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KASILOF HILLS BLK 9 LT 5
Kasi'01of Hills Block 9 Lot 5 #015 -131 -OS ✓1 Development Services Department Building Safety Division *Ak On-Site Water & Wastewater Program4700 Elmore RoadP.O. Box 196650MarkBegich Anchorage, AK 99507 Mayor.- www.muni.oro/onsite (907) 343-7904 Pump InsWiation Log Well Drilling Permit Number: SW Date of Issue: Parcel Identification Number: Legal Description11 Property,Owner Name & Address:, / / W k'$Terl Snt 171 KZ-1 t o . �i lls 107N,PtOSlit, C nncl eragC , *14 Pump Installation Date: / 0 -7 - fO Pump Intake Depth Below Top of Well Casing: %d feet Pump. Manufacturer's Name: 14y me.Don At� r Pump Model: VL30 66✓ 1j46 Pump Size V/0 -k- hp Pitless Adapter Burial Depth: 10 feet Pitless Adapter Manufacturer's Name: Pitless Adapter Installer: Well Disinfected Upon Completion? [R es ❑ No Method of Disinfection: r loicing, 191W 'U Comments: Pump Installer Name: 4r)C'h0"-C W111 Attention: The pump installer shall prov. -Mee pump installation log to the DSD within 30 days of pump installation. MUNICIPALITY OF ANCHORAGE Heal and Environmental Protec on Fourth Floor west 825 L Street Anchorage, Alaska 99501 264-4720 -- ----- IP SPIECTION REPORT ON-SITE SEWACE DISPOSAL, SYSTIPA NAf.1E(/��"`''�K"�"_-_�-'.✓<.1AILING ADDRESS �-�1%/ j - ----- PFIONEc'����_��� LOCATiOI. ���!� _-____— LEGAL PE SCRIPTION _.-�l_L_ SEPTIC TAidK: DISTANCE NUMBER OF - FROM WELL-__ I•AAi'•PJ`rAC1UREF2 ,�S��. __i�QnTFRIAL�L '�.-��'i�(� COPAPARTPAENTS_ INSIDE LEfJGII-i_ -_____ -INSIDE WIDI-H_ LIQUID DEPTH LIQUID CAPACITIt�� GALLONS. SII If I -LIEF MELD: `� / TOTAL LENGTH DISTANCE FROMii WELL FOUNiIATION l> _NEARF_SF LCT LINE` e)__.. --_-_-_OF LINE _ of Lines 1 - DISTANCE BEI"'WEEN LINES-/"��—TRE NCH ;'JIDTL�V IN. TOTAL EFFECTIVE ABSORPI ION AREA SO. FT. LENGTH OF EACH LINE DEPTH OF FILTER DFPTH: TOP OF TILE TO 1 NIISH Gi2ADE MATER!/,L BENEATH TILE SEEPAGLL M T: Dl. METER Log Crib Rings Crib Size OR WIDTH-_-., LENGTH__ : DIAME'IER___DEPTH_! --__IN. ABOVE TILE DEPTH DISTANCE FROM: WELL IN. TOTA1. EFFECT IVF BUILDING FOUNIDAI ION-__. NEAREST LOT LIME __ . ABSORPTION AREA (WALL AREA) __-_.SQ. FT. Well Class: Depth: Well Distance To: Lot Line _ Bldg: _ Sewer Line: j Pipe Materials: �_ erv' r of Bedrooms: Installer: Remarks: __- _ DATE - 1 I I I I , __- _ DATE - � �ILA ����11 0 1. 6 H .0 11- W.-.11 11, If 119 4 11 11' R � . DEPHRTMENT O �EHLTH HND ENVIRONMFNTHL F TECTION ^ ' 825 'L' STREET/ HNCHORHGE/ HK. � 279-2511 V_�c ����� ��A� �������~� ����� ����� — PERMIT NO. ( 77742 ) fol PPLICHNT CHRL ICfI� INGER SRH BX. 94 LOCHTION P°~�---T �—�--------� LEGHL LT51::::K.9 KHSILOHILLS LOT SIZE 45000 SQUHRE FEET TYPE OF SOIL HBSORBTION SYSTEy__[~[RH ENC—`— MHXIMUM NUMBER OF BEDROOMS � Z SOIL RHTING (SQ FT/8R)= 85 THE REQUIRED SIZE OF THE SOIL HBSORPTION SYSTEM I5� V.,)' II: ��~�A� ���� �������� ������ � THE LENGTH DIMEN�ION IS THE LE�GT� (�N F��T) OF THE T�ENCH OR DRHINFIELD THE DEPTH OF H TRENCH OR PIT I� TME D�STA NC� FETWEEN THE SURFHCE OF THE GROUND HND THE BOTTOM OF THE EXCHVHTICIN (IN FEET). THERE IS NO SET WIDTH FOR TRENCHr— E. I_ EEL DEPTH IS THE MINIMUM DEPTH OF GRHVEL BETWEEN THE OUTFHLL PIPE HND THE BOTTOM OF THE EXCHVHTION (IN FEET) IF, Ii,j] I—. Ir��� ����H__. T II.E.-� �����~�� ��������� ��~���� �F������� R PHCKHGE PLHNT MHY BE INSTHLLED HT THE PERMITTEE'S OPTION SUBJECT TO THE F0LLOWING CONDITIONS� J. EITHER H CLAS'._, I OR II NSF APPROVED PLHNT MHY BE INSTHLLED 2H CONTINUOUS MAINTENANCE HGREEMENT IIREDIF H MHINTENHNCE HGREEMENT IS NOT KEPT CURRENT YOU MHY BE REQUIRED TO ENLHRGE THE SOIL HBSORPTION SYSTEM HND/OR YOU MHY BE SUBJECT TO PROSECUTION ..... ....... �������.... ........ ��...... ���... ... ���������������� ��11.z... F if����� R. It.J1F 11 BHCKFILLING OF RNY SYSTEM WITHOUT FINHL INSPECTION HND HPPROVHL BY THIS DEPHRTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTHNCE BETWEEN H WELL HND HNY ON—SITE SEWHGE DISPOSHL SYSTEM IS 100 FEET FOR H PF' 1. WELL OR 200 FEET FOR H PUBLIC WELL WELL LOGS HRE REQUIRED HND MUST BE RETURNED TO THE DEPHRTMENT WITHIN ]0 DHYS OF THE WELL COMPLETION. OTHER REQUIREMENTS lei AY HPPLY� SPECIFICHTIONS HND CONSTRUCTION DIHGRHMS HRE HVHILHBLE TO INSURE PROPER INSTHLLHTION. �IF.. .F .�� ���������� I CERTIFY THHT 1� I HM FHMILIHR HE R�QUIRIEMENTS FOR ON~SITE SEWERS HND WELLS HS SET FORTH BY THE MUN TY OF HNCHORHGE. 2� I WILL IN L SYSTEM IN HCCORDHNCE WITH THE CODES� ]� I UNDERS T HE ON~SITE SEWER SYSTEM MHY REQUIRE ENL RESIDENCE I D TO INCLUDE MORE THRN ] BED .... .... _~~��.... ~_~__���—� ' � HPPLICRNT CHRL LUCHSINGER / 5nVI C OIYUOVA n OOF ,0e7 r: r,HC .:o ie nra_, A, cs ;A ^vs ,: r] Pit 112�1.n2� -n.c ire eras .Fn�.ocis-rs i�i_Anruenv s�nvrvuu� August 25, 1977 Mr. Carl Luchsinger SRA Box 94 Anchorage, Alaska 99502 R&M No. 751217 Subject: Soil Investigation for Sanitary Sewer System, Lot 5, Block 9, Kasilof Hills Subdivision, Anchorage, Alaska Dear Mr. Luchsinger: At your request of August 15, 1977, we conducted a subsurface soils investigation on the subject lot. Test Hole No. 4 was drilled at the proposed location of the sanitary sewer system. Included in this report are the locations and soils logs of 5 additional test holes drilled at other locations on the lot. The investigation complied with those procedures required by the Municipality of Anchorage, Department of Health and Environmental Protection. On August 18, 1977, Test Hole No. 4 was drilled to a depth of 15.5 feet below the existing ground surface. Test Hole No. 4 was sited according to your instructions and its location is shown in attached Drawing A-01. Drilling was accomplished with a rotary drill rig using continuous - flight solid -stem auger with an outside diameter of 6 inches. A sample was taken at the depth shown on the soils log in Drawing A-03. The sample will be held in storage at our lab for approximately six months. In addition, all material brought to the surface by the augers was continuously monitored by an experienced engineering geologist. The topography at the drilling site is generally moderately sloping to the west. At the time of the investigation the lot had original vegeta- tion consisting of alders, willows and grass. The top of Test Hole No. 4 was located at ground surface in an area previously stripped of surface organics and now covered by a re -growth of 5 to 10 -foot high alders. The soils encountered in Test Hole No. 4 are shown in the test hole log in Drawing A-03. The symbols used in the test hole log are explained in Drawings B-01 and B-02. The log of Test Hole No. 4 displays specific conditions encountered at the proposed location of the sanitary sewer system. Groundwater was not encountered. Bedrock was encountered at a depth of 15.0 feet. At the time the hole was drilled seasonal frost was not present and permafrost was not encountered. Subsurface conditions, as indicated in the additional test hole logs, may vary in other parts of the lot without any apparent surficial evidence of the change. IncHpeI« I I AI I;J A r, I' I JUNE_,IJ _I Al I 5 I I ..1,III : ,. A percolation test was performed within Test Hole No. 4 at the depth shown in the attached Table 1. All depths were measured from the top of the hole. The data in Table 1 show average infiltration from the depths indicated to the bottom of the hole. The measured percolation rate was 1.8 minutes per inch. We appreciate this opportunity to be of service to you. Please contact us if you have any questions concerning this letter or if we can be of additional service. Very truly yours, R & M CONSULTANTS, INC. Michael Mitchell, Jr. Senior Geologist MM:JMB/rds Jim McCaslin Brown, Ph.D. Head, Earth Science Department Attachments: Drawings A-01, A-02, A-03, A-04, B-01, B-02: Table 1 i ---------- DWN: o�p�'1-�/. _D W4LOCATION SKETCH Ci<GRID: R&PA [.'.C3I4llcUL..-rA TS, INC. CART LUCHSIHGE.R •NOiN[[P• dLt]L 06�N'�l '.0 �1A'.N[I.l PVnVl v4l4 DATE: 8--25-77 I PROJ.NO 751217 _____----__-----�-------_-------_-_-. _ J ANCHORAGE, ALASKA - SCCLEN.T.S. DWG.NO. A-O]- TEST HOLE NO. 1 Scale: 1"=3' ORGANICS 0.0' °`• '' GRAVELLY SAPID WITH SOME ..QST•.: SILT (SM) %1Scattered Cobbles 0.5 to 7.0' 4.0 o°o°a SANDY GRAVEL WITH SOVE SILT (G11) ° --- — -- — —7.0' at 00,00; SANDY GRAVEL WITH SOME p6' SILT (GM) ocu Probable Highly Weathered aa' Bedrock A :,a9 Ol — — -- — — — 10.0' WEATHERED BEDROCK J-3.5' T.D. i Auger Refusal DW N' CKD MM R&M CONSULTANTS, TANTS, Ii AC" DAIS 8-25—.77 a"oimaane nenwaiera auwnvn, vonvc.ena _ i SCALE_]."=3' - TEST HOLE PIO. 2 Scale: 1"=3' 0.0' :o° GRAVELLY SAND WITH SOME SILT o:u (SP1) Scattered Cobbles :Dv _ 7.5' WEATHERED BEDROCK 10.0' Auger Refusal subsurface soils the test hole. See id B-02 for explana- TEST HOLE LOGS I1O. 1 F 11O. 2 GRID CARL LUCHSINGER PROJ_NO 75217 l ANCHORAGE, ALASKA DWG.NO. A-02 i n��wn ( TEST HOLE NO. 3 TEST HOLE NO. 4 ! Scale: 1"=3' 0.0' Scale: 13' 0.0' ORGANICS 0p GRAVELLY SAND WITHSOME o 0 III o': SILT (SII) _ — — 0.2' Al.'o SILT WITH TRACE SAND AND Scattered Cobbles GRAVEL GRADING WITH SME, SAPID TO SILTY GRAVEL (M to GM) •0' n 4. 0' i pU0 GRAVEL WITIi TRACE TO SOME � p.• " 0 up SILT (GW -GM) o' • do • a: 0;)'• 009 7.0' c0 0 0 WEATHET_2ED BEDROCK 0 8.' 0 T.11. 0 000 pp i 0 0i 0 00 Ob06 I poo I A 0 � oU Q0 0. 0 000 u 00 0 00 i 00 j 0 00 00 0 I 00 Q 01 00000 i o0p 0 15.0' op BEDROCK I 15.5' T.D Each log depicts subsurface soils observed within the test hole. See Drawings B-01 and B-02 for explana- tion of symbols. DWN M MQ,TEST HO LE LOGS NO. 3 F O CKD MMI NO. 4 GRID J f -F Irvsx. 25 --77 k«o•„t oe .Olo UfS tf ,N'!A� P,INvkvpNG - — DATE: 8 � CARL LUCHSTNGER FROJ.NO 751217 SCALE: 111=31 ANCHORAGE, ALASKA DWG. NO. TEST HOLE NO. 5 Scale: 1"=3' 0.0' ORGANICS �� — -- — — — — — — 1.01 SILT WITH ORGANICS 0 GRAVELLY SILT (PIL) 2.0' 0 ° o Scattered Cobbles 2 to 5' 0 0 4.0' A. GRAVELLY SAND WITH r. SOME SILT (SM) A :? n 8.01 v .a W. D. o.'n �.•o I '`...---------- 10.0' SANDY SILT/SILTY SAND (SPI-mLpm-sPI) BEDROCI: 14.0' T, D. TEST HOLE NO. 6 Scale: 1"=3' � ORGANICS SILT (P/L) 0.0' -- 0.5' — -- — — — — — — 3.0' SILT WITH SOME SAND AND SOME GRAVEL (SPI -11L) �.°. Cobble at 5' °• _ ____ _ __ 5.0' .0''.00, GRAVELLY SAND WITH SOME u. SILT GRADING TO SAPID WITH SOME o:v SILT AND SOPIE GRAVEL (SPI) A O Each log depicts subsurface soils observed within the test hole. See Drawings B-01 and B-02 for explana- tion of svmhols. 12. 0' 12.5' T.D. DWN: _EN/L—_ TEST HOLE LOGS NO. 5 F.B�__ _— CKD R&M 00NSUL,rANTa,!NC. & NO. 6 GRID — DA'FE 8-•25-77 +w�,,y.A pL4uie�n ..���.4e o ..e«a CARL LUCHSINGER PS20J_ 751217 SCALE l"=3' ANCHORAGE, ALASKA DWG. NO A-04 TABLE NO. 1 PERCOLATION TEST Carl Luchsinger R&M No. 751217 TEST HOLE NO. 4 ELAPSED TIME TIME INCHES DROP 7:N INCHES 10:30 0 16.5 0.0 10:31 1 18.0 1.5 10:32 2 19.0 1.0 10:33 3 20.0 1.0 10:34 4 20.5 0.5 10:35 5 21.0 0.5 10:36 6 22.0 1.0 10:37 7 22.5 0.5 10:38 8 23.0 0.5 10:39 9 23.75 0.75 10:40 10 24.5 0.75 10:45 15 27.75 3.25 10:50 20 31.0 3.25 10:55 25 33.25 2.25 11:00 30 36.0 2.75 11:10 40 40.5 4.5 11:20 50 45.0 4.5 11:30 60 50.0 5.0 33.5 Inches Total Drop 1.8 Minutes Per Inch SOILS CLASSIFICATION, CONSISTENCY AND SYMBOLS CLASSIFICATION: Ident-if-ication and classification of the soil is accomplished in accordance with the Unified Soil Classification System. Normally, the grain size distribution determines classification of the soil. The soil is defined according to major and minor constituents with the minor elements serving as modifiers of the major elements. For cohesive soils, the clay becomes the principal noun with the other major soil constituents used as modifier; i.e. silty clay, when the clay particles are such that the clay dominates soil properties. Minor soil constituents may be added to the classification breakdown in accordance with the particle size proportion listed below; i.e. sandy silt w/some gravel, trace clay. no call - 0 - 3% trace - 3 - 120/0 some - 13 - 305'(,, SOIL CONSISTENCY - C.RITERIA: Soil consistency as defined below and determined by normal field and laboratory methods applies only to non -frozen material. For these materials, the influence of such factors as soil structure, i.e. fissure systems, shrinkage cracks, slickensides, etc. , must be taken into consideration in making any correlation with the consistency values listed below. In permafrost zones, the consistency and strength of frozen soils may vary significantly and unexplainably with ice content, thermal regime and soil type. Cohesionless Cohesive N''(blows/f-t) Relative Density T- (tsf-) Loose 0 - 10 0 to 40% Very Soft 0 - 0.25 Medium Dense 10 - 30 40 to 70% Soft 0. 25 - 0.5 Dense 30 - 60 70 to 90% Stiff 0.5 - 1.0 Very Dense - 60 90 to 1000, Firm 1.0 - 2.0 *Standard Penetration "N": Blows per foot of Very Firm 2.0 - 4.0 a 140 -pound hammer falling 30 inches on a Hard - 4.0 2 -inch OD split -spoon except where noted. DRILLING SYMBOLS WO: Wash Out WD: While Drilling WL: Water Level BCR: Before Casing Removal WCI: Wet Cave In ACR: After Casing Removal DCI: Dry Cave In AB: After Boring WS: While Sampling TD: Total Depth Note: Water levels indicated on the boring logs are the levels measured in the boring at the times indicated. In pervious unfrozen soils, the indicated elevations are considered to represent actual ground water conditions. In impervious and frozen soils, accurate determinations of ground water elevations cannot be obtained within a limited period of observation and other evidence on ground water elevations and conditions are required. DWN: L.D.S. CKD G.L.B. DATE 3-1-72 SCALE N/A 0 0 R&M CONSULTANTS, INC. GENERAL NOTES F B N /A GRID N/A PROJ.NO GENERAL DWG. NO 8-01 STANDARD SYMBOLS tihN ORGANIC MATERIAL ® COBBLES 8 BOULDERS JJ� IGNEOUS ROCK SPOON SANDY SILT CLAY oo (C�✓ CONGLOMERATE f////J/J METAMORPHIC ROCK NJ///l11 Ss SILT GRADING TO SANDY SILT ® SILT SPOON SANDSTONE ICE, MASSIVE o o SANDY GRAVEL, MODIFIED SHELBY TUBE SI .... 2.5" SPLIT (ROCKS FRAGMENTS) SAND HAMMER MUDSTONE ICE -SILT PITCHER BARREL a SAN YYERED GRAVEL ND 00000.0. GRAVEL ® [ LIMESTONE ORGANIC SILT I'I-Z-4 SILTY CLAY w/TR.SAND SAMPLER TYPE SYMBOLS St .. . .. 1.4" SPLIT SPOON WITH 47# HAMMER Ts . .. . SHELBY TUBE Ss ... 1.4" SPLIT SPOON WITH 140# HAMMER Tm. . . . MODIFIED SHELBY TUBE SI .... 2.5" SPLIT SPOON WITH 140# HAMMER Pb , , , . PITCHER BARREL Sh ... . 2.5" SPLIT SPOON WITH 340# HAMMER Cs .. CORE BARREL WITH SINGLE TUBE Sx .. ... 2.0" SPLIT SPOON WITH 140# HAMMER Cd . .. CORE BARREL WITH DOUBLE TUBE Sz . ... . 1.4" SPLIT SPOON WITH 340# HAMMER Bs 13ULK SAMPLE Sp .... . 2.5" SPLIT SPOON, PUSHED A . . . . . AUGER SAMPLE Hs . . . .. 1.4" SPLIT SPOON DRIVEN WITH AIR HAMMER G. .. GRAB SAMPLE HI , .. . , 2.5" SPLIT SPOON DRIVEN WITH AIR HAMMER SAMPLE LOCATION 30'—DRILL DEPTH NOTE: SAMPLER TYPES ARE EITHER NOTED ABOVE THE BORING LOG OR ADJACENT TO IT AT THE RESPECTIVE SAMPLE DEPTH. DWN' L.D.S. CKO G.L.B. DATE FEB. 1972 SCALE NONE TYPICAL BORING LOG BOR/NG NUMBER-�T. H. 30-15 Elev. 274.6 ® ELEVATION /N FEET DATE DRILLED„ 10-21-70 All Samples Ss_,'SAMPLER TYPE DWG.NO. B-02 0 ^ ORGANIC MATERIAL Consid. Visible Ice 0-7 ICE+ML I ICE -SILT SAMPLER TYPE,,, Estimate 65% Visible Ice Ss OI 90, 56.2x/0 STRATA CHANGE 7 WATER TABLE _� 9,* —_ SANDY SILT GRADATIONAL CHANGE/APPROXI MATE STRATA CHANGE _ _ _ 000 ° .b'.o.o. Little to No Visible Ice 13=30' Vx % -ICE, DESCRIPTION 8 CLASSIFICATION Ss 09. 2 72, 571 x/ x,85.9pcf, 281, GP (CORPS OF ENGINEERS METHOD) . 0 9.0" q UN/PIED ORFAA CLASSIFICATION xooA,o \ TEMPERATURE, F FROZEN GROUND .094 4p o DRY DENS/TY WATER CONTENT Qo. G BLOWS/FOOT �o- O'o°' ..adx SAMPLE NUMBER ;o,'R0o SANDY GRAVEL 26' Cd 3 95 SCHIST +— GENERALIZED SOIL OR ROCK DESCRIPTION SAMPLE LOCATION 30'—DRILL DEPTH dE W.D.-WHILE DRILLING, A.8 -AFTER BORING EXPLANATION R&M CONSULTANTS,pINC. . OF SELECTED SYMBOLS F.B N/A GRID N/A PROJ.NO GENERAL DWG.NO. B-02 Wei l Log Location_,-- ..�f� ...`���['�... �............ Date completed-doe,�'da....,;��1...1...,�............................. Depthof well...... r6...`....................................................... Size of casing....... .6.. �.... .... ...................... Distance to water........ �. i....................... .. .......................... Distance to water while pumping........".,`.j.f.....................................at rate of......... (...1/60 ............................gallons per hour. Formation from I to !� — I — s_ I Driller DELTA DRILLINGh COMPANY SRA BOX- 394 B ANCHORAGE. ALASKA99507 Municipality of Anchorage Development Services Department - L Building Safety Division On -Site Water 8 Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 e— 1 5 S (.L C-1-2 C L CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I. D. 015-131-01 COSA# 05 C, i% 7 J 0 1. GENERAL INFORMATION Expiration Date: 1 I /_ % Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address KASILOF HILLS; BLOCK 9, LOT 5 10741 PROSPECT DRIVE *ANCHORAGE AK 99507 JOHN GIVENS Day phone 512-827-6869 10741 PROSPECT DRIVE *ANCHORAGE AK 99507 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3- Day phone Day phone 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well 0 Individual On-site Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site Z-1 Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the 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 GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179 Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date —1 b, Engineer's Comments In conducting this evaluation. GEG, LtD, attempted to provide a thorough, 00000pO� dap conscientious engineering analysis or the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the the o OF q "�� "" • performance of system under the conditions encountered at the time of the test, and separation .'954 distances measured to readily identifiable features. The operational life of all wells and 4 septic systems depend on the local soils condition, groundwater levels that may ... fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test .. ...... ....... . QO results do not guarantee future performance of the system, nor do they guarantee that f G ess: there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to most the Q 9, -, CE 79 3 •' a`� �4 ..77 P^ 6. 4p operational requirements of the ADEC or MOA DSD. The content of this report is for Pp•p 0� F'o ��� r°f the sole benefit of the owner listed above. Any reliance upon or use or this report by any - essij o� OOOopOo other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATUREN ` y Ut`ig/tfi, ''r ��� Approved for bedrooms. 2 ON-SITE Disapproved. _� WATER AND Conditional approval for bedrooms, with the following stipulations: WASTEWATERPROGRAM /SSE i j�t� Attachments: COSA Checklist Arsenic Advisory Septic System Advisory Maintenance Agreements Well Flow Advisory Supplemental Engineer's Report Nitrate Advisory Other By: Original Certificate Date: (km iims) i Municipality of Anchorage ' Development Services Department_ Building Safety Division On -Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: KASILOF HILLS; BLOCK 9, LOT 5 Parcel I D:015-1� 0 A. WELL DATA *CASED TO BEDROCK Well type PRIVATE If A, B, or C provide PWSID# N/A Date completed 10/20/77 Sanitary seal (Y/N) YES Total depth 85 ft. Date of test Static water level Well production Cased to *6 ft. FROM WELL LOG 10/20/77 WATER SAMPLE RESULTS: G! Coliform © colonies/100 ml. Arsenic: N() ug./L. B. SEPTIC/HOLDING TANK DATA Well Log (Y/N) YES_ Wires properly protected (Y/N) YES Casing height (above ground) 12+ in AT INSPECTION 2/28/2012 22 ft. —9 -P.M. 0.75 g.p.m. Nitratej. J(�mg_/L Collected by: GF aW Ltd Date of sample: 7 / t g/12__ Tank Type/Material SEPTIC/FIBERGLASS Date installed 9/23/77 Tank size 1000 gal. Number of Compartments 2 Cleanouts(Y/N) YES Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A Date of pumping / I t Pumper MCDONALDS PUMPING C. ABSORPTION FIELD DATA *BELOW 3/` EXISTING GRADE Date installed 9/2_ Soil rating (g.p.d./ft or /bdrm RA Length _26 ft System type TRENCH Width 3 ft. Gravel below pipe **4.5 Total depth *8.75 ft. P ft. Eff. absorption area***255 ft2 Monitoring tube YES Depression over field NO Date of adequacy test 2/28/12 Results (Pass/Fail) PASS For 3 Fluid depth in absorption field before test 0 bedrooms in. Water added 455 gal. New depth Oin. Elapsed Time: 0 min. Final fluid depth 0 in. Absorption rate >= 4_ 5� g P.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN THE CO AT THE BEGINNING OF THE TRENCH COULD NOT BE FOUND. THERE yes IS AN e MTt & CO T END OF THE TRENCH. SEE ATTACHED DOCUMENTATION. MT APPEARS TO EXTEND 4' INTO DRAINROCK. **PER 1997 HAA ***PER 1977 INSPECTION REPORT D. LIFT STATION Date installed Size in gallons Manhole/Access (YIN "Pump on" level at in. "Pump ofr level a ---v . High water alarm level Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankAtft station on lot 100'+ On adjacent lots 100'+ Absorption field on lot 100'+ Public sewer main N/A Sewer /septic service line 25'+ On adjacent lots 100'+ Public sewer manhole/cleanout N/A Holding tank Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Properly line 5'+ Absorption field 5'+ Water main 10'+ Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parkingtvehi ge storage 11NK Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSH guidelines in effect on this date. Engineer's Printed Name JEFFREY A. GARNESS Date I1 ,?6I /Z COSA Fee Date of Payment Receipt Number (Rev. 1IM5) Waiver Fee Date of Payment Receipt Number Municipality of Anchorage e Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www. ci. anchorage. ak. us (907) 343-7904 Water Well Advisory Certificate of On -Site Systems Approval (COSA) # 121064 During a recent COSA on-site inspection and test of the potable water supply well on Block 9, Lot 5 of Kasilof Hills subdivision, the well's productivity was determined to be 0.75 gallons per minute. The minimum well productivity required by this Department (AMC 15.55) for a 3 -bedroom residence is 0.31 gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. Municipality of Anchorage c" Community Development Department Development Services Division On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 Nitrate Advisory Certificate of On -Site Systems Approval # 121064 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 9, Lot 5 of Kasilof Hills subdivision. This inspection revealed a nitrate concentration of 5.06 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. Municipality of Anchorage • '-� Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 015-131-01 COSA# L4 1. GENERAL INFORMATION Expiration Date: (ra ' a2-" /.2 Complete legal description KASILOF HILLS; BLOCK 9, LOT 5 Location (site address) 10741 PROSPECT DRIVE *ANCHORAGE, AK 99507 Current Property owner(s) JOHN GIVENS Day phone 512-827-6869 Mailing address Lending agency Mailing address Real Estate Agent Mailing address 10741 PROSPECT DRIVE *ANCHORAGE, AK 99507 Day phone SHARNEE EPLEY W/ REMAX OF ALYESKA Day phone 783-4217 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 TE LY: ASTEWATER-0ISPOSAL: --- — — Individual Well Individual On-site N Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, t 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 GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name Engineer's Comments: JEFFREY A. GARNESS, P.E. In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA - DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of ail wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE Approved for 3 bedrooms. Disapproved. Phone 337-6179 Date _Z—Alm ............. ys�o4 . . ...... ......... '•.J r y A. Gar ess; p 7/g Conditional approval for bedrooms, with the following stipulations: Attachments: / COSA Checklist v Septic System Advisory Well Flow Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Nitrate Advisory Other By: (Rev. 11N5) itI 01 A*C 4� ......,••y0 ON SITE WATER AND WASTEWATER : a PROGRAM = Original Certificate Date: Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 3437904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: KASILOF HILLS; BLOCK 9, LOT 5 A. WELL DATA *CASED TO BEDROCK Well type PRIVATE If A, B. or C provide PWSID# N/A Date completed 10/20/77 Sanitary seal (Y/N) YES Total depth 85 ft. Cased to *6 ft. FROM WELL LOG Date of test 10/20/77 Static water level 15 ft, Parcel I D: 015-1 Well Log (Y/N) YES Wires properly protected (Y/N) YES Casing height (above ground) 12+ in. AT INSPECTION 2/28/2012 Well production 4 —9-P m. 0.75 —9-13 in WATER SAMPLE RESULTS: p Coliform In colonies/100 ml. Nitrateb b 1 mg./L. Collected by: GEG. LQSG, Ltd. Arsenic: iv v ug./L. Date of sample: 2/27/12 B. SEPTICIHOLDING TANK DATA Tank Type/Material SEPTIC/FIBERGLASS Date installed 9/23/77 Tank size 1000 gal. Number of Compartments E Cleanouts (Y/N) YES Foundation cleanout (Y/N) YES Depression over tank (YIN) NO High water alarm (Y/N) N/A Date of pumping � I Pumper MCDONALDS PUMPING C. ABSORPTION FIELD DATA *BELOW EXISTING GRADE Date installed 9/23/77 Soil rating (g.p.d./ftor /bdrm 85 System type TRENCH Length 26 ft. Width 3 ft. Gravel below pipe **4.5 ft. Total depth *8.75 ft. Eff. absorption area***?55 ft' Monitoring tube YES Depression over field NO Date of adequacy test 2/28/12 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test 0 in. Water_added 455 gal. New depth 0 in. Elapsed Time: o min. Final fluid depth 0 in. Absorption rate >= 450+ g. p, d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date N/A THE CO AT THE BEGINNING OF THE TRENCH COULD NOT BE FOUND. THERE IS AN MT & CO AT END OF THE TRENCH. SEE ATTACHED DOCUMENTATION. MT APPEARS TO EXTEND 4' INTO DRAINROCK. **PER 1997 HAA ***PER 1977 INSPECTION REPORT D. LIFT STATION Date installed Size in gallons Manhole/Access (YIN "Pump on" level at in. "Pump off' level�t `High alarm level at Cycles tested Meets alarm & circuit requlrements7 E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankANt station on lot 100'+ On adjacent lob Absorption field on lot 100'+ On adjacent lots Public sewer main N/A Public sewer manhole/cleanout 100'+ 100'+ Sewer /septic service line 25'+ Holding tank N/A Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Water main 5'+ 10'+ Wells on adjacent lots 100'+ Property line 5'+ Absorption field 5'+ Water service line 10'+ Surface water 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A � Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage Un " n Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS DUE TO SNOW CONDITIONS COULD NOT FIND SEPTIC ON TIMERBLINE S/D, LOT 1. 4( WELL ON KASILOF HILLS. BK 9. L5 IS GRANDFATHERED. Iocl'� Pe -9- 1978 IN G. ENGINEER'S CERTIFICATION I certify that t 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. Engineer's P 'nt d Name JEFFREY A. GARNESS Date 8 f X712 COSA Fee $ � d Waiver Fee $ Date of Payment 31-"112 Date of Payment Receipt Number i1Receipt Number (Rev. 11/06) oo�opp4 4.4TH...........°. f Garne s: y; E 7 a����P��essioroQo Municipality of Anchorage s Community Development Department Development Services Division On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 Nitrate Advisory Certificate of On -Site Systems Approval # 121064 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 9, Lot 5 of Kasilof Hills subdivision. This inspection revealed a nitrate concentration of 6.69 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. Municipality of Anchorage ' Development Services Department Building Safety Division A ET�Y' On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 Water Well Advisory Certificate of On -Site Systems Approval (COSA) # 121064 During a recent COSA on-site inspection and test of the potable water supply well on Block 9, Lot 5 of Kasilof Hills subdivision, the well's productivity was determined to be 0.75 gallons per minute. The minimum well productivity required by this Department (AMC 15.55) for a 3 -bedroom residence is 0.41 gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. SGS Ref.# 1120604001 Client Name Garness Engineering Group, Ltd Project Name!# Kasilof Hills B9 L5 Client Sample ID Kasilof Hills B9 L5 Matrix Drinking Water Printed Date/Time Collected Date/Time Received Date/Time Technical Director 03/05/2012 16:51 02/27/2012 14:45 02/27/2012 15:13 Stephen C. Ede Sample Remazks: 450ONO3-F - Total Nitrate/Nitrite - MS recovery is outside of QC criteria. Refer to LCS for accuracy requirements. Allowable Prep Analysis Parameter Results LOQ Units Method Container 1D Limits Date Date Init Metals by ICP/MS Arsenic ND 5.00 ug/L EP200.8 C (40) 02/28/12 02/29/12 NRB Waters Department Total Nitrate/Nitrite-N 6.69 0.100 mg/L SM20 450ONO3-F B (<10) 03/05/12 CMA Microbiology Laboratory E. Coli Negative 1 100ml- SM21 9223B A 02/28/12 SDP Total Coliform Negative 1 100mL SM21 9223B A 02/28/12 SDP %1Cpa5fa rIN91FD iLQ^P EIEV. (A541Ya1) A � I 0 C(RNEY ZCNNa NSIM4i PONT SUKONO SC11I SCE BWpNO SETBACK I EIIIAMt SETBMJt 50' 4 7 I\ 267.42• S860 40'20-E 1 Gee 0 G o� , � N '� APPROXIMATE r � � OFIYEWAY LOCALION v TO SM1VWI r / N/�//IOVE ry N ,1 Q COs rN Q / I n W IfI / J EXISTING HOUSE W s rr sHE r F. !A WELL N v/ ONOTE: r � r EQn NOTABLE TOLLGATE I W WELL OR SEPTIC OO (DUE TO SNOW) r 00 Q r p_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ J O 10' UTIL ESMT z 241.84' - N89° 58' 53"W 30' UNDER NO CIRCUMSTANCES SHOULD AN AS–BUILT BE USED FOR CONSTRUCTION OR FOR ESTABLISHING BOUNDARY OR FENCE LINES. THE SURVEYOR TAKES RESPONSIBIUTY FOR THE INITIAL TRANSACTION ONLY AND ASSUMES FINANCIAL UABlUrY ONLY FOR THE COST OF THE SURVEY. LISTED DISTANCES PREVAIL OVER SCAUNG. REPRODUCTION MAY CAUSE ERRORS IN SCALE. LJ LOT SURVEY SURVEY TYPE SYMBOLS ❑ FWNDATON AS -BUILT El FINAL STRUCTURE AS-BULT o SET REBAR we =FDRAINAGE D ASPHALT ❑ PLOT PVN ... AS -BUILT... LOT SURVEY... TOPOGRAPHY O FOUND REBAR H3--0 9 WOOD FENCE '"�`� CONCRETE AS-BULT ... No CORNERS SET M RECERMPOATION AS -BUILT ... NO CORNEAS SET 11 ASSUMED ELEV. K If If METAL FENCE ® WOOD DECK PLOT PLANS & LOT SURVEYS NOTE: IT IS THE RESPONSIBILITY OF THE BUILDER OR OWNER, PRIOR TO ONLY THOSE IMPROVEMENTS ABOVE GROUND AND VISIBLE WALL BE CONSTRUCTION, TO VERIFY PROPOSED BUILDING GRADE RELATIVE SHOWN. FENCES, WELLS, SEPTIC CLEANOUTS, SIDEWALKS, DRIVEWAYS, TO FINISHED GRADE AND UTILITY CONNECTIONS AND TO DETERMINE ETC.. ARE SHOWN IN THEIR APPROXIMATE LOCATION, ONLY. SNOW THE EXISTENCE OF ANY EASEMENTS, COVENANTS OR RESTRICTIONS MAY PREVENT SOME IMPROVEMENTS FROM BEING SEEN AND LOCATED. WHICH DO NOT APPEAR ON THE RECORDED SUBDIVISION PLAT. ALL DISTANCES ARE RECORD UNLESS OTHERWISE NOTED. SURVEY CERTIFICATION 01 '771"r/1♦ Prepared by Robert Johns,Assoc. PLOT PLAN b°ef.tl.pIx,",.tlAan, ,�P.Wr.N,°«l I Tn mrEt .%ra ••r\1 ♦.♦ ProfessionalLand Surveyors mw wWn 4 a ow wt -�.••P•.(\�, •.♦• 1700 Brink Driw. ANCHORAGE, ALASKA 99504 antloMgo...rI puhw ww�a �. Scale: II — t Rec. Lot S.F. Roc. Plat File No. T101�V1° B"° wi0 °'1110 I 4 � FOUNDATION AS–BUILT •••••'• '• •..... '• 1 — 50 I. Boe.-e [. AMA r., Iwsy urory awe nn" OwrumM m N-BWt vwY M 1M 1 % •• . Date Surwywd: 2/29/12 Drawn b C Y RG Checked by J K M em.Twm1 as em.,wm� " w / ROBE E. J / Date Draw: 2/29/12 Grid: 2 541 W.O. 12-48 ••P ••ap21 AM FINAL STRUCTURE AS -BUILT rbIW<'.lq.tBarNL .a"wOBN Legal Description .m- L"wmmpo"wmeu,P.ww°n� mmEm ,qwCM1m4w •."•••.••,•'rd LOT 5BLOCK 9 ♦` ♦♦♦i�1111%:•�� wH °m KASILOF HILLS Sonja Blewett From: Jon Givens [givensjt@gmail.com] Sent: Thursday, March 01, 2012 1:16 PM To: Sonja Blewett; Sharnee Epley; Kristan@kristancole.com Subject: septic Sonja Please let the engineer know that roto rooter came out today and snaked from clean out to cleanout. I will get you a copy of the receipt which reflects this. Where is your office physically located? Also I spoke with Mr McDonald today from old mcdonalds pumping and he pumped my septic back in September and he is going to fax you a receipt to show it was pumped in september 2011 The water test results are supposed to be in on Monday. Please email me re the results. The water should fail the nitrate test which is why 14 years ago the last owners installed a nitrate removal system. I had the nitrate system serviced in September 2011 and culligan did a nitrate test on the water from the tap and it tested fine for nitrate. regards Jon 1 E: z m bmm O r- D < O O mco x0 o O D D m D O C O m m m -I t m o' D O rM r m O Z Z D O 1 a x m -- m p D D p p S D m Z m D p < Z m m m -n mm m< W Ti v4 O om O m 0 ro O< -moi m z D m 5> Q a O 0 0 = p Z rtj C+ o O v p m m G s ^ m y {l m x x x x x x x x � ®ti 5 0 � 0 k9 a Q)(9 0 0 k9 0 cn — — m (! c x o D - cn _ O ( s v n 2 mm } ��� (Ali X co Q W O_ o mw � co y r%3m61 Rob Campbell From: Rob Campbell Sent: Wednesday, February 29, 2012 9:23 AM To: 'Crewdson, James A.' Cc: Jeff Garness Subject: Kasilof Hills L5 B9 COSA Attachments: _0229090849_001.pdf Tracking: Recipient Delivery 'Crewdson, James A.' Jeff Garness Delivered: 2/29/2012 9:23 AM Hello Jay, Please find the attached document. S and S installed double cleanouts afterthe tank, and also replaced the sump at the end of the drainfield with a traditional monitoring tube and cleanout. I believe this work is sufficient in taking the place of the previous cleanout at the beginning of the drainfield as the field can be cleaned out from two different locations. Let me know as the owner is waiting to have an as -built survey completed soon. Thanks Jay! Blessings on your day partner. Rob Campbell Superintendent/Engineering Consultant Garness Engineering Group, Ltd. 3701 E. Tudor Road, Suite 101 Anchorage, AK 99507 Office: (907) 337-6179 Cell: (907) 317-9433 Fax: (907) 338-3246 http://www.garnessengineering.com/ "the Son can do nothing by himself; he can do only what he sees his Father doing, because whatever the Father does the Son also does. For the Father loves the Son and shows him all he does" John 5:19-20 „ }4 MUNICIPALITY OF . JCHORr ^:” 1 �r DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Envirc:mmOntal Services On -Site Services Section P.O. Box 196650 Anchoragn, Alaska 99519-6650 MUNICIPALITY OF ANCHORAGE 343-474•' ENVIRONMENTAL SERVICES DIVISION IFICATF OF I :AI I:. APR 2 B 7997 f AP AL FOR A SINt.;LE FAMILY DWL_J.,L LNG Parcel I.D. It G 3 S — 1 3' — 0 / HAA 8 �..-CE1—VE ® 1. GENERAL INFORMATION Complete Ic,,gal description —_Lot 5; Block 9;iKasi_lof trills Location (site address or directions) 10741 Prospect Drive Anchorage, AIC Property ner _Jeff_ . i afa ___-- Day phone 265-8456 C/OSeat'_;._ Mortgage Attn: Jennifer Smith 4300 "B" St. Anchorage, A!, Mailing address — __ g 9950 ". "Lending agency_ Day phone — Mailing�.------..,_-- Agent ---------- — --- Day phone Address Unless otherwise requested, i -IAA will be held for pickup. RECEIVED �� e , / 2. NUMBER OF BEDROOMS: 3 t/ R E C E I V E 3. TYPH OF WATER SUPPLY: APR 2 8 1997 Individual well XXX Municipality of Anchorage Community well Dept. Health & Human IimIces 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 ADE -C cffestirg to the legality and status of system. 72-025 (Rev. 1191) Front Mork. k2', 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, "ordinagces,.and regulations in effect on the date of this inspection. S& S ENGINEERING 9 y- % 7% Name of Firmveroop Road Nu, z04 Phone Address Eagle River, Alaska 99577 Engineer's signature 6. DHHS SIGNATURE 1 Approved for �� �/ bedrooms. Disapproved. Conditional approval for Date `I Aa 9'/9 7 , .�•'�'C� OF44"( VUtKT QIACUWAN 7 C CE -8801 .. bedrooms, with the following stipulations: Note: The well for this property meets existing State and Municipal Codes. There are nitrates present. It is suggested that a periodic testing be performed to insure the wells continued suitability. Nitrate concentration is 7.65 ;-i4/1. EPA 'mutta—conCaptr.at.i Qp ig JO -0 mg/1 More information on nitrates is - available from the On -Site Services Section at DHHS, 343-4744. 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 courtesyto 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. 72-026 (Rev. 1/91) Back MOA k21 Municipality of AnchorageeN RNICIPALiTYof NMENTAL SER DEPARTMENT OF HEALTH &HUMAN SERVICES Environmental Services Division ��1rA� ON 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-47449 2 8 7997 Health Authority Approval Checklist RECEIVED Legal Description: t 0 s7 9). k A5 i to F N" -r -S Parcel LD.: 01 S - 13 1 1 A. WELL DATA Well type P /R J v4 rf - If A, B, or C, attach ADEC letter. ADEC water system number 9 _ Log present &N) Date completed 10 % 3 u % 7 Total depth 5 _ Cased to 6 6-f' 2 e �K Casing height (above ground) Sanitary seal ON) % t j Wires properly protected (e)N) FROM WELL LOG AT INSPECTION Date of test _ r 0 d A -7'7 Static water level Well production _ ' %, g,P,m. 13 g.P,m. WATER SAMPLE RESULTS: Coliform c� Nitrate -7, 0 Other bacteria -'3 Date of sample: `r' �� 3 7 Collected by: S & S ENGINEERING 17034 Eagle River Loop Road No. 204 B. SEPTIC/HOLDING TANK DATA Eagle River, Alaska 99377 Date installed '143 7 11 _ Tank size l P 00 Number of Compartments Cleanouts QN) Ye- I Foundation cleanout -ON) y4 S Depression (YO ^' High water alarm (Y/O 3 /9 7 Pum or ate o umprng __ p C. ABSORPTION FIELD DATA Date installed y a 3/-7 7 Soil rating (g.p.d./ftz or� /bdrm �� _ System type Length i�6 ` Width Gravel thickness below pipe t//. S --Total depth Effective absorption area '� _ Monitoring Tube present NN) Y"S Depression over field (Y/W^' 0_ Date of adequacy test � `t A G . Results q P s Fail) /'� � � For _ � bedrooms Fluid depth in absorption field before test (in.); O Immediately after�91 gal. water added (in.): 0 Fluid depth (ins) Minutes later: v 1,4 Absorption rate= _ �� Sy `/ g.p.d. Peroxide treatment (past 12 months) (Y/N) � /vo L,A-%22 V` 6J4,2Vf 0 i,v Pn"I;rdA, � 72-026 (Rev. 3/96)" __ If yes, give date , 'I-d,J f- 0 ^� tj :3 /Q '7 D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tes E. SEPARATION DISTANCES "Pump *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: e i' holding tank on lot J 00 _/_ Absorption field on lot 100 r -� Public sewer main /v /A Size in gallons On adjacent lots On adjacent lots ,,Pump oWUoff OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION APR 2 8 1997 RECEIVED /06 Public sewer manhole/cleanout k) IX Sewer /septic service line t ° o �+ Lift station SEPARATION DISTANCES FROMISEPT —IbHOLDING TANK ON LOTTO: Foundation .S' / Property line o /� Absorption field Water main/service line JO 4- Surface water/drainage Joe Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: , Property line Building foundation 30 P Water main/service line Surface water / o o ( -J- Drivewa arkin /vehicl t r Curtain drain Nd N�- iC N)0 w A-/ F. ENGINEER'S CERTIFICATION Y, p g e s o age area Wells on adjacent lots J o u 4- / l certify that l have determined thru field inspections and review of Municipal ing conformance with IyIO� H,pApuideliges�in effect on this date. Signature Engineer's Nameit/ �. �d ��1 �✓ Date( of l y % HAA Fee Date of PE Receipt Ni 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number OF 1C�o are ,13,; ROMT C. COWAF! d Ci 41 are ME Environmental Services Inc. � �rlru9rA..ro��uLu�so®r�7�r/�'�Joawl CT&E Ref.# Client Name Project Naoael# Ciient Sample ID Matrix Ordered By PWSCD 971922001 S & S Bagineering n/a LS 139 Kasilof HillS Drinking Water Client PO# Printed Date/Time 04/28/97 15:52 Collected Date/Time 04/23/97 09:15 Received Date/Time 04/23/97 09:45 Technical Director: Stephen C. Ede Released By t -/id I (I " Q.A Saonple collected by: Bob C. CT&i'x Microbiology Drinldng Water Program certification status is provisional as of 4/8/97. 0 Parameter Nitrate -N Total Cotiform Results PQL Units 7-65 0.500 mg/L 3 oD w/o COU COL/109 ML Allowable Prep Method Limits _ Date sM18 4500-No3F 10 max sM18 9222D i Analysis Date snit 04/23/97 JRL 04/23/97 RAM 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. # c i T – ) 31 – C1 HAA # 1. GENERAL INFORMATION Complete legal description Loa 5; a*oci 9; Kae�2a H�7.2.� Location (site address or directions) 10741 P-co,spect D)u.ve Anchona.ge., AK Property owner I ay 062bc Day phone 346-�6 Mailing address P.O. Box 101994 Ancho�caae., AK 99510-1984 Lending agency Day phone Mailing address Agent Mahe PoWenl Rea ,tu Nor1:h Day phone 333-8117 Address 3724 Bie u-Le.n DtLive. Aneho-zaae. AK 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 ;:XX Holding tank Community on-site — Public sewer — NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1191) Front MOA 421 6. By: 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 a s FNjrlNFF41Nr 6 '7 Address 17034 Eagle River Loop Road No. 204 Phone Engineer's signature DHHS SIGNATURE Approved for Disapproved. -r_ bedrooms. Date / / 3 ; / * OF,j,� r _p / 1 r, ROBERT C, COWAN __.• �. C� ssol ; •. Conditional approval for 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 orderto 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 x21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825"L" Street, Room 502 a Anchorage, Alaska 99501 • (907) 343-4744 Health Authority Approval Checklist T, p� i0 i` .$ Rt-ic c1 t<AsILAG l-I1LLS v(S -! 31 —n IV®� W`, � Legal Description: Parcel I.D.I. � S A. WELL DATA Well type Pn I v A r C r `n Cy G If A, B, or C. attach ADEC letter. ADEC water system number Log present 6�N) y 9- } Date completed 10 / )-O_/ -71 i Total depth s" _ Cased to ll za c Casing height (above ground) Sanitary seal &N) Wires properly protected &N) _ FROM WELL LOG Date of test 10 /Jo/ -77 i Static water level I S Well production >�, 0 g.p.nt. WATER SAMPLE RESULTS: Coliform 0 Date of sample: _ . / /,;L S- / 16 AT INSPECTION C, it+ yE S 1 , 3 g.p.m. Nitrate Ei. y Other bacteria U Collected by: S & S ENGINEERING —17934£ayter-Rivar-kaoip Road No. 204--- B. SEPTIC/IiOLDING jTANKDATA agla River, Alaska 99377 Date installed ( Tank size Number of Compartments,I _ Cleanouts 6" VE3 Foundation cleanout (YIN) `IE S Depression (Y& /V -o Date of Pumping 11 `4 ( I S Pumper A `f" C. ABSORPTION FIELD DATA Date installed °I 1.7 _7 Length 1 "1G Width High water alarm (Y/�i,� H o Oomi S6'VlcEj. _ Soil rating (g.p.d./W of ft /% drn _ 3 c Gravel thickness below pipe System type _r /. ft mit �1, S Total depth 7 Effective absorption area =2 S S Monitoring Tube present(VN) yrs Depression over field (YO N a Date of adequacy test 1 aY y Results (Pass/Fail)' For 3 - bedrooms Fluid depth in absorption field before test (in.); O Immediately afterl- �9gal. water added (in.): O Fluid depth o _(ins.) Minutes later: b _ Absorption rate = !q s`o -� g.p.d. Peroxide treatment (past 12 months) (YIN) J1 l i- icN u crnl If yes, give date _)_ Pi2 L -t 63%7J * IN M % $- C/o /Fr- ENO o#: '7'45_NC,4 a,v I c%to r'`1 (7(A,o p,iiw'S tip o�A!"17) ALfo „ 1111L_96 PJ'N 41 nrien;7 0"A ( ell Cr ) 0n/ , )/�/air_ D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* E. SEPARATION DISTANCES Size in gallons "Pump on" level at* *Datum "Pump off' level at* SEPARATION DISTANCES FROM WELL ON LOT TO: - Se tic folding tank on lot 10 0 / ; On adjacent lots 1 o O / Absorption field on lot 1 ° - ; On adjacent lots I U o Public sewer main tv Public sewer manhole/cleanout Sewer /septic service line l 0 0 + Lift station "' 6t SEPARATION DISTANCES FROM SEPTI HOLDING TANK ON LOT TO: Building foundation S' t- Property line 4 0 !-/- Absorption field 20 Water nfaiff/service line 1O i-/- Surface water/drainage /00 ~ Wells on adjacent lots 10V /4' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation 3 y -4 Water main/service line 3p -A Surface water 1 0 o % Driveway, parking/vehicle storage area a Curtain drain Ivo N e k o w �J Wells on adjacent lots 100 /-k Property line lip F- F. ENGINEER'S CERTIFICATION 1 certify that 1 have determined thru field inspections and review of Municipal records that th�,,Qt><ayg„�; in conformance wit MOA MA_A guide 'fes in effect on this date. :^ t.'F; '....... a Signature e3_ /� ' /°•{'fit: i Engineer's Name /c ��'i27 C (aLIV01X) %Eu?'' eec3 / <He Date I / 31 /q HAA Fee $ S(po.00 Date of Payment a- \ -9 Receipt Number b) 19 51-1 Rev. 8/95 OSS: haa.wk.doc Waiver Fee $ Date of Payment Receipt Number ,is are y ROBERT C. Cl - 1 ------------ ,i `f . �® RECEIVED Municipal &flQc* fte o �G��`9EPA'� MENT F HEALTH{& HUMAN SERVICES qty ° of ft ttfi! 00"999-0650 0� FFA o'aAILS W I �10\ PERFORME�AR l V14" C9 sY- i3 0 LEGAL DESCRIP DEPTH (FEET) 1 3�, 6/ , 0 U 4 - Z - Ie ` rj F, C 6 SE J i -�t 7 8 � c 9 r v- 10 � Y 11 - J 12 13 ° 4 14 J. 15-- 16 5 — 16 17 18 19 20 l' iI k� 1`, l 11� • ' ROBERT C. COWAN -r z, < DATE PERF( RMED C7-- S- Rt k: 0/u- Nt/L57ownship, Range, Section: SLOPE SITE PLAN off) 1"o CK (RtfTvsA v) Depth to Water After Monitoring? Dale: ■ 6-m (docK at NEW WAS GROUND WATER Yc ENCOUNTERED? IF YES, AT WHAT - DEPTH? /s off) 1"o CK (RtfTvsA v) Depth to Water After Monitoring? Dale: S L 0 p e__ E Reading Date Gross Net Depth to Net Time Time Water Drop I f PERCOLATION RATE _ (mmutes/mch) PERC HOLE DIAMETER u TEST RUN BETWEEN FT AND — FT / Cr)MMFNTR Si/'A:2A jrC rJ l_ X/1? I 13E Try ¢. E'7„' t�)J i TJ/�l G/--/c.1JM !"�/r,-/J J'. '�/✓C/./ l7N[7 litii)l�tlC is CLiiAn.G.; I/vS7fi r -Lk✓) <I--E;1'S7 C, j 0/-7 O i/ e/.- 7 S & S ENGINEERING ' r 1 - PERFORMED BY: - -�:'z - r�-^'"�- CERTIFY THAT THIS TE T WAS PERFORMED IN 17034 Eagle River Loop Road o a // �i %�`� ACCORDANCE WIT ��4%Tf Atq",l rVy7kL GUIDELINES IN EFFECT ON THIS DATE. DATE: / 72-008 (Rev. 4185) ■ NEW MENEM N NJ � S L 0 p e__ E Reading Date Gross Net Depth to Net Time Time Water Drop I f PERCOLATION RATE _ (mmutes/mch) PERC HOLE DIAMETER u TEST RUN BETWEEN FT AND — FT / Cr)MMFNTR Si/'A:2A jrC rJ l_ X/1? I 13E Try ¢. E'7„' t�)J i TJ/�l G/--/c.1JM !"�/r,-/J J'. '�/✓C/./ l7N[7 litii)l�tlC is CLiiAn.G.; I/vS7fi r -Lk✓) <I--E;1'S7 C, j 0/-7 O i/ e/.- 7 S & S ENGINEERING ' r 1 - PERFORMED BY: - -�:'z - r�-^'"�- CERTIFY THAT THIS TE T WAS PERFORMED IN 17034 Eagle River Loop Road o a // �i %�`� ACCORDANCE WIT ��4%Tf Atq",l rVy7kL GUIDELINES IN EFFECT ON THIS DATE. DATE: / 72-008 (Rev. 4185) 01/30/96 14:13 ME ES[ RNCHORRGE 4 9076941211 MiE Environmental Sorvice9 Inc. CT&V Ref.# 96.0272-3 Matrix WATER Client '9ample ID L5 BLK9 KASILOF HILLS SID Client Name a & $ ENGINEERING Ordered By R. COWAN Project Name Project# PWSID UA Sample Remarks; SAMPLE COLLECT4D BY: BOB C. INV. CGG Wc, WORK Order 20853 Printed Date 01/30/96 O 12:36 hra. Collected Date 01/25/96 M 14:45 hrO. Received bate 01/26/96 m 09:20 hrs. Technical Director STEPHEN C. E�DEE Releaeed Byre+--+�.+•"�""—� /""" Allowahle Ext. Rnal QCInit Parameter Results Aua1 Units _ ---- __--------- -------------------•- 01/29/96 EMS Nitrate -N -'-'- " ----' -- 9.4 D mg/L i1PA 353.2 10. WO VO 1^ LC==DO Fl.•�====�^^a ..._.._____^_"___===s-_' «__=.,__a----" ^yes vw UA .. Vnavailable special Instructions Above NA - Not Analyzed 2S** qct Sample Remarku DoveLT is the practical quantification limit. - Le4a Than Than `jU = Undetected. Reported value GT = Greater u: S'D J = Secondary dilution- MUNICIPALITY OF ANCHORAC DEPARTM• .,T OF HEALTH AND ENVIRONME(N..\L PROTECTION 825 L Street, Anchoraap.. Alaska 99501 264-4720 #1: Time 9:30 a.m. #2: Time Date Received: January 5, 1978 #3: Time Date 1-9-78 Monday Date `^ Date Insp Pratt Insp Insp REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES 1.. Lending Institution Request: Alaska Mutual Savings Bank — Mailing Address: Post Office Box 1120 99510 _ Phone: 274-3561 — 2. Property Owner: Carl E. .Luchsinger _ Phone: Mailing Address: Star Route A Box 94 99507 3. Legal Description: Lot 5 Block 9 Kasiloff Hills Subdivision ^Y 4: Single Family Residence: (x) Number of Bedrooms: Two Multiple Family Residence: ( ) Number of Bedrooms: 5. Well System: Individual Well (x) Community/Public System ( ) Permit # 77742 Depth of Well _85 Well Log on File ( ) �- t Construction r "°' _ Bacterial Analysis- !� Note: 16 611 long on file. 6. Sewage Disposal System: On-site System (x) Public Utility ( ) Permit # 77742 Installed 1977 Installer Septic Tan], Size — Manufacturer Absorption Area Soils Rate — Material 7. Distances: Well to Septic Tank to Sewer Line to Nearest Lot Line Nearest Lot line to Absorption Area Absorption Area 1. MUNICIPALITY OF ANCHORAGE Department of Health and Environmental. Protection 825 L Street, Anchorage, Alaska 99501_ 264-4720 � �equest for Approval of Indi_vi-dual Sewer_ and Water Va'cil.�i-ties � / l Property Owner;mailing Add Addr 2. Name of Buyer: _pad Mailing Address: -- A. �___�__—._ Phone: --- -- 3. Lending Institution: Mailing Address: ---- ----^- —---_--._ Phone: --- _ 4. Realtor/Agent: - Mailing Address: Phone: 5. Legal Description: _ ------------- Street Location: 6. Single Family Residence: ( L� Number of Bedrooms: ---_ Multiple Family Residence: ( ) Number of Bedrooms: 7. Water Supply: *-Individual Well (') Public/Community System ( ) If Individual Well, well depth If Conununity System, name of system 8. Sewage: Disposal System: *tn-site System (✓} Pu lic System ( ) If On-site System, date of installation: *NOTE: A well log is required on ALL wells drilled since 6/75. ** If on-site sewer system is over, two (2) years old, an adeclu,icy test- is required by this depart-ment. A fee of $7.5.00 must accompany each request before processing can be initiated. 3/77 Page Two Department of Health and Environmental Protection Request for Approval of Individual Sewer and Water Facilities Legal Description.: Lot 5 Block 9 Kasiloff Hills Subdivision Comments: Affadavit Attached: ( ) Letter Attached: ( ) Approved: y Date Disapproved:]Date: Department Worksheet: