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SEAVIEW HEIGHTS BLK 2 LT 6 (LT 16)
Height lock 2 Lot 6 (lot 16) 011-261 -11 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMEt~ITAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME MAILING ADDRESS LEGAL DESCRIPTION PHONE '&7 ~-q¥// [] NEW [] UPGRADE LOCATION 5om e P (ace Well I o IDISTANCE TO: I I Manufa~{urer I ILiq. capacity ~n gallons ' ~ IF HOMEMADE: ~ ~ ~ Manufacturer Q Well ~ ~ DISTANCE TO: ~ · Topof~eltofinishgr!de ~ Length Width ¢ ~ J Type of crib Crib diameter ~ DISTANCE TO: Well ~ Class ~ /_ Depth ~ I DISTANCE TO Buildin~fsu~dati°n ~- DImO/'lO~ ~'/V/ NO. OF BEDROOMS Absorption area Dwelling PERMIT NO. i Oo ' ~ '3 7 ' ~ ~306- Mate~%E ( No. of compartments Inside length Width Liquid depth Dwelling PERMIT NO. Liquid capacity in gallons Foundation /7' Total length of lines Material beneath tile Material Nearestlotline la ,~ ' Trench width PERMIT NO. Distance between lines 6 inches Depth PERMIT NO, Crib depth Total effective absorption area Building foundation Nearest lot line DriLlerl~ ,'fl Sewer line OTHER PIPE MATERIALS SOIL TEST RATING INSTALLER R EMAR KS , Total effective absorption area 970 m' Dista~_e~to lot line Septic tank I0~~ PERMIT NO, Absorption area(s) APPROVED DATE LEGAL 72-013 (Rev. 3/78) i ' t ?. O. 6650 AIN~,H~.,R~,G~. ALASKA 9950£-0650 ~'cn'~ 264-4111 T iSNv 4 i,q 'r .:~: F' DEPARTMENT OF HEALTH & HUMAN SERVICES January 10, 1986 TO: Permit Applicant Subject: Permit # 850305 Lot 16 Block 2 Seaview Heights Subdivision A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 1985. 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 pvivate engineer inspected the installation of the on-site sewer system the original as-built inspection report(three part form) 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, Susan E. Oswalt Program Manager On-site Services SEO/ljw enc: Copy of Permit MUN I C I ~i~L I T.Y' Q~--- DEPARTMENT []~EALTH AND ENVIRONMENTAL ~TECTION 825 L STREET., ANCHORAGE,. AK: 9950 ON--S I TE SEWER ~ WELL. F'ERM I PERMIT NO: DATE ISSWED: 850505 06/17/85 APPLICANT: ADDRESS: CONTACT F'HONE: JEFF BROWN 1056 EAST 7TH AVEr #A ANCHORAGE, AK 99501 272-4411 LEGAL DESCRIP: LOT SIZE: LOT LOCATION: MAX BEDROOMS:' SUBDIVISION: SEAVIEW HEIGHTS SECTION: 9 TOWNSHIF': 12N 12000 (SQ. FT. OR ACRES) PER PLAT CASE ~5504 - BLOCK 2 LOT: l& BLOCK: RANGE: 4W Listed below are the options available to you in designing your septic system. Choose the option that best fits your site. DEPTH TO PIPE BOTTOM (FT.) ~RAVEL DEPTH (FT.) TOTAL DEPTH (FT.) GRAVEL WIDTH (FT.) GRAVEL LENGTH (FT.) GRAVEL VOLUME (CU. YDS.> TANK SIZE (GALS) SOIL RATING (SQ.FT./BR) TRENCH BED W. DRAIN 4.0 4.0 4.0 2.0 0; 5 1.0 6; 0 4.5 5.0 2.5 21.0' 5.0 ' 181.0 ** 42.0 127.0 ** 41.9 52.7 ~5.5 1~000.0 ** 1~000.0 ** 1,000.0 ** 562 290 ** GRAVEL LENGTH > 75 FT. REQUIRES MULTIPLE RUNS (NOT EXCEEDING 75 FT. EACH) ** TANK MUST HAVE AT LEAST TWO COMPARTMENTS 'I certify that: u 1. I am ~amiliar with the requirements ~or on-site sewers and wells as set ~orth by the Municipality o~ Anchorage (MOA) and the State of Alaska. 2. I will install the system in accordance with all MOA codes and regulmtions, and in compliance with the design criteria of this permit. 5. I will adhere to all MOA and State o~ Alaska requirements for the set back distances from any existing 'well, wastewate.r 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 2 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 '(5) THE ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN. APP'L I CAN'T: ISSUED. B Y _~4~_~~~ _~_~_~. DATE: DATE: I MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SOILS L(~G [~PERCO LATION TEST '?, O %/ SLOPE SiTE 'PL/~N - 1 2 3 4 5 6 WAS GROUND WATER ~.~ S ENCOUNTERED? t -. OL p' E IF YES, AT WHAT DEPTH? 9 10 11 12 13 14 15 .-~16 17 18 19 2O Reading Date Gross Net Depth to Net Time Time Water Drop COMMENTS ' ' ., PERFORMED BY: , ,_..~/~ ~ ~:~:~ CERTIFIED BY: PERCOLATION RATE q(~ (min~J~sl/inch) ' FT AND ~/' FT 72-008 (6/79) WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological ~ Geophysicol Surveys Drilling Permit No. LOCATION OF WELL (Please complete either la, lb or lc.) A.D.L. No. ,a.llBorough Subd~,~e,on Lot B,ock '/.,,re. Sec,,on No. To..e,,,,O .o.0o Anch 1 6 --of--of--of- S~ W~ lc.ii DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS ' 5. OWNER OF WELL: Seaview Heights ~"~: ~ ~- Street Address end Areo of Well Locmfion 2. WELL LOG Feet Below 4. WE~h~EPTH: (final) 5. D~TE OF C~MPLETI~ Surfoce ~v~ ft. -- 0 _ Moteriol Type Top Bottom ~:~ ~' ~ ~ ~'Auger ~deffed ~ Bored ~ Other: her' si~ ~n .:~m~ ~0 100 ~ ,~=~.o. ~,.=..rg. gravel 1 50 1 65 8. CASIN~: ~ Threaded ~ Welded purple gray-silt-clay 165 1 ~0 4~. ~ ~.. ,o 205 ,. ~,p,h W.,,h,~.,~s./,. brn silt wet -. ~ .... ~ 18Q~) - ' ,~. i,. to ft. De~th Stickue ft. r~ gray-bla, ck sil't-w/grawel we1 190 199 9. FINISH OF WELL: cemente grave'L H20 199 205 Type: oDe~ h:.:'[,? Diameter: Slot/Mesh Size: Length: ~-~ ~[~ Set between ft. and ft. Backfilling Gravel pack I0. STATIC WATER LEVEL: ft. ~' ~ Above or ~ Below land surface Date Equipment used: II. PUMPING LEVEL below land surfaoe and YIELD __ft. after hrs. pumping ~ ~ g.p.m. ..... PALI~ r OF ANQ ....... DE~. ~ .... iO~GE : ft. after hrs. pumping g.p.m. , w.,, eNVIRO~ ~ ~ .... ~ Material: ~ Neat Cement ~ Other: Length of Drop Pipe ft. capacity g.p.m. '~:L:I V~[) 0Subm. 0 Jet 0 Centrifica, 0 Other 14. REMARKS: 16. WATER WELL CONTRACTOR'S CERTIFICATION: 15. Woter Temperature o ~ F ~ C / This well ~as drilted under my jurisdiction and this report is true to the best of my knowledge and belief; Alaska ~- ~l ~/Vern' '~~ "~ --1 Registered B~si~es~ ~eme Conlrecf hicense ~umber ~t~ Avion Street ,~nchorage~ AK 99516 ~ufborSzed Represenfefive Form O2-WWR (H/~I) Copy Di~fribufion~ WHITE-Stele D$G$, PIN~-Driller, CANArY-Customer MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519~6650 343-4744 Parcel I.D. # CERTiFiCATE OF HEALTH AUTHOR,TY APPROVAL FOR A SINGLE FAMILY DWELLING 011-261'-11 HAA# GENERAL INFORMATION Complete'legal description Lot 16; Block 2; Seaview Heights SubdiVision Location (site address or directions) 8610 Sommers Place Anchorage: AK Property owner Ed Gaynor Day phone Mailing address R61 ~ .qc~mm~=r.~ PI ~.~ Anchorage: AK Lending agency Day phone Mailing address Agent Kevin Hanrahan/Prudential Vista Day phone Address 245-7337 99502 223-9245 '4. Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 2 TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: XX If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 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 number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations'~t~('r?;~&ate of th; inspection. Name of Firm Phone ~'3 7-/- t 7 ~ Wa~tewater Cons~, Engineeds signature · Alaska Water & Wastewater Consultant, Engineering Se ices Pmv DHHS SIGNATURE ~ Approved for ~ ~0 bedrooms. Date (,, ./Z-/~'~' Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: ~'~'~ Z,t' J: ~~/'~ Date The Municipality of Anchorage Department of 'Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA ~ioip~lj~ Of Apohmrage i~ ~ C E J V J': ~~ dUN 02 ~ 82'5 L Street, ROOm 502 · Anchorage, Alaska 99501 · t~~[3~ A~ Authority ApproVal Checklist Parcel I.D.: (~77~' 2..-~'/-// I:f A, B, or C, attach. ADEC letter. IADEC water system' number Date completed q/~/o~--~ ! - Ca,~d to ~Q.O~' Casing height (above ~round) Wires proper~,y pr°tected~/N) Date. of test Static w~r ;level FROM WELL LOG ~/~/~. AT INSpIECTION Well produCtion I ~ g.p.m. ~--~' 5 g.p.m. WATER SAMPLERESULTS: Coliform Date. of sample: Nitrate ' ~' ~'~y//-' Other bacteria q ColleCted by: /~J~/J/l/(-, .~/3Q_.. B'~ SEPTI~BINQ TANK'DATA Dete.installed ~/2/~'/~Z Tank size /¢ 43 0 1Number of Compartments c~ Cleanout~/N) I Depression (Y/~ ~0 High ~r a~ l~¢ ~¢ me,,,~d Soil ,rating (g.p.ddff:,or ff~bdrm)',c~ q ~ System type ' 8~-~ Leah ~0 W~ ~/ Gravelthicknessbelow~pipe ~n Tot~,~th ~/~-- .~,.~w.~=n ~.. q~O ~ ~ =on.~,no .u~.,r..n,~) ~ o.,.--~n O.r=~ ~ ~ ,Date'~ad~a~t~t q/~! q'q Resul~ail) Pa~ .For ~ bedr~ms Fluid depth;in abSerption'~d'.beforer~e~t (in.); Fluid; depth ~' 5" (irl~)'Miflutes- later: ~¢0 Pero~ide:,treatmem'(past, 12 months:.):('(IN) 72-026 (Rev. 3/96)* Immediately afterb°5 gal. wa{er.added (in.): ..f-. = ~:3d~O g.p.d. If yes, give date. ,, D. LIFT STAllON E= Date installed Manhole/Access (Y/N) SEPARATION DISTAN~S ~at*'. "Pump, off'~ level ~*- *Datum Abserptien field on lot Public sewer main Sewer/septic, serVice line' SEPARATION DISTANCES FROM WELL ON LOT TO: 'Septic/holding tank on lot /~ ~ ;Qn adjacent lots On adjacent lots Public sewer manhole/cleanOut /f~//~ Lift station" '~'" ' "/~///~ SEPARATION' DISTANCES PROM SEPTIC/HOLDING TANK ON LOT TO: /' / 'Foundation ~ 'J'" ' . Propertyline /~) ''/'' AbsorptiOn field Water main/serVice~line /~ ~'- Surface water/drainage/~?~ ~' Wells on adjacent lots $EPARATION DISTANCE FROM ABSORPTION 'FIELD ON LOT TO: PrOperty line - ~/~:) /''/'- Building foundation /~:) '/- Su.rface~water '/~0 ~- Cu~ain drain Water main/serVice line Driveway, parking/vehicle stom§earea/ . Wells on adjacent lots. Engineeffs:Name Date andreview HAA Fe~ $ Date of Payment.. ReceiptNumb*er L 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment .... Receipt' Number. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # APi:;RCVAL FOR A SINGLE FAMILY DWELLING 0 II-- ~6 / -- I( HAA# ...... GENERAL i~'~FORf~ATION. C;omplete le2al de;;cription 20 -c [,.ocation (site address or directions. P;~per(y ow,~er Mailing addraSs Lending agency Mailing address Agent AddreSs Day phone Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~ TYPE OF WATER SUPPLY: Individual well X Community well Public water NOTE: TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site If community well system, provide written confirmation from State ADEC attest- ing td the legality and status of system. Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and sfatus of system,. 72-025 (Rev. 1/91) Front MOA 221 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 number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. S & S ENGINEERING ~'~ ~ - ~. ~ -7 ~) Name of Firm 17~,.~4~=u,~ ........... ,.,.~, L~p ~.~oC ~;~, -':c4 Phone Address Eagle River, Alaska 99577 Engineer's signature ~,~f~Z ~ .. Date z-~//,.r-lq7 DHHS SIGNATURE ·/~ Approved for ~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By:" / ./ ~he M~'~'ici~ality of ~r;~h0rage Department of Health and Human Services (DHHS)issues Health Authority · ~Ppr. oVal C~tificat~aSed only upon the representations given in paragraph 5 above by an independent profess,onal engJneer 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. Em ployees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025(Rev. 1/91) Back MOA#21 ~AL ~ER¥~CES DIVISION 825, L ~reet, Room 502*Anchorage, Alaska 99501 * (907) 3~3,4744 Legal Description: L.o T' I ~. A. WELLDATA Well type PR t ~4- ~ F_ Log present ~N) Total depth ~O ~' If A,' B, or C, a~ach ADEC letter, ADEC water system number Sanitary Seal :,~)/N) Date completed ! Cased to ~,0 .~ ; Casing height (above,ground) Wires properly proteCted :~/N) Date of test StatiC water, level FROM WELL-LOG Well prod~Uction I ~ WATER SAMPLE~RESULTS: g.p.m. AT INSPECTION ! g.p.m. Coliform o Date, installed R'/9 3 / f:~' Tank Size Nitrate Collected by: Other~bacteria O S &$EI~ING 17034 Ea~le Ri~ ~Eea~ i~',2~4 loc0 ~-~. Number'ofCompartments ~% cleanouts~lN) 'Depression (Y/~ ~ 0 Highrwater alarm ~ ~vO Soil rating (g~p.d:/~-o~~. ,3 ~JO System :type ~ ~).:'~ Gravel thickness~ below pipe O. ~' Total ~p~ Effe~.~r~:~/.~ ~'~'~itor~g Tube present ~) y~5. ~m~ over ~id.~ '~ ...'.--..' ,~,~...~ . . · . D~e~of~~est ~/~3 'q 7 'R~ts~Fail] ~'~'~ For bedrooms Ftuid:depthin abseq~tion i~-betOre test(in.); Fluid.,depth. z/- (k~s) Minutes: later: Peroxide, treaO~ent -(past 12 ,months)', (Y/NJ Immediately after gal. ,~ added (in.): = .g.p.d. ~]f.yes, give:date 72-026 (Rev. 3/96)* D, MFT~A*T ~f~N Date installed Manhole/Access (Y/N) H. igh water :alarmJevel att' · size~in g~llons "~Pump off" level at* R SEPARATI~ DISTANC:ES FROM.WELLON~LOT TO: ~irtg ~tank:on lot AbseR~on field:On lot ! 0 o Pub[~ sewer~main. N / 4 SeW/.~-~fic se~"li~., SEPARA*I~;,~ANGESI~OLDING TANK-ON .LOT TO: / Foundation Pro~ line Water mair~/service line .~.0. '~ Surfaoe water/drai,nage / 00 ~ Wells on adjacent,lets · On adjacent lots On adjacent lots Public sewer ~manhole/cleaneut ! ! ! oO "~ SEPA'RATIONDIS~TANCE'~::~OM~:ABSORPTION FIELD. 'ON LOT TO: . Prop~;,line. Su~ :water .~ ~. '~Mi~. ~ foUndation 3- o Water main/sewice.line Driveway, parkingNehicle storage area ~r 8 .~, ~ /=,w,,/~ -.' Wells on adjacent :tots / o '3 Eng~er's .Name.. Date ,Date ofr Pey~t 72-026,,(Re,~. 3/96)* Waiver FeeS Date.of. Payment Receipt Number ~~i' ' ~ ' .~-...:..i.:.~,...:,_.?,,.: ...... :~.: ~. '~ ~/- ~.2 z-~" ':' ~' I PRLTDENTIAL VISTA RE.iL E ...................................... i ...... : ........ ii~.~ ~;,:' ....... 1" ~8~M~NT$ O~ R~GORO, OTHER ThAN ~a~.~<.=~.~" i AS-BUILT NO.CORNE, B8 SET THIS: DATE not o~laP ~ ~ero~ ~ ~e ~ro~e~ty lying a~s~nt ~ere- ~, ~et no ~p~v~en~ on p~per~y ~tng ~ja~nt ~ ~ on ~s p=e~ ~ qa~on and ~a~ ~ ~e nc FRED WA[,ATKA & ASSOC[ATtik~ Engineera and Surveyora 05/27f~9 THU 1~:58 FAX 907 582 5485 · '' PRUDENTIAL VISTA REAL E ! i EASEJVlENT$ OF REOORD, OTHER T~AN THOSE SHOWN ON THE RECORDED 'PLAT ARE NOT SHOWN HEREON ~h... i [ A$.llUILT NO.GORNER6 SET THIS DATE ,. FROM : RLRSKR WRTER & W~STEW~TER PHONE NO. : 907~383246 Jun. 04 1999 11:13~M P1 Alaska Water & Wastewater Consultants, Inc. 6901 Debarr Road, Suite 2-B ~ Anchorage ~ aska 99504 Phone (907) 3~7-6179 - Fax (907) 3~-3246 Consulting Engineers May 26, 1999 Ed Gay-nor c/o Prudential Vista Real Estate 4241 B Street Anchorage, Alaska 99503 Attn: Kevin Hanrahan Subject: Well & Septic System Inspection at Lot 16, Bk 2, Sea View Height S/D. 8610 Sommers Place. Dear Mr. Craynor, Per your request, we performed an evaluation of the well and septic system serving the subject property. The results of the field investigation and adequacy tests are summarY, ed as follows: WELL: Prior to the start of the test (5/19/99) the statb water level was 167 feet below the top of the casing (BTC). Over a period of 175 minutes, 605 gallons of water was pumped from the well (3,46 gallons per minute), during which time the liquid level in the casing remained unchanged. Based upon this data it was concluded that the well exceeds the MOA requirement for a 2 bedroom house (.21 gallons per minute). SEPTIC SYSTEM ADEQUACY TEST: The drainfield is a bed type system that was installed in September of 1985. It is my understanding that the system was inspected by S & S En~irieering in April of 1999 and was determined to be operamting in a surcharged (failed) condition. Per your comments, at that time, the drainfield was being flooded with spring runoff that was entering through a broken standpipe. It is my understanding, per your cornmerxts, that aider th~ pipe was repaired, and the runoff stopped, the level in the drain~ld, subsided. It is also my understanding that the septic tank was pumped on the following dates: · Northland Pumping: 4/7/99 · Northland Pumping (1000 gallons): 5/19/99 During our conversation on site (5/20/99) you indicated that on, or about, 5/13/99, Alaska Dminfield Restoration (Jerry Leach) introduced some microbial additive to your system which was supposed to eliminate the biomat, however, they did not Terralffi the system. FROM : ALASKA WATER & WASTEWATER PHONE NO. : 9073~83246 Jun. 04 1999 11:15AM P2 Page Two Lot 16; Block 2; Seaview Hts. On the day of our test (5/20/99) the liquid level in the drainfield was 4 inches below the drainpipe invert in the southeast sump, which is the only 'functional clem-out/monitoring tube in the system, Over a period of 175 minutes, 605 gallons were introduced into the drainfield, which caused the level to rise 7.125 inches (84.9 gallons per inch). The last 358 gallons introduced caused a rise of 3.125 inches. The recovery of the systean was monitored 23.25 hours later and the level in the field had dropped 3.125 inches, indicating that over 300 gallons bad been absorbed. It is important to note that the system had to be filled to 100% of its capacity in order to achieve this absorption rate. Prior to obtaining tirol approval of the system you will nccd to have the following repairs done: a. Locate the fa-st compartment clean-out on the septic tank, have it extended above grade, and have the first compartment of the taxtk pumped out. Have the pumper fax us a pumping receipt. b. Repair the monitoring tube located along the south end of the bed so that it extends 6 inches l~low the invert (bottom of the lateral drainpipe) elevation. I discussed with the MOA as to whether the two non-functional (severely bent) clean-out pipes, on the north side of the bed, will need to be repaired, and they indicated that it will not be necessary. NOTE: The adequa,~y o.f a septic system is influenced by numerous factors, including, but not limited to, seasonal surface water infiltration, groundwater variatior~,, septic system maintenance (frequency of septic tank pumping, usage of biological additives), condition of drain pipe and pipe joints (which can be damaged by seismic activity and deteriorate with age), type of substances deposited in septic system (cigarette butts, sanitary napkins, misc. objects), and the amount of water being introduced on a continual basis. Consequently, the results' of this adequacy test are only valid for the specific day of the test. Furthermore, because of the limited nature of this investigation, it is possible that there are hidden defects which may not have been detected. No warrantee is made regarding the future performance of this well or septic system If you have any questions contact me at 33%6179, or 244-9612. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & 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. # 011-261-11 HAA# HA930010 GENERAL INFORMATION Complete legaldescription Lot 16 Block 2 Tract 6 Sea View Subdivision Location (site address or directions) 8610 Sommer Place, Anchorage Property owner Patrick Mc Donald Day phone 248-1508 H 564-4131 W Mailin§address 8610 Sommer Place Anchorage Lending agency City Mortgage % Rita DalzernoaDayphone 277-0700 Mailing address 121 West Fireweed Lane, Anchorage, Alaska 99503 Agent Glen Carlson % Willawaw Realty Day phone 563-4010 Address 3333 Denali Street, Suite 220, Anchorage, Alaska 99503 Un/ess otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: NOTE: two ( 2 ) Individual well xxxxx Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: XXXXXXXX If community wastewater system, provide written confirmation from State AD£C attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 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 number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm S & S Enqineering Phone 694-2979 Address 17034 Eagle River Loop Road, Suite 204, Eagle River, Alaska Engineer's signature DHHS XXXX SIGNATURE Approved for two (2) Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/gl) Back MOA #21 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Lot 16; Block 2; Tract 6..- Sea Vi~2~ Heigh~ Location (site address or directions) 8610 Sommer PZace, Anchoraqe Property owner Mailing address Lending agency Mailing address Pa~_rx'_ck McDonald Day phone 8610 Sommer Place, A~chorage, Alaska City Mortgage/Rita Dalz'ernoa Day phone 121 W. F~.~.~.E la~.~ A~hn~ag~.~ A2a~.a 99503 248-1508 277-0700 Agent Glen Carlson / Willawaw Realty Day phone Address 3333 Denali, S~ite 220 Anchorage, Alaska 99503 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: NOTE: 563-4010 XXX Individual well Community well Public water If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. XXX TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 564-4131 72-025 (Rev. 1/91) Front MOA #21 '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 number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address Engineer's signature DHHS SIGNATURE Approved for .~-'~)(""~-'),. _ Disapproved. Conditional approval for 17034 Eagle ~iver Loop Road Phone bedrooms. bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does th is as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA #21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL, CHECKL,IST Legal Description: LoT I(,, i3LO~.~ 7_ 'rt~c.T ~. .rS ~ Parcel I.D. A. WELL DATA Well type FRWeTE If A, B, or C, attach ADEC letter. Log present (~/N) YES Date completed Total depth ~o5' ' ~ Cased to ~.05- t Sanitary seal (~N) YE.~' ~' Date of test Static water level I./AJK/vo~/J Well flow 1 ~' Pump level U Id K, MocWJ SEPARATION DISTANCES FROM WELL TO: Septic/~ tank on lot Absorption field on lot Public sewer main /do~JE Sewer service line ~'~ ~ FROM WELL LOG /oz. ADEC water system number ~ / ~ / ~.5" Driller V~r~5 l.~l~l/U~, 'f ~1:'. Casing height lO' Wires properly protected ~.~N) ~u_o AT INSPECTION /zlxl/'/z. o ; On adjacent lots I0O '/' ; On adjacent lots /OO ~/- Public sewer manhole/cleanout ~O~&' P/z,Cj'~JF Petroleum tank tuo/.aE /quo~J/J WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate /~/, Collected by: Other bacteria 0//OO m / ~,¢ ._% E,J (., B. SEPTIC/I=I~III~I~ TANK DATA Date installed Cleanouts (~)'N) ~E~' High water alarm (Y~) /t)O Date of pumping /~1/~o/~ Tank size /~00 ~--_=~/- Compartments FoundatiOn cleanoutCN) ~/~'-~' '~ Depression (Y,~ Alarm tested (Y/N) "- Pumper ~¢' Ho,,t.4E SEPARATION DISTANCES FROM SEPTIC/-~IEI~II!tt~TANK TO: Well(s) on lot To property line Surface water/drainage ! Onadjacentlots /OO".-f- Foundation "'~? Absorption field ~'~ Water main/service line 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE Meets MOA electric~ SEPA~ANCE FROM LIFT STATION TO: .~et~on lot On adjacent lots D. ABSORPTION FIELD DATA Date installed ~ / ~ ' Total absorPtion area .Depression over field (Y~D Results p~/fail) Peroxide treatment (past 12 months) (Y/N) Soil rating Z ~(-.2 z:~ ~ System type G ra,_~el thickness __ Total depth ~(~ ~ %leanouts present {~N) Date of adequacy test for ~-- -'~ bedrooms If yes, give date ,~J///~' SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water //(~.3 ~-/- Curtain drain On adjacent lots /&3~/ Property line 19' To existing or abandoned system on lot Cutbank ~/,~ Water main/service line /0/~ Driveway, parking/vehicle storage area /'~ ~'/- E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in Signature Engineer's Name Date $ & S ENGINEERING 17034 Eagle Ri,ver Loop Road No. 204 Eagle/<iver, Alaska YY.~77 of this inspection. HAA Fee $ '~'-"~ Date of Payment Number 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lOt, block, sub. ti.vision, section, township, range) Lot 16 of tho ?.ccubdivisicn of Lot 6; Block 2; Seaview Heights Subdivision Location (address or directions) 8610 Sommers Place~ Anchorage, Alaska (b) Property owner HUD ¢111-036-330-203 Telephone'(home) Business Mailing Address (c) Lending Institution Mailing Address Telephone (d) Real Estate Company and Agent HARgmON PR©PRRmTRA/,7~Nn ~ube~ Address 4t05 Tu~nag~n~ An~h~g~ ~]aska 248-1717 Telephone V (e) Mail the HAA to the following address: (or check here~, if hold for pick up.) List contact person and day phone number below: S & S ENGINEERING/694-2979 17034 Eagle River Loop Road, Suite 204 Eagle River, Alaska 99577 2. TYPE OF RESIDENCE Singl'e-Family:~j~ Number of bedrooms 3. WATER SUPPLY Individual Well ~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site;~X: Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025 (Rev. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigati0~ of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional .and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm _,, & $ ENGh'4F.F-P-h~G Telephone 17'034 Eagle Ri>ter Loop Road No. 204 Address F..acjie ~:w:, ,.* ..... Date 6. DHHS APPROVAL Approved for ~ Approved Disapproved Terms of Conditional Approval The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated based only upon the representations given in paragraph $ above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements, Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 7/88) Back Page 2 of 2 RECEIVED. WELL DATA Well ClaSsification ~Z~;~ Ie -/~',~.n~]~ . IfA, B, C, D.E.C. Approved (Y/N) /~/i~ Well Log Present (Y/N) c~ . Date Completed fi' ~ - ~-~""/ Yield ~. ~ ~ona ~ Total Depth ~_~~Cased to ~ DC' Depth of Grouting ~ ~ (o - i~ - c~ O ~j Static Water Level ! I~ lc, Pump Set At ~)/~ ' k~UNt~OF AN~'~PA. LITY OF ANCHORAGE (MOA) '"y,O E~,vlc~s ol~tl~ Authority Approval (HAA) ENVi ~) CHECKLIST. FEBRUARy 1984 JBI 5 1.990 343-4'/44 Legal Description: II Sanitary Seal on Casing (Y/N) ~/ Depression Around Wellhead (Y/N) hJ Casing Height Above Ground Electrical Wiring in Conduit (Y/N) ; On Adjoining Lots { ~Oo ; On Adjoining Lots To Nearest PUblic Sewer Cleanout/Manhole -~ + ~ ~--------~J~O~V'~J~ ; Date I ! lDO SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot' ! ~ 2 To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments Bo SEPTIC/HOLDING TANK DATA Date Installed ~-.z ~-~- Size Standpipes (Y/N) ~1 t'l Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) k)/P, I ~ OO~,el No. of Compartments Air-tight Caps (Y/N) Foundation Cleanout (Y/N) ~ 6J Date Last Pumped /~ / ~ -- ~ 0 ;for /~/~ / Holding Tank High-Water Alarm (Y/N) .k)/~ Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well To Property Line ! ~ /'~ To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course Comments .'.~-D"/~('C_~ ~ONt,D~ ! · I ! To Building Foundation To Disposal Field ~ 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata ~ ~'/0 ~_./~. Type of System Design Date Installed ~ -- .2, ")r' - ~I~" ,//~' Length of Field / Width of Field ~ (::) Depth of Field Gravel Bed Thickness ~' ~'0 '~ Statndpipes Present (Y/N) Square Feet of Absortion Area Depression over Field (Y/N) Date of Last Adequacy. Test Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: ! To Water-Supply Well / / To Building Foundation Lot ~)/~ To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line ! 2.. ~- ; On Adjoining Lots To EXisting or Abandoned System on / %o To Cutback (if present) Comments D. LIFT STATION Date Installed ' Size in Gallons: "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes(Y/N) 'N,, Comments Dimensions Manhole/ACcess (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. $ & $ ENGINEERING Signed ilO;~4 ,-agie Ki.ver i.oep Road No. 204 Company Ea_ele River: Alaska 99577 Date ~///~ 5'"~/~'''~ MOA No. (~ / ~'~/-- ~--~ ReceiptNo ,=~-/~/' /~'/(::~ [~_~0..3-..~ ReceiptNo. DateofPa~ment- ' ~ ' / ~ ~ ~ Waiver Fee:$ Amount: $ / 7 ~ 0 ~ Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date 7-1,-86 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 16, Block 2, Seaview Heights Sbbd. Location (address or directions) S0mmer Drive (b) Applicant Name jeff Brown Applicant Address 236 W. 10th (c) Telephone: Home Business 276'~4411 Anchorage, Alaska Applicant is (check one): Lending Institution !-1. Owner/builder"~] · Buyer I-1' Other [] (explain); (d) Lending Institution Northern~Mortgage Address Anchorage (e) Real Estate Company and Agent None Address Telephone Telephone (f) Mail the HAA to the following address: Hold for pick I.~.p TYPE OF RESIDENCE Single-Family I~1 Multi-Family [] Number of Bedrooms Z~ Other Onsite [] Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation attesting to the legality and status. - . ': Page 1 of 2 WATER SUPPLY Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL vironmental Conservation "si C .o.t. c. ' : Dl. T E E R , AND INFORMATION :5: :' ENGiNEERiNG FiRM i': AUthOritY APproval 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 °btained 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_~pection. . ' . ~ .~. ~ Datum £n§'lnee¥"]ng end Sur'Ve..V'in§' ':.Telephone 563:3].42 !:~' : .. : AddreSs~i' 4500 Business Pa~.k B'lvd, . :': :Date: :i: ::, 7.:t:86 :,: ,: ' ; ;:,: :. · :: ~ : ; ::::: :.::~.:.. 6.DHEP APPROVAL Appr0ve~ for · ~: ,Apl~'rove:d ~ii,.~ .. Engi'nee¢'s seal ,~,~c~: ~__.~__/~edroOms by ~~'~-' ~ ~'~'~ . Conditional 3nal ~Pi~;al :::-,:.:'.: .. ,.,,, :~?~i::, ~.,.. CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certific-.~tes based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP doeS this as a courtesy to purchasers of homes and their lending institutions in order to S'atisfy certain federal and ~s~ate ~equirem~nts. Employees of DHEPdo not conduct inspeCtionS:hr analyze data before'a certificate is issued. The Municipality of'Anchorage is not responsible for errors or omissions i~ the professional engineer's work. .:,?,,: .... ..-~ Page 2 of 2 : 72-025 (11/84) WELL DATA MUNICIPALITY OF ANCHORAGE ,(MOA'~' HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 Lot 16, Legal Description: Seaview Heights B1 ock 2N,° -u~-z°~d IYLN:I~/NO~llAN~ Subd. aeVaOH~N¥ :~3 Well Classification Private Well Log Present ('~'/N) yes Total Depth 205 ' ~ Cased to 205 ' ~ Static Water Level Casing Height Above Ground 10mm Electrical Wiring in Conduit '(Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot If A, B, C, D.E.C. Approved (Y/N) Date Completed 9-9-85 v" Yield Depth of Grouting N/A Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) 15 G.P.M? yes no 100+ 100+ 100+ g'Z:~'~' ~.,__~.~...~, On Adjoining Lots 100+--: To Nearest Edge 0f Absorption Field on Lot ,"<~,~ ; On Adjoining Lots To Nearest Public Sewer Line Clean0ut/Manhole Water Sample Collected by Water SamPle Test Results comments N/A To Nearest Public Sewer To Nearest Sewer Service Line on Lot ~-r~ ; Date ,-~-~,4-~,~ ? Negative Col iform - ~,,,"n.~'~,~.--ro~-f' ,.,,-""? 50' SEPTIC/HOLDING TANK DATA Date Installed 9-27-.~~Size 1000 gal Standpipes (Y/N) .)/es Air-tight Caps (Y/N) Depression over Tank (Y/N) no Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) no Separation Distances from Septic/Holding Tank: No. of Compartments 2 yes Foundation Cleanout (Y/N) yes Date Last Pumped new system N/A ;for Temporary Holding Tank Permit (Y/N) no To Water-Supply Well 100+ To Property Line 15 m to south TO Water Main/Service Line 3(3'+ Course none property line To Building Foundation 37' To Disposal Field 6' +. or'- To Stream, Pond, Lake, or Major Drainage Comments 2(3' south is neighbors absorption field Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed 9-?-R5 Width of Field 30' x 33' 29O ft2/ Length of Field 30' (X 5 Depth of Field 4' + Gravel Bed Thickness Standpipes Present (Y/N) 990' ~ B.R. "" Type of System Design Bed lines) 150' total yes Square Feet of AbsorptiOn Area Depression over Field (Y/N) rio Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot N/A To Water Main/Service Line !00+ ?~' + - 30' +- To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Cut bank present up hill of Date of Last Adequacy Test N/A new system /~,,¢~6~/~1~6 Proper~y Line 24' tn _~outh property 1 ine ~/~'" ~ '~'~.//~ TO Existing or Abandoned System on On Adjoining Lots To Cutbank (if present) N/^ 15' +- system where driveway was cut in approximately 8' high. D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Pj~-~'te~ Bedroom Rating Against HAA Request ** I certify ~C~ed,,~l./~_ conformed to all MOA and HAA guidelines in effect on the date of this inspection. signed ~ /_/~'~' //"~'~'--' - D~te 7-1-86 Company Datum Fngin~mring MOA No. ST 85'294 Receipt No. Date of Payment ' Amount: $ ~., ?.. 4.~t, Page2 of 2 ' 72-026 (11/84)