Loading...
HomeMy WebLinkAboutHIGH HOME BLK 1 LT 2High Horne Block 1 Lot 2 #050-321-60 Drilling Permit Number: SW� — I Identification Number: Description H 1 GN klolA installation Date:. Intake Depth Below Top of Well Casing: 232 feet ) Manufacturer's Name: ¢( V AAn? dc- .Id ,Model; AVIO ;7$ P3i.7V�S Size 3/y hp s Adapter Burial Depth: / d feet s Adapter Manufacturer's Naoae: s.�.t.aiater osta`:der: ris.'a feCi3u ilp Jit tx1 �9•T.'lsir.':tet9oa: ;T ta1T Log Date of lssue: _L/z+/;,IZ Prroparty n ner Name & Address: l R'7 1(0 PFS' 44, .avy R.j- PumpinsWlerNime: ��cnayl �dwl�r=l 4WP-S ©Sb-- 301-(ao Attention: The pump installer shall provide a pump imtaliaticu log to thl DSD within 30 days of puttp installation. 39dd '-NT 'SdMV Zt,LOCVZL©G er:ea ZTK/S©/Z.T Marc Begic7 Mayor _;,:n; •. Pump Installatio Drilling Permit Number: SW� — I Identification Number: Description H 1 GN klolA installation Date:. Intake Depth Below Top of Well Casing: 232 feet ) Manufacturer's Name: ¢( V AAn? dc- .Id ,Model; AVIO ;7$ P3i.7V�S Size 3/y hp s Adapter Burial Depth: / d feet s Adapter Manufacturer's Naoae: s.�.t.aiater osta`:der: ris.'a feCi3u ilp Jit tx1 �9•T.'lsir.':tet9oa: ;T ta1T Log Date of lssue: _L/z+/;,IZ Prroparty n ner Name & Address: l R'7 1(0 PFS' 44, .avy R.j- PumpinsWlerNime: ��cnayl �dwl�r=l 4WP-S ©Sb-- 301-(ao Attention: The pump installer shall provide a pump imtaliaticu log to thl DSD within 30 days of puttp installation. 39dd '-NT 'SdMV Zt,LOCVZL©G er:ea ZTK/S©/Z.T MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION PHONE / /`U4 -L NEW NAME — � _ MMK John/Kathleen H2U50Y T[( 7'� UPGRADE 'ri/Kathleen fi LEGAL DESCRIPTION G a 13 ft/4! /7//0�/c-s, _ LOCATION _5 ec 7-/ creCLr s� NO. OF B ROOMS Uy DISTANCE TO: Well AbsoJ "on area !� yl- ©� i/^, 7 ell�ng �� PERMIT N0. ,-5-0® �13 ww Z Manufacturer �/S� Mat` I � � No. of comp` ents Liq. capacity in gallons ?Q�+• i IF HOMEMADE: Inside length Width Liquid depth - DISTANCE T0: Well Dwelling PERMIT NO. I D`Z Oz H ___ Manufacturer _ _ Material _ Liquid capacity in gallons O w 2 DISTANCE TO: - Well �� �'�(J'-i7 Foundation,,, + � Near st lotfjpe� ; /"6 PERMIT NO. x LL ZNo. P Z ut of lines Len f Ca/ch line / W Totals qg of lines /'` Trench width v Distancebetweet� lines f Q F Top finish de _inches Material beneath file Total effect e ab�sorptio area of file to gr �• / a fel inches5 G Length e Width Depth PERMIT NO. ILIA QF- Type of crib Crib diameter Crib depth Total effective absorption area Wp' Lu DISTANCE TO: Well Building foundation Nearest lot line J Class Depth Driller® Distance to lot line PERMIT NO. J w Building foundation Sewer line � DISTANCE TO: Septic tank Absorption areas) (gyp e Y eCArt OTHER PIPE MATERIALS �� sre� ` c — SOIL TEST RATING 19/ Z 7" e 5 CL)i4L (�C: 2 CN) K 4C71n)�- REMARKS— �[ t2 c) (p�' eDMir •il t 9• �_ it _ ��.`� fi ? £ d c �a� NO. _173111-L �ifsjan - .n ,i7 4 ii �3 `�'�f �.i1�� .� S t `Y• '.e hr — __ APPROVED DATE / -W-7 LEGAL AA��%�� / /,( 1-'K00-kq 1�v15'��►�r� a)NLC_,`3 r PERMIT NO: DATE ISSUED: APPLICANT: ADDRESS: CONTACT PHONE: LEGAL DESCRIP LOT SIZE: MAX BEDROOMS: 850093 04/09/85 JOHN & KATHLEEN HAUSER SRB 1320 EAGLE'RIVER RD EAGLE RIVER, AK 99577 694 5019 SUBDIVISION: HIGH HOME SECTION: 6 TOWNSHIP: 14N 34773 (SQ"FT. OR ACRES) 3 rF- s F do/? * '-� ,ff0 76 (/,E LOT: 2 BLOCK: 1 RANGE: 1W Listed below are the optionsilable to you in designing your scptic sysL em. Choose the optio: that best fits your site. ~T 170 RE I'voK7; RA fl�DrE�� DEPTH TO PIPE BOTTOM (FT.) 4.0 4.C) 4.0 GRAVEL DEPTH (FT.) 3.5 0.5 2,5 TOTAL DEPTH (FT.) 7"5 4.5 6.5 SRAVEL WIDTH (FT.) 2"5 GRAVEL LENGTH (FT.) 134.012).0 ** GRAVEL VOLUME (CU.YDS.) 49.7 44.5 IS TANK SIZE (GALS) 1�000"O 000.0 ** 1�000.� ** SOIL RATING (SQ"FT.MR) 312 264 312 ** GRAVEL LENGTH > 75 FT" REQUIRES MULTIPLE RUNS (NOT EXCEEDING 75 FT. EACH) ** TANK MUST HAVE AT LEAST TWO CDMPARTMENTS I certithat: 1" I am [amiliar with the requirements |or on-site Ewa wero and wells as set forth by the Municipality of Anchorage (MOA) and the State o[ Alaska. ` 2. I will insLall the system in accordance with all MOA codes and regulations� and in compliance with the design criteria oi this permit. 3" I will adhere to all MOA and Siate oi Alaska for, the set back dista:ces Orom any existing well� wastewater disposal system or public sewerage ��stem on this or an; adjacent or nearby lot. 4, I understand that this permit is valid [or a maximum of 3 bedrooms and any enlargement will require an additional permit. IF A LIFT STATION IS INSTALLED IN AN AREA COVERM BY MOA BUILDING CODESr THEN r. J. A BUILTS WI 'NOT B SPECTION REPORT; AND (3) 11 E ECTRICAL OR ECTRICIAN. DATE: APPLICANT: JOHN / ISSUED BY DATE: �� DEPARTMENT OF HEALTH AND ENVIRONMENTAL FROTECTION 825 L STREET� ANCHORAGE, AK 99501 264-4720 tip H 40 Ej X 1 All 171 ET TAT M 1 Q too W K 1. . L. I PERMIT NO: DATE ISSUED: APPLICANT: ADDRESS: CONTACT PHONE: LEGAL DESCRIP LOT SIZE: MAX BEDROOMS: 850093 04/09/85 JOHN & KATHLEEN HAUSER SRB 1320 EAGLE'RIVER RD EAGLE RIVER, AK 99577 694 5019 SUBDIVISION: HIGH HOME SECTION: 6 TOWNSHIP: 14N 34773 (SQ"FT. OR ACRES) 3 rF- s F do/? * '-� ,ff0 76 (/,E LOT: 2 BLOCK: 1 RANGE: 1W Listed below are the optionsilable to you in designing your scptic sysL em. Choose the optio: that best fits your site. ~T 170 RE I'voK7; RA fl�DrE�� DEPTH TO PIPE BOTTOM (FT.) 4.0 4.C) 4.0 GRAVEL DEPTH (FT.) 3.5 0.5 2,5 TOTAL DEPTH (FT.) 7"5 4.5 6.5 SRAVEL WIDTH (FT.) 2"5 GRAVEL LENGTH (FT.) 134.012).0 ** GRAVEL VOLUME (CU.YDS.) 49.7 44.5 IS TANK SIZE (GALS) 1�000"O 000.0 ** 1�000.� ** SOIL RATING (SQ"FT.MR) 312 264 312 ** GRAVEL LENGTH > 75 FT" REQUIRES MULTIPLE RUNS (NOT EXCEEDING 75 FT. EACH) ** TANK MUST HAVE AT LEAST TWO CDMPARTMENTS I certithat: 1" I am [amiliar with the requirements |or on-site Ewa wero and wells as set forth by the Municipality of Anchorage (MOA) and the State o[ Alaska. ` 2. I will insLall the system in accordance with all MOA codes and regulations� and in compliance with the design criteria oi this permit. 3" I will adhere to all MOA and Siate oi Alaska for, the set back dista:ces Orom any existing well� wastewater disposal system or public sewerage ��stem on this or an; adjacent or nearby lot. 4, I understand that this permit is valid [or a maximum of 3 bedrooms and any enlargement will require an additional permit. IF A LIFT STATION IS INSTALLED IN AN AREA COVERM BY MOA BUILDING CODESr THEN r. J. A BUILTS WI 'NOT B SPECTION REPORT; AND (3) 11 E ECTRICAL OR ECTRICIAN. DATE: APPLICANT: JOHN / ISSUED BY DATE: �� IIID ALASKA SOIL TESTING AND ENGINEERING 6100 A Street, Anchorage, Alaska 99502 (907) 561-7453 March 20, 1985 Cathy hauser 3120 ha.gle River Road r�agle River, AK 99577 subject: Lot 2, Bko 1, high dome 6ubd. wear iis. Hauser: Transmitted herein are the results of the soil investigation of the above referenced. site. The scope of work was restricted to determining the suitabi:Li.ty of the soil. for on --site wastewater disposal. This letter comprises our invoice in the amount of u450.00 (Four Hundred Fj,j.ty Dollars and No Cents) for services consisting of the soil exploration and percolation testing. Please call again if 1 may provide additional service. Very truly yours, Alaska 6oi.i Testing and Engineering Mark Iiolum, L.i,. ivianager PERFORMED FOR: LEGAL DESCRIPTION DEPTH (FEET) 1 GN 2 S 3 4 S 5 6 7 8 9 S 10 11 12 13 S 14- 15 16 17 1s 19 20 COMM GM. Illfix- ALI .(A SOIL TESTING AND EP .;INEERING 6100 A Street, Anchorage, Alaska 99502 (907) 561-7453 SOILS LOG 'fest Boring 1 SOILS LOG — PERCOLATION TEST Cathy Hauser DATE PERFORMED: Lot 21 Bk. 1, High= -Home Subd. ; Sec. 6, T14N, RIIJ., S.M. COMPLETED 3-11-85 WAS GROUND WATER NO S ENCOUNTERED? L (DRY 13.51— P IF YES, AT WHAT 3—].8-85) E DEPTH? SITE PLAN L'J PERCOLATION TEST 3—a.4.-85 Date SLOPE Net Time Depth to Water BROWN SILTY GRAVEL WITH I 3--ILt-85 12:44 pm 0 OCC. COBBLES AND BOULDERS, 2 " 1:02 D/+'ISP, DENSE (FRO'LEN 0' -5' ) 76 1/4 3 1:20 36 11 76 3/4 mum H' GRAIN 61ZE DIST. I'IG. 1 2: o4 0 to 77 0 MOIST.= 6% " 2:33 29 IT so 3//+ 11 6 " fv REFILL BROWN SILTY SAND, DAMP, DENSIS 7 It B1 GRAIN 61ZE DIST. FIG. 2 8 it INN BROWN SILTY GRAVEL 'vJ.ITH 76 3 4 IN mum It NUMEROUS COBBLES AND BOULDERS, MM 76 3/4 3/4 MIN DdI•SP, VERY DENSE 0 GRAIN 0-121E DIST. FIG. 3 0 HI01ST.= 3% COMPLETED 3-11-85 WAS GROUND WATER NO S ENCOUNTERED? L (DRY 13.51— P IF YES, AT WHAT 3—].8-85) E DEPTH? SITE PLAN L'J PERCOLATION TEST 3—a.4.-85 4g 2' " 5% 0'0 Reading Date Gross Time Net Time Depth to Water Net Drop I 3--ILt-85 12:44 pm 0 In 2 " 1:02 I 76 1/4 3 1:20 36 11 76 3/4 mum 4 2: o4 0 to 77 5 " 2:33 29 IT so 3//+ 11 6 " 2:49 REFILL 75 7 It 3:03 0 IT 8 it INN Mw 76 3 4 IN mum It 4:03 MM 76 3/4 3/4 MIN 4g 2' " 5% 0'0 Reading Date Gross Time Net Time Depth to Water Net Drop I 3--ILt-85 12:44 pm 0 75 3/4" 2 " 1:02 18 m:i.n. 76 1/4 3 1:20 36 11 76 3/4 4 2: o4 0 to 77 5 " 2:33 29 IT 77 3/4 3//+ 11 6 " 2:49 REFILL 75 7 It 3:03 0 IT 8 it 3:33 30 IT 76 3 4 9 It 4:03 3C f 76 3/4 3/4 PERCOLATION RATE 40 (minutes/inch) 6.3'e.�_ ��1t; (6 Inch ilia. Test Bor. TEST RUN BETWEEN ,g,)J"; �1VD �'I Ylight Auger. Samples adios s _ 11�71 n A Test boring located :in cleared area. PERFORMED BY: Mark Holum ST 85-260 3-20-85 CERTIFIED BY: / / TE: f'.'• MARK HOLOM "r' "1 Ck 5734 PERFORMED FOR: LEGAL DESCRIPTION: DEPTH IIIP�u� ALS CA SOIL TESTING AND Ef _;INEERING 6100 A Street, Anchorage, Alaska 99502 (907) 561-7453 L7 SOILS LOG Test Boring 2 SOILS LOG — PERCOLATION TEST K7 PERCOLATION TEST Cathy Hauser. 3-J-3-85 DATE PERFORMED: Lot 2, Bk. 1, High -Horne Subd.i Sec -6, T14N, RIW, S.11. (FEET) BROWN SILTY SAND, DAi4P 1 SM LOOSE, (FILL) 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 COMMENTS BROWN SILTY SAND WITH TRACE OF 0161iNICS AND OCC. COBBLES, DAMP, MEDIUM DENSE GRAIN SIZE DIST. FIG, t. srt M016T. _ 5% Gill PERFORMED BY: GRAIN Slur, DIST. FIG. 5 MOIST.- 8% SLOPE IJ 0 r-- �_ vt w BROWN SILTY GRAVEL WITH a OCCASIONAL COBBLES AND BOULDERS, DAMIDf Dc;NSE WAS GROUND WATER NO ENCOUNTERED? (DRY 13' 3T2o-85) IF YES, AT WHAT DEPTH? COMPLETED; 3-13-85 SITE PLAN S L O P E Reading Date Gross Time Net Time Depth to Water Net Drop 1 2 3-14-85 If 1:26 pm :4 0 mi.n. 1 " 26 1/2" 2, 1/4 3 4 " " 2:02 2:2' 36 Rk;FILI, 2'7 5/8 26 — 5 6 " 2:32 :02 0 0 27 1P 28 8 V8 7 3:32 30 29 1/4 7/8 " ■■��®��■IN S L O P E Reading Date Gross Time Net Time Depth to Water Net Drop 1 2 3-14-85 If 1:26 pm :4 0 mi.n. 1 " 26 1/2" 2, 1/4 3 4 " " 2:02 2:2' 36 Rk;FILI, 2'7 5/8 26 — 5 6 " 2:32 :02 0 0 27 1P 28 8 V8 7 3:32 30 29 1/4 7/8 " PERCOLATION RATE 34 _ _ TEST RUN BETWEEN —Z FT ANVzbN Flight Auger Samples^rr 0-i �r F _ , CERTIFIED BYipL' I`1ark Holum ST 85-26o (minutes/inch) n..—• FT (6111)ia `].'est Bor. ) Ai^.PK 1101 -UM TE: 3-2o-85 100 go x cz 80 w 70 m 60 m 50 Lu 40 ti 30 x Lu 20 G ¢ 10 W 4 0 o O o O O �o N i CBL U.S. STANDARD SIEVE SIZE SIEVE ANALYSIS HYDROMETER O O O �D -:r N H �o -' N r -i �'D -f N r- \10 -7 N H O O O O O O • O O O O GRAIN SIZE IN MILLIMETERS GRAVEL I SAND 1 FINES PROUcC'T Lot 2, Bk. 1, High -Home Suhd. CLIENT Cathy Hauser TEST BGRI\G OR PIT 1 6Ai',1PLE I DEPTH 2-2.5' UNIFIED SOIL CLnSSIFICATION GN FROST CLASSIFICNTION SOIL TEXTURAL CLASSIFICATION Silty Gravel U.S. STANDARD FER CENT SIEVE SIZE FNSSING 311 211 11/ztl loo 111 96 3/411 92 3/811 68 4 51 10 40 20 30 60 22 100 19 200 15 0.02 mm ALASKA s RAIN SIZE DISTRIBUTION TESTING AND ENGINEERING I FIGURE 1 U.S. STANDARD SIEVE SIZE �— SIEVE ANALYSIS HYDROMETER _ o O 10O D -t W\N 1-4 \ � c00 D O -t � O1 N ti go x 80 3 70 ' 60 to a 50 W x 40 ti 30 x W 20 V ¢ 10 W C. o O O �D Q O O �D -:I- N ri �o -I' N r-4 �o -7 N 1-1 �D -' N rl • O J O O O O O GRAIN SIZE IN MfLLIMETERS o 0 0 0 CBL GRAVEL I SAND— FINES PROJECT Lot 2, Bk. 11 High -Home Subd. CLIENT Cathy IIauser TLaT BGRItiG OR PIT 1 SAkIiPLE 2 DEPTH UNIFIED SOIL CLASSIFICATION SM FROST CLA16SIFICHTION SOIL TEXTURAL CLASSIFICATION Silty Sand U.S. STANDARD PER CENT SIEVE SIZE PASSING 311 211 1%211 100 111 99 3/411 96 3/81 85 4 67 10 S0 20 38 60 2J 100 �3 200 1.9 0.02 mm ALASKA SOIL BRAIN SIZE DISTRIE(ITION TESTING AND ENGINEERING FlGURE2 U.S. STANDARD SIEVE SIZE SIEVE ANALYSIS HYDROMETER O O o 0 0 o0 � ,a — 1G0�o ti 90 z m 80 W 3 70 ' 60 m m 50 W 40 k a 30 z W 20 U ¢ 10 W 4 G O O O O O O �0 _-,r N H �.O -' N N �1 O O �D � N 0 0 O O O O O O o 0 o O JGRAIN SIZE IN MILLIMETERS Fc—B—L7 GRAVEL I— SAND FINES PROJECT Lot 2, Bk. 1, High -Home SuUd. CLIENT Cathy Hauser TEoT BORING OR PIT l S,;i',iPLE 3 DEPTH 9-9.51 UNIFIED 601L CLASSIFICATION GM FROST CLASSIFICATION SOIL TEXTURAL CLASSIFICATION Silty Gravel U.S. STANDARD FER CENT SIEVE SIZE FASSING 311 211 1'/211 100 111 93 3/411 87 3/811 67 4 48 10 36 20 29 60 21 100 18 200 15 0.02 mm ALASKA TESTING SOIL AND RAIN SIZE DISTRIBUTION ENGINEERING FIGURE 3 100 I- go U.S. STANDARD SIEVE SIZE �� SIEVE ANALYSIS ���� HYDROMETER iii i iii IMI mi iliIll 111momm IN � 11111mmi����'►'�I�i mill� �I IIIIN I ■�INIIII�1 1 1 11111 Nil III�1 �H ■t � � �������� �IIIIIII�I ■II �� 111 1111 1/10101111 Mimi Milo■ PROJr;CT Lot 2, Bk. 1, High --Home Subd. CLIENT Cathy Hauser TEaT BGRIXG OR PIT 2 SAMPLE 2 DEPTH UNIFIr:D SOIL CLASSIFICATION SN FROST CLAS61FiCATION SOIL TEXTURAL CLASSIFICATION Silty Sand U.S. STANDARD FER CENT SIEVE SIZE FASSING 311 211 1'12 it 1" 3/4" 100 3/8" 99 4 96 10 go 20 83 60 68 100 58 200 46 0.02 mm 5-5.5' IALASKA SOIL IGRAIN SIZE DISTRIBUTION TESTING AND J ENGINEERING FIGURE s�U.S. STANDARD SIEVE SIRE �— SIEVE ANALYSIS HYDROMETER O O -- - O ADO O O O O �L) �- I+1 N r i ri N -zr �D 1 N IOO ti 90 z 0 80 W 70 60 m cc 50 W z s 40 Ll• 30 z W 20 v x 10 W a 0 O O O O O O �D -:f N H D -T N •-I I'D -f N ri \,D 7 N .-i O 0 �o �- N r-1 0 0 O O 0 0 O O c\ GRAIN SIZE IN MILLIMETERS 0 0 0 CBL I GRAVEL I SAND FINES PROJr,C'T Lot 2, Bk. 1, High --Home Subd. CLIENT Cathy Hauser TEo'I' BGRING OR PIT 2 6AViPLE 3 DEPTH 7-7.5' UNIFIED SOIL CLiiSSIFICATION SM FROST CLASSIFICATION SOIL TEXTURAL CLASSIFICATION Silty Sand U.S. STANDARD PER CENT SIEVE SI:E PASSING 311 2" 1'/z" 100 1" 98 3/4" 95 3/8 t t 83 4 73 10 65 20 54 60 40 100 30 200 18 0.02 mm ALASKA SOIL TESTING AND GRAIN SIZE DISTRIBUTI®N ENGINEERING FIGURE 5 LOC.rA'f ION OP WELL (Please complele either to, Ib or Is.) Boro oil Subdivision Lot Ib. I/4 qt rs. 7. USE: Q Domestic Irrigation El Test Well FBIJ.k r.`. _. of ( L/�.Ji ice•_ Ic1l DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS Sf rcu; A,G rase. and Arou of Well Location 2. WELL. LOG r'atorial Type IOU 1 01i�Ntl I IG, NAT Eli WE CON"rRACTOR'S CI". RTI F I CAI ION: 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. TownahipN� Range E❑ Meridian S❑ WE] 3. OWNER OF WELL: z Address t Feet Below 4. WELL DEPTH: (final) 5. DATE OF COMPLETION SurfaceC)r,' f 1. Top Bottom - _ g ,Q•bable tool 'U- Rotary E] Driven Dug _% ❑ Auger ❑ Jetted Q Bored Other: 7. USE: Q Domestic Irrigation El Test Well Public Supply Recharge 0 Other: E] Industry Commerical - - B. CASING: Ej Threaded r- diam. - in. to _ diam. into O Welded ff. Depth Weight Ibs./ft. ft. Depth Stickup ft. - m ❑ Subm. 0 Jet Ej Centrifical Other 9. FINISH OF WELL: Type: f'; ,'i' Slot/Mesh Size: Set between Backfilling _ / Diameter: Length: ft. and Gravel pack ft. Date - 10. STATIC WATER LEVEL:y-'> Above or E�j Equipment used: ft. Below land surface Date 11 . PUMPING LEVEL below land surface and YIEt,.D _ _ ? ft. after i hrs. pumping - - g.p.m. ft. after hrs. pumping g. p. m. 12. GROUTING Well Grouted: ❑ Yes n,No r•li,r Material: O Neat Cement E] Other: _ 13. PUMP: (if available) NP c ca Length of Drop Pipe ft. capacity g. p.m. m ❑ Subm. 0 Jet Ej Centrifical Other r a 14. REMARKS: z 0 1 15. Water Temperature -0 This Yr'01 s ar-'led inner my jurisdiction and this report is true to the best of my knowledge and belief' it r•li,r � d Business Name Contract License Number t-__71 Date - AthcriZejl-' Rc o res ental; vo °onn 02 -WW1? (il!81) Copy Dist-thution: WHITE-Stoto OGGS, PINK-Drillor, CANARY -Customer 0 0 r�(AP Municipality ®f Anch®ragOn-Site Water and Wastewater Program(907) 343-7904 JJCERTIFICATE OF ON-SITE SYSTEMS A S Parcel I.D. 050-321-60 Expiration Date: 1. GENERAL INFORMATION Complete legal description HIGH HOME BLOCK Location (site address) 18740 UPPER McCREARY ROAD EAGLE RIVER, AK 99577 Current Property owner(s) DEAN CIMMIYOTTI Day phone Mailing address Real Estate Agent 18740 UPPER McCREARY ROAD, EAGLE RIVER AK 99577 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual Individual Water Storage ❑ Holding Tank ❑ Community Class _Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Distance: Received by: Date: 5 (o COSA to be released to the engineer, unless oO ' requested by the engineer. COSA Fee $ Date of Payment �� g10 Receipt Number Oo 122-7 COSA# cbd(,PV40 Waiver Fee $ Date of Payment Receipt Number Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified;by*mV4,1 affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm ARCTERRA CONSULTING, INC. Phone 868-3791 Address 20441 PTARMIGAN BLVD., EAGLE RIVER AK 99577 Engineer's Printed Name KENNETH M. DU_FFUS Date 4/26/2016 Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future occupants or can ArcTerra guarantee that no unseen f oE� �� , encroachments, deficiencies or discrepancies exist. 0*1q,)TII P �, 6. DSD SIGNATURE xamnst System #1 Approved for bedrooms. c, f �¢ Cy System #2 Approved for bedrooms. 1sEo"/16 F'OFESSIOti�1i Disapproved. Conditional approval for bedrooms, with the following stipulations: Original Certificate Date: 5 i 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. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue shset_10-10-12.dw If more than 1 septic system is on the lot: COSA Checklist # _of _ Structure served by this system _ Certif cate of On -Site Systems -Approval Checklist Legal Description: HIGH HOME BLOCK 1, LOT 2 Parcel ID: 050.321.60 A. WELL DATA Well type PRVT If A, B, or C provide PWSID # Date completed 612311985 Sanitary seal (Y/N) Y Total depth 300 ft. Cased to 55' ft. FROM WELL LOG Date of test 6.23.85 Static water level 15 ft. Well production 0.5 g:p.m. Well Log (Y/N) Y Wires properly protected (YIN) Y Casing height (above ground) 24+ in. AT INSPECTION 3/31/2016 ft. 9.p -m. WATER SAMPLE RESULTS: Coliform NEG colonies/100 mL Nitrate `12.9 mg/L Arsenic: ND ug/L Date of sample: 3/3112016 Collected by: ARCTERRA B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC I STEEL Tank size 1000 gal. Number of Compartments 2 Foundation cleanout (Y/N) Y Depression over tank (Y/N) N Date of pumping 3/3012016 Pumper JRs C. ABSORPTION FIELD DATA Date installed 711985 Cleanouts (Y/N) Y High water alarm (Y/N) N Date installed 711985 Soil rating (g.p.d./fe orftz/bdrm) 312 System type TRENCH Length (70 & 66) 136 ft Width 3 ft. Gravel below pipe 3.5 ft. Total depth 10.6 ft. (Measured 3/31116) Eff. absorption area 952 fe Monitoring tube Y Depression over field N Date of adequacy test 3/3112016 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test 0 in. Water added 470 gal. New depth 29 In. Elapsed Time: 1080 min. Final fluid depth 0 in. Absorption rate >= 450+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date %�E D. LIFT STATION Date installed S¢e in gallons °Pumpoff"levelat_in_--"PuWaf levelat_in. Datum Cycles tested E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lit station on tot 1001+ Absorption field on lot 1001+ Public sewer main 751+ Sewer /septic service line 251+ Animal containment areas 501+ SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 51+ Manhole/Access (YIN)- High- Water YIN)High water alarm fevel-at- --- Meets alarm & circuit requirements? On adjacent lots 1001+ On adjacent lots 1001+ Public sewer manhole/cleanout 100'+ Holding tank 100'+ Manure/animal excrete storage areas 1001+ Absorption field 5'+ Water main 101+ Water service line 101+ Surface water 1001+ Wells on adjacent lots 1001+ ABSORPTION FIELD ON LOT TO: Property line 101+ Building foundation 101+ Water main 10'+ Water Service line 101+ Surface water 1001+ Driveway, parking/vehicle storage 10'+ Curtain drain 50'+(NONEKNOWN) Wells on adjacent lots 1001+ F. COMMENTS *No parts in the top 55'- see 907 Water Wells letter. Only the trench closest to the house was tested G. ENGINEER'S CERTIFICATION I certify that / have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Q ow Engineer's Printed Name KENNETH M. DUFFUS�,) Date 4126/2016 *LJ j TH COSAcanarysheet 2.IS-15.doc - rAW ot AV in. Municipality of Anchorage P� iiiilii l'=G� ' Development Services Department = Building Safety Division On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 Nitrate Advisory Certificate of On -Site Systems Approval # OSC161140 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 1, Lot 2 of High Home subdivision. This inspection revealed a nitrate concentration of 12.9 milligrams per liter (mg/L) was reported for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. u 0 C / pj jg� • Oj ASBUILT ypy�s7: xs�� - sT,7/ SEVARD" & ASSOCIATES LAND SUR IftG 694-0829 1 HEREBY CERTIFY THAT I HAVE SURVEYED THE SCALE woetw FOLLOWING DESCRIBED PROPERTY- , / -� OF At % 4� Y/_G///s11c1/ lo7Z-'I �.E . S AND THAT NO ENCROACHMENTS EXIST EXCEPT AS ;�16 fK INDICATED. IT IS THE RESPONSIBILITY OF THE i I% OWNER TO DETERMINE THE MOSTENCE OF ANY GRID s""' r`"'• EASEMENTS, COVENANTS, OR RESTRICTIONSwzsy���. WHICH DO NOT APPEAR ON THE RECORDED SUBDI- ii o„ ma, 5ew,.a VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD FE t� L5-5 %,t8� �� ANY DATA HEREON BE USED FOR'CONSTRUCTION � �`rr • /'. •Ices OFFENCE LINES, OR FOR ESTABLISHING BOUND- ARY LINES. DRAWN: RESIDS#ITIAL& COMMERCIAL WATER AND WELL &ERVIAMS 2411A AND EMBRGaNCY SRRVIORS AVAILABLE PRIM ESTIMATES John Afe 4 rt 6630 Earth" Ave Arxirorage Al®Sia ,p��y 49iOa 997-230-1$6$ ' Y — 1 $ 04/26/2016 In regards to the property located at 18740 Upper McCrary ( High Home Blk1Lot2) A well camera inspection was conducted on this property due to high nitrates the following observations were found. Well has proper conduit and well cap. Seal is intact and in good condition. Pitless adapter is sealed and ne evident leaks noticed. The well casing extends to 55'. No water entering through bottom of casing. First sign of water was at 60 feet with damp rock noticed. First sign of production is from 100 ft to 112 ft. Water entering at a rate of 1-2 g.p.m (visually). At further descent no significant increase of water is visible as upper zone produces enough to flood side walls with cascading water. S.W.L was at 88'. No signs of construction contributed causes were seen to lead to cause of nitrate levels found. Saw no cracks breaks or perforations in cased area of well. John Netherton 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 1. D. # i HAA # -DQLQ 1. GENERAL INFORMATION Complete legal description Lot 2; Block 1; High Home Subdivi6tion Location (site address or directions) 18740 upper. McCnany Rd. Eaa.2e Riven, AK 99577 Property owner FgED91E MAC c/U Bob Ba n Day phone 243-247�F Mailing address 3742 W. 42nd Avenue Anchorage, AK 99517 Lending agency Day phone Mailing address - Agent A ent "gonna Haynes/ VISTA REAL ESTATE Day phone 562-6464 Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well XXX Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site XXX 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. 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 furtherverify 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 ENGINEERING Address 17034 EtkV'_! Engineer's signatur�le River, 6. DHHS SIGNATURE Approved for Disapproved, Conditional approval for Additional Comments M bedrooms. Phone `� —2_g 7 % Date �6 //l / f15 'a : �q pr i� v, tt�yl.r;. ,11S tl Wt.,n .r.. _...moo ,u •. se [•K., ,`. b F ' 1}A L�-P �1"�7il: 4::i"tri\tet 5:11 bedrooms, with the following stipulations: Date 6 — Z 6 " �?3 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. 7911 5In— 11011 A—V UnA.11 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: �� 7- �'� ` �<<„� r'D�� S,� Parcel I.D. A. WELL DATA Well type Pe -1\J Q6-- If A, B, or C, attach ADEC letter. ADEC water system number LAP - Log present a/N) --_ Date completed �-3�`3 S — Driller '-P � Total depth -2'a —Cased to Casing height vz Sanitary seal iy) Date of test Static water level Well flow Pump level FROM WELL LOG �-25- 8<�-- Sk Wires properly protected &N) b.� 9 -p.m AT INSPECTION ;V - ii -- L Iii P C` 3 . ? 0 ` 1-0 g.p.r� rri CA 2�\ t E:) SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot � o0) \; On adjacent lots Absorption field on lot Public sewer main Sewer service line WATER SAMPLE RESULTS: t,004- k k- k d _ ; On adjacent lots \ b o - Public sewer manhole/cleanout ��a k Petroleum tank � _- Coliform C) Nitrate 2 I Other bacteria (o�`a -`13 (01 �3 Collected b S & S ENGINEERING �4 — Date of sample: �— Y 17 i-EaUt&4Nver kI; �R Eagle River, Alaska 99577 B. SEPTIC/HOLDING TANK DATA Date installed ' g'c Tank size k Compartments _ Cleanouts(�N) Foundation cleanout 'S''N) 4 -Depression (YQ AJ -- High water alarm (Y& — -Alarm tested (Y/N) I. -L � - Date of pumping ��� -`13 Pumper L _ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: � ar , •1- Well(s) on lot � o On au)acent lots I L�) L� Foundation Absorption :field Lv Water main/service line j �I- To property line l 5 In Surface water/drainage — \ C> 72-026 (Rev. 7191) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent(Y/N) High water alarm level Meets MOA electrical c "Pump on" level at Manufacturer Manhole/Access (Y SEPARATISIN'DISTAN CE FROM LIFT STATION TO: on lot D. ABSORPTION FIELD DATA On adjacent lots "Pump off" level at Cycles tested Surface water _ Date installed i —gam Soil rating 312 f System type i Length �-22 lamWidth �� Gravel thickness 3'S Total depth %, S� Total absorption area G1 `'�2I Cleanouts present 6 'N) Depression over field (Y/9- ^� Date of adequacy test Lo -7 cl3 Results as ail) Pb`for (Lfr� bedrooms Peroxide treatment (past 12 months) (YLU 42 �� 0 v -t � If yes, give date 3 � SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot \ 0ov On adjacent lots �'Dov� Property line 1, To building foundation �k On adjacent lots o To existing or abandoned system on lot l Cutbank ~ A Water main/service line 1 t, t A- t -E - Surface water �"d Driveway, parking/vehicle storage area Curtain drain tAII>- E. ENGINEER'S CERTIFICATION I certify that I have ch Signature e Engineer's NarntIO 4 Eagle River Date HAA Fee $ Z 70 oU Date of Payment 6 `/`�- ` Receipt Number x4/78.137 or conformed to all MOA and HAA guidelines in effect on the date of this inspection Waiver Fee: $ Date of Payment Receipt Number COMMERCIAL TESTING & ENGINEERING CO. ENVIRONMENTAL LABORATORY SERVICES S'.CE'908 REPORT of ANALYSIS Chemlab Ref.# :93.2510-1 Client Sample ID :L2 B1 HIGH HOME S/D Matrix :WATER Client Name :S & S ENGINEERING Ordered By :R. SHAFER Project Name Project# PWSID :UA Sample Remarks: ROUTINE SAMPLE COLLECTED BY: RAY. QC Parameter Results Qual. Units Nitrate -N 5633 B STREET ANCHORAGE, AK 99518 TEL: (907) 562-2343 FAX: (907) 561-5301 WORK Order :66735 Report Completed :06/07/93 Collected :06/01/93 @ 14:00 hrs. Received :06/02/93 @ 14:30 hrs. Technical Director :S 'P E C ED Released By :�_ Method 2.7 mg/L EPA 353.2/300.0 Allowable Ext. Limits Date ---------------- 10 Anal Date Init ------------ 06/03 CMR * See Special Instructions Above UA = Unavailable ** See Sample Remarks Above NA = Not Analyzed U = Undetected, Reported value is the practical quantification limit. LT = Less Than D = Secondary dilution. GT = Greater Than t�) a�S Member of the SGS Group (Soci616 GdnArale de Surveillance) ENVIRONMENTAL SERVICES IN ALASKA, COLORADO, UTAH, ILLINOIS, OHIO, MARYLAND, WEST VIRGINIA, NEW JERSEY, SOUTH CAROLINA 1401----) P)e.K u P' MUNICIPALITY OF ANCHORAGE ',. DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH ' CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL 1 OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date 1. GENERAL INFORMATION i (a) Legal Description (include lot, block, subdivision, section, township, range) 46g h 4o fib, '56 - r 14t4 R 1 `n1 — Location (address or directions) i EAJP OV UPP-C-R MBC eAL4-? 9,D — (b) Applicant NameJc-jhn14;wS_4uy_ Telephone: Home _ Business _419 131 b Applicant Address ( �� _ �� � '�� Ga!fl 2.r 'Q_q5_q77 i I (c) Applicant is (check one): Lending Institution C] ; Owner/builder It; Buyer Cl ; Other ® (explain); i (d) Lending Institution Telephone = — Address (e) Real Estate Company and Agent Address — Telephone _ (f) Mail the HAA to the following address: 2. TYPE OF RESIDENCE Single -Family 2K Multi -Family ❑ Other Number of Bedrooms 3 3. WATER SUPPLY Individual Well 2' Community ❑ Public E Note: If communitywell system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite 9 Public El Community ❑ Holding Tank El Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 R, 72-025 (11,64 r. 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DA'I A AND INFORMATION 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 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 con "i'ru tna &nCI)Y)e0^, )r\(� Telephone 514G'.ac�o Address — Wool Suc wOfr\Afr D,r �e Date 10 — -Z, , -- — 6. DHEP APPR7 Approved for bedroo Approved— Disap Terms of Conditional Approval N,�ya�'YSCS�j� A g g�is y� O in94^.Ob'!®R,I OCeinn9S�l�p 9pp pC <9 4f a�Va q ' Eq idP.17al J � j rJf3�3�;�.�' ms byAAAA Q AlDate O_ proved Condit o I ®— CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates 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 satisfy certain federal and state requirements. Employees of DHEP 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. Page 2 of 2 72-025 (11/84) MUNICIPALITY OF ANCHORAGE DEPT. OI' HEALTH & MUNICIPAL) i Y O(- diNCHORAGE (MOA) ENVIRONMENTAL PROTECTION HEALTH AUTHORITY APPROVAL (HAA) �J 7U 17U�1 CHECKLIST -FEBRUARY 1984 264-4720 ED Legal Description: `� I 14 t " [�►VJ A. WELL DATA r�l`�\V�`,'L F Well Classification _ ,T It A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) Date Completed''—Yield I&'V Total Depth Cased to ' " — Depth of Grouting Static Water Level _ l: " Pump Set At Casing Height Above Ground ` r Sanitary Seal on Casing (Y/N) Y Electrical Wiring in Conduit (Y/N) i Depression Around Wellhead (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot )CY_) ; On Adjoining Lots I t Cl + — To Nearest Edge of Absorption Field on Lot i�>[) d ; On Adjoining Lots��� r To Nearest Public Sewer Line _ '� To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot _ Water Sample Collected by —C_` ; Date — ' T `i' Water Sample Test Results Comments wG--LL. � of �"i l PrC ia�t7 B. SEPTIC/HOLDING TANK DATA Date Installed `� �1`" t =� Size 100(") 0(") No. of Compartments Standpipes (Y/N)— Air -tight Caps (Y/N) ____YFoundation Cleanout (Y/N) Depression over Tank (Y/N) (Ii Date Last Pumped LL—A-Xi)= Pumping/Maintenance Contract on File (Y/N) f,4 ; for Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) — Separation Distances from Septic/Holding Tank: To Water -Supply Well — IC�Y) `'t' To Building Foundation — G' To Property Line — �' To Disposal Field To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course � 1) Comments fJ c, �) r^T:- L.L. \ i 1 i�P ( 'C-KA, 11 � �a Page 1 of 2 72-026(11184) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Sig ne of System Design i i�N4ta=-.7 Date Installed nI—� Company lsr� St__ Length of Field i >�-� �'-.'o 4-r o Width of Field Depth of Field Gravel Bed Thickness et Z, n Square Feet of Absorption Area Ci S 7 > 'P. Standpipes Present (Y/N) Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: ICY)"f To Water -Supply Well To Building Foundation Lot IV Date of Last Adequacy Test ^) To Property Line ; On Adjoining Lots To Existing or Abandoned System on c7U `d-' To Water Main/Service Line � )10 To Cutbank (if present) f To Stream/Pond/Lake/or Major Drainage Course r,1 (l To Driveway, Parking Area, or Vehicle Storage Area . °-°6 Comments N<---) Id-)9f°)LL/l-t' IOZ,1 LJ31 FL -7,e A\ IT D. LIFT STATION Date Installed V l' Dimensions Size in Gallons 4 Manhole/Access (Y/N) "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments "Pump Off" Level at ** Check Permitted Bedroom Rating Against HAA Request ** Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA I certifyI ve h cked,verified, or conformed to all MOA and HAAguidelines in effect on the date of this inspection. p Sig ne Date nI—� Company lsr� St__ � (� rs- -L-MC-MOA No. -5-T Receipt No.P- Date of Payment Amount: $ �So.1 - est�e ♦.rbc Page 2 of 2 72-026 (11/84)