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T12N R3W SEC 27 LT 48A
T12N R3W SEC 27 Lot 48A #018-092-66 Municipality of Anchorage Development Services Department \� Building Safety Division On -Site Water and Wastewater Program, 4700 South Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 Pagel of 6 www.cl.anchorege.ek.us (907) 3417904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number SWSWO50373 PID Number. 018-092-66 Nrrr Wastewater System: ❑ New ® Upgrade Address. w ABSORPTION FIELD Ph—. r ?L Nlwrbw CO Bstroam: '%� _ / 0 Dsap Trerch 0 stream Trrrh 0 Bed 0 Lw,d 0 Other LEGAL DESCRIPTION Sodfttka Total Depth bonargWCrude: Barn. La 48ARrgs Depen to pipe batpm from orfedrsf grade. Gravel defib brwm pipe Twp' seabrt Fill added abm oV.* Wade: Grave Large, Well: ❑ New® Upgrade Grove! td wm: Nwftw of Div,,,,,ve. DiDiv,,,,,bsb,,~fres classisraem (private. A B. C): Taal Dspev Cased b: ToW abowpbon area P" Materia: Draer Dare DaMd'. strk)walr Lew: M InNer Dale aWaeed' Yard: Pup Sar: Cube H* W Above G'o d 10 GPM 148 Ft. 1.5 Fl TANK SEPARATION DISTANCES ® Septic ❑ Holding ❑ S.T.E.P. 17 Other. To Septic. Absorption Lift Holding wicmitvate monwo rK. capacityFrom Tank Field Station Tank Sewer Line Anch Tank 1000aw Wed 139.4 121.1materr' ;Steel :: ; NunWraCrTadmWs 2 suface war 100+ 100+ ''''''' LIFTSTATION La Lar 25 11.8 Sao FA,xiat. 1 36 1 36 *P,.v orf level at: 'Pero ar level r: High wtr alarm at In In M C~ Drakr50+ 50+ Pup rake & mom V; .S Etecariw knaiearru wormed by: Remess: 2" Ri id Insulation over tank Field & Lines. ExIst'q BENCH MARK tank & crib crushed & Filled in place. Logan rad Slabm. Garage iab Assunrd Elavran: 392.0 FL Engineer's Stamp le ♦AV • Jam,.'y•. Inspections performed by: PES. LLC Dates: 1"11/6/2005 ? THe+� �.....h... 2"d11-6-05 .. ......... 0 Development Services De artmant approval .................. ........... . r I _ I Reviewed and approved by: Date: ♦ Steven R. Ponnonej aT �� s'• n]'�CE/ 8t49 ✓: (Rev. 77A0) I .I-, 1 1 •�.•�Y.�JIIO �.••''.••CI PERMIT NO: 050373 RECORD DRAWING P.I.D. NO: 016-092.66 WASTEWATER DISPOSAL SYSTEM LOT 48A T1 2N, R3W, S27 EXISTG UNDOCUMENTED SYSTEM -IN FAILURE ABANDONED IN PLACE EAST 138th AVE CO A B 384' C1 21.9 67.5 388' T1 28.0 71.5 2e T2 32.6 73.9 Dc 34.5 75.0 18.5 1 -8M2 yr H2 IN C2 36.2 48.4 11 d III Mi 36.6 48.9 III ddd III Ip C3 80.8 124.2 III III III M2 80.9 124.3 NEW UPGRADE SAS III III 0 II 5E TRENCH III EXISTG CRIB SYSTEM 90 LFx 3.03.0'' ED 6.0' T.D. lup 2 T7ABANDONED IN PLACE T 1 III '•��. CRUSHED 6. FILLED III C1 -, LOT UNDEVELOPED III `\� NO WELLS OR SEPTICS AL.,� EXISTG 1000g WAN 100 FEET 11,8 M ICp w` 1 °pj SEPTICTANK 20 CRUSHED 6. FILLED NEW 1.000g V,, EXIST'G38R SEPTIC TANK /� 20/ 8139.4 HOUSE FF ELEV=392.0' / NOTES: /47$1) All work shall ba performed in 121,1^ 4Q $Qaccordance with AMC15.65. 2) Materials used shaft be in accordance with those specified In 8 AMC15.65, Wastewater Disposal. 3% I 8 3) Maintain 10'separation to all lot I 30/c 8 I lines and water lines, unless noted otherwise. DESIGN CALCULATIO S: ' fl 4) Lots served byprivate water \ BEDROOMS: 3 $ \ systems. No wells within 100' of SOIL RATING:1"0 PI proposed system. APP RATE: 250 SF bl§TG WELL / 750 SF ROD D E ENED 8 \ 5) Existing crib will be excavated and - 5-WIDE TRENCH, 3.0' ED, 6' TD Inspected. If It is found usable, record '� RED'N FACTOR • 0.58 4b, drawings of its size will be devioped. 90 LF OF TRENCH `� \ IJ&SIZE TANM000g / 388' ��,�404 0 \'4r\ ,m N�.395' ....,• ,'m p.,,............ N ` �' �O G SAS EXIST'G SAS ,. 49 ^—' '. �i f EXIST I 0... .... r r r t- •••••one z r PREPARED FOR: PANNONE ENG. SVC .Steven R. Pannone ,LLC 1� •, i Dan 8 Susan Church 149 P. O. BOX 102954 Q � 13820 Davis Drive ��(tJ, ,.••''•�i� Anchorage, AK 99516 ANCHORAGE, ALASKA 99510 345.2406 -352 P. 72-8218 Fax ,' DATE: 5 s A. E 1•=50 PLAN PERMIT NO:SWO50373 RECORD DRAWING DETAILS P.I.D. NO: 018-092.66 WASTEWATER DISPOSAL SYSTEM LOT 48A Tl 2N, R3W, S27 R R 1110 NV3TJ a.. l..{: M3 Ho" iv aero tlOirgn :i irt�'f W a" ` o LU LLJ J ON3 Nava av LLI aeruuo mm IWNV313 "�+�' O ILL o N 13.. 1nom310 0 VIONY310 IL Z ��EOF .........., .♦�pi 1 0HY310 -jr TH mr i. �... .... ..........I....; 0 ..... ........ PREPARED FOR: PANNONE ENG. SVC, LLC ♦ ;Steven R. Pannone �� Dan &Susan Church P. O. BOX 102954 ♦���• 13820 Davis Drive •"�' Anchorage, AK 99516 ANCHORAGE, ALASKA 99510 �1,,,, 345-2406 DATE:227-35221-&05 2$218 Fax SCALE: NTS DETAILS SOILS LOG - PERCOLATION TEST .......... , PANNONE ENGINEERING SERVICES •'Cp; • ' "• P.O. BOX 102954 • 49 TN l^l •••••%; ANCHORAGE, AK 99510 �" • +•• .. ..........1.....� �............. S J ..� • (907) 272-8218 �s �. ;Steven R. Pannone •••• {pm PERFORMED FOR: Dan Church E 8149 DATE PERFORMED: 11-5.05 �� •'''•• , �� ��� LEGAL DESCRIPTION: LOT 48A. T1 2N R3W. S27 alk •'•••••• TEST HOLE 1 SLOPE TOPSOIL ear---- 7w fer 2 ML BROWN SILTS � TH2 NN , 3 N IN m N 4 N S TH1 IN I© I 6SM/ 1 GM 7 B Silty SAND to • `2 \�\ Silly Gravel / 91 10 o�E 1 48 \� f/47 1 „ 11 i �3% m �3% I 1 1 12 4 I � 13 \ WAS GROUND WATER SLOPE 11 ENCOUNTERED? N 75 IF YES. AT WHAT 18 DEPTH? �• TH 1 17 BOH DEPTH TO WATER AFTER MONITORING? -DRY - te DATE: 11.8-05 19 READING GATE CLOCK NET TIME WATER 20 TIME LEVEL NLT DROP PEROLATION RATE 25 fminAn I PERC HOLE DIAMETER 6Inches TEST RUN BETWEEN 7 FT AND 8 FT COMMENTS: Test hole excavated by AK Divers. Test Hole was presoaked before perc test PERFORMED BY: Steven R. Pannone P.E. I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDLINES IN EFFECT ON THE DATE OF THIS TEST. READING 17-Sa5 72:10 �� O fA' 0' 2 1]:70 ]0 MIN 1 75/10• 1 L/6' ] 17:70 —� T 0' 1 1210 ]O MIN I17/iT 1118' 0 17:10 � 01p' p 0 U:70 b MIN 6 7/76' 7 7116- SOILS LOG - PERCOLATION TEST �•P��`OF •♦ PANNONE ENGINEERING SERVICES •���,.• • •• P.O. BOX 102954 �1.i 49 TH •s r}♦j, ANCHORAGE, AK 99510 .•••••i ••• •••• ........... ••.i ..... � (907) 272-8218 v �...............• �°.Steven R. Pannone ..�= i PERFORMED FOR: Dan Church DATE PERFORMED: 11-5.05 ♦♦♦ �••.CTjC)/49j LEGAL DESCRIPTION: LOT 48A, T12N R9W, S27 ♦1♦,,, ;. '�• TEST HOLE 2 SLOPE SITE PUN Top Sol wr wn 1 OR----- .----------- .--------- .---------------------- r 2 %-1— ' w r TH2 Silty SAND It SMI GRAVEL H7 GM T 5 8 9 1 48 T\ 4/47 TEST 10 SPI Poorly graded SAND to Silly HOLE 1 DX 11 SM SAND I 3% 1 12 17 WAS GROUND WATER SLOPE 14 ENCOUNTERED? N 15 IF YES. AT WHAT TH 2 18 DEPTH? 17 M BOH DEPTH TO WATER AFTER ONITORING? DRY 18 DATE: 11.8-05 19 WATER 20 TIME PEROLATION RATE 16 (minAnehl PERC HOLE DIAMETER 6lnches TEST RUN BETWEEN 5 FT AND 6 FT COMMENTS: Test hole excavated by AK Divers. Test Hole was presoaked before perc test PERFORMED BY: Steven R. Pannone P.E. 1 CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDLINES IN EFFECT ON THE DATE OF THIS TEST. BLOCK READING DATE NET TIME LEVEL NET DROP READING 1 11.7-05 11:52 � 7P p• 2 12:02. 10 MIN 5't LS' � 1202 � 8' 0' � 12:12 5 12:72 10 MIN 5I' SW 0• 7 S 72:22 10 MIN FROM : PLPINE DRILLING F;N NO. : 907 345 0202 Nay. e6 2005 03:0MM Pi ALPINE DRILLING & ENTERPRISES Permit Number. *SUb Date of Itaoe: Parcel Identification Number: Data Started:11 7 -OS Date Computed: 114-05 Is well located at Approved permit locati=7 ® Yet ❑ No Legal Daoription: T 12N R 3W S 27 J& 4A6 Property Owner Name & Addrew Mark & Tammy Totten 138 th $t. Borehole Data: Depth (ft) Method of Drilling ®air rotary ❑cable tool Soil Type. Thkimc s & Water Smug From To — Casini nTx: lel exl&7ng weft 0 57 Wall Thickness: IN inches water send & grovel 57 59 Diameter. ¢ Inches Depth: §7 feet gravely at 59 106 Liner Type: ffiasl salty sand & walei 106 109 Diameter: j taches Depth:- 141 feet Casing stickup above ground: 15 feet silt 109 115 gravelly sr7t 115 127 Static water level (from, ground level): §feet moping kyd:l 9+ feet after siky welersand & gravel 127 130 2 hours pumping 12 "M gravely all, 130 145 Recovery Rate: 19 gpm watersand gravel 145 148 Method of Toting—.(jQ Well Intake Opening Type: ® Open End ❑ Open Hole ❑ Screeoed Stott feet Stopped feu ❑ PerforatIons Start feet Stopped __ fat Grout Type: benronite Trout Volume: Qg, Depth: Suet Q feet Stopped fiQ fat Pump: Intake Depth _ feu Pumo size ht) Brand Name Well Dialnfeeted Upon CompletiouT ® Yes ❑ No Method of Disinfection: chbime tablets Comments: well,e grwoed jr0m 010 601plus car grow war bulafled between the S and 6Inch casbtp mallet to follow the 5' catfngas It war driven. Well Driller. Alpine Dr>ing & Enterpriaea PO Box 110496 Anchorage AK 99511 Attention: The well driller shall provide a well kg to the property owner within 30 days of completion and the property • .... .. A. .II J.tI/...1.11 u..ti......11•.....t.n...1......�P....tr.. n...........L41. MUNICIPALITY OF ANCHORAGE �\ Development Services Department On -Site Water & Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: Sep 28, 2005 Expiration Date: Sep 28, 2006 Permit Number: SWO60373 Parcel ID: 018-092-66 Legal Description: T12N R3W SEC 27 SUBDIVISION LOT 48A Design Engineer: 0062 Pannone Engineering Services Site Address: 4440 E. 138TH AVE Owner Name: DAN & SUSAN CHURCH Lot Size: 49484 SO. FT. Owner Address: 13820 DAVIS STREET Total Bedrooms: 3 Permit Bedrooms: 3 ANCHORAGE. AK 99516 - This permit is for the construction of: ❑✓ Disposal Field 0 Septic Tank E] Holding Tank [:] Privy All construction must be In accordance with: 1. The attached approved design. Private Well [] Water Storage 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, seated, and heated to prevent freezing. l�/y/ate Ec��. r o�cooa3 u�d, o�p\.cca�l.oc. cos�(a� o�' Dd9 /4a Exp Received Bv. Dale: I? Issued By: W, ✓ " Date: Municipality of Anchorage • Development Services Department Building Safety Division - Onsite Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 ON-SITE SEWER/WELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. 018.09266 Permit Number SW O ,57'0 3 73 Property owner(s) Dan & Susan Church Day phone 345.2406 Mailing address (1)13820 Davis Road A 1 °taSlto Mailing address (2) Anchorage, AK Zip Code 99516 Legal description (Lot, Block & Sub'd.) Site Address: u U yo -G I ?V I1 a(1z, Legal description (Section, Township & Range) _ Lot 48A T11 2N. R3W. S27 Lot Size 49484 Acres/Sq.Ft. Number of Bedrooms 3 THIS APPLICATION IS FOR: Sewer Only ❑ Well Only ❑ Sewer and Well ❑ Water Storage ❑ Sewer Upgrade THIS PROPERTY CONTAINS: 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) Permit Fees: Date of Payment: Receipt Number. (Rev. 12=) Waiver Fees: Date of Payment: Receipt Number: 9I.MzLz (LOB) Pannone Engineering Services, LLC Consulting Engineers 907 272-8218 September 27, 2005 Municipality of Anchorage Development Services Department On -Site Water & Wastewater Program 4700 S. Bragaw Street P. O. Box 196650 Anchorage, Alaska 99519 Subject: Lot 48A, T12N R3W S27 Septic System Upgrade Permit Request Ladies and Gentlemen: P.O. Box 102954 .ge, Alaska, 99510 I am writing to request that a permit to construct an upgraded septic system be issued for this property. The proposed systems will serve an existing three-bedroom house. The existing crib was abandoned in place and an undocumented system is in failure. The existing 1000 -gallon septic tank will be inspected and replaced if necessary. The lot is served by a private water system. I. Soils. See the attached soils logs. Soils from the surrounding lots were gathered to determine the average of the soils in the area. The average percolation rate was 17 mpi, with ground water was measured at a depth of -6.5 feet below ground surface. Bedrock was not encountered in the test holes. It is my opinion that the overall soils appearance of the soils, an application rate of 0.45 gallons/day/square feet should be used using standard treatment system. 2. Trench Design. a. Percolation Rate: 30-60 Min Per Inch b. Application Rate: 0.45 gpdpsf c. Number of Bedrooms: 3 d. Design Flow: 450 gallons per day e. Min. Absorption Area: 1000 sf f. Total depth: 2.5 feet g. Effective Depth: 1.0 feet h. Width: 5 feet i. Reduction Factor: 0.87 j. Minimum Length: 174'feet k. Design Length: 187 feet I. Effective Absorption Area: 935 sf m. Septic Tank Size: 1000 gallon, If required Q\Work\Letters\48AT12N R3W S27.001.doc Cont'd on page 2 Page 2 3. Surface Water: There is no surface water within 100 feet of the proposed system. The proposed systems will maintain at least 100 feet from all surface water and drainage ditches. 4. Topography: The average topography in the area of the proposed septic system is approximately two to three percent in the area of the SAS. This permit request is at the request of your department so a conditional Health Authority Approval can be issued. The plan is to expose the old crib and ascertain its condition. If it is in a usable state, it will be completely exposed and its size documented and then reconnected to the house. Most likely an auxiliary lift vault will need to be installed after the septic tank since the tank appears to be lower than the old crib. If the old tank is failing, and the crib is usable, a new 1250 -gallon S.T.E.P. tank will be installed. If these option fail, this design will be installed. The proposed installation will not affect the future development of the surrounding or existing lots. There are no wells or septic systems within 100 feet of the proposed septic location. If you have any questions or concerns, please contact me at 227-3522 or 272-8218. Sincerely, "'' LS5a3i C:\WORK\LETTERS\48A T12N R3W S27.001.DOC .� OF " �.�p�........!al. 0 •. Steven R. Pannone, P.E. Civil Engineer .' 0•.....; i... • .r.. i........:..., �0 t .Steven Po nonea* Attachments: �1.�!�%_ No. CE 8149 '_ "'' LS5a3i C:\WORK\LETTERS\48A T12N R3W S27.001.DOC PERMIT NO: DESIGN DRAWING P.I.D. NO: 018-092.66 WASTEWATER DISPOSAL SYSTEM LOT 48A T1 2N, R3W, S27 EXISTG LIND SYSTEM IN FAILURE 'tl ABAND N IN PLACE lbI 384' \\— 388' 51.1 2% 22.0 F-- )I I Ill III p1 ill III II 2% III III I I EXISTG CRIB SYSTEM PROPOSED UPGRADE SAS I ABANDONED IN PLACE 5 -WIDE TRENCH, 87 LFx 3' ED I ��I III \ ATTEMPT TO REUSE 6' T.D. III III 22.5 EXISTG 10009 LOT UNDEVELOPED III-- 2.6 20 SEPTIC TANK NO WELLS OR SEPTICS I / t �� \ VERIFY INTEGRITY WAN 100 FEET PROPOSED UPGRADE EXISTG 3 BR �� HOUSE 1.000g SEPTIC TANK o / 2 �0 122.5 e FF ELEV=392.0' / NOTES: \ If 1) All work shag be performed In 4 accordance with AMC15.65. IF 108.8 ' \ $/ 47 2) Materials used shag be In accordance with Besse specified in I AMC15.65, Wastewater Disposal. g' 3% 8 3) Maintain 10'separation to an lot I 3"/0 8 I lines and water lines, unless noted otherwise. ' S EXISTG 4) Lots served by community water WELL 8\ systems. No wells within 200' of fb proposed system. \ 4 \ DESIGN CALCULA NS: ' BEDROOMS:3 b SOIL RATING:15-30 MPI'4 388' �'� APP RATE: 250 SFIBR (0.6 044441 rca\ / • 395' GPDPSF)750 SF ROD ..�Q,� . ,,,,�1� r� 1WASSUME WATER 5 -WIDE TRENCH. 33' D F'� 'V TM ;. A0, G SAS I /-EXISTG SAS I R.F. = O. r TG 87 LF OF � g 0. MIN SI AN009 1- •••••••••• j�•� PREPARED FOR: R. Pannone Dan d Susan Church \?� E 13820 Davis Drive �� Anchorage. AK 99516 "'•••••"�4Y_�� 345.2406 PANNONE ENG. SVC, LLC P. O. BOX 102954 ANCHORAGE, ALASKA 99510 227-3522 P, 272-8218 Fax ATE: 9.22-05 PLAN PERMIT NO: DESIGN DRAWING DETAILS P.I.D. NO: 018-092-66 WASTEWATER DISPOSAL SYSTEM LOT 48A Tl 2N, R3W, S27 a.,.r�_7 orr3 rave av Gena uoanow P`ri;a,Fl to (I%i7 O ti O A.':".,-6 J w z U g, W wnrgva av a s a l 1 e JIIO nV31� t Ol uwrano w Q �� ano nvno TH �... ..i.....0 • 0 • PREPARED FOR: 1Steven R. Pannone PANNONE ENG. SVC, LLC �# . Dan a Susan Church P. O. BOX 102954 CF�^81 ,5. 13920 Davis Drive ANCHORAGE, ALASKA 99510 ' .{ `D i Anchors a AK 99516 01''..�. 3452406 DATE$529 19-05 2$218 F8X SCALE: NTS DETAILS U PERMIT NO: DESIGN DRAWING DETAILS P.I.D. NO: 018-0926 WASTEWATER DISPOSAL SYSTEM LOT 48A Tl 2N, R3W, S27 EAST -138th AVE nK.np. roc.i�w nK.rY. YMryL�• IAC.rM M4n�ryltlJ nK.iM F�R�ni�.p 21A THIS PROJEaT28A Fan�rruJ vsn�r�u.p F.ru rr�.p an�ui�as 23 24 25 26 27 EAST -138th AVE Tm R Pannone Fj DE ARMOUN ROAD Dan & Susan Church 13820 Davis Drive Anchorage, AK 99516 345.2406 PANNONE ENG. SVC, LLC P. O. BOX 102954 ANCHORAGE, ALASKA 99510 227-3522 P. 272-8218 Fax ATE: 9-16-0s VACINITY :ALE: 1- i 200' nK.np. roc.i�w Fan�rruJ vsn�r�u.p F.ru rr�.p an�ui�as 448 52 51 50 49 47 18 !L� �C 45 Q 14A O 1.6 nK�M nK•1V, nK.Mp, nK.iM YYn1111i�AF ynn111y1�.p F�1, 11rr�m F�n11rr�.p Cl)' , 61 53 54 BOA Q 55 56 57 58 69 C)I 81A1 Tm R Pannone Fj DE ARMOUN ROAD Dan & Susan Church 13820 Davis Drive Anchorage, AK 99516 345.2406 PANNONE ENG. SVC, LLC P. O. BOX 102954 ANCHORAGE, ALASKA 99510 227-3522 P. 272-8218 Fax ATE: 9-16-0s VACINITY :ALE: 1- i 200' FROM : P"ONE ENG SVC I j .I 1 1 PHONE NO. : 272 8218 j I I i ' I l l; i l► l i i! f► 1; � i i � I j I! ' ' i I ► I i ��jl ! �I►��;II I ;�fll�►! I Il,i j I i I I I 5 i i r i I i ' I l l; i l► l i i! f► 1; � i i � I j I! ' ' i I ► I i ��jl ! �I►��;II ;�fll�►! Il,i i I I I 5 i i r i _OCATION OF WELL (Please complete either lo, Ib or lc.) o. Borough Subdivision Loot Block Ib. t/4 gtrs. h l 48 1 _of_of_of — ic. DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS Street Address and Area of Well Location WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological a Geophysical Surveys Drilling Permit No. A.D.L. No. Section No. Township No Range En M®ridion 27 ri s p�(i� w 3. OWNER OF WELL: -_ Address. Feet Below 2. WELL LOG Surface Material Type Top Bottom boulders @ 6' gravely 0 12 and pan w/cobbles & bouider 12 39 lenses H2O in cemented gravel 45 57 and hardpan 5 gpm @ 501 to 57' 4. WELL DEPTH: (final) ( 5. DATE OF COMPLETION �! ft. 6. C] Cable tool-QDtotary C:] Driven n Dug 11 Auger O Jetted [3 Bored [3 Other: 7.USEX�Domestic 0 Public Supply 0 Industry F] irrigation 0 Recharge 0 Commerical p Test Well p Other: 8. CASING: 0 Threaded x:a Welded diam. in. to__,90_ ft. Depth Weight tbs./ft. diam. in. to ft. Depth Stickup ft. 9. FINISH OF WELL: --- Type: Diometert Slot/Mesh Size: Length: Set between ft. and ft. Backfilling Gravel pock 10. STATIC WATER LEVEL: 14 ft. Above or )(0 Below land surface Date Equipment used: II . PUMPING LEVEL below land surface and YIELD it. after Ara. pumping _ 9-P. M. ft. after hrs. pumping g.p.m. 12.GROUTING Well Grouted: 0 Yes Ea�No Material: El Neat Cement 0 Other: c 13. PUMP: (it available) HP Cn Gill m Length of Drop Pipe 545e m capacity g.p.m. Cn r- unicipality ct A not aYID Subm. [3 Jet E) Centrificol Other 0 Crept. Healln a 14. REMARKS: i 16. WATER WELL CONTRACTORS CERTIFICATION: 15. Wafer Temperature a This well was drilled unser my jurisdiction and this report is true to the best of my knowledge and belief; Alaska -Now -`Nell -Vern' s Drilling & Ent AA3327 Registered Business Name Contract License Number Address: SQA R x 1560 Anchorage Alaska 99507 SS Signed : rS �� Date: Authorized Repre entative Form 02-'WWR (11/81) Copy Distribution: WHITE -State DGGS, PINK -Driller, CANARY -Customer F 11 C ` K, -0 L-5 11 �f����� Ulu E07 ���� ���� DEPARTMENT L. HEALTH AND ENVIRONMENTAL rmOTECTION 825 'L' STREET, ANCHORAGE, HK. 99501 264-4720 PERMIT NO. ( 830974 ) APPLICANT JACK L DEES POB 10308 ANCHORAGE 99511 552-4015 LOCATION SINGLE FAMILY DWELLING LEGAL T12NR3W S.27 L48 LOT SIZE 999999 SQUARE FEET i`iINIMUM DISTANCE BETWEEN H WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR H PRIVATE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL MINIMUM DISTANCE FROM H PRIVATE WELL TO H PRIVATE SEWER LINE IS 25 FEET AND TO H COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION. `OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. ��Tit �I -TT ��U--' T FR E� "T E> E= ED E= V1 ED E= F? ��0 AL 02 53 _1:�: I CERTIFY THAT i: I HM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. ISSUED BY . .. . ........ ....... DATE ---- 9-Q6 Y4.0 ��������� �W��~���������� ���� ��������� ^xx��.�"�"^ "`=�""="^°^=� ""'"�"^ =="^~"~°="" Department of Environmental Quality 333UCStreet Anchorage, Alaska 9Q503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM SEPTIC TANK: DISTANCE NUMBER OF FROM WELL _______MANUFACTURER MATERIAL CQMP*RTrNENTS______. INSIDE LENGTH _______ INSIDE WIDTH ______- LIQUID DEPTH —LIQUID CAPACITY GALLONS. NUMBER oFPITS _____. L|m}mG MATERIAL BUILDING FOUNDATION— ADDITIONAL ABSOnpT|ON LTAAW DIAMETER —OR Vv|oTH___. LsmGT*__'' DEpTH _-_Cn/8 SIZE: D|8METEn___DEPT*___-DISTANCE FROM: TOTAL EFFECTIVE _. NEAREST LOT L|NEABSORPTION AREA (WALL AREA) Tvps comsTnocT0m BUILDING NEAREST FOumoAT|om_____-. LOT ums_____- CESSPooL________. OTHER SOURCES - APPROVED _______D|S*PPROVED____ o|sramcE6: INSTALLED BY: PIPE MATERIAL: LOT SLOPE: . REMARKS: NEAREST . SEWER LINE nExx*nx5 WELL ospTn DISTANCE FROM: ssPT|c 5Espaas T*mK_____'. SYSTEM . DIAGRAM OFSYSTEM -� .�'RE,A; 'R ANCHORAGE EA BOFti H �` P J DEPARTMENT OF ENVIRONMENTAL QUALITY I� �(� 0 n ^330 ••C•• STREET ANCHORAGE, ALASKA 99503 � LA -4, 1 i��TEL 274-4561 J - �'PL +• ��'�k[O NKA ~', ��� � • � 1 76 SEWAGE DISPOSAL SYSTEM - APPLICATION AND PERMIT, NAME OF APPLICANT C � ` /' MAILING ADDRESSAT / eF jZjy /yam P'ONE ,� � 36 % INSTALLATION LOCATION,(y Ly' LEGAL DESCRIPTION /r 7 INSTALLATION OF: SEPTIC TANK i/ SEEPAGE PIT DRAIN FIELD OTHERy�Vc��"( TYPE AND SIZE OF FACILITY TO BE SERVED FINANCED THROUGH // TO 13E INSTALLED BY solL TEST RESULTS%8�CNC� dJr s!w �� S���CSE / NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST COMPLETION DATE ANTICIPATED FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEPTIC TANK SIZE TYPE �� 4�SEEPAGE AREA SIZE /r TYPE p a:�/✓� MINIMUM DISTANCES, REQUIREMENTS FOUNDATION TO SEPTIC TANK �5 rJ�- FOUNDATION TO SEEPAGE PIT DRAIN FIELD SEPTIC TANK TO SEEPAGE PIT WALL SEPTIC TANK SEEPAGE PIT �� DRAIN FIELD ®` L TO NEAREST LOT LINE. l WELL TO SEPTIC TANKSEEPAGE PIT f DRAIN FIELD —! �'Z'1 ALSO CONSIDER AREA WELLS. WATER MAIN TO SEPTIC TANK / SEEPAGE PIT DRAIN FIELD % SEPTIC TANK,�.5� i SEEPAGE PIT DRAIN FIELD —, TO RIVER, LAKE, STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS. S'C ,/ � �yV_ Ir �c'qi✓; �>� l GRAVEL BACKFILL � - iL. CONFORM To BOROUGH REGULATIONS REGARDING INSTALLATION. / G.A.A.B. OR LICENSED DESIGNER DIAGRAM OF SYSTEM 1 CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 26-68 AND THAT THE ABOVE DESCRIBE/,z EM IS IN ACCORDANCE WITH SAID CODE. DATE T APPLICANT'S SIGNATURE FOR NO. EQ- 1 6 � � Performed for LugJl Description: This form reports:- 50i Uepth GREATER ANCHUK8CL XRL8 *]RUULu, Department of Environmental Quality 3330 xC" Street Anchorage, Alaska 99b03 S011,S LOG - YFDO[AT{O0ICSI _ s Percolation 5uz ' *°/;K S^U " 2- S'O i Sc,- S C r I '^T - 10 17 5 W- C_ LJ ]0 /[»5- }3 - | 14 -- Was. ground water encountered? AID ---If ves, at wiiat depth? Readi ng Date Gross Time Net Time Depth to Water Net Orop ParcO|8t10D rate mlnute, -Proposed -installation: 3ecTage Pit Drain Field Depth of Inlet Depth to bottom of pit or trencti COMIENTS: f-9-' Certified By: jate: FU -040 (S/74) / A,1 epLft/I MUNICIPALITY O F ANCHORAGE Development Services Department ', Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On-Site Systems Approval �y q Parcel I.D. 018-092-66 Expiration Date: "1 --- I ` " � l 1. GENERAL INFORMATION Complete legal description T12N R3W SEC27 L48A Location (site address) 4440 E 138TH AVE Current property owner(s) Mark Sc Tammy Thelen Day phone Mailing address Same Real estate agent Day phone 2. TYPE OF DWELLING: 0 Single Family(w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well Private Septic Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer,unless otherwise requested by the engineer. COSA Fee $ En6/0-//9 Waiver Fee $ Date of Payment Date of Payment Receipt Number Receipt Number COSA# 0'5CO1aya- 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. In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA COSA guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition,ground water levels that may fluctuate during the year,and the water usage of the family being served by the system. These conditions are outside the control of the evaluator cf this system.All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments.Therefore we cannot provide any warranty for future performance, nor can we estimate remaining life of the system.The content of this report is for the sole benefit of the owner listed above. Name of Firm Pannone Engineering Services Phone (907) 745-8200 Address P.O. Box 1807 Palmer, AK 99645 Engineer's Printed Name Steven R. Pannone P.E. Date /9'696 /9-- 6. DSD SIGNATURE *149....• t ; System#1 Approved for S bedrooms -!•anrione System #2 Approved for bedrooms ;4•• (E 8149 .: Disapproved ''AItOIN• Conditional approval for bedrooms, with the following stipulations: \\\�1/4. .sr(ttOF rrr(cj/rj( ON-SITE WA1tR AND WASTEWATFR oz PROGRAM Jam' '�SER G\\\" By: �-- (�E Original Certificate Date: (p'/ 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: T12N R3W SEC27 L48A Parcel ID: 018-092-66 If more than 1 septic system on lot: COSA Checklist# of Structure served by this system 1 A. WELL DATA ❑Well log is filed with Onsite (or attached) Well production at time of test 3.89 gpm Date drilled 1118/05 Water storage tank volume N/A gallons Total depth 148 ft Well disinfected for coliform test? ❑Yes 0 No Cased to 148 ft j Coliform bacteria is Negative E=I Sanitary seal is functioning correctly Nitrate 2.62 mg/L ❑ Nitrate less than MRL(ND) Wires are properly protec i,\ Arsenic ug/L 0 Arsenic less than MRL(ND) Casing height(above ground) in. Collected by Pannone Engineering Date of flow test for COSA 6/4/2019 Date of Sample 6/4/2079 Static water level at beginning of test 78.8 ft. Comments B. TANK DATA C. LIFT STATION Age of tank(s) 14 years ❑ Required maintenance completed Tank type/material ''s1i1 Age of lift station years Measured operating fluid level in septic tank 48,. Lift station material . 0 Standpipes/foundation cleanout per record drawing Comments: Date of pumping D. ABSORPTION FIELD DATA Shallow Trench Which system tested (date installed) 11/6/05 Adequacy test date 6/4!2019 ❑Q ALL standpipes present per record drawing Results ['Pass For 3 bedrooms Total measured depth from grade 7 ft(max) Fluid depth prior to test 0/16 in Measured depth to pipe invert from grade 4 ft(min) Water added 450 gal ❑ N/A—pressurized field 0/16 New depth in Monitor tubes go to bottom of effective. If not, state Elapsed time 120 min depth into effective 2.0. ■❑ Final fluid depth 0/16 in Code-required soil cover over field Absorption rate >450 gpd ❑System presoaked (Required if vacant for greater than 30 days prior to Any rejuvenation treatment(past 12 months) n/a date of test) If yes, enter date Gallons introduced gallons Comments/Deficiencies: COSA Checklist yellow sheet E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot> 100' Community Sewer Manhole/Cleanout> 100' Q Yes if No ft 0 Yes if No ft Neighboring Tank> 100' 0 Yes if No ft Private Sewer/Septic Line >25'Q Yes if No ft Absorption Field on Lot> 100' 0 Yes if No ft Holding Tank> 100' 0 Yes if No ft Neighboring Absorption Fields> 100' Animal Containment> 50' Q Yes if No ft -✓ Yes if No ft Manure/Animal Excreta Storage> 100' Community Sewer Main > 75' p✓ Yes if No ft ril 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' I Yes if No ft Private Wells> 100' 0✓ Yes if No ft Water Main> 10' 0 Yes if No ft Community Wells>200' ✓❑ 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' ✓Q 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' D✓ Yes if No ft Water Service Line> 10' 0 Yes if No ft Community Wells>200' E✓ Yes if No ft Surface Water> 100' [J Yes if No ft , F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION ��OF Atis411} 8 1 certify that I have determined through field inspections and review ''��. _. .'Y of Municipal records that the above systems are in conformance with `* 49 Tl l ,tr�• � MOA COSA guidelines in effect on this date. /J j Ste":en ^ Poni'.00 �d 4 /, 81. 3 1{ter ' ?:i......:: •. r. -• ,;;. COSA Checklist yellow sheet 8483H E. 138th Avenue c> o co co N89°51'54"E 165.03 .0 • I' II Illit 1 O '� r Ret.wall(typ) • m ISeptic vent gyp)- I J . ..•o Asphalt I7✓ ti Oi I 32.0 0 t co tV W N I 10.0 6.5 23.7 34.3 N 1' o I( �. N. I g�,� ' 1 Story Frame House M ij F. s l' SCALE: 1"=50' I � t co� 1_ 48.9-: L 42.0 23.7 �I Lo 1 0 O o till • `.. Z emt,A.0\it e 1 Well LOT 47 • OF '• 'j. LOT 49 'e S„a.t_ o '• Q�� i Patio ,0,...'49} •.9 0 ' LOT 48A ;�..i;�s�,. ' Zflrj��z�C 1 i ^ •€fizobeth L. Wclatkc:1 or, i • od /+sl� 8036-LS •yea, 4+'e ••• •• •••.•oS f ROF5s ow.'_ ' , I®0\\N.',�o & f4 -- t9 _10' lltilit ._EasementAs-BUILT NO CORNERS SET THIS DATE N 89°50'27"E 165.00 I hereby certify that I have performed a Mortgagee's inspection of the following described property: LOT 48A, LOT 57A I SECTION 27, T12N,R3W,S.M. AK _ I I Anchorage Recording Precinct.Alaska,and that the improvements situated thereon are within the property lines and do not overlap or encroach on the property lying adjacent thereto,that no improvements on the property tying adjacent thereto encroach on the premises in question and that there are no roadways,transmission lines or other visible easements on said property except as indicated hereon. Dated at Anchorage.Alaska EASEMENTS OF RECORD,OTHER THAN I this 10th day of JUNE .2019. THOSE SHOWN ON THE RECORDED FRED WALATKA 3 ASSOCIATES,L.L.C. PLAT ARE NOT SHOWN HEREON. Engineers and Surveyors UNLESS OTHERWISE NOTED REJ, FB 19-5, pg 10-12 BE 907-248-1666 `A71 Municipality of Anchorage Development Services Department Building Safety Division Onsite Water and Wastewater Program 4700 South Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 018-092-66 1. GENERAL INFORMATION 4k HAA # IIA -ON -041(o Expiration Date: 71//0(, Complete legal description T12N R3W Section 27 Lot 48# Location (site address or directions) 4440 East 138"' Avenue, Anchorage, AK Current Property owner(s) Mark & Tammy Thelan Day phone 349-5024 Mailing address 4440 East 138"' Ave.. Anchorane, AK 99516 Lending agency Day phone Mailing address Real Estate Agent Becki Powell 0 ReMax Day phone 244-5881 Mailing Address Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by: 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual On-site Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ 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) on properties served by a single family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to home owners. 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 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 engineers work. (Rw nes) 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, 1 verify that my investigation based on procedures outlined in the Health Authority Approval Guidelines for 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 applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm _Pannone Eno. Svc. Phone 272-8218 Address P.O. Box 102954, Anch, AK 99510 Engineer's Printed Name Steven R. Pannone, P.E. Date 70/O.5— Engineers Comments: In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MOA DSD Guidelines & Regulations. The reported results describe the performance of the system under the conditions encountered at the time of i the test, and separation distances measured to readily identifiable features. nc operational life of all i wells and septic systems depend on the local soil condition, ground water levels that may fluctuate i {t during the year, and the water usage of the family being served by the system. 7tmese conditions are i outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results ••• 0 do not guarantee future perfommance of the system, nor do they guarantee that there arc no hidden dcf or encroachments. PES can therefore not provide any warranty for future performance nor give any estimate of how long the system will continue to meet the operational requirements of the ADEC or 0 C) MOA DSD. 71e content of this report is for the sole benefit of the owner listed above. Any reliance upon #1 or use of this report by any other person or party is not authorized nor will it confer any legal right whatsoever. 6. DSD SIGNATURE Approved for 3 bedrooms. Disapproved. ren R. Pannone! No. CE 8149 ............. ����� Conditional approval for bedrooms, with the following stipulations: Attachments: HAA Checklist Septic System Advisory Well Flow Advisory By: Expirat n Date: -71, 10 � (R«. 11W) X Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: f 17211-r Reissue Date: Municipality of Anchorage • Development Services Department Building Safety Division OnSfte Water and Wastewater Program S 4700 South Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.a.anchorage.sk.us (907) 3437904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: T12N RSW Section 27 Lot 481: Parcel I.D.: 018-09266 A. WELL DATA Well type i Date completed 11/812005 Total depth _10_ft If A, B, or C provide PWSID * Sanitary seal X Cased to -19—ft FROM WELL LOG Data of test 1118/2005 Static water level 131 ft Well production 10 g.p.m WAT=R SAPifUrT$y��- Coliform _9_colonies//100jjml Nitrate 1.37 mg/l Date of sample: 11MD1005 Collected by: LRP B. SEPTICfHOLDING TANK DATA Tank Type/Material _Anchorsae Tank Steel Well Log X Wires property protected Y Casing height (above ground) —11+ --in. AT INSPECTION 11/812005 81 ft 10 g.p.m d11 Other bacteria __L colonies/100 ml Arsenic NIA mg/1 Date installed y/6noos Tank size 1000 gal Number of Compartments I Cleanouts Y Foundation cleanout X Depression over tank ly High water alarm IIIA C. ABSORPTION FIELD DATA Date installed 11/812005 Soil rating (g.p.d./fl? or fe/bdrm) 2& System type Shallow Trench Length j( ft Wkdth _§_ ft Gravel below pipe 3 ft Total depth It Effective absorption area my Monitoring tube y Depression over field JL Date of adequacy test 111d d Results (Pass/Fall) Pass For I bedrooms Fluid depth in absorption field before test Water added= gal. New depth=n Elapsed Time: = resin Final fluid depth =in Absorption rate Q.p.d Any rejuvenation treatment (past 12 mo.) (YIN 8 type) I If yes, give date (Rev. 11M) D. LIFT STATION Date installed 'Pump on" level at _ in'F Datum E. SEPARATION DISTANCES size in 0 JU SEPARATION DISTANCES FROM WELL ON LOT TO: Manhole/Axess High water alarm level at _ in Mee rn 6 circuit requirements? . SeptictankAiR station on krt 100+ On adjacent lots 100+ Absorption field on lot 100+ On adjacent lots 100+ Public sewer main 100+ Public sewer manhole/deanout 100+ Sewer /septic service One 60+ Holding tank 100+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 25+ Property line 10+ Absorption field_ 10+ Water main 100+ Water service One 60+ Surface water 100+ Drainage 100+ Wells on adjacent lots 100+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property One 10+ Building foundation 60+ Water main 100+ Water Service One 60+ Surface water 100+ Driveway, parkl"hicle storage 20+_ Curtain drain None Observed Wells on adjacent lots 0 F. COMMENTS G. ENGINEER'S CERTIFICATION .•� t " `< '!44 • �P �4 1 certify Mat I have determined through rueld inspections and ` review of Municipal records Mat the above systems are in - coruformance wUh MOA HAA guidelines in effect on Mis datei Sleven Fonnene '- Engineer's Printgd Name Steven R. Pannone. P.E. ssc 8149 Data (�'��/J©� — �_ ..�D�;�� ,� 6�' Date of Payment (112� / I -? Recelpt Number 1 Nq.iQ `h (Rev. 114M Waiver Fee $ Date of Payment Receipt Number ra.o m+krr •. rAGNr elApq lelw.Ot ,• / \ I/�/�. i' r... euaw tEle.Nf C. D, a t s at� 44 C.D.s . � '�� •• .�RUfL-.� o: d9 v iot'�r Z3R" $S� N � � HOu3EG r 4 B 66 238. IDS N 49 °' 47 1S. ►NEL G o L 48A9 c p \Tj q Q N 7 S.00 SURVEY CERI1RCAnON ��Wttt•• Prepared by PLOT PLAD AN .•♦P��:!: '••, Robert E. Johns, Jr. & Assoc. �• , Professional Land Surveyors Ww lr. w.YIY.. r M M W �M w� I 4.-I- •' .• 1 i 1...: 1700 BRINK r W. « r e....r n.•a ""w""ei•«ww�t. ; •• •"9• �` _... ANCHORAGE, ALASKAA 99504 Scaler 1U v '50, i Nee. Lot S.F. Nee. Plat File No. 1 •, • FOUNDATION AS—BUILT I •"0 Date Surveys&. [)town 11-11-05 O' REJ Check" by n Dau Drown: 11-11-05 aria: $W2936 w.o. 5-379 '°"�^ i • � ♦�a; �.; :412 S •' .� FINAL STRUCTURE AS—BUILT to ~r..Er.. % '•), f "; �•.•' �i 1♦ red .){. .A5 ♦ Legal Description: e9 P i iZul e�+I w..k.. wwW«eWww. .L.i..:a•• Pro b(, �R3W."'SEC ., ;�♦♦� T12NLot 27 . ❑ WT EI1RvEY SURVEY TYPE SYMBOLS ❑ FOUNDAMON AS-BUILT ❑ NUL EtRUCT1NR AS-BMT • SET REBAR DRAINAGE O ASPHALT 13 ROT PLAN ... BUILT ... LOT Am KY ... RVOR ���� O FOUND REBAR o�� WOOD FCNCE CONCRETE El v- T Nm e ♦ At-MK Y o tLw/ ASSUMED ELEV. ��... METAL FENCEXA W O DECK PLOT PLANS k LOT SURVEYS NOTE: IT IS THE RESPONSIBILITY OF THE BUILDER OR OWNER. PRIOR TO ONLY THOSE IMPROVEMENTS ABOVE GROUNC AND VISIBLE WILL BE CONSTRUCTION. TO VERIFY PROPOSED BUILDING GRADC RELATIVE TO FINISHED GRACE AND UTILITY CONNECTIONS AND TO DETERMINE SHOWN. FENCES, WELLS. SEPTIC CLEANOUTH. SIDEWALKS. DRIVEWAYS. ETC.. ARE SHOWN IN THEIR APPROXIMATE LOCATION. ONLY, SNOW THE EXISTENCE OF ANY EASEMENTS. COVENANTS OR RESTRICTIONS MAY PREVENT SOME IMPROVEMENTS FROM BEING SEEN AND LOCATED. WHICH DO NOT APPEAR ON THE RECORDED SURDIVISION PLAT. AL1_ OISTANCFS ARF RFC a UNI S F UNDER NO CIRCUMSTANCES SHOULD AN AS—BUILT BE USED FOR CONSTRUCP.ON OR FOR ESTABLISHING BOUNDARY OR FENCE LINES. THE SURVEYOR TAKES RESPONSIBILITY FOR THE INITIAL TRANSACTION ONLY AND ASSUMES FINANCIAL LIABILITY ONLY FOR THE COST OF THE SURVEY. LISTED DISTANCES PREVAIL OVER SCAUNG. REPRODUCTION MAY CAUSE ERRORS IN SCALE. �� eY /J r CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 018-092.1x10 1. GENERAL INFORMATION HAA # d 5 OLM Expiration Date: 12 - -2, 9 - 0 5 - Complete legal description Lot 48A T12N. R3W. Sec. 27 Location (site address or directions) L1u-0 i✓ 13�Fh �E Current Property owner(s) Dan & Susan Church Day phone 727-7689 Mailing address Lending agency Mailing address Real Estate Agent Mailing Address 13820 Davis St., Anchorage, AK 99516 Day phone Becki Powell 0 ReMax Day phone 244-5881 Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by: 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ TYPE OF WASTEWATER DISPOSAL: Individual On-site �- -Municipality of Anchorage Community On-site Development Services Department Public Sewer Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw Street y . P.O. Box 196650 Anchorage, AK 99519650 www.ci.anchorage.ak.us (907) 343-7904 �� eY /J r CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 018-092.1x10 1. GENERAL INFORMATION HAA # d 5 OLM Expiration Date: 12 - -2, 9 - 0 5 - Complete legal description Lot 48A T12N. R3W. Sec. 27 Location (site address or directions) L1u-0 i✓ 13�Fh �E Current Property owner(s) Dan & Susan Church Day phone 727-7689 Mailing address Lending agency Mailing address Real Estate Agent Mailing Address 13820 Davis St., Anchorage, AK 99516 Day phone Becki Powell 0 ReMax Day phone 244-5881 Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by: 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ TYPE OF WASTEWATER DISPOSAL: Individual On-site 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) on properties served by a single family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to home owners. 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 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. (Rev. 7199) 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 Health Authority Approval Guidelines for 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 applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Pannone Eno. Svc. Phone 272-8218 Address P.O. Box 102954, Anch, AK 99510 Engineer's Printed Name Steven R. Pannone, P.E. Date Engineers Comments: In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MOA DSD Guidelines & Regulations. The reported results describe the performance of the system under the conditions encountered at the time of •" •'••• 40, the test, and separation distances measured to readily identifiable features. The operational life of all AW, �,.•��� - A wells and septic systems depend on the local soil condition, ground water levels that may fluctuate i {s ; r + during the year, and the water usage of the family being served by the system. These conditions arci . 49 _ . ............ outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden deice ��• ••............ „ or encroachments. PES can therefore not provide an warranty for future Pormance nor give Steven R. Pannone estimate of how long the system will continue to meet the operational requirements of the AD 'or or ���i No. CE 8149 d MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon .s + or use of this report by any other person or party is not authorized nor will it confer any legal right 1� �''•�•�. whatsoever. 6. DSD SIGNATURE Approved for bedrooms. Disapproved. X_ Conditional approval for 3 bedrooms, with the following stipulations: 0 Money to be placed in escrow for 1.5 times the amount of estimate given by Pannone Engineering. Work to be performed pursuant to the attached permit No. SW05-0373. Money in escrow shall not be relaesed until this office has given final Additional Comments approval. The work shall be completed not later than June 15, 2006. Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other By: �n� h'/ Original Certificate Date: oZ(R.Expiration Date: Reissue Date: 17 -;7- (R.. . 11M) Municipality of Anchorage ,__ .• • '' Development Services Department `•; Building Safety Division Onsite Water and Wastewater Program = • _ 4700 South Bragaw Street P.O. Box 196650 Anchorage, AK 995196650 www.ci.enchorage.ek.us (907) 343-7904 . HEALTH AUTHORITY APPROVAL CHECKLIST u _ _ A. WELL DATA Well type a It A, B, or C provide PWSID 0 Date completed 10111M983 Sanitary seal Y Total depth „ U_R Cased to _¢Q_R FROM WELL LOG Date of test 10111M983 Static water level 14 R Well Log Y Wires property protected Y Casing height (above ground) 14 in. AT INSPECTION 9/16/2005 16 ft Well production E 9 -p.m 3.6 9 -p.m WATER SAMPLE RESULTS:/ Coliform �colonies1100 ml Nitrate 13. L Other bacteria g colonies/100 ml Date of sample: 9/1612005 Collected by: Laura Pannone Arsenic NIA mgA B. SEPTICIHOLDING TANK DATA Tank TypelMatedal Fiberalass Date installed 7MOM976 Tank adze 1000 gal Number of Compartments 1 Cleanouts Y Foundation cleanout Y Depression over tank 11 High water alarm NIA Date of pumping 9/1512005 Pumper A• Home Services C. ABSORPTI RSELD DATA *i'* bEE COM Mill.T5 -�–T t� 9 1c�5yDate krsta847fo Sall rating (9.p.d.lR= or R=Axirm) jgg system type .cam .25 t Length -7ft Width �_ R Gravel below pipe 4 ft N Total depth ],¢ R Effective absWW M Meflr Monitoring tube 8 J5 Depression over field IL Date of adequacy test 9111612005 Results (Pass/Fal) =� a>A4k For j bedrooms Fluid depth In absorption field before test _ in Water added,_ gal. New depth_ in. Elapsed Time: _ min Final fluid depth _ in Absorption rate :-- _ g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) If yes, give date (ROV. r M) D. LIFT STATION Date installed Size in 'Pump on' level at _ hoPump off" I Datum E. SEPARATION DISTANCES Iv in hole/Ao High — High water alarlar m level at in SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankilift station on lot 125+ Absorption field on lot 125+ Public sewer main 100+ Meets alarm b circuit requirements? On adjacent kNs 100+ On edjaoent kits 100+ Public sewer manholeldeanout 100+ Sewer /septic service One 25+ Holding tank 100+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 25+ Property line 25+ Absorption field V Water main 100+ Water service line 76+ Surface water 100+ Drainage 100+ Wells on adjacent lots 00+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 20+ Building foundation 20+ Water main 1100+ Water Service line 25+ Surface water 100+ Driveway, parkinpehide storage 10+ Curtain drain None Observed Wells on adjacent lots 100+ 7 t�eSf F. COMMENTS u�f�OGU011e?� 5Y`e4^n i rl L1-" 1►i`J��t1 P G l •Req Qooitcwal HAA 04-i i I oil e k-a'10-fOr c-ar'1IQ`oltb�i �i 011 `�K G. ENGINEER'S 1 certify that I have determined through field inspectlons and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name Steven R. Pannone. P.E. Date HAA Fee S 4 �M .0 + 11S 00– t ISS Date of Payment g Receipt Number 44� 1aU1''�aN1�� (Rev. t1AM I Fee $ Date of Payment Receipt Number M IWIA AM M W.M. err Y ILAO•U Y1A � +y 4. 4$A A 14 W x7 IL-W,maoMM&Uamv "trod, by !Wr PJ,4 �, •. Robert E. Johns, Jr. & 'Assoc. �;„.�•.•,,,,,;.,w.�. �'�r� /�4P: '"♦. " � Prcfeaticrt olo L�d Sy�rvp +' .�•« ..,r w rf .•1ri i•+iw •n'ir{{ f tiA "C r, .!"' U! OtADL KI gf0a •,wh+M w. A.•RL F Ra-•50' VI 1. .R, pki n0.- W We•.ww w w ♦n, � / r ..,.... , � «�.« �'��•�.�,� 0� 4� ''A.R� 1 eak Y... .n"•+M M �. W N tlVil M M s•9''20tO.'s $3o 5,-312 MAJ. L tf -.TVA[ ".[U.L• +„� t,• 21 _ r, �l+ •i•w+.nwYYr•�w•.,•Aw.I,�•.i.r..w.�1wrr♦N.rtsyM.,'.•�. nw�irrr.wwnn� Mwwwrw.!a .. *1Op+•A r.rnnn«r«r�' • a5J ���O A to • a / ♦111 K'. d�'•i TI�''S F^ 1.' LJr T.AK. .. .. .... R+u; Tr. V.i .0+1 • ter /Cts D n�T tiAn .. u.w.nr ... me• /JR'/GT . , . rsr'wr,r • rv+ FNAqR.reC Cp�er.cR PIL • ' IP'LAMS 4t LOT 6 'N( •(9►pN7'�I'�i:' C► �.[ !J U' (R Ci C1'NF,R PR'CR TQ ONLV NIOlC !VPpOKu(NY2 AIOK OROIINS ANO MMOL[ W" lot =a•'S'RVC_.IaN, TU VCN+FT PR!WJ[10 *d•i.9NIT GRAOk R[LAMV[ WOInT[ F[NOU. %et.1 !t/*o RII.iANOJS'S.•110tr4wir, CM nYww'.R, TO .INMmCD BR•Ct lipUTUT:' ¢ONN[LT.ONi'AN,7 T-- O[T[RL4'N[ [N.. A1[ TJN OAN FI M^p .A/rgpNlNAfIL-LGCA^.ION. CW.'I. 4%Clk '�! Er.16r[NCi iw• U!'I [aftM[NTf, Ccv[vw4TS OA pEtTR1CaON6 NAY MA9VW7 SOUS WAOWMINM FROM 69%0 et[N ANO I.00w�D, •vy ♦♦ l NC1 Aw ^ n AT twly E1AiRYAK L•n JKII NO Lr.'.JJST*4US Yr0.'S AN AiL.SUCT 9E US= FCA CON'1'f1UC70N 01! KR RS','ML lCVIiOARY '►tate UNSX,' NE '3L'RKTA '.'AXCI KPO`i11M." FGF Tn[VOTIAL "SACT44 OKY AIiD Af WES FlNiKUI: VLftly; k.T fpm iNe ta.f�OF TK. SIRKT, L'OT(D Digo"C[i FRtvAIL &VER ZCK140, RVftMe ION YAr [AUK-SR&M IH *SCA!,i •N' ZChe 2a' C 3 1>_J3A0. D08G?LLL06 SF':FL 501E/AL/5E 0e-22-06;10:33 ; ;907 66' 6301 u 1/ 1 SGS Environmental Services Inc 200 W. Potter Drive Anchorne, AK 98515 Tel: (907) 562.2343 Faso (907) 501-5301 SOS Rat #: 1056140 Art doissAlmes are Alseka Standard Tine Ctlent Name: Pannone Engineering Primed DetaMme: 091=5 10:30 Pm;ed Name: 13820 Davis St Collected Datumme: 09116/0s 14:45 Clan' Sample ID: 13820 Davis St Received Dat&'Time: 09/16/03 1548 Maffix: Dr!nkiry Water TechnlGl Dlrecor. 51ephGnk M'VS:D Raleated Allowable Prep Analysis Parameter Results PQL Units Method Llrn.ts Date Date INt Bacbr'.a 0.00 9222B 09116N5 09/16/05 it Nitrate 13.18 0.10 mVq EPA300.0 10.00 09115,05 09118105 mx , RENT O MUNICIPALITY OF ANCHORAGE • �. DEPARTMENT OF HEALTH d HUMAN SERVICES Division of Environmental Services ik On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. a 018-092-29 HAA 8 t\f-\C\ La 10- S_\ a 1. GENERAL INFORMATION Complete legal description Lot 48 T12N 8341 Section 27 Location (site address or directions) 13820 Davis Street, Anchorage Property owner Daniel Church Day phone Zb2-D602 Mailing address 13810 nasdis "Id,-Aps1;Qra�g9_5}6 Lending agency N/a Day phone Mailing address Agent N/A Day phone Address Unless otherwise requested, HAA will be held for pickup. , 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: fMpgt� Individual well Y FMttsFgFcyo Community well p 4116% Fso� cF Public water NOTE: If community well system, provide written confirmation from State AD Ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site X 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. n.0251R.,. 1191) 11,a l MOA 421 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system Is safe, functional and adequate for the numberof 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 ox 773294, agle River. AK 99577 Engineer's signature Date 1 . w 1^u:; . l.:Cpi '4�,•� art: 6. DHHS SIGNATURE �C— Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: tIITIC The Municipality of Anchorage Department of Health and Human Services (DHHS) Issues Health Authority Approval Cenlflcates 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. Empl oyees 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 engineers work. rims (ft, w) 8.er MOA V21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SE Environmental Services Division 825 L Street, Room 502 • Anchorage, Alaska 99501 Health Authority Approval Checkll Legal Description: Jel1 -1/19 27-14 R,31✓ SF-C,Z% Parcel I.D. A. WELL DATA Wolt type , ?VIVA16 If A, B, or C, attach ADEC letter. ADEC water system number NIA Log present (YIN) Date completed Total depth 5 % Cased to SD Casing height (above ground) 3r!0 Sanitary seal (YIN) YCS Wires properly protected (YIN) SFS FROM WELL LOG Date of test /0&3 Static water level Woll production 5 O.P.M. WATER SAMPLE RESULTS: • •u1 C AT INSPECTION moi• 7 g.p,m. Nitrate Z• 9/ Other bacteria Date of sample: ()8h d2 Collected by: SFS B. SEPTIC/HQ=ING TANK DATA Date Installod /2 7f Tank size 000 Number of Compartments a2 Cleanouts (YIN)_Y Foundation cloanout (YIN) Depression (YIN) iJ High water alarm (Y/N)1414 Date of Pumping "6op,44,6- Pumpor %S�/?S C. ABSORPTION FIELD DATA Data installed / 9 7 s Sol] rating (g.p.dJft' or ttz/bdrm) 1n s- System typo -e,%cit'a IV' Length 7rr..� *,,-.)Width ti+^•4 7 • Gravel thickness below pipe Total depth 7.b � Effective absorption area *e 3 /S fd Monitoring Tube present (Y/N)_Y Depression ovor fiold (YIN) Ij Date of adequacy lostD/ U Results (PasslFail) Pas- For bedrooms Fluid depth In absorption field before test on.);Immediately after-7p-6gal. water added (in.):'L_ Fluid depth 18 (Ins) Minutes later: ISG Absorption rate = ?, /'/-,- 3—p" a.p•d• Peroxide treatment (past 12 months) (YIN) tJ It yes, give date d�A 72-026 (Rev. 3196)* D. LIFT STATION INIA Date installed Manhole/Access (Y/N) High water alarm level E. SEPARATION DISTANCES Size love[ at* "Pump oft" level at. *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: Soptic/helding tank on lot Y /00, On adjacent lots f/001 Absorption field on lot __ t /00 r On adjacent lots trop' Public sewer main N14 Public sewer manhole/cloanout AJ 1A e=M /septic sorvico line _ f Z S " Lift station/✓1A SEPARATION DISTANCES FROM SEPTICMBL-OMGTANK ON LOTTO: Foundation NIA Properly line f'30/ Absorptionfield °sr w Water maWservice line r-'° Surface water/drainago A/M / Wells on adjacent lots 'f"100 r SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: i Property Una t30 Building foundation &—A Water main/service line Surface water Driveway, parkingA ohicto storage area s b' Curtain drain -A/ONF_ A60,4E'WT Wells on adjacent lots -vlav' F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal record$;Uttit the avNejsystems In conformance with MOA NAA guidelines in effect on this date. are =; ; ' ',,,;; • •,: 1: .r Signature .�-� � � • • "• ., .' > •�� =-!�"-='� ,•:. Engineer's GUUiS /�G/T�Zif�• g y— f if• �yiy;:y �. Date A-V�'i —%C loot, A. Ufora J ,, HAA Fee Date of Pe Receipt Ni 72.026 (Rev. 3M6)' Waiver Fee $ Date of Payment Receipt Number