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HomeMy WebLinkAboutTIMBER RIDGE BLK 2 LT 8Onsite File Timber Ridge Block 2 Lot 8 #050-321-26 Municipality of Anchorage On -Site Water and Wastewater Section - (907) 343-7944 Page 1 of 3 OIC -SITE WASTEWATER INSPECTION REPORT Permit Number_ 0SP201275 PID Number- 050-321-26 Dwelling: X Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New Q upgrade Name EEDORF FAME M & CAROL L ABSORPTION FIELD [� Deep Trench ❑ Wide Trend ❑ Bed ❑ Mound Site address 19440 Timberline Dr ❑ Other Phone Number of Bedrooms Sail Rating Total depth from original grade 227-8417 14 Gpois S LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe F Subditgsion Block Lot TIMBER RIDGE BLK 2 LT 8 Fill added above original grade Fd Gravel, length F Township Range Section Gravel vAdth Ft. Beds: Number of Lines - Distance between lines - F SEPARATION DISTANCES Tod Septic absorption � Holding � Sewer Total absorption area Number of trenches Dist. between trenches From Tank ii;ft Station I tryold Tank I Line F0 F Well 100'+� na ? na na TANK © Septic ❑ S.T.E.P. ElHolding © Other Manufacturer Greer Capacity 1250 G2 Surface %later 1 l,}0'+ l Material Plastic Number of =npartmants Lot Line '� �'}" I na na NA i ��n larsn I('+ D 'i na ( LIFT STATION manufar'lwer Gapachy a Remarks Septic Tank Replacement Ga Alarm location Electrical im;talled by PIPE MATERIAL- House to tank D3034Tank to D3034 dralnfield Installer Dean Drainfield COMT D3034 Inspector (1, orthRim Eng. BENCH MARK (Assumed elevation) 100 ft Inspection 1 , 919/20 9110/20 Location and description c ,31" 41!1D ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineers Stamp Conditional Approval: [date +++�� OF 449,1" M 1 TH *�f ��,l�Steve SeptiC SySteM Eng Approved [pato 1 � � �Z�C[� ?�s ;�yyQ� CE-6256�as CI 11'/4%2�+ U) Z C) C) x �70 rT,V Z N) CD Ar F- --- F- F---' < C-) td m tj M 70 m Mm F- tj r7 C-) m CC) F- 1> 7u m E:l C) F -I tj OM W 4-1 o rT, N C) CD 0 ril 0 x 4 :3 rq rq r 0 :7j C) N) 00 13 ro UT Q :3 co. 7 rD 0 C6 rD R) ro < p . ..... .... 0 -r- 3 <+ 0 oCD n -0 0 C+ :5 p p p 3 - 0 0 0 :3 < p I> F9 T-< M ro -3 Q- P ro :5 Q- 0 7'� C+ C- H F9 F D m 1>z rD M �i- < P FTI -u 5 < :K :3 0 P 0 -0 0 :3 ro -9 0 ro F -Q � (D lD Cil I cn (D p 0 c <+ Ln CD --- w rD C+ aF- O FTI m :K L<- P ro N7� Ln 4rD +n :3 5- ---q ro co M 0 F- oh roa n E-1 C-) rD -0 p 900 p :3 r- U) (D (D ro 0 ro 90 :3 n ro :5 n 0 t) w MUNICIPALITY OF ANCHORAGE On -Site Water iir Wastewater Program �ancr� PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 �� n http://www.muni.org/onsite - t e- "Pt On -Site Wastewater Disposal System Permit Permit Number: OSP201275 Effective Date: 7/31/2020 Work Type: SepticTank Upgrade Expiration Date: 7/31/2021 Tax Code Number: 05032126000 Site Legal Address: TIMBER RIDGE BLK 2 LT 8 G:0255 Site Mailing Address: 19440 TIMBERLINE DR, Eagle River Owner: SEEDORF JAMES M & CAROL L Lot Size in Sq Ft: 38284 Design Engineer: NORTH RIM ENGINEERING Total Bedrooms: 4 This permit is for the construction of: ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction shall 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 wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing �— 7/3/ao Received By: Date: Issued By. ?, yf' �% Date: 131 Q 0;2o SteveEng.com Steve Eng, PE, PH 907-694-7028 SteveEngPE@gmail.com Date: 7/24/20 Number of Pages: To: MOA On-Site Services Subject: Timber Ridge Block 2 Lot 8 Septic Tank Failure The subject septic tank has failed- a new tank will replace the old one. The existing seepage trench appears to be working OK. Please issue a permit so the tank can be replaced. Please review as soon as possible. This is a large lot with no nearby neighbor conflicts. If there is need for additional information or clarification please give me a call. Thanks-Steve Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201275, Rebecca Carroll, 07/31/20 Timber Ridge Block 2 Lot 8 SPECIFICATIONS & DESIGN GUIDELINES Wastewater System Sizing: The current septic tank has failed- the seepage trench still functions. This lot is over an acre. No adverse impacts are expected from tank replacement. The easements are depicted on the lot. The slope is indicated in the area of the septic system. No conflicts to neighbor properties. Specification Requirements: All components and work must comply with the Municipality of Anchorage Specifications (AMC) & State of Alaska Drinking Water Regulations and Wastewater Regulations. New 2- compartment, 1250 gallon septic tank. Watertight couplings on inlet & outlet. 5 minimum between the tank and trench. 5 to property lines & 10 to house. 4 of cover or insulation is required for tank; an equivalent of 1 ⇤ insulation for 1 foot soil cover. Tank & solid pipe must be set on well compacted, stable soil. No large rocks for tank bedding. Plastic/fiberglass tanks require special bedding per MOA- sand or pea gravel. 4⇤ diameter cleanouts with airtight caps are required 1 to 4 from foundation wall, prior to any 90 degree bend in 4 inch line, in each tank compartment, and two adj acent opposing cleanouts between the tank and the absorption field, not more than 10 from the tank positioned to provide cleanout access towards the tank and towards the absorption field. All cleanouts must extend to at least ground level. In solid pipe runs, ASTM D-3034 may be used in lieu of cast iron. Insulation must be placed over any pipe installed under driveways or parking areas. Approved pipe materials include cast iron, PVC ASTM D3034, PVC ASTM F789, ABS ASTM D2661, Sewer Service Line is minimum 2% slope. Septic Tank to be pumped every two years or when required. Insulation board to be extruded direct burial polystyrene (Dow Styrofoam HI/equal) Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201275, Rebecca Carroll, 07/31/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201275, Rebecca Carroll, 07/31/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201275, Rebecca Carroll, 07/31/20 72-013 (3,85) MUNICIPALITY OF ANCHORAGE r"•, • DE. ATMENT OF HEALTH AND HUMAN SER, .ES Environmental Health Division 825 ••L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name S / DISTANCES TO FROM SEPTIC TANK ABSORPTION FIELD WELL pNE L. Address o dow 77o/Oz Fe, ,57J�7 onelsl Permd No No. of Bedrooms WELL /OD f /UDlf 974 6 03 LOT LINE LEGAL DESCRIPTION Lot 8 Block Z Suad,wswd .� JS ED PV 20 JSEo h7 R F FOUNDATION r� r� Iownsmp. Range. section �� / ✓•� AS -BUILT DIAGRAM driveway water DOdies. (Snow location of wen. etc 1 septic system. property ones, Iounoation, � TANKS I ,rL SEPTIC ❑ HOLDING Manmacimer Capacity m ganons Metro, No. of Companment� TYPE OF SYSTEM �, �, TRENCH ❑ BED ❑ W. DRAIN ❑ OTHER .X / o I Dept" to pry" oottum Irom total dr -pin nom original grade ong,nal grade / _ FT FT r - h e adorfd awi,e Ongma, gratll• Gtavel w.•pm oeneam pipe 4 A. e"r FT /O ' FT brave, ,enya, Grerel wAm r' 0 ! C 28 FT Z �J FT I otai absorption area I Distance d;tween firs 6D jr6 O SO FT N /4 r I NUmUCr tit Imes Soit rating P,pe material 3 SOFT vL D 30 3 C ,ns;aner Date Instal ea r3 3 3v WELLS XPRIVATE ❑ OTHER Vclentitvl Lo Ue»A�ceawr IA.b Cl Iota, Deptn Cased to Fi FT unta.,n Date Insimcd i A T 6 RE61ARKS: G�SF_ •J -O A.0,07-/0 A) o -7- IAJ Scale: 7 77A144= O/= itlS' Inspections Verfor0 by c.. > ENGINEkrL5 SEAL •, .. ,,e -"e�_ -: Dale /7 /0 qr ,. •� . r m S 81 S ENGINEERING �' T' •Ya, SR B 196X •,•�� certify that this inspection was perlonned according to all YV57/ °' • •• ." •.. °} • . P•l..fl A. Y►.Y; ,.:._r rAK �e, �2.i/aQ is Municipal and Stale guidelines in tlleG on Nis e: d r,. 1 tM� t ��" t r _• q / j, .. Health Department Approval:,I, is�L!//�C p ^—'-' —JyLJL���rv",r_v:S>•'o 72-013 (3,85) i MUra I C I F=(aL I TY CJ 1= ANI -i L-3F:(aGF= DEPARTMENT OF HEALTH AND ENVIRONMEWAL PROTECTION 825 L STREET, ANCHORAGE, AK 99501 264-4720 C3V4—S ITE SCWF=FZ P< WALL FBF=FSM I T plR., � ss<Qw, PERMIT NO: 860039 <&�Ph+c_�+r. ,s n DATE ISSUED: 02/05/86 of a�J. nt wR�l "� ` c_ ��4.. � .moi e.�o ✓� f'L�, Yc+... r^ /n�.Gj-rYa.� 4 - APPLICANT: SYDNEY A. HUFFNAGLE ADDRESS: P.O. BOX 770102 EAGLE RIVER, AK 99577 CONTACT PHONE: 694-9746 LEGAL DESCRIP: SUBDIVISION: TIMBER RIDGE LOT: 8 BLOCK: 2 SECTION: 6 TOWNSHIP: 14N RANGE: IW LOT SIZE: 38333 (SQ.FT. OR ACRES) MAX BEDROOMS: 4 Listed below are the options available to you in designing your septic system. Choose the option that best fits your site. ** TANK MUST HAVE AT LEAST TWO COMPARTMENTS - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - I certify that: 1. I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage (MOA) and the State of Alaska. 2. I will install the system in accordance with all MOA codes and regulations, and in compliance with the design criteria of this permit. I will adhere to all MOA and State of Alaska.requirements for the set back: distances from any existing well, wastewater disposal system or public sewerage system on this or, any adjacent or nearby lot. 4. I understand that this permit is valid for a maximum of 4 bedrooms and any enlargement will require an additional permit. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES, THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE ELECTRICAL WORE: MUST BE DONE BY A LICENSED ELECTRICIAN. SIGNED y / -- •DATE: APPLICANT:'S UNEY A. HUFFNAGLE ISSUED BY �Q. -��o , DATE: ". 5: _S 41 -------------------------------------- Tf=ENCF-F LSI ___ ID W - DFRA I N DEPTH TO PIPE BOTTOM (FT.) 4.0 5.5 6.0 GRAVEL DEPTH (FT.) 10.0 0.5 1.0 TOTAL DEPTH (FT.) 14.0 6.0 7.0 GRAVEL WIDTH (FT.) 2.5 16.0 5.0 GRAVEL LENGTH (FT.) 28.0 32.0 60.0 ' GRAVEL VOLUME (CU.YDS.) 27.3 19.0 16.7 TANK SIZE (GALS) 1,250.0 ** 1,250.0 ** 1,250.0 +�+� SOIL RATING (SO.FT./BR) . 137 85 85 ** TANK MUST HAVE AT LEAST TWO COMPARTMENTS - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - I certify that: 1. I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage (MOA) and the State of Alaska. 2. I will install the system in accordance with all MOA codes and regulations, and in compliance with the design criteria of this permit. I will adhere to all MOA and State of Alaska.requirements for the set back: distances from any existing well, wastewater disposal system or public sewerage system on this or, any adjacent or nearby lot. 4. I understand that this permit is valid for a maximum of 4 bedrooms and any enlargement will require an additional permit. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES, THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE ELECTRICAL WORE: MUST BE DONE BY A LICENSED ELECTRICIAN. SIGNED y / -- •DATE: APPLICANT:'S UNEY A. HUFFNAGLE ISSUED BY �Q. -��o , DATE: ". 5: _S 41 -------------------------------------- v h i j ArPRotC• toa/tT[o� " / op Srdt.S Ora --.T Allf�, / -r« is Sere PL -^4 5""`-P 1iVes4eDE -rale Coe.4T[ooll OF ANP SEPT'ta• syr3TE[" tS oiV ADT/1�P-�T �Tr+• SM PRELI11fINARY I hereby certify that I have surveyed the following described property: L o T C', /o c. i 2L, F t t•vt S M Anchorage Recording Precinct, Alaska, and that the pro- ' posed improvements, as planned thereon by the builder, will be within the property lines and will not overlap or encroach on the property lying adjacent thereto, that no improvements on property lying adjacent thereto encroach on the prembes in Question and that there are no roadways, transmission lines or other visible case- ments on said property except as indicated hereon. Dated at Eagle River, Alaska this `7-7 1 day of So ,, 19r= ROBERT C. JOHNSON SCALE: SCALE: Registered Land Survevor No. 880 -LS 1' = i( -p ' Box 456. Eagle H er, Alaska Phone C94-2543 l r • v h i j ArPRotC• toa/tT[o� " / op Srdt.S Ora --.T Allf�, / -r« is Sere PL -^4 5""`-P 1iVes4eDE -rale Coe.4T[ooll OF ANP SEPT'ta• syr3TE[" tS oiV ADT/1�P-�T �Tr+• SM PRELI11fINARY I hereby certify that I have surveyed the following described property: L o T C', /o c. i 2L, F t t•vt S M Anchorage Recording Precinct, Alaska, and that the pro- ' posed improvements, as planned thereon by the builder, will be within the property lines and will not overlap or encroach on the property lying adjacent thereto, that no improvements on property lying adjacent thereto encroach on the prembes in Question and that there are no roadways, transmission lines or other visible case- ments on said property except as indicated hereon. Dated at Eagle River, Alaska this `7-7 1 day of So ,, 19r= ROBERT C. JOHNSON SCALE: SCALE: Registered Land Survevor No. 880 -LS 1' = i( -p ' Box 456. Eagle H er, Alaska Phone C94-2543 l is -, N' N� v h i j ArPRotC• toa/tT[o� " / op Srdt.S Ora --.T Allf�, / -r« is Sere PL -^4 5""`-P 1iVes4eDE -rale Coe.4T[ooll OF ANP SEPT'ta• syr3TE[" tS oiV ADT/1�P-�T �Tr+• SM PRELI11fINARY I hereby certify that I have surveyed the following described property: L o T C', /o c. i 2L, F t t•vt S M Anchorage Recording Precinct, Alaska, and that the pro- ' posed improvements, as planned thereon by the builder, will be within the property lines and will not overlap or encroach on the property lying adjacent thereto, that no improvements on property lying adjacent thereto encroach on the prembes in Question and that there are no roadways, transmission lines or other visible case- ments on said property except as indicated hereon. Dated at Eagle River, Alaska this `7-7 1 day of So ,, 19r= ROBERT C. JOHNSON SCALE: SCALE: Registered Land Survevor No. 880 -LS 1' = i( -p ' Box 456. Eagle H er, Alaska Phone C94-2543 • flT�ex#ifi�d DOC co. 00' SULLIVAN WATER WELLS P.O. BOX 670272. CHUGIAK, ALASKA 99567 • TELEPHONE 6882759 OWNER OF LAND i> O 4-1U r:-' OL1'lll OF WELL c'JA C) ADDRESS L �Ja t Z 7i1 u)-) -I E 2 STATIC LL%'EL OF WATIAl FT. LEGAL DESCRIPTION DATE. Started 3L2� Ended ��F c, PERMIT NUMBER KIND OF FORMATION: DRAWDOWN FT GALS. PER IIR /(I KIND OF CASING 6 * c) 0 From n ' FL to—=L—Fl. C.v'c,,,., f' _S 'S <Je- From Fl. to Ft. From 0 Ft. to 'I r -=.f it fA7 =,J From Ft. to Ft. From--A�—Ft.to%7 Ft. GAr"­c <jr From Ft.to Ft. From Ft. to Ft. From Ft. to Ft From47 Fl. tom—Ft. C4, erY S fA•41c5- From I. to I'1 From ALFl.to,?1? Ft. ! From Fl.M 11. From. 89" Ft. to g7Ft.1f (y[ �,� (.RF_F� _ From Ft. to Ft. From FI. to Ft. O ['t ? From Ft. to Ft. From 17 Ft. to 105' Ft !I fA,? n c r_ [<a•5t O"' From Fl. to Ft. From Ft. to FI./ -RR, 7•-j,t tcl Froin—Ft. to Ft. From_iJ2//��.TFLto E> Ft. �- 0i7^r" rk'r=c,J From FLlu Fl. FromJ_[7.�.Ft. toZ1Ft. nE'/r On f tii7DQU� From Ft. to Ft. � From Ft. to Ft. 6 -Atli -✓f EQ % S- d r''7' From Fl. to Ft. From1-75Ft. to 202 Ft. 4r -!r/10 «. /,30t..n.v• Froin Ft. to Ft. From d nF Ft. to J r 1 Ft. %)� O o c ,._ F'ti d c i ✓^< < From FI. to — —Ft. Front Fl. to FL -11 J fw From Ft. to Ft. From, .�_Ft. to 2-1Z_Ft. .0 A17 o <_ iG t From Ft. to Ft MISCL. INFORMATION: MOM N0I.03108d 1V1N3WNCWlAN3 T H1Td3H d0 '1d30 BOV80H�NV 40 kLrWdIOINnW DRILLER'S NAME f'r41 S "� Municipality of Anchorage June 23, 1986 r`, P.O. BL,.. 196650 ANCHORAGE, ALASKA 9951M650 (907) 2644111 TONY KNOWLES. MAYOR DEPARTMENT OF HEALTH A HUMAN SERVICES Sydney A. Buffnagle P.O. Box 770102 Eagle River, Alaska 99577 Subject: Lot 8 Block 2 Timber Ridge Subdivision On-site Sewer b Well Permit 6860039 - Issued February 5, 1986 On May 20, 1986, The Anchorage Assembly approved a new ordinance regulating on-site wastewater disposal systems (septic systems). All septic systems constructed after the effective date of this ordinance are subject to the provisions of this ordinance. Our records show that you currently hold a permit for the installation of a septic system. We strongly urge that you contact this office prior to constructing your system. Any changes in the code that could impact the construction requirements of your septic system will be identified and brought to your attention. Please contact the Environmental Services Division at 264-4720. Thank you.for your cooperation. Sincerely, / Susan E. Oswalt Program Manager On-site Services SEO/SSM/ljw f MU" I C F}AL I TV OF ANG ORALE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STREET, ANCHORAGE, AY 99501 264-4720 O N —SIT E S EWE R he W E L L PERMIT NO: 840755 DATE ISSUED: 09/06/84 APPLICANT: C/O S & S ENG'G. SID HUFFNAGEL ADDRESS: SRB 196X EAGLE RIVER, AK 99577 CONTACT PHONE: 694-2979 F"EF-,:M I T LEGAL DESCRIP: SUBDIVISION: TIMBER RIDGE LOT: 8 SECTION: 6 TOWNSHIP: 14N RANGE: IW LOT SIZE: 38333 (SQ.FT. OR ACRES) MAX BEDROOMS: 4 Listed below are the options available to system. Choose the option that best fits - - - - - - - - - - - - - - - - - - - - - T R E N C H DEPTH TO PIPE BOTTOM (FT.) 4.0 GRAVEL DEPTH (FT.) 10.0 TOTAL DEPTH (FT.) 14.0 GRAVEL WIDTH (FT.) 2.5 GRAVEL LENGTH (FT.) 28.0 GRAVEL VOLUME (CU.YDS.) 27.3 TAN): SIZE (GALS) 19250.0* SOIL RATING (SQ.FT./BR) 137 BLOCK: 2 you in designing your septic your site. - - - - - - - - - - - - - - - - - - - L -:ED W _ nF2A I N 5.5 6.0 0.5 1.0 6.0 7.0 16.0 5.0 32.0 60.0 19.0 16.7 1,250.0 ** 1,250.0 ** 85 85 ** TANK MUST HAVE AT LEAST TWO COMPARTMENTS - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - I certify that: 1. I am familiar with the requirements for on-site sewers and wells as set forth by the'Municipality of Anchorage (MOA) and the State of Alaska. 2. I will install the system in accordance with all MOA codes and regulations, and in compliance with the design criteria of this permit. 3. I will adhere to all MOA and State of Alaska requirements for the set back distances from any'existing well, wastewater disposal system or public sewerage system on this or any adjacent or nearby lot. 4. I understand that this permit is valid for a maximum of 4 bedrooms and any enlargement will require an additional permit. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES, THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE ELECTRICAL WORK. MUST BE DONE BY A LICENSED ELECTRICIAN. SIGNED�� �� G. S`ID H FNAGE�� DATE: APPLICANT: C/O S t ISSUED BY_si.a/ C-ctt'-------------- DATE: ���Y r . fi unlclpallty y of Anchorage r`, POU, ti 6-650 ANCHORAGE. ALASKA 99502-0650 (907)264-4111 TONY ANOV.! f., A!AYOH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Permit In: 840755 January 31, 1985 TO: Permit Applicant SUBJECT. Lot 8 Block 2 Timberidge Subdivision A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 1984. Permits are issued on a calendar year basis by authority of Municipal Ordinance. A new permit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. if you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site sewer system, the original as -built inspection report and the yellow copy must be sent to this office for review and approval, and for documentation. If there are any further questions, please call this office at 264-4720. Sincerely, Keith E. Bandt�sor Environmental Engineering Program KEB/ljw enc: Copy of Permit SWP/057 •�II DI SOILS LOG ' MUNICIPALITY OF ANCHORAGE ( \ DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION TEST 625 L. Strtrot, Anchorage, Alaska 99501 2644720 C/ J SOILS LOG- ERCOLATION TEST QN PERFORMED FOR: G /� �!>L�aLng /VyK C DATE PERFOORMEM v —✓ LEGAL DESCRIPTION: L OT B CP -K // ML4BC /) iJZv �� SLOPE SITE PLAN 1 2 3 4 5 6 7 8 \J 9 10 11 12 13 v 14 15 16 17 18 0R-bA M1Cs GP -I LtGPtT StLT�j 15-0 d/e4- (D�&(-SS- `61 73(Z WAS GROUND WATERO S / Y SP - lJJ �I�a ENCOUNTERED? OL P IF YES, AT WHAT E DEPTH? L PERCOLATION RATE &//—W (minutes/inch) TEST RUN BETWEEN FT AND FT M, MOM -__m__i ___m__ PERCOLATION RATE &//—W (minutes/inch) TEST RUN BETWEEN FT AND FT n PERFORMED BY: I 8R'3 I93X 7 CERTIFIED 72-008 (6/79) DATE: P4 MUNIUPAUTY OF Development Services Department On -Site Water & Wastewater Section Phone: 907-343-7904 Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 050-321-26 Expiration Date: it. - 2 )'_>(— 1. GENERAL INFORMATION Complete legal description Location (site address) TIMBER RIDGE BLK 2 LT 8 19440 Timberline Dr Current property owner(s) Mailing address Real estate agent SEEDORF JAMES M & CAROL L 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or. Duplex) 3. NUMBER OF BEDROOMS: 4 Day phone 227-8417 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well Fx_1 Private Septic 0 Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ � 12.50 GDvI p Date of Payment 1152ZOZ D Receipt Number COSA # OS C 2.a I(; I Date: Waiver Fee $ Date of Payment Receipt Number, Waiver # S. 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, Biased 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 verifie that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm NorthRim Eng. phone 694-7028 Address FO Box 770724, Eagle River Engineer's Printed Name Steve Eng pate 11/4/20 7 6. DSD SIGNATURE System -1 Approved for bedrooms stems E� System h'2 Approved for bedrooms ��-sass_�� Disapproved \� 11V/4%2 Conditional approval for bedrooms, with the following stipulations: ,,t<<ltltcrrrrr�,_ '�J))t1)))1W)11 By: Original Certificate Date: The Municipality of Anchorage Develocment Serfices DNision (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph a by an independent prcfersional civil engineer registered in the State of Alaska. The Nlvnicipality ci Anchorage is not responsible for errors or omissions in the professional ongineer's work. 7. ATTACHMENTS: CASA Checklist I Nitrate Advisory Septic System Advisory Arsenio Advisory Legal Description: TIMBER RIDGE BLK 2 LT 8 If more than 1 septic system on lot: COSA Checklist # A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 3/86 Total depth 220 ft Cased to 60,5 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 18 in. Date of flow test for COSA 4/29120 Static water level at beginning of test 90 ft. Comments B. TANK DATA Age of tank(s) new years Tank type/material septicpl Measured operating fluid level in septic tank new ❑ Standpipes/foundation cleanout per record drawing Date of pumping new D. ABSORPTION FIELD DATA 8/17/86 Which system tested (date installed) same FOR ALL standpipes present per record drawing Total measured depth from grade 14 ft (max) Measured depth to pipe invert from grade 4 ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Comments/Deficiencies: COSA Checklist yellow sheet of Parcel ID: 050-321-26 Structure served by this system Well production at time of test 6+ gpm Water storage tank volume gallons Well disinfected for coliform test? ❑ Yes ❑ N IN Coliform bacteria is Negative Nitrate mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by NRim Date of Sample 5/18/21 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 4/29120 Results F, --]Pass For 4 bedrooms Fluid depth prior to test 0 in Water added 600 gal New depth 20 in Elapsed time 30 min Final fluid depth 5 in Absorption rate 600 gpd Any rejuvenation treatment (past 12 months) If yes, enter date no 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' if No ft Community Sewer Manhole/Cleanout > 100' F] Yes if No ft Q Yes if No ft [V Yes if No ft Neighboring Tank > 100' ✓ Yes if No ft Private Sewer/Septic Line > 25 Q Yes if No ft Absorption Field on Lot > 100' Q Yes if No ft Holding Tank > 100' Yes if No ft Neighboring Absorption Fields > 100' Yes if No Animal Containment> 50' Yes if No ft fl Yes if No ft Yes if No ft if septic tank is under driveway comment below Manure[Animal Excreta Storage > 100' Community Sewer Main > 75 211 Yes if No ft [] Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required Building Foundations > IV ( Yes if No ft Surface Water > 100' F] Yes if No ft Nroperty tine > 5' Yes Yes it No it Wells on Adjacent lots: 0' Absorption Field > 5' [] Yes if No ft Private Wei Is > 100' Yes if No ft :Vater Main > 10' Q Yes if No ft Community Wells > 200'[]✓ Yes if No ft ?Vater Service Line > 10' Yes if No ft if septic tank is under driveway comment below From Absorption Field on Lot to: (Please Enter distances if less than required) Building Foundation > 10' Yes if No ft if absorption field is under driveway comment below Property Line > 10' ] Yes if No ft Wells on Adjacent Lots: :Vater Main > 10' 0' Yes if No ft Private Wells > 100' [] Yes if No ft Water Service Line > 19 Yes if No _ _ _ ft Community ~,Wells > 200' R Yes if No ft Surface Mater > 100' Q; Yes if No ft F. ENGINEER'S COMMENTS p0e� OF G. ENGINEER'S CERTIFICATION ffi Cl) I certify that t have determined through field inspections and revieti, 0 - of of Jvlunicipai records that the abollle systems are in conformance with MOA COSAcdciidelirres in effect on this date. � %.eve MUNICIPALITY OF ANCHORAGE Development Services Department Y Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Parcel I.D. 050-321-26 Certificate of On -Site Systems Approval Expiration Date: ; — ( '?—�% 1. GENERAL INFORMATION Complete legal description TIMBER RIDGE BLK 2 LT 8 Location (site address) 19440 Timberline Dr Current property owner(s) SEEDORF JAMES M & CAROL L Day phone 227-8417 Mailing address 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: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well 0 Private Septic 0 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 $ JcoviU Waiver Fee $ Date of Payment 1 �5/ ZOZ b Date of Payment Receipt Number Receipt Number COSA # 05C2.D I(; I I Waiver # S. STATEMENT CSE 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 cosies, ordinances, and regulations in effect at the time of installation, I acknowledge that On -Site staff may visit the site to verify the information submitted. Mame of Firm NerthRim Eng. Phone 694-7028 Address PO Box 770724, Eagle River Engineer's Printed Name Steve Eng Date 11 /4/20 Ar 6. DSD SIGNATURE f 7 R Systems Approved for bedrooms System #-2 Approved for bedrooms f�� CE -6256 Ar Disapproved 11%%2C Conditional approval for bedrooms, with the following stipulations: By: Crigin2l Certificate Date: The Municipality of Anchorage De%,elop:ment Services DNision (DSD) issues ceriffioates of On -Site Systerns Approval (COSA) based only upon the representations given in paragraph 5 by an independent preiessiortaI oivil engineer registered in the Statc- of hla5ka. The tatunicipality of Anchorage is not responsible for errors or omissions in the professional cngincer's work. 7. ATTACHMENTS: COSA Checklist � Nitrate Advisory 7 Septic System Advisory / Arsenic Advisory Legal Description: • If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 3/86 Total depth 220 ft Cased to 60,5 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 18 in. Date of flow test for COSA 4/29/20 Static water level at beginning of test 90 ft. Comments B. TANK DATA Age of tank(s) new years Tank type/material septicM Measured operating fluid level in septic tank new ❑ Standpipes/foundation cleanout per record drawing Date of pumping new D. ABSORPTION FIELD DATA 8/17/86 Which system tested (date installed) same ❑ ALL standpipes present per record drawing Total measured depth from grade 14 ft (max) Measured depth to pipe invert from grade 4 ft (min) ❑ N/A — pressurized field WE Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Comments/Deficiencies: COSA Checklist yellow sheet Parcel ID: 050-321-26 Structure served by this system Well production at time of test 6+ gpm Water storage tank volume gallons Well disinfected for coliform test? ❑ Yes ❑ No ❑ Coliform bacteria is Negative Nitrate mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by NRim Date of Sample 10/15120 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 4/29/20 Results ElPass For 4 bedrooms Fluid depth prior to test 0 in Water added 600 gal New depth 20 in Elapsed time 30 min Final fluid depth 5 in Absorption rate 600 gpd Any rejuvenation treatment (past 12 months) no If yes, enter date From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tankil-Ift Station on Lot > 100' M-1 Yes Community Sewer Manhole/Cleanout > 100' It Yes if No ft 0 Yes if No ft Neighboring Tank > 100' Yes if No ft Private SeweriSeptic Line > 25 Yes if No ft Absorption Field on Lot -- 100' Yes if No ft Holding Tank > 100' Yes if No ft Neighboring Absorption Fields > 100' if No ft Animal Containment > 50' R Yes if No ft Yes if No ft ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' Yes if No It 21 Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' Yes if No ft Surface Water > 100' Yes if No ft Hroperty Line > 5' M-1 Yes it No It 'Neils on Adjacent Lots, Absorption Field > 5' Mv Yes if No ft Private Wells > 100' Yes if No ft Water Main > 10' Yes if No ft Community Wells > 200' Yes if No ft Water Service Line > 10' Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances it less than required) Building Foundation > 10' Yes if No ft If absorption field is under driveway comment below Property Line > 10' Yes if No ft Wells on Adjacent Lots: Water Main > 10' Yes if No ft Private Wells> 100' Yes if No Water Service Line > 10' Yes it No It Community Wells > 200' Q Yes if No Surface Water > 100' [D' Yes if No ft F. ENGINEER'S COMMENTS 07' OF AC 1111lkill Ar G. ENGINEER'S CERTIFICATION X49 ��� certilly that I have deteralined thfough Field inspections and review A of Municipal records that the above systetris are in conformance with MCA COSA guidelines in affect on this date, , -AJ k /4%20w ft ft NOTE: DRIVEWAY SHOWN IS APPROXIMATE DUE TO SNOW COVER.. L ' WELL a I48,u \ �p0 GRAVEL..-.... 7 6,52. Lot\,9�,� 2.0' x 5.0' CANT N ASPHALT ' PAVEMENT 4.0' x 14.5' BALCONY W/ 2.0' CANT BELOW rn SEPTIC MANHOLE 0 SEPTIC,, PIPES I �8 x x \� \ 12.0' x 12.0' \ \ HOT 7U8 GAZEBO Lot 2 \ \ 10' UTIL.IiY EASEMENTS L=32.19' R=30.00' . '�' 0 , K 100.3' Z 51 �10E h6 0 R�510 Lot 8 38,284 s.f. 12.2' x 16.3' SHED N ...--CHAIN-LINK FENCE N 87'19'05"E 296. Lot 7 Z r PLOT PLAN AS BUILT X SCALE 1" = 50' GRID NW 255 Project No. 20-706/A1 ,,,, Associates, � 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lan & A S S o C i a t e S inc. (907) 522-6476 Phone 9 (907) 522-4625 Fax �oQaoo0p4�Q Professional Land Surveyors kenmlangsurvey.como O F A �p jonathan®langsurvey.com '� ,0 I hereby certify that I have surveyed the following described property: LOT 8, BLOCK 2, TIMBER RIDGE SUBDIVISION (Plat No. 70-219) G' * 49TH**' Anchorage Recording District, Alaska, and that the Improvements situated thereon are""""""""" """"""i within the property lines and do not encroach onto the property adjacent thereto, that no improvements on the property lying adjacent thereto encroach on the surveyed 0�', ICENN tAN premises and that there are no roadways, transmission lines or other visible �, o G easements on sold property except as indicated hereon. ' Dated this the �Da of I`U+s��»>-ice 'ca L �q p LS 5202.•' gJp y at Anchorage, Alaska ,o 40QROFESSIONAG 1 A� It is the responsibility of the owner to determine the existence of any easements, �4pppoQ� covenants, or restrictions which do not appear on the recorded subdivision plat. AECC963 0 , MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH 8 HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. N 050-321-26-000 1. 2. 3. 4. GENERAL INFORMATION Complete legal description Timber Ridge, Lot 8, Block 2 T14N R1W Sec.6 Location (site address or directions) NHN Upper Skyline Drive, Eagle River Property owner Sydney H 1f nagle Day phone 694-9746 Mailing address P.O. Box 770102, Eagle River, AK 99577 Lending agency Northland Mortgage/Barbara Day phone 274-5150 Mailing address 2605 Denali, Suite 100, Anchorage, AK 99503 Agent N/A Day phone Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4 TYPE OF WATER SUPPLY: Individual well X 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 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. 72-025(Rw.1/91) P"t MOA.21 lu row *g W "W om '>IJom sJaaut6ua puotssa;oJd ayi ui suotss!wo Jo siono Jo; elglsuodsoi lou st o6eJoyouV Io Al!ledlotunr4 syl •pansst st aleo!I!1Jao a eJo;aq eiep azAleue Jo suotioadsut ionpuoo lou op SHHo;o saaAold w3 •sluawaimbaJ aiels pue leJapal u!evao A;s!les o1 JapJo u! suotln;l;su! 6u!pual Jlayl pue sawoy;o siaseyoJnd of Asalinoo a se sty1 saop SHH4 sy,J_ *uXselV Io alelS syl u! paJalsl6aJ Jaou!6ua leuo!ssa;ad luepuadapu! ue Ag anoge 9 ydeJ6eJed u! uaA!6 suo!3eluasaJdej 6y1 uodn Aluo paseq sale3!1!U90 lenaddy Al!JoylnV 411eaH sanssi (SHHO) saDINDS uewnH pue yileaH;o luawpvdap e6eJoyouV;o Al!led!o!unVq eyl �3 4 :Ag sluawwoO leuoll!ppV muopelnd!ls 6utmollo; ayl yl!m 'swooJpaq Jo; lenoJdde Ieuotl!puoO Ic,ot g tN ........... m` •panaddss14 •swooJpoq JO) panoJddy i {� aunIVNDIS SHH4 '9 0.��}�.w dr aleQ eJnleu6!s sl99u!6u3 LLS66 XV '=anti; aTbeg '66ZELL xog 'O'd ssolppV S6TS-669 auoyd sooTA3aS b[rcxaauibug zaATH aT612g wJ13 Io awsN •uotloadsut slyl Io eiep eill uo loa;;a ut suol35ln6aJ pue 'saoueulpJo 'sapoo alelS pue ledtotunVq Ile qpm aouetldwoo ut sl welsAs tesodslp Jolemalsem Jo/pue Alddns Jalem alts-uo ayi 'uotloadsut pue uolle6l3sanut Aw woJl pue soli; e65JoyouV;o Ailledlo!unlnl eyl woJ; pautelgo uo!lewJolut eyl uo paseq Imp AI!JaAJayiJnl I •utaJay pa3eolput ainlonJls;o adAl pue swooJpaq Io Jagwnu ay1 Jo; a3enbape pue leuotioun; •a;es st walsAs tesodslp Jalemalsem Jo/pue Alddns Jalem alts-uo ayl lsyl smogs uotleolldde IsnoiddV AluoyinV yl!eaH slyl Io uolie6rlsanu! Aw Ieyl A;lJaA I 'molaq umoys alep uolleplleA ayi Io se pus olaJay pax!I;e leas Aw Aq pall!1J03 sy 833NIJN3 AB NOLLOUSNl 30 1NBIWILVIS 'S Municipality of Anchorage ARL Department of Health & Human Services AULAlow HEALTH AUTHORITY APPROVAL CHECKLIST CUIEW Legal Description: V&g6e R/D66, LOT 8 &0ak9 Parcel I.D. 050 - 32/ - 2(0 -006 A. WELL DATA Well type PRIV476 If A, B, or C, attach ADEC letter. ADEC water system number / J -d Log present (Y/N) yEs Date completed 03.Z F& Driller 5 21-01/AA1 Total depth 2 Cased to 66, S 'r Casing height /.75 i Sanitary seal (Y/N) %/E 5 Wires property protected (Y/N) yr -5 Date of test Static water level Well flow Pump level FROM WELL LOG �h/J 2.'15 9 -p.m z W AT INSPECTION " n */9 / m L1J > ff9' N cc :> o 6. S g.P T N �• LU 20P z tVLt 9 SEPARATION DISTANCES FROM WELL TO: ZW Septic/holding tank on lot —� ; On adjacent lots 160 1 - Absorption Absorption field on lot ; On adjacent lots /O6' 4 - Public sewer main /t1�f1 Public sewer manhole/cleanout UTA .&sb3i-- sewer service line /� Petroleum tank SIA WATER SAMPLE RESULTS: Coliform _ Nitrate Other bacteria Date of sample: f) $A? OZ9 / Collected by: F�uh/ vFEk2 B. SEPTIC/HOLDING TANK DATA Date Installed 0 21_G Tank size 1250 Compartments Cleanouts (Y/N) yFs Foundation cleanout (Y/N) %e� Depression (Y/N) A/D High water alarm (Y/N) Alarm tested (Y/N) N1� Date of pumping SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s)onlot 1100 46'7Onadjacent lots 100 4 Foundation �Or r � Topropertyline 3r Absorptionfield /0 Water main/service line Surface water/drainage 72-M (Ft". 191)FrMt MOA 21 CONTINUED ON BACK PAGE C. LIFTS�LOn 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 Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA On adjacent lots _ tested Surface water Date Installed��J�1i�a Soil rating 137 System type ENC Length'' 7 r Width 2.5 L Gravel thickness /n Total depth 112L Total absorption area [U Cleanouts present (Y/N) %/i�S C Z ) Depression over field (Y/N) NO Date of adequacy test aF —U)— Results Results (pass/fail) PASS lld6k) for % bedrooms Peroxide treatment (past 12 months) (Y/N) /y0 If yes, give date 11A SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot 100 4- On adjacent lots - /Q0 V- property line is To building foundation a S'- existing or abandoned system on lot "'I4 Onadjacentlots fi3n' Cutbank '"1A Water main/service line to' Surface water NIA Driveway, parking/vehicle storage area Irv' Curtain drain E. ENGINEER'S CERTIFICATION I certily that I have checked, verified, or conformed to all M0A and NAA guidelines in effect on the.�ate of this Inspection. ^'�0F .••'.... ... Arc,y Signature Le...✓ .CS.., Engineer's Name ?f"— .•..>.ca.. .. ........... , • Date HAA Fee $ J %O. Q71 Waiver Fee: $ Date of Payment Date of Payment Receipt Number �! 3 412/ l S� , Receipt Number 72-M(Rm. X1(13 ck MOA 21