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Home My WebLink AboutASPEN HIGHLANDS #3 BLK 3 LT 10Aspen Highlands #3 Block 3 Lot 10 #017-013-76 Municipality of Anchorage Page I of .3 DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 all Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Sw iL 0373 O 170117 b Permit Number. PID Number. Nam: Wastewater System: O New Xupgrade A°°rei: 13ro/ rA)oote.r AorA. , AR_ ABSORPTION FIELD Phar. NO'g0 Uvr ' O Deep Trench O(Shsllow Trench O Bed O Mound O Other LEGAL DESCRIPTION Soil Plating: TdwDepth fremanp"% Permit No. 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 LegalDoscription: ~o~'/J?! J~3c~/_~, A3fEIJ 4~Z.H/,.A/JO$ ~'PIDNo.: I Permit No. SW 9L 0 373 Page 3 of 3 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 Legal Description: t4 ID, gioUL $, IQs/EN 14A91ANQS *�3 PID No.: 01701576 N • 1 ice- e4 � o c MdOd ! IM/� �L Pyr\�°�'.r e 1 No.! b •. 1a lo, , Gyj lo' • e � ,. 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 PAGE 1 OF ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW960373 DESIGN ENGINEER:ANDERSON ENGINEERING OWNER NAME:SAGAN ALEXANDER J & OWNER ADDRESS:13101 MIDORI DR ANCHORAGE, AK. 99516 DATE ISSUED:12/06/96 EXPIRATION DATE:12/06/97 PARCEL ID:01701376 LEGAL DESCRIPTION: AS~EN~HIGHLANDS #3,~BLK 3 LT 10 ~ LOT SIZE: 27886 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK 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 ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: ISSUED BY: DATE: November 19, 1996 Municipality of Anchorage Department of Heath & Human Services 825 "L" Street Anchorage, AK 99502-0650 Subject: Lot 10, Block 3, Aspen Highlands Subdivision, Unit No. 3 Septic System Design Impacts to Adjacent Properties Dear On Site Services Engineer: The absorption trench on the subject lot failed a recent adequacy test and must be replaced. We are proposing to place the new absorption trench at the location indicated on the attached site plan with a flow diverter at the old absorption trench for future use if required. Sufficient area is available on the lot for the new trench and no conflicts with existing wells in the area will occur. A percolation test completed on the soils in the new trench resulted in an absorption rate of 15 minutes per inch. We propose to place 4' of drainfield rock beneath the new distribution line and a total length of 75' of trench. The'ground surface slope in the area of the new trench is fairly flat and conducive to placement of the new absorption area. The existing septic tank will be replaced with a new 1,250 gallon tank to upgrade the system for a four bedroom home. If the system is constructed as designed the following statements can be made: 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. 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. Lot 10, Block 3, Aspen Highlands November 19, 1996 Page Two The system, if constructed as designed, will have no adverse impact on reserved space, either surface or subsurface, on any lots located in the area. The system, if constructed as designed, will have no adverse impact on drainage patterns in the area. The current drainage pattern will be maintained. Sincerely, Michael E. Anderson, P.E. Attachments LOT 10, BLOCK 3, ASPEN HIGHLANDS SUBDIVISION UNIT NO. 3 JOB SHEET NO.. CALCULATED BY CHECKED BY OF DATE DATE ~0{~uCi'~04.t W Se~) 2~5-t (~} ~e Inc.. 6mme. Ma~. 0147t. Te 0~e~ Ffl0NE ~- FRE 1 ~'~3e0 LOT 10, BLOCK 3, ASPEN HIGHLANDS SUBDIVISION UNIT NO. 3 PLACE NEW 1 , 2 5 0 GALLON SEPTIC TANK .............. AND 2 POST TANK CLEANOUTS ALONG WITH ZABEL DIVERTER VALVE. NOTE: SHEET NO OF, CALCULATED BY DATE CHECKED BY DATE SCALE SCALE 1" = 30' .............................................................. ~,,,'~i. ~."'"'"'~"/~i~'i:~i7.~¥~'""~ LOT 10, BLOCK 3, ASPEN HIGHLANDS SUB.. UNIT NO. 3 DESIGN FACTORS: SYSTEM REQUIREMENTS: Four Bedroom Home Perc. Rate: 15 Min./Inch Application Rate: .8 GPD/SF Wide Trench System New 1,250 Gallon Septic Tank 4' Gravel Beneath Dist. Line 4 Bedrooms X 150 GPD = 600 Gallons Per Day 600 GPD/.8 GPDISF = 750 SF / 5 SF/LF X .5 Red. Factor = 75 LF Total Length Therefore: Construct a Wide Trench System With One Lateral a Total Length of 75'. Lateral to Be Placed at'2' Below'Existing Ground Surface. Mound Over Trench a Minimum of 1' Above EXisting Ground. I _ Il NOTE: I TYPICAL WIDE TRENCH SECTION (NO SCALE) Minimum 3' Cover Over Trench. Grade Area Over Trench to Drain Away. (ENGINEER'S SEAL) Municipality ol Anchorage . ;} ~'"' %? DEPA.R..T..M, MET OF HEALTH & HUMAN SERVICES ~ -~ , },~ 825 I~ Street, Anchorage, Alaska 99502-0650 ; ~ , SOILS LOG -- PERCOLATION TEST "'~ '''~ r ' ~ ~ ~ ~ ~ '~/~ Township, Range, Section: 1 2 3 4 5 ~ 6 7 8 9 10 11 12 ;, 13 14 15 16 17 18 ~'T/OL. WAS GROUND WATER ENCOUNTERED? SLOPE J~oqTo ~,~ o~ IF YES, AT WHAT DEPTH? !~tlo~? SITE PLAN 0%- Gr°. Net Depth to Net R~gling Date Time Time Water Drop 'PERCO~.ATION RATE /~" (minutes/,nch) PERC HOLE DIAMETER ~)" TEST RUN BETWEEN ~' FT AND ~ FT ACcoRDANCE WITH ALL STATE AND MUNICIPAl- GUID~iNES IN EF ' PERFORMED IN 72-008 (Rev. 4/85) ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION AND MATERIAL SPECIFICATIONS SUBJECT: Lot 10, Block 3, Aspen Highlands Subdivision, Unit No. 3 GENERAL: 1. The scope of this project includes furnishing and installing a new 1,250 gallon septic tank. Work also includes abandoning the existing absorption trench by placing a diverter valve and constructing a new 75' long absorption trench with an effective gravel depth of 4'. 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 1. A new 1,250 gallon septic tank must be procured from an approved source and installed at the location shown on the Site Plan. Lot 10, Block 3, Aspen Highlands Subdivision November 19, 1996 Page Two 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 settling or shifting of the tank. bedded to prevent 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. Lot 10, Block 3, Aspen Highlands Subdivision November 19, 1996 Page Three 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. 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). Septic tank inlets and outlets shall be fitted watertight couplings (Caulder, Fernco, or equal). with Lot 10, Block 3, Aspen Highlands Subdivision November 19, 1996 Page Four 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: A minimum of two inspections are required by Municipal Ordinance. 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. 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 DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT ??731 [] UP*.ADE MAI LIN~ADDR ESS ' ~ ~Well ~ ~ , Absorption Dwelling ~ Z Manufacturer ~ ~~ / Mater,~ No. of compartment~ /~ ~ DiSTAN~ ~ ~~ Dwelling PERMIT NO ..................... ~ -- ~ Material ~ Liquid capacitv in gallons ,~ DISTANCE TO: ~~o'~s~l w,d~o ~( ~0 Total ef~i~a~ption area Q ~ inches Length ~~ ..... ~ ~th PERMIT NO. ~ ~ Type ~ Crib diameter Crib depth~ Total effective absorption area Well Building foundation ~ea/est lot line DISTANCE TO: ........ . .... C~~_~ ~ Depth Driller Distance to lot line PERMIT NO, ~ ~ DISTANCE ~: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE ~ ~ SOILTESTRA N) ~ ' REMARKS ~ ' 72-013 (f 78) ~ "~' i...I,!:.:: G :;,r' HI", i::lb,![) ","l.-fJ~:~ E C "."-.r'c H OF' 'T'H!i:~. E:::'::Cf:IVFYT :[ Cfi',! ,:: ): ?'.!-- ~:.:--~~.~ .... i!"' ~-...Ji ~.:~ii~: .... !!" ~:-:'? ,F:ii!: ~"..4i C':: ~-..ii 1~,.-..~ :':C F:"~ 'T" tF.,!! :,r/ ~::¥.;: ~~! ~?_'~_ '.'if,:::" E:i:!: El!.:.': '"F" THE: F!Hi::, THiS CONSTRUCTION TEST LAB "One Test is worth a~Thousand Opinions" 2204 Cleveland Anchorage, Alaska 99503 277-0231 Performed for Legal Description: This Fern reports: Joe Beason Lot 10 'Block 6 SOILS TEST yes Date Performed 10'/8~/7~9 Subdivision Aspin Highlands #3 PERCOLATION TEST yes Depth Feet Soil Characteristics 10" Reddish Silt Sandy Gravel Trace of Silt GW 6 1/2 ' Perc Zone Brown Sandy Silt ML with Occasional Gravel 16' Bottom of Test Hole '2' ! Was Ground Water Encountered If YES, What depth? No ~ I 8/6/~9 SaturationIPeriod I :" 8/7/79 I 0 Hrs. 7" 0 " " " 3.0 Hrs. } 3.5 Hrs 5" , " "" i 4.0 Hrs. 12.5" 1/2" Percolation Rate 1/60 ~4inute Proposed InStallation: SEEPAGE PIT DRAIN FIELD Depth of Inlet Depth to Bottom of Pit or Trench CO~4ENTS: 125 square fDet drainage area from '1' to 6.5 and 330 square feet drainage are~ ~om~6[~',to 16'~ Test Performed by i~'~i/' Data Certified By: Construction Test Lab ' ~- Pau'l ~ Date : 10/8/79 9 .��C� / ►� �irn�o�«- 1 b1� - .�P C..t�9asn,0V�l P 3 � 5 y� Ai coo lozp �r C b • Municipality of Anchora ,SRA On -Site Water and Wastewater Program (907) 343-7904 Certificate of On -Site Systems Approval Parcel I.D. 017-013-76 Expiration Date: S1 "7 — 1 1. GENERAL INFORMATION Complete legal description Aspen Highlands #3, Block 3, Lot 10 Location (site address) 13101 Midori Drive Anchorage, AK 99516 Current Property owner($) Ronald and Jane Peck Day phone Mailing address Real Estate Agent P.O. Box 113383 Anchorage, AK 99511 2. TYPE OF DWELLING: f_x� Single Family (wlwo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: Four Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well I] Individual Q Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request Received by - �� a `�, Date_ � COSA to be released to the, engineer, unless otherwise requested by the engineer. COSA Fee $ 6rA6. a) Waiver Fee $ _ Date. of Payment AN 11tt Date of Payment Receipt Number 6& 1`%4% Receipt Number COSA # 05 oq MP 5 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 Anderson Engineering Address P.O. Box 240773 Anchorage, AK 99524 Engineer's Printed Name Michael E. Anderson, P.E. 6. DSD SIGNATURE System #1 Approved for zi bedrooms System #2 Approved for bedrooms Disapproved Phone 522-7773 Date 1/29(2014 .?• 19th �•i' MICHAEL E. ANOERSON { O. CE -4381 -J = �CV _ — JA' ..i..ef l Conditional approval for bedrooms, with the following stipulations: By: ti /Y �� -e_--Original Certificate Date: The `Municipals of AriWf d6age Development Services Division (DSD) issues Certificates of Ort -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 CASA blue sheetf L� c 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: Aspen Highlands #3, Block 3, Lot 10 A. WELL DATA Well type Private If A, B, or C provide PWSID # Date completed 10/31/79 Sanitary seal (Y/N) Y Total depth 300 ft. Cased to 238 ft. FROM WELL LOG Date of test 10/31/79 Static water level 236 ft Well production 5-10 g P m WATER SAMPLE RESULTS: Coliform 0 colonies/100 mL Nitrate 8.40 mg/L Arsenic N/D ug/L Date of sample: 1/16/14 B. SEPTICIHOLDING TANK DATA Parcel ID: 017-013-76 Well Log (Y/N) Y Wires properly protected (YM) Y Casing height (above ground) >12 in. AT INSPECTION 1/27/14 227 ft. 4.1 9 - p.m -Collected by: Anderson Engineering Tank Type/Material Septic/Steel Date installed 12/15/96 Tank size 1,250 gal. Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (YIN) N Date of pumping 1/24/14 Pumper Around the Clock Pumping C. ABSORPTION FIELD DATA Date installed 12/15/96 Soil rating (9.p. d./ft2 or felbdrm) ' S 8 GPD/SF type 5' Wide System YP Length 75.5 ft. Width 5 ft. Gravel below pipe 4 ft. Total depth 8-9 ft. Eff. absorption area 755 ft2 Monitoring tube Y Depression over field N Date of adequacy test 1/27/14 Results (Pass/Fail) Pass For 4 bedrooms Fluid depth in absorption field before test 36 in. Water added 656 gal. New depth 42 in. Elapsed Time: 1,440 min. Final fluid depth 36 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 ofr level at in. Cycles tested E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot >100' Absorption field on lot >100' Public sewer main N/A Sewer /septic service line >25' Animal containment areas >50, SEPTIC/HOLDING TANK ON LOT TO: Manhole/Access (YIN) High water alarm level at in. Meets alarm & circuit requirements? On adjacent lots On adjacent lots >100' >100, Public sewer manhole/cleanout N/A Holding tank N/A Manure/animal excrete storage areas >100, Building foundation >51 Property line >51 Water main N/A Water service line >10' Wells on adjacent lots >100, ABSORPTION FIELD ON LOT TO: Property line >10' Building foundation >10' Water Service line _>10, _ Surface water >100 Curtain drain None Noted Wells on adjacent lots >100' F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through held inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineers Printed Name Michael E. Anderson, P.E. Date 1/29/2014 COSA brown sheet -1 0-10-1 2.doc Absorption field >51 Surface water >100' Water main N/A Driveway, parkinglvehide storage >10, 0 MICHAEL E. ANDERSON No. CE -4381 O Municipality of Anchorage Community Development Department f Development Services Division On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 Nitrate Advisory Certificate of On -Site Systems Approval # 141023 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 3, Lot 10 of Aspen Highlands #3 subdivision. This inspection revealed a nitrate concentration of 8.4 milligrams per liter (mg/L) was reported for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. 'AUG, 6.2002e 2;2TPMgrtrt :'FIRST AMERICAN TITLE 562 0540 X^" gv ° VZ!V, 328 s�P� 2�p� �, GRAVELVE� 4 A l a N SEMENT. ` — — 160A0' `-' LEGEND: :'� � � � �owar q•.9lti� s/a' sEaaR �q 4 YUTEIU i T ej� S LIC sc o tATMMML + EAGLE RIVER ENGINEERING SERVJCES ASSUILT SURVEY t•�o i.0. Boar 77J294 >/1s/ar 1��l 10421 VFW ctpfve OYKJER; NANCY GORE -agle Rhv, Alastra 8957 OESCRIPTICW:ASPEN HIGHIANRS 7) �►3 Nmvilm a)-•026 tis 31gs FAX ltrovl , �a7 4710 Ep 0CX 3 CICO Fla Nmns m-amm reby narwy that t have eur"Yed the felonriay dexrmed �orapn Raxrdtnq Prseinot, Alaska. and that no a eros FNC;HtAtIC8 jSi, LD1 to BL06 9 tA�6fi r1eGspondpllty Of tha a•,nar to datarm�a hfe'elatenea of fxf eft O0 lknuumte4 It, 'ittisnp Is +itkFl do net cppaer on the raoprded sub easam "ta. eevenonte, or data hereon ba•f4ed far b eon pia Under no etratmstanep s>•otrld esulateuotion eF (amts lino, or for —toblishtaq boundary Ones ■m W� Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program ; r 4700 South Bragaw St.. . P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.enchorage.ek.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY.DWELLING . dA- o/0373 : A. Parcel I.D. 01 % — D / 3— % (P HAA # Expiration Date: / O GENERAL INFORMATION Complete legal description j 0 Location (site address or directions) la I Q I 1 t ICED f t� Current Property owner(s)l 61 1 i P✓ a- �' IILI "_60_V1'6 Day phnone' c 7- Mailing address L2tnt Mi(IDf� �1d10(0.�i� "q�%5)(0 Lending agency Day phone " Mailing address Real Estate Agent Mailing Address u,;Zg 1 a s.>! �%,r,ltoraqe_, AK Unless otherwise requested, HAA will be held by DSD r pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well to Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ phone 5(pa -&glp4 TYPE OF WASTEWATER DISPOSAL: Individual On-site 10 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 State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results less than 30 days old. (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, shovrs chat 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 Eagle River Engineering Services Phone [PQ 95 Box 773294, Eagle River, AK 99577.3294 Address 2 Engineer's Printed Name( DQ i5 A• �c ✓a fir' Date S �•N71K N•NII••pj,• •J Y••.•.N.N N1.•N IY®l1 A. Butera 5. DSD SIGNATURE °4+ •ti Louis CE -6736 ' Approved for bedrooms. p • .... - y2�4 Disapproved. - - ttR"iilrrrit� �dtkP \Z Y OF 6. Conditional approval for bedrooms, with the following stipulalib�Q ,. • C' �.ZS 0 �ziW.•, ATE . WA�rrRAND o PROGRAM �/� !per _ .. • • �Ga".` Additional Comments I ' Note: i1 he well for this property meets existing State and rlunicipal Codes. There are nitrates present. It is suggested that periodic feeding hp Perfarme o4risure4he iye!6-e� itftmHtr' Current nitrate concentration is 5.49 mg/l. EPA maximum concentration is 10.0 m;/I. Vlore infor tatiOnOnliffint., 3 available from the On-Sitescrilecs Program,at -7904. Attachments: HAA Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineers Report Other__ By:C%�G? 7 „�,/��/ Original Certificate Date: -7 (Rev, MIN) Municipality of Anchorage • Development Services Department Budding Safety Division : • • r Orr -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196850 Anchorage, AK 995196650 www.ci.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: A�� ] Parcel ID: 01-1-015-740 A. WELL DATA Well type rime- If A, B, or C provide PWSID # Nlw Well Log (YIN) Y Date completed 4311-79 Sanitary seal (YIN) L_ Wires properly protected (Y/N) Totaldepth 5ft. Cased to ff. Casing height (above ground)"" IQ ln. FROM WELL LOG AT INSPECTION Date of test )��31�7q 7-Io-ot Static water level ft. 014,2 ft. Well production 5—IQ 9--p-m- 3.i g•p.m. WATER SAMPLE RESULTS: Coliformcolonies/1070 P'd Nitrate5=4n— mg.A. Other bacteria A61/ colonies/100 ml. Date of sample: Collected by: jj�k B. SEPTIC/HOLDING TANK DATA Tank Type/Material slrerorl Date installed Tank size fl.L gal.Number of Compartments Cleanouts (YIN) ��// 7 Foundation deanout (YIN) -]_ Depression over tank (YIN) J�- High water alarm (Y/N) VIA Dateof pumping 7 - / y- • Pumper 4wpA•r a c m oi•/ Pe ^� C. ABSORPTION FIELD DATA t Date installed I- CIISoil rating (g•p•d•/ft` or ftr/bdrm) .$ System type 5 W uz e, 4-l'P.IK' k Length 3�. S ft. Width Sr ft. Gravel below pipe + ft. Total depth -7 ft. Eff. absorption area755 ft° Monitoring tube -L— Depression over field MO Date of adequacy test 7 -r r - o J Results (Pass/Fail) Al', . For -�L bedrooms Fluid depth in absorption field before test7 rr in. Water added PaI gal. New depth L0 in. Elapsed Time: 3# min. Final fluid depth III_ in. Absorption rate >= 94 o g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) h) If yes, give date --- D. UFT STATION A) (� Date Installed 'Pump on' level at _ in. Datum i E. SEPARATION DISTANCES S In gallons Pump \level at _ in. Cycles testa& Manhole/Access (Y/N) High water alarm level at Meeh alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: 1 Septic tankAltt station on lot -1- lcor On adjacent lots _ 4 Its Absorption field on lot 4 IM 1 On adJacent kits - 4 IODu Public sewer main 0 A Sewer /septic service line t .% s" ' Public sewer manhole/deanout /014 Holding tank N A SEPARATION DISTANCES FROM SEPTIC/HQ6BfN&YANK ON LOT TO: t 1 Building foundation +- Property line + IO r Absorption field +5 r Water main + 101 Water service line t",* " Surface water + 100 Wells on adjacent lots } l QO SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line + IDI Building foundation + to' Water main + l 1 Water Service line tiv' Surface water 4 lQD u p + ( r Driveway, parking/vehicle storage o Curtain drain'Upai, t Wells on adjacent lots (� F. COMMENTS G. ENGINEER'S CERTIFICATION I cedlfy that I have determined through field inspections and i ' Ty✓I review of Municipal records that the above systems are in y Y49JJ1 conformance with MOA HAA guidelines in effect on this date.�'..', ..... Engineer's Printed Name LA L( (S Q.�✓ri s Lads euTiiia Date ""I—1 3—D I I e7>d .0 'e HAA Fee $_�� c�0 Date of Payment Receipt Number (Rev. 12100) Waiver Fee $ Date of Payment Receipt Number In. 7-r,W-w Parcel I.D. # 1. GENERAL INFORMATION Complete legal description Aspen Hi.qhlands #3 MUNICIPALITY OF ANCHORAGE ' DEPARTMENT OF HEALTH &'HUMAN SERVICES DiVisi°n of EnvirOnmental. SerVices · ', On-S te Services Section P.O. Box 196650 .Anchorage, Alaska ~-99519-6650 CERTIFICATE OF HEALTH AUTHORITY ' APPROVAL FOR A SINGLE FAMILY DWELLING' Lot 10, Block 3 Location (site address or directions) 11301Midori Drive, Anchorage Property owner Mailing address Lending agency Mailing address Agent Address Alexander Saqan & Gretchen Gunter Day phone 694-5195 msq 11301Midori Drive, Anchoragee, AK 99516 Premier Mortgage 3000 A Street, #102, Scott Christian Anchoraqe, Day phone 563-7736 AK 99503 Day phone ~7R-?nnl Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~ TYPE OF WATER SUPPLY: Individual well NOTE: TYPE OF WASTEWATER DISPOSAL: on-site Community well · . Public water "' -:'-~ ........ If community·well system; provide written confirmation from State ADEC attest- ing to the legality and status of system~' .:'- . · . ,;.,,,. ,~,.. If commUnity ~ attesting t° the legalit~~anc 72-025 (Rev, 1/91) Front MOA#21 . written· Confir~at)on' from- st~t~ ADEC-; system.'.'; 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I veri-fy 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 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 in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Eagle River Engineering Services ' Phone 694-5195 Address P.O. Box 773294, Eaqle River, AK 99577 Engineer's signature ~ Date DHHS SIGNATURE Approved for 4 Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional CommentsNote: The well for th~.~ property meet.~ ew~.~t~ng State and Municipal Codes. There are nitrates present. It is o,,e~ ~o~ ~ ~ericdic testing ~ performed ~ ~ ....... ~ ..... ~ · continued suitability. Nit.rate concentration is 5.07 mE/1. EPA By:"~:~' ~~ Date 2-~-~ 'The U~i~li~ of A~6rage Depa~ment of Health and Human Se~ices (DHHS)i~ues Health Authori~ APproval C~ificates, 5ased only upon the representations given in paragraph 5 above by an independent professional eng~p~r registered ~n the State of Alaska. The DHHS does this as a cou~esy to purchasem of homes and their lend~ng ~nst~tubons ~n order to ~t~s~ ce~mn federal and state requirements. Employes of DHHS do not condu~t inspections or analyze data before a ce~ificate is issued. The Municipali~ of Anchorage is not responsible for errom or omissions in the profe~ional engin~fs work. 724)25 (Rev. 1/91) Back MOAi~21 Legal Description: A. WELL DATA Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division .~.~.. 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 ~': Health Authority Approval Checklist /'//~/-/LH/J/--'~-~¢~ __~ Parcel I.D.: Well type /P~'/v~7'/.~. If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) y~5 Date completed /0/$//~ ? Total depth ~0C) / / Cased to ~..~ ~ Casing height (above ground) Sanitary seal (Y/N) ~'~'~ Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test ./0/3/ / 7~ ////5-//~' 6 Static water level ~ ~ i ,.~ q~: , Well production ~'-"' /0 g.p.m, z/'r o g.p.m. WATER SAMPLE RESULTS: Coliform / Nitrate Date of sample: /D-/.3. ~7/?& B. SEPTIC/I'I~L-BING TANK DATA ~ ~ Date installed /.3/5'~' Tank size /.~ cu Foundation cleanout (Y/N) /V Date of Pumping /v/,4'~,~,,~,) ,~", ~ ~ ~'~/~- Other bacteria Collected by: ~'~E~ ~) Number of Compartments =3. Cleanouts (Y/N) . Depression (Y/N) vt,/ High water alarm (Y/N) Pumper ABSORPTION FIELD DATA Date installed / ~"/ Length 7~-, ~- Width Effective absorption area Date of adequacy test /~/~'~ Fluid depth in absorption field before test (in.); Fluid depth ~ (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) Soil rating (g.p.d./fff or fF/bdrm) ~ ~' System type _5-t ~ Gravel thickness below pipe ~ Total depth Monitoring Tube present (Y/N) J/~-~ Depression over field (Y/N) }/0 Results (Pass/Fail)w~ ~ For 4/ bedrooms Immediately after gal. water added (in.): Absorption rate = .g.p.d. If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Si Date installed Size in ga~ Manhole/Access (Y/N) ~at* "Pump off" level at* High water alarm level at* / *Datum SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/hcldL~g tank on lot '~/~P Absorption field on lot /- Public sewer main /'~///~ ~/septic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIO/I-I~L=B~q'G TANK ON LOTTO: Foundation ~ / Property line ./-/z)" Absorption field ~-,.~' z .Water tacit/service line Surface water/drainage Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line /'-/0 / Building foundation ~-/~" Surface water ~/o,~ ~ Curtain drain _/~/~)b]~-~ /~/~/EEy(/7~ Water tach'r/service line Driveway, parking/vehicle storage area Wells on adjacent lots F. ENGINEER'S CERTIFICATION I certify that I have determined, thru field inspections and review in conformance with MOA HAA guidelines in effect on this date. Signature ~~ Engineer's Name ~.~UI.~ Date HAA Fee $ Date of Payment ///~ ~./~ Receipt N umber -.~,~/~~~~~. 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORSGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Property owner Mailing address Lending agency, Day phone Day phone Mailing address Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site 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. 72-025 (Rev. 1191) Front MOA #21 ~. ST,'3,T'E~'IE31T..,""-,- ]~ISP~_CT]C~,i 3Y --~tGiNEER o As certified by my seat affixed I~ereto and as of the validation date shown below, 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 further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, Ihe 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 //~(4~,~.)/~,.//-j,-,; ~ ~OrD-~r~..j-)b/o Phone Engineer's signature ~~'/~ ' ~ate /~-/ / / ' DHHS SIGNATURE ~i Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: Date 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. 72-025 (Rev, 1./91) Back MOA #2t e Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~)'~- //D, S/O0,~ ,~; . Parcel I.D,. WELL DA. }~:,TA/,,'1, .~',,/ Well type ~ If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) yp Date completed //~- ;~/-'7~ 'i~/_~ Cased to 2~' Total depth Sanitary seal (Y/N) Driller..-~lF'~/~ / Casing height ! Wires properly protected (Y/N) Date of test Static water level Well flow Pump level FROM WELL LOG U-lO g.p.m. AT INSPECTION SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot /(~/~' Absorption field on lot /~)~/~ Public sewer main Sewer service line ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank g.p.m. /OD' WATER SAMPLE R/~: Coliform 0 Nitrate Date of sample: Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed /~--'29 Cleano~t,$.(Y/N) Hig~,~ateFalarm (Y/N) Tank size /,, 00~) Compartments Foundation cleanout (Y/N) ~/~--,~ Depression (Y/N) / //~(~) Alarm tested (Y/N) /~]//~' Pumper,/~,/')L~h/~~. . . / Dat~ of pUmping /(_~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) On lOt To property line Surface water/drainage On adjacent lots /(~(~//' Foundation Absorption field /~(~ ~/'- Water main/service line 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed /~)~ 7C~ Length ~"~'"/-'// Width. Total absorption area. ~. Depression over field (Y/N) . Results (pass/fail) ?~ Peroxide treatment (past 12 months) (Y/N) Soil rating ,/~"~"~'-' Gravel thickness Cleanouts present (Y/N) Date of adequacy test System type Total depth ! bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Wellon lot /~)(~) To building foundation On adjacent lots Surface water ~70/~, Curtain drain /L)/~ On adjacent lots /~/'P Property line ~)~///- To existing or abandoned system on lot. Cutbank ~:~'/"J/- Water main/service line . Driveway, parking/vehicle storage area If yes, give date E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature Name-~/~,~~ _('~. ;~/~ HAA Fee $ Date of Payment / (~) '~,~'~ ~:~ Receipt Number ~-~"-'/-?~ Waiver Fee: $ Date of Payment Receipt Number 72-026 (Rev. 3/91) Back MOA 21 W n 5. LEGAL DESCRIPTION �aT o ��kfic DATE RECEIVED STREET LOCATIONM'b ' Tf�'9 6 C INSPECTION APP01 TMENTS o R 6. TYPE OF REWUENCw 'p NUMBER OFB ROOMS ❑ One ❑ Four ❑ Other TIM r 't J TIME TIME ❑ Two ❑ Five DATE D / DATE *ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) INSPECTOR .. - INSP CTOR INSPECT MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE DEPT. OF I :"ALT! I & DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTLIOIROfUf.ENVI: F,'."ICfION 825 L Street • Anchorage, Alaska 9MI`ENVIRONMENTAL SANITATION DIVISION APR L 1980 *�'�v Telephone 264-4720 D �� ((�� FF [[ jj)� REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEViv+ 1t91L i�3/ DIRECTIONS: Complete all parts on page . Incomplete requests will not be processed. Please allow ten (101 days for processing. ERTY_OWNERiO�C �7 E/4 ON ��DSD �/G /L d+O d, 1 / F2.8UYE PHONE TJYY RESIDENT (1f clferent from above P /V � B-. - - H NE R d - MAILING ADDRESS �. LEND IN1C,WSTITUTION' PHONE - 19 K 76-6 o d uRJTt AILING ADDRESS J 4. REAL R/AGENT EASa PHONE b o� MAILING , DRESS J� d 3D L7/ d RG T 5. LEGAL DESCRIPTION �aT o ��kfic Jv STREET LOCATIONM'b ' Tf�'9 6 C ` - / G f -S v E / E" R M A d o R 6. TYPE OF REWUENCw 'p NUMBER OFB ROOMS ❑ One ❑ Four ❑ Other SINGLE FAMILY ❑ Two ❑ Five ❑ MULTIPLE FAMILY ❑ Three ❑ Six 7. WATER SUPPLY S�'INDIVIDUALe *ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) 8. SEWAG� DIS/POSAL SYSTEM 19' INDIVIDUAL/ON-SITE" YEAR ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REOUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) 72010 (Rev. 6/79) THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER , ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL - ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMITNUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED Y" 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON -SITE ❑PUBLIC UTILITY Connection Verified ❑Septic Tank or ❑Holding Tank Size: -1 00 If Tank is homemade give dimensions: PERMIT NUMBER DATE INSTALLED %0 _Iti INSTALLER SOILS RATING 1 TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL T l �l-tiFA.1.� 4. DISTANCES WELL TO: Absorption Area to nearest Lot Line Septic/Holding Tank Absorpuon Area Sewer Line Nearest Lot Line 5. COMMENTS Cl— APPROVED FOR � BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE By r M"-) 72010 (Rev. 6/79)