKE EXTRA CARE TD ASURE THAT P4U.ATILN CDIRSE IS LEVEL N ALL DIRMTMC 4. BACKT'RL ARDMD TAW LP TD INVERT X 4' 1MLLENT AND 1414' ETTLLENT LPES VITN FREE-aDVIAG AV WERUL FREE Or LARGE STIACS W BLLLDERS PO' C I /-- A MUR TUBE 1-14' SCIfDtLE 40 PVCr V/ 1/D' FQES P 30' TOP AND BOITw A SAND/GPAVEL BACKFILL AS BUILT 49th IBY SPLIRKLAND No. CE -2223 , as MUMN W'UNKLANU F.L. LOT 6 RANSOM RIDGE SEPTIC SYSTEM SHEMA77C 203 907. 277 K.TH.9-391166 AVENUE RANSOM RIDGE ROAD DATE. MAY 4, 2004 (NCH. 99BEN WY SHEET • 3/3 GRID: 3337 PERMIT # SVO20173 pID # 020-092-14 RSR00063.B10 , 1 i �•�� 1 1 I 1 �' 1 :, , r ------------------ , u INSTALLATII)N L EXCAVATE A 1D' x m' x 10' DEI? ME FDR MYCLE SYSTEM Z PLACE A NIVIMM D" 4' SMD DY GRAVEL FO? LEVELING MRSE X TI[ BDTTOV X A[ EXCAVATZk CDWACT AS REQUIRED 2 PLACE 4 SWM or r x B' x e DIRECT MIAL RIGID DKStLATMV DV TLP Zr COMPACTED LEVELM CD.RS£ TO PROTECT BOTTOV Or nk-RQASS TAHL TAKE EXTRA CARE TD ASURE THAT P4U.ATILN CDIRSE IS LEVEL N ALL DIRMTMC 4. BACKT'RL ARDMD TAW LP TD INVERT X 4' 1MLLENT AND 1414' ETTLLENT LPES VITN FREE-aDVIAG AV WERUL FREE Or LARGE STIACS W BLLLDERS PO' C I /-- A MUR TUBE 1-14' SCIfDtLE 40 PVCr V/ 1/D' FQES P 30' TOP AND BOITw A SAND/GPAVEL BACKFILL AS BUILT 49th IBY SPLIRKLAND No. CE -2223 , as MUMN W'UNKLANU F.L. LOT 6 RANSOM RIDGE SEPTIC SYSTEM SHEMA77C 203 907. 277 K.TH.9-391166 AVENUE RANSOM RIDGE ROAD DATE. MAY 4, 2004 (NCH. 99BEN WY SHEET • 3/3 GRID: 3337 PERMIT # SVO20173 pID # 020-092-14 RSR00063.B10 FROM : ALPINE DRILLING FAX NO. : 907 345 020` May. W 2004 0G:21PM PS +Mck Municipality of AnchorageDepartment of Health and Human Services 8259UStreet 665P.O. Box 190 Anchorage. Alaska 99519-8650 t wvwww.QLWIChorapa.ak s Mayor Permit Number. #SW 02013 Date of Issuet 6-13 02 Parcel Identification Number. 0?0-092-14 Date Started: &22-0?, Date Coanpieted: 6.23-02 1a well Coated to approved permit location? ® Yes U No Legal Descrk*ion: Ransom Rkkm U 6 Property Owner Name & Address Ben May 4204 Garfield Avenue Borehole Data: Depth (it) Method of Drilling ® air rotary ❑ cable tool Sort Type. 7bickam do Water Suaia From To Casing type: stick-up 0 2 Wall Thickness: ,Z§Q inches omanics & a11t 2 4 Diameter: 6 inches Depth: 4Q feet aim 4 11 Liner Type: gravellysim 11 33 Diameter: inches Depth feet Casing stickup above groand: 2 feet Bedk 33 207 Static water feud (from ground level): Meet Pumping level: 207 feet after 2 hours pumping 19 spm Recovery Rate., Spin Method of Testing: air Wets Intake Opening Type: ❑ Opee End ® Open Hole ❑ Scraped Startfeet Stepped fat ❑l'afarariors Startfeet Stopped feet Groat Type: Bentmitc gnmks Volume: LAg ,Depth: Start Q feet Stopped _ foet Pump: LitaLe Depth feet Pump size ho Brand Name 11 Well Disinfected Upon Completion? ® Yes ❑ No Method of Disinfection: chlorine tablets Comments: Wall Driller. Alpine DrUling & Enterprises PO Box 110496 Androrage Alaska 99511 Atteadon: The =11 driller shall provide a wolf log to tic property owner within 30 days of eotnplotion and the property / - . May 03 04 OS:41p Ben May 6 Gretchen Specht 907 569 4309 _P-2 RightFax 4/29/2004 6:18 PAGE 1/1 RightFax InaPOCUon Report Municipality of Anchorage, Yuilding safatV Divlaion 4700 South Braeaw INSPECTIONI VOICE 343-0300 INSPGCTIONI PAX (907)249-7777 INFOt 347-7982 Name BEN MAY Permit 02-0703 LegalAddress LT 6 RMSON RIDGE RD Phone 569-4309 Subdhrlalon RANSOM RIDGE InapeCUOR Date 4/29/2004 ubA Comments Or Oiractione REINSPECT'"ANYTIME TODAY b+aPeetlon F4»I Elseftai Relnayection Y L� NO NONCOMPLIANCE OBSERVED ❑ CORRECTIONS ESSENMLAS EXPLAINED BELOW ❑ WILL RE-EXAMINE AT NEXT INSPECTION [3FIN DO NOT CONCEAL UNTIL RSPECTICN COMMENTS: (for inspwWr use cny) � r i u l� Dates �liil ° a 4A1,j MUNICIPALITY OFANCHORAGE Development Services Department On -Site Water& Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 ONSITE WASTEWATER DISPOSAL SYSTEM I WATER SUPPLY PERMIT Initial Date Issued: Jun 13, 2002 Expiration Date: Jun 13, 2003 Permit Number: SW020173 Parcel ID: 020-092-14 Legal Description: RANSOM RIDGE LT 6 Design Engineer: 0007 Tobben Spurkiand, PE Site Address: 016700 RANSOM RIDGE RD Owner Name: Ben May Lot Size: 94974 SO. FT. Owner Address: 4204 Garfield Ave. Total Bedrooms: 4 Permit Bedrooms: 4 Anchorage , AK 99503 - This permit is for the construction of: ❑✓ 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: Issued By: Date: Z' OZ Date: 3 LO 2 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 SEWERMELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Permit Number SWOZO/7 ._ Parcel I.D. Day phone Sol -5522, Property Mailing address (1) ,w " Zip code qQ►✓r- a3 Mailing address (2) Legal description (Lot, Block & Sub'd.)Lam— Legal description (Section, Township & Range) Lot Size q�71./ Acres/ q.Ft. THIS APPLICATION IS FOR: Sewer Only ❑ Sewer and Well Sewer Upgrade THIS PROPERTY CONTAINS: Hot Tub Swimming Pool Therapy Pool Number of Bedrooms Well Only Water Storage ❑ Jacuzzi' ❑ Water Softening Unit 171 C ❑ El I certify that the above information is correct. I further certify that this application is being made fcr a Single Family Dwelling and is in accordance with applicable Municipal Codes. (Signature of properly owner f authorized agent) Permit Fees: 5 _ Waiver Fees: _ Date of Payment: b/ i �d 2. _ Date of Payment: Receipt Number: go 7v -I Receipt Number: (Rev. 12100) T.3PZJPJKr-L1!TD ]P.E. 203 W 15th. Avenue, Suite 203 ANCHORAGE, ALASKA 99501 (907) 279-3916 Fax (907)-2766013 SEPTIC SYSTEM DESIGN LOT 6 RANSOM RIDGE RANSOM RIDGE ROAD Municipality of Anchorage Development Services Department Building Safety Division On Site Water and waste Water Program 4700 South Bragrw Street Anchorage, Alaska 99519-650 June 3, 2002 We are submitting an application for the installation of a well and septic system for this lot. The submittal consists of three (3) drawings showing the present improvements on the lot and the adjoining properties, (sheet 1/3), the proposed improvements of the lot, of which only the well and septic system is subject to this permit application, (sheet 2/3), and a schematic of the septic system, (sheet 3/3). Soil logs and percolation tests of applicable test holes are also enclosed. The septic system design is based on the following: Groundwater @ 6 feet. Use Standard Bed with BioCycle Soil Rating. From Test hole 09/20/00. I> minlin - 4 gal per sq.ft/day No. of Bedrooms 4 Required Area per Bedroom: 15014 = 37.50 sq.ft. Total area required: 37.5 x 4 - 150 sqft Minimum Bed Size 10 x 15 SYSTEM CONFIGURATION BIOCYCLE STANDARD 150 SQFT BED TOTAL LENGTH 15 FT TOTAL WIDTH 10 FT TOTAL DEPTH j FT ROCK DEPTH 0.5 FT COVER 3 FT The installation of this well and septic system will not prevent wells and septic systems from being installed on the adjacent lots. There are natural surface drainage courses on this and the adjacent lots. The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface runoff will not result from this Installation. so 0 50 Ix 150 ?007 250 X0 SCALE, 1' = 100 FT. TOBBEN SPURKLAND P.E. RANSOM RIDGE LOT 6 SEPTIC SYSTEM DESIGN 203 W 15TH. AVENUE DA TE.- JUNE 3, 2002 ANCH. AK. 99501 BEN MAY SHEET, • 1/3 GRID. 3337 /nn71 970_ TO f AC I PERMIT A SV02OXXX PID # YY RSR00061.DVG � I dx \ cA 0 VA TER \_ / � I I 25 0 25 50 75 !m \ 1 150 SCALES 1' = 50 FT. \ \ 1 1—Tt I OBB£N SPURKLAND P.C. I I RANSOM RIDGE LOT 6 I I SEPTIC SYSTEM DESIGN I 203 W 15TH. AVENUE DATE: JUNE 3, 2001 ANCH. AK. 99501 BEN MAY SHEET. 2/3 GRID: 3337 InATI gze_zme PERMIT N SV020XXX PID A YY RSR00062DVG \ ,pwvp i1} � I I 25 0 25 50 75 !m \ 1 150 SCALES 1' = 50 FT. \ \ 1 1—Tt I OBB£N SPURKLAND P.C. I I RANSOM RIDGE LOT 6 I I SEPTIC SYSTEM DESIGN I 203 W 15TH. AVENUE DATE: JUNE 3, 2001 ANCH. AK. 99501 BEN MAY SHEET. 2/3 GRID: 3337 InATI gze_zme PERMIT N SV020XXX PID A YY RSR00062DVG b FUNDDArnN aEav LT/7 4' MNITM ASTM 3031 GRADE TO MAN /SUPE FDVISIED GRADE AVAY aurarar r 6' NIN 1 F� �' BV ALL DIRECTDNS Z4' X4X BACK FILL �!-1/ PVC DISCHARGE _+ 1 �' PVC DfLLCNT 7 SEVER RLCK 10' TOTAL i NINNS — 0AERArMV CHWER b m CLARIFIER v m ® ®DISCHARGE CILWBER 15' ~ STANDARD BED rm7 L:- TAK HTS .... ............... ............�2' BLLEB! wv INSL"rmv INSTALLATION L EXCAVATE A 10' x 10'x By DECP AlE FCR BlXYaE SYSTLH P. PLACE A HINNKN CF I' SAND LR CRAM FCR LEVaAG CGI.RSE IN TFC BURN LT TIE EXCAVATRX CLWACT AS RCOUIREB 3 PLACE I SH?TS 6 e x D' x P' DIRECT MAL RIGID RMLATBN CN TIP DF CLIPACTED LEVELIAG COME TII PROTECT BOTTCN LF fZWRaASS TAAK. TAKE EXTRA CARE W ASSLRE THAT MUATILTV CCLRSE IS LEVEL IN ALL DIRECTIONS t BACKFILL ARaW TAW LP TO INVERT Or I' MLENT AND 1-1/I' EFFLLENT LAES VITH FREE-FLOVW AISi MTERIAL FREE X LARGE STCTES LR BaLMRS 15' A11L SAND/GRAVEL BACKFILL 7-y 1-1/I' EOE- - 40 PVCC V/ 1/S' - - - 30- IOP AAD 00170Y h O .................. ��11 49th......'s� •� •TDB EN •SPURKLAND•• TOBB£N SPURKLAND P.E.I I LOT 6 RANSOM RIDGE I I SEPTIC SYSTEM SHEMARC 203 W 15TH. AVENUE DATE: JUNE 3, 2002 ANCH. AX 99501 RANSOM RIDGE ROAD (907) 279-3916 BEN MAY SHEET 3/3 GR/0: 3337 P£RHIT # SVO20XXX PID # YY RSR000632I0 PERFORMED FOR: It" LEGAL DESCRIPTION: Lt Munlclrallty of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG - PERCOLATION TEST DATE PERFOR 7, Range, Section: SLOPE SITE PLAN 10 i WAS GROUND WATER ENCOUNTERED? 11 14AlaQ PAN IF YES, AT WHAT 12 DEPTH? Depth to Water Ater 13 Monitoring? 14 15 16- 17- 18- 19 6171819 . ■■■M■■■■ ■■■■■■■■■■ 20 Lj PERCOLATION RATE(minutevmcE) PERC HOLE DIAMETER TEST RUN BETWEEN yL F T AND —q_ F T DISCLAIMER• rrnundwater rnnditinns indirated are fnr the dates shown Only. Past and future presence and/or depth of groundwater can not be predicted rom tnese ci rva 1 n PERFORMED BY: 1--" —1 %, s CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIC ELINES IN EFFECT ON THIS DATE. DATE: • - ZZ -e*o 72-008 (Rev. 4/85) DP �H �fWr.'+ VT 1 /' 0 a6 Ni( -4. 2 U C' G r/�7ra✓tfu�LL� A•w(sC 3 P 4 F r e� r %%�il•L S , Soy �tp� 6 7 9 DATE PERFOR 7, Range, Section: SLOPE SITE PLAN 10 i WAS GROUND WATER ENCOUNTERED? 11 14AlaQ PAN IF YES, AT WHAT 12 DEPTH? Depth to Water Ater 13 Monitoring? 14 15 16- 17- 18- 19 6171819 . ■■■M■■■■ ■■■■■■■■■■ 20 Lj PERCOLATION RATE(minutevmcE) PERC HOLE DIAMETER TEST RUN BETWEEN yL F T AND —q_ F T DISCLAIMER• rrnundwater rnnditinns indirated are fnr the dates shown Only. Past and future presence and/or depth of groundwater can not be predicted rom tnese ci rva 1 n PERFORMED BY: 1--" —1 %, s CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIC ELINES IN EFFECT ON THIS DATE. DATE: • - ZZ -e*o 72-008 (Rev. 4/85) T14 MunlcIrallty of Anchorage 7. DEPARTMENT OF -iEALTH 6 HUMAN SERVICES 825'L" Street, Aechorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST PERFORMED FOR: �l-G_t_dr LEGAL DESCRIPTION: (�Township, Range, Section: T, Cff SLOPE SITE PLAN t � e 2- 3- 4- 5 3 4 5 6- 7 9 10 11 12 13 14 15 16 17 18 19 20 0a4AKICS ClrtAvj "JI, AawC Cr - Sa."'.x WAS GROUNDWATER ENCOUNTERED? S IF YES, AT WHAT O f L O DEPTH? P E Depth to Water Atter Monitoring? Oetr. PERCOLATION RATE Immutevmchl PERC HOLE DIAMETER TEST RUN BETWEEN FT AND FT DISCLAIMER• Grnundwater rnnditions indicated are for the dates shown only. Past and future presence and/or depth of groundwater can not be predicted rom these 0 serV�l ions. PERFORMED BY: i It _ 1 f S CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIE ELINES IN EFFECT ON THIS DATE. DATE: Y22/e0 72-008 (Rev. 4/85) r:,, y11 (ENGINE FR'S SEAL)' "t •, : ,V � j is r L' .. T." `✓`< «•O DATE PERFORMED: LEGAL DESCRIPTION: (�Township, Range, Section: T, Cff SLOPE SITE PLAN t � e 2- 3- 4- 5 3 4 5 6- 7 9 10 11 12 13 14 15 16 17 18 19 20 0a4AKICS ClrtAvj "JI, AawC Cr - Sa."'.x WAS GROUNDWATER ENCOUNTERED? S IF YES, AT WHAT O f L O DEPTH? P E Depth to Water Atter Monitoring? Oetr. PERCOLATION RATE Immutevmchl PERC HOLE DIAMETER TEST RUN BETWEEN FT AND FT DISCLAIMER• Grnundwater rnnditions indicated are for the dates shown only. Past and future presence and/or depth of groundwater can not be predicted rom these 0 serV�l ions. PERFORMED BY: i It _ 1 f S CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIE ELINES IN EFFECT ON THIS DATE. DATE: Y22/e0 72-008 (Rev. 4/85) To: On-site Water and Wastewater municipality of Anchorage 4700 South Bragaw Street Anchorage, AK 99519 -From- Ben A. -May & Gretchen Specht 4204 Garfield, A Anchorage, AK 99503 907-56941309 June 10, 2002 Re: excavation by owner/builder at Ransom Ridge, Lot 6 In talking to the staff at your desk I was told to give you notice that we intend to do the excavation ourselves at our building site. This is our intention as I have experience with operating backhoes and excavators. Our permit has been applied for by Tobben Spurkland on June 5th. Your department has been helpful in answering my questions and I appreciate the service your office provides. SigZ, Ben A.M aay Municipality of Anchorage *A. Development Services Department Building Safety Division On -Site Water and Wastewater Program4700 Bragaw Street P.O. Box 196630 Anchorage, AK 99519.6650 www.ci.anchomge.ak.us (907) 343-7904 PROPERTY OWNER AGREEMENT FOR THE MAINTENANCE OF AN ON-SITE WASTEWATER DISPOSAL SYSTEM This agreement, dated G, — 13 —o% . is made between the Municipality of Anchorage Development Services Department (DSD) and the property owner(s) of: 2A-n/.5oA�_ OL- 0 -C __r_L.0 — G This agreement is made for the purpose of maintaining an on-site wastewater disposal system on the subject property. The property owners agree to the following: Submit to the Municipality of Anchorage, on an annual basis, an inspection and operation statement from a registered professional engineer. This inspection and operation statement shall verify that the engineer has inspected all effluent and air pumps, timers, and alarms, and that any deficiencies have been repaired and that the system is functioning as designed. (Signature) (Signature) 13E►1/ A- _b6 A- `/ (Printed Name) (Printed Name) The Foregoing Ins ent was acknowledged before me by ;rt t tm1C on this � day of 20&-�_ Wi ess m seal. Pub ' ignature — (Notary's printed name) My Commission Expires / E 9