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HomeMy WebLinkAboutKNIK VIEW BLK 2 LT 9Knik View Block 2 Lot c) #051-031-40 Municipality of Anchorage Page I of DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O: Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: <~'{/~'/c:J~O~'~-~ PID Number: 0-~'1-- O3 ~-- ~ Name: ~0~ ~/~P~lq Wastewater System: ~ New D Upgrade A~,e,~; ~0 ~ ~5~?,~/~/~ ~7 ABSORPTION FIELD Phone: ~_ ~ I.o. of Bedrooms:~ ~ Deep Trench ,ShallowTrench .Bed .Mound .Other LEGAL DESCRIPTION SoilRating: J,~ GPD/Sq. Ft. Total Depth from original grade: Lot: ~ Block: ~ Subdiv~'on:~ I~ ~1 ~ ~pth to pipe bottom from original~gr~e: Ft. Gravel depth beneath pipe Township: ~ Range: Section: Fill added above originsl grade: Grovel length: WELL: D New ~ Upgr~ araveiwidth: 5 Number of lines: Ft. { Ft. C ~s f cat on (Pr rate, A,B,~) ~ Cased To: Total absorption ar.~ I Pipe mate~ah ~b{ I~ ~ ~ Ft. Ft. SO. Ft. A¢T~ D30~q~lO ~~ ~,~ ~t ~. TANK SEPARATION DISTANCES ~s~c ~ Ho~ng : WelY ~ ~ ~ ~ __ ~.,~da.: 5tee J NumberofOompa.ments: ~ Sudace Water l~V l~ LIFT STATION C~.~?~n --~0~, /~-- ~ IEl~tricallnsp~ti°nsped°=edby: Remarks: P*~c ~a C~=~ 5~] BENCHMARK Assumed Elevation: I O~ Inspections pedormed Y'~gie ki~r, Aiaska ~zz ~nd ~- 1~-~ ~ no"~nT C. COW~ Depadment of Heallh and Human ~e~ces approval -- ~.--. ... ~. 72-013 (Rev. 9~J1) MOA 25 PERMIT NO SW990073 PAGE 2 or 3 Municip. cti$_ _y_..oC Anchorcae DEPARTMENT OF HEALTHAND HUMAN SERVICES ENVIRONNENTAL SERVICES DIVISION P.[D, Box 196650 ·Anchopcge, Atcskc 99519-6650·TeLephone~ 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL LOT 9, BLOCK 2, KNIK VIEW S/D P.I.D. NO. 051--031--40 / LO? 8, 1250 GALLBN // / / / / LOT 10 ROBERT CE - 8801 PERMIT NO SW990075 PAGE 5 OF 5 Municip.~U~.. _y_..o~ Nnchor~ee DEPARTMENT OF HEALTHAND HUM'AN SERVICES ENVIRONMENTAL SERVICES DIVISION P,B, Box 196650 eAnchor'o, ge, A[o, sko, 99519-6650eTetephone~ 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL LOT 9, BLOCK 2, KNIK VIEW S/D P.I.D. NO. 051--051--40 90.1' FINAL NEW 1250 GAL SEPTIC TANK GRADE ~INSULATION '85.9' C01 C02 MT2 MT1 CO1 = 86.1' ~[1~~.~ 2" INSULATION ~1~ CO1 83.6' MT2 = 80 9'ff ~MT1 = 80.9' · NO WATER FOUND 73.4' B,0.H. A B FCO 17.5' 15.5' ST1 23.0' 15.0' ST2 28.0' 21.5' DBL1 29.5' 23.5' DBL2 S0.5' 24.5' ~rl 28.5' 46.0' Col 27.0' 46.5' ~02 70.5' 48.0' MT2 68.0' 46.5' Municipality of Anchorage. DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS. LOG -- PERCOLATION TEST LEGAL DESCRIPTION: LO+ ~ ~lO~:~ 2.,~#]~V,~R~Township, Range,Section: 4- 5 6 7 8 9 ..10 11 12 13. 14 15 16 17. 18- 19- 20- SLOPE WASGROUND WATER ENCOUNTERED? IF YES. AT WHAT DEPTH? Gel)th lo Water After ~- Menitoril~g? Oate: SITE PLAN I N Reading Dete Gross Net Depth to Net Time Time Water Drop 0 P,e£;ll~* ~" 60~;-i ~" I~/~'' PERCOLATION RATE'~'~ ~'~ (minutes/inch) PERC HOLE DIAMETER ~ ~.t TEST RUN BETWEEN .~ FT AND ~' FT COMMENTS ~3~'/~- ,,IO~.~3~T' ~ ~V~5~o~) ~lb~ ~c,'L~ ~0 /~ ~/ ~ ACCORDANCE WI~[~EE~8~L GUIDELINES IN EFFECT ON THIS DATE. DATE: F /7 / ~ ~ 72-008 {Rev. 4/~) i'ROBERT C. COWAN, RE. ROBERTA. SHAFER, EE. CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 WELl. INSPECTION &FLOWTESP Municipality of Anchorage DEPARTMENT OF HEALTH AND HUM~/q SERVICES 825 L Street P.O. Box 196650 Anchorage, Alaska 99519-6650 RECEIVED MAY 2 4 1999 Municipality of Ancr~orage Dept. Health & Human Services The septic i~ections for the referenced property were performed on |0-99 and ~-IO-9~ · Prior to submitting the On-site Wastewater Disposal System and~or Well Inspection Report we are waiting for the ~'~,~ ~W to be completed. If we may be of further service please contact us. Sincerely, Robert C. Cowan, P.E. 17034 NORTH EAGLE RNER LOOP · SUITE 204 · EAGLE RIVER. ALASKA 99577 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-Site Services Program 825 L Street, Room 502 P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Initial Date Issued: Apr27, 1999 Expiration Date: Apr 26, 2000 Permit Number: SW990073 Legal Description: I~J~I~i~f,,BLK 2 LT 9 Design Engineer: 0003 S & S Engineering Owner Name: Leroy Alderman Owner Address: PO Box 670045 Chugiak, AK 99567- Parcel ID: 051-031-40 Site Address: Lot Size: 20000 SQ. FT. Total Bedrooms: 4 Permit Bedrooms: 4 This permit is for the construction of: [] Disposal Field [] Septic Tank [] Holding Tank [] Privy [] Private Well [] Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ). 3. The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling (907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. 5. The following special provisions. At the time of construction an additional soils test shall be performed to cover the South end of the Alternate site. The ML./SP layer underlying the GW layer shall be perced at that time. Any changes to the attached design are subject to approval of DHHS. Received By: Issued By: ENGINEERING STUDIES AND REFORTS APR 09 1999 MUNICIPALITY OF ANCHOPo~'(~J~OBERT C. COWAN, P.E. ENGINEERS (907) 694-2979 FAX (907) 694-1211 April 8, 1999 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services P.O. Box 196650 Anchorage, AK. 99519 REFERENCE: Lot 9, Block 2, Knik View Request you issue a permit to install a septic system to serve the four bedroom dwelling on the referenced property. A test hole was excavated and a percolation test was performed. The approximate location of the test hole is'located on the attached site plan. At the time of excavation 3/30/99 water was not found. After seven days of ground water mon~toring the monitoring tube was dry. We do not anticipate any adverse effects on neighboring wells, septic systems, reserve areas or drainage patterns by the installation of the proposed septic system. The construction of this system will not prevent any future development on any of the adjacent properties. If you require additional information, please contact us. S~cerely, Robert C. Cowan, P.E. RCC/jbm Enclosure 17034 NORTH EAGLE RIVER LOOP * SUITE 204 · EAGLE RIVER, ~KA 99577 ' '. 1"'= 40' ' PLOT PLAN DESIGN SCALE .... / I TO PERFORMED FOR: LEGAL DESCRIPTION'? Municipality of Anchorage. DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST DATE PERFORMEr Township, Range, Section: 4- 5-' 6. 7. 8. 9. 10- 11- 12- 13- 14- 15- 16- 17- 18- 19- 20- COMMENTS WAS GROUND WATER ENCOUNTERED? SLOPE SITE PLAN IF YES, AT WHAT DEPTH? I N ~ I~-~ P--~ S Dep~ lo Waler Alter Mofl~ring? ~)/~ "~ Date: Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE '~ ~ (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN "~ FT AND L~ FT PERFORMED BY: ~'-~ ~ -'--,- ~ , ..... I CERTIFY THAT TH~S TEST WAS PERFORMED iN ...... , ........... ~ ........ ._ . , ,~/ /,~ ACCORDANCE W~L~"~rL~Z~PAL GUIDELINES I" EFFECT ON THIS DATE. DATE; ~1 72-008 (Rev. 4/85) SEWER&WATER INSPECTION ENGINEERING STUDIES AND REPORTS ROBERT C. COWAN, P.E. ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 REFERENCE: Lot 9, Block 2, gafik View Aplil 8, 1999 GENERAL: The scope of this project includes the installation of a 1250 gallon septic, tank and leachfield trench for the four bedroom house located on the referenced property. Construction shall be in accordance with the approved site plan and design drawings, Municipal permit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. The contractor shall be responsible for obtaining any necessary underground utility locates. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. SEPTIC TANK INSTALLATION: A septic tank is to.be constmcted by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. All standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 17034 NORTH EAGLE RIVER LOOP SUITE 204 "EAGLE RIVER, AL,~KA 99577 Page 2 Lot 9, Block 2, Knik View April 8, 1999 Septic tanks installed with less than 4 f~. of cover shall be insulated. A foundation cleanout shall be installed one to four feet from the building foundation. In the line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10 fi. fi.om the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. Final grading over the septic tank shall be such that a positive slope exists away fi.om the septic tank. ABSORPTION TRENCH/DRAINFIELD INSTALLATION: Excavate the proposed trench to the dimcmsions shown on the design. The bottom of the excavation shall be within 2 inches of level. If the sidewalls of the excavation become smeared, they must be raked or scratched (ruffed-up) before gravel (sewer rock) placement. Once the gravel is installed, the distribution pipe is to be installed level with the perforations faced downward. Gravel is then to be placed over the distribution pipe to provide a minimum of 2 inches of cover over the pipe. A silt barrier must be installed between the final gravel layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill. Monitor tubes shall be of four (4) inch diameter, installed approximately in the locations shown on the design, and extend a minimum of 12 inches above final grade. The portion of the monitoring tube extending through the gravel shall be perforated from the bottom of the trench to the invert of the distribution pipe. This is equivalent to the effective depth of the gravel as noted on the design. Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than tlfirty-six (36) inches. The finish grade over the trench must be mounded to prevent the formation of a depression after settling. Page 3 Lot 9, Block 2, Knik View April 8, 1999 S/D MINIMUM MATERIAL SPECIFICATIONS: Any septic tank proposed for installation must be constructed by a Municipal approved septic tank manufacturer. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Type of Pipe Perforated Solid Cast Iron Yes Yes ASTM D3034 (PVC) Yes Yes ASTM F810 (HDPE) Yes No ASTM D2662 (ABS) Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). Septic tank inle~ and outlets shall be fitted with watertight couplings (Caulder, Femco, or equal). A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill. All leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the #200 sieve. When sand is being used as a filter material, its gradation specifications must conform to current M.O.A. or D.E.C. reqnirements, which ever requirement applies. INSPECTIONS: Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: Page 4 Lot 9, Block 2, Knik View April 8, 1999 · S/D The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before this inspection. The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. 3. The final inspection is to occur upon final grading of the property. Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre-construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or control in any way the contractors activities. The owner shall contract with the contractor to perform the work outlined in these specifications and plans and in accordance with the attached M.O.A. permit. There will be no contractual arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be the owner's representative and will inspect the work as stated above to document the contractors activities. Final acceptance of the contractors work rests with the owner and the M.O.A. S & S Engineering shall have no liability to the owner or to others for acts or omissions of the contractor or may other persons performing work on this project or the failure of the contractor to carry out the work in accordance with these construction documents. S & S Engineehng's inspecting engineer will not be responsible for the construction means, metbods, techniques, sequence, procedures or the safety precautions incident to this project. CONTRACTOR/INSTALLER MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # O~-/ '-O~l - ~/O 1. GENERAL INFORMATION Complete legal description CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING HAA# Lot 9, BlOck.:2, K~ik:View-Subdivision NHN Inlet Vista Drive Location (site address or directions) %iM~211Leroy Alderman ~P~ropert~/owner % ~ Day phone · ?--'M~ilinga~'dr~ ....... ?.0..18o× 670045, Chugiak, A~ 99567 688-3403 ~:l-e' ~gency,-'- ,, Day phone ;Mailing address Agent ' -~.~ Day phone Address Unless otherwise requested, HAA wifl be held for pickup. NUMBER OF BEDROOMS: 4 TYPE OF WATER SUPPLY: Individual well Community well Public water × XX' NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Re~. 1/91) Front MOA ¢r21 5. STATEMENT OF INSPECTION BY ENGINEER AS certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm S ~, S £NC:::?=~:;;C, Phone c~ ~ ~ ~. ~/ ? 17034 Eagle River Loop Roa¢{ No. 2G4 Address Eagle ~iver, ~.l~sl(a/5~5~7~ / Engineer's signature ~)/~._~ ~ / /h ~ Date o DHHS SIGNATURE C'//' ApProved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date The Municipality of Anchorage Department of 'Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professio hal engineer registered in the State of Alaska. The DH HS does this as a courtesy to purchasers of ho mss and their lending institutions in order to satisfy certain federal and state requirements. Employees of DH HS 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, "  Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICE~UG Environmental Services Division Health Authority Approval Checklist LegalDescription: ~-e~-°l 8~oc,~ ,,~ K~,~ v,,~cJ ParcelI.D.: 05'~/ -OD A. WELL DATA Well type If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Total depth Sanitary seal (Y/N) Date of test Static water level Date completed ~ Cased to Casing ~ground) ~erly protected (Y/N) FROM WELL LO~ AT INSPECTION Well production Date f~sample: g.p.m, g.p.m. Nitrate Other bacteria Collected by: B. SEPTIC/HOLDINGTANK DATA Date installed 5-'//o/~ Tank size )3 5-o Foundation cleanout~/N) '"f,~ / Depression (Y~ ~ O High water alarm (Y~ Date of pumping ~'//A ~-,u~.~ Pumper -- C. ABSoRpTION FIELD DATA ": Date installed ~'-/I ~ / ~J °~'i Soil rating r fF/bdrm)/,- :~L System type 7 ~ e...,.,, c- ,'~ Length' ~ c~ W~dth :' ~" Gravel thickness below pipe ~ '/~ Total depth EffeLive absorption area ~T,~ I ~ Monitoring Tube present~/N)~J Depress on over field (Y(~. Date of adequacy test /"//4 - ~u ~ Results (Pass/Fail) For Fluid depth in absorption field before test (in--er added (in.): Fluid depth · · : ' = g.p.d.  Absorption rate = Pemxid~past 12 months) (Y/N) If yes, give date Number cf Compartments ~- C eanouts(~N). '~'~J bedrooms 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump o "..~Je~~ ~Pump off" le,~el at* High water alarm level at* .-----/*Datum Cycl~ E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding lank on lot On adjacent lots Absorption field on lot ~ Public sewer main ~Public sewer manhole/cleanout S~ Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation ! ~ Property line ~ I Absorption field Water main/service line I0 --/- Sudace water/drainage /o o ~ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line Building foundation ~) '~ Water main/service line Sudace water )Oo 4- Driveway, parking/vehicle storage area Curtain drain /,~ JoY* F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal records in conformance wt'th ,MOA HAA guld. elines in effect on this date. Signature Engineer's Name Date HAA Fee $ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* mnq ROBERTC. COWAN, P.E, CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 SEWER&WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAO DESIGN SOILTEST PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS August 13, 1999 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services PO Box 196650 Anchorage, AK 99519 REFERENCE: Lot 9, Block 2, Knik View Subdivision Request you grant a waiver on the referenced property for the horizontal separation distance between the septic leachfield and the north property line at 5 feet. We do not anticipate any adverse effect on the adjacent property. [f you require additional intbrmation, please contact us. Sincerely, RCC/sh i<ECEIVED AUG 19 1999 /'/tUNICIPALITY OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION 17034 NORTH EAGLE RIVER LOOP · SUFFE 204 · EAGLE RIVER, ALASKA 99577 Rick Mystrom, Mayor Municipality of Anchorage Department of Health and Human Services 825 r'L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 http://www,ci.anchorage ak.us S & S Engineering ATTN: Robert Cowan, PE 17034 Eagle River Loop Rd, #204 Eagle River, AK 99577-0000 August 25, 1999 Subject: Waiver Request forKNIK VIEW BLK 2 LT 9 Waiver # WR990059 Lot Line Request for Parcel ID 051-031-40 Dear Engineer: Your request for a waiver of the required 10 feet horizontal separation of the on-site wastewater disposal system to the lot line has been approved The approved separation distance is 5 feet. This waiver approval applies to the current on-site wastewater disposal system and lot line separation only. Any future upgrade to the on-site wastewater disposal system and lot line will require all separation distances to be met or another waiver approval from this department. If there are any further concerns or questions regarding this waiver, please call our office at 343-4744. Sincerely, Jeff' Poet Engineering Technician III On-Site Water Quality Program WR~ WR990059 PID~ 051-031-40 Date Received: August 19, 1999 Legal Description: Lot 9 Block 2 Knik View Engineer: Robert C Cowan, PE~ S & S Engineering 17034 Eagle River Loop Road~ Suite 204, Eagle River. Alaska Applicant: Leroy Alderman % MC2I MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-site Services Section Waiver Review Worksheet HA~ HA990421 Permit ~SW990073 99577 Waiver Requested: line of 5 feet. Lot line waiver from the leachfield to the north property Criteria: 1. Geology: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation TOTAL: 2. Special Conditions: Points: 3. Other: Waiver is Granted: Waiver is NOT Granted: List Conditions or Reasons for above: N~e/~f~viewer Rec ~: #05249/7859 Amount: $ 115.00 Date Paid: Aug 19, 1999