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HomeMy WebLinkAboutNORTH WOODS BLK 1 LT 9 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Heallh Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name A ~ ~C DISTANCES ~/_ ~ Tfl SEPTIC ABSORPTION Phone(s) Per'it No. ' No. of Be ~ WELL -- I ~ o° oo~ ~ LOT LINE Z o 't '¢ : FOUNDATION Township. Range. Section ~]~ ; J~W~ ~ ~C ~ driveway, water bodies, etc.) ~ SEPTIC ~ HOLDING Material No. of Compadments ~ ~ ~ TRENCH ~ BED ~ W. DRAIN ~ OTHER Fill added above original grade Gravel depth beneath pipe ET Total absorption area ~ SQFT Distance between~/linesFT ~'~ ~ g PRIVATE ~ OTHER {Identify) ~ ~ REMARKS: Insp~eHormed by: E~ ' ...... Alaska'~--~5~ ~' ~ ~ ce~aHhisJnspe~ion~s~peflormd~_~according to all / / ~unicipal~l~es i~ effect ~ Ibis date: 72-013 (3/85) L,:::d'. l...~,.'.:~,ga i: Sub c:l i v :ir ~!; :i. C)!"] )', NORTH I/,IO0:OS '~ l....o'L ii 9 S~+?x:::tic, n',: 3 "l'ownsh:i.p~ :(.SN Range~ [..cr~:. S:L;~:~..) :26964 (scl,, {"~'..,, oc i"iax Bced r" c:)oms :~ T h :J. s l::'e r m i 'L: 3 'For a ]. Capac: :L t y: .[ iq!i?[ ALI.... F'ER EI',IG]:NEi:EFi'.S ATTACHED DES]:GN,, NOT]:F::Y DHHS F'R IOR "FI] ALL :!: NSF'F~:C'i' IONS,, F;:'F~OV ]:DE: ADDED SO ILS L..OG T'O C[]I~!F']:RI~ SAME: SO :[ L..S t,,' ....... ~ ......... ~:l..~t_~j..' '1~:~/~:~0 OR DLJFk]:NG , ~' ~... !_JL.d~ ..)!..J I )": FT) ..,F.E.~. ,, :[ F' CONSTF:;:L~CTED '"' ....... ' ......4/. .... F:'RIE:EZ.[NG WETHEr:R, E:XCAVA'i']:ON ?IUS"I BE CiF::'ENED. AND CLOSE:[) lin ONE: DAY UNL.ESS ]:'f' IS COVE:RE:O AN:O HEATED,, TH~S F'!~EF:;tPIIT ]:S :ISSUED i::'OR 'I"HE i~ X :[ ST' ~ h!G S :1: NGI....I~E I:::'AM I I....Y t'"![)ME~: AND EX F' ]. RES ON :L 2 73 1/90 ,, CERfIF:V THAT: .!.,,:[ ,::tr!1 {~'~m:i. 1:i..:~ti" with '{'..h(.? p(.:.:.h::Tlu~r",'.:.:~l~l~!"Its ~:'oP c~i"l-si'~'..(.~ s¢-:~.~t.~:.~r.~ .:'~tFtd ~R~:.)].i~; 6'~ ~'c:u"'Lh by '~'..}"~:z, F1unic:i.i::~a].:LtY oF Aric:hc~rage (MOA) and the Sta'}:..e c:,(' 2.,, ]: w:i.].]. :Lns'La11 -~th~:, syshem in ?;';tc:c:opd¢~d"~c(4~ ~,~J. th a].t I¥iOA c:od~:)s and and in cc~mp].:Lanc~:, w:i.'Lh 'Lhe design cri-Leria c:){' 'Lh:i.s pe?m:Lt,, :::.~;~ :[ w:i. il adhere.:-? 'Lo all MOA at~d :~?l'..a'L(.:~.? (::){ Al.aska rc.~qu:i.i"em~.::.~r'~ts .l'¢:)p th,:.~,:, s,:.~:d:., back d:i. stai]c::,~.:.:,s {'i".(]Ri any exis'L:i, ng w~?:~].]., wast. e,,~atx.~' disposal ~ys'Lem c:m public ~iip}}.}ij',?:~i,i~a{;:j(.:k:, t]iys-ls.(.~.)m (:'li"l 'i:..h:i.s c)r' any a(::!jac:(.'.'~n'L. (::ii" t'ie:.:,~l"~;)y · ~,, :[ I..U"i,::I~:'.:'P~EFi'.?:?d"i(::I that th:i.s ~:I(.~H'iII:i.'~.. :LS V'~r].:i. Ci {C:'t~ a maximum of' 3 bc.x::lr'.oc>ms. a.[s(] LH'tch.:~H"S'~'.4L:~r'1C~ 'J:..ha'~L 'IL f-d.):.) capatc:i, ty 0{' the:, '~.c)tal sys'~.~[~.}m :i.~s :]; L:)E. cJpc)om:~; ai"H::J ~.[!y ,:.'.:,i"~:J.(~.i".!:~(;:~,i'~l(~:,J'/'~. ~,~:L].]. r'equ:i.r'{~ ar~ add:i, tior~ai per. mi'L. A ,, i...~ ,, I:;:' ,, !:2: ,, ~ .) A T F: (Own (i.i? ~" ) ................... I SCALE Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG PERCOLATION TEST _ ~fi~FO~M[D FOB: . ~ ~ ~ ~ 1 2 3 4 7 8 10 WAS GROUND WATER ENCOUNTERED? 11 s IF YES, AT WHAT ~ ~. I.~..I L Depth to Water AfterI 13 Monitoring? ~ /'7-'~' Date: Reading Date Gross Net Depth to Net Time Time Water Drop I ~-'~,o 7._: ~-~, ----. ~- - 14 15- 16- 17 18 19 2O PERCOLATION RATE ~ (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ~ FT AND ~ FT -/ COMMENTS ./' / S & S ENGINEERING </< · / q 17034 Eagle River L~mp Read 1~1o. :~04/~/ / //// :E;= .... ! - : '~A'~ / N~¢''~*~''--~- S EST WAS PERFORMED IN PERFORMED BY .~1,~ 17,v~_r Alaska 99577 ~, CERTIFY THAT THI T 72-008 (Rev. 4185) SCALE ,4 I i~ '~.j 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 REPORT NAME LEGAL ~ESCRIPTION ~ DISTANCE TO: ~ ~ Absorptio~a}e~ Dwelli~ :~/~ PERMIT NO. ~ ~ Manufacturer Mater~ ~ ,o. ~mportments ~ ~ Well PEBMIT ~0. DISTAN~ Dwelling ~aterial Z_~O ~ ~ Ma~er ~~~ Liquid capa~in gallons ~ BISTANCE TO; ~ ¢~.~ Fo~~ li~/ , PERMIT NO. ~/O/~ ¢ ~ ~ ~ ~/ ~ ~¢nches Total effecti* a~t~n area ~ ~ Top of tile to finish grade Material beneath tile Length ! Width Uepth PERMIT NO, ~~~ Buil~in~ foun~ ~t lot line ~ ~ANCE TO: ~ ~ Depth Driller Distance to lot line PERMIT NO. Building foundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: OTHER PIPE MATERIALS SOl L TEST RATING ,,, ............. REMARKS I APPROVE~ ¢ DATE LEGAL 72-013 (R] fl 3/78) HERLTH aND EI~ IF._NHENTHL '3TECTION LDCm(L/-J/~-~) PERMIT NO. RPF'LICRNT P.J'&S INC (:]~D~_'-~ E. BENSON BL',,,'D LOCBTION PETERS CREEK LEGBL L9 Bi NORTHNO0[:'S LOT SIZE TYPE OF SOIL BE:SORF'TION SVSTEM IS: TRENCFI MB.~-~:IMLIf't NUMBER OF BEDROOMS = ]: SOIL RBTING (S',Q FT,-."BR.)= THE REQUIRED SIZE OF THE SOIL RBSORPTION SYSTEM IS: 27' ?-"'52"2. 20OF'lEI '5..-.~LfFIRE FEET THE LENGYH [:, I MENS I ON IS YHE LENGTH (IN FEET[:, OF THE YRENCH OR DF.:RINFIEL[:,. YHE DEPTH OF FI YRENCH OF.: PI'[ IS THE DISTBNCE BETWEEN YHE SURFFICE OF YHE GROUND FINE:, YHE BOTTOM OF YHE EXCFIVBTION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRB',/EL DEPYH IS THE MINIMUM DEPTH OF GRR',/EL BETNEEN THE OUTFRLL PIPE RND THE BO'FTOM OF' THE E::.::CRVRTION <IN FEET::,. PERMIT RPPLICRNT HFIS THE RESPONSIBILITY TO INFORM THIS DEPRRTMENT DURING THE INSTRLLRTION INSPECTIONS OF BNY NELLS RDJFtCENT TO THIS PROPERTY RN[:' THE NUMBER OF RESIDENCES THFIT 'THE WELL WILL SERVE. 8RCKFILL!NG OF FtNY SYSTEM WITHOUT FINRL. INSF'ECTION RND FtPPROVRL BY THIS DEPRRTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM [:,ISTRNCE BETWEEN R NELL RND RNY ON-SITE SEWRGE DISPOSFtL SYSTEM IS 'I_E~E~ FEET FOR R PRIVRTE WELL OR ZSF'~ TO 2~_--~E~ FEET FROM R PUBLIC .WELL DEPENDING UPON THE TYPE OF PUBLIC NELL MINIMUM DISTRNCE FROM R PRIVRTE NELL. TO R PRIVFtTE SEWER LINE IS 25 FEET RND TO R COMMUNITY SEWER LINE IS 75 FEET. OTHER REQUIREMENTS MRY RPPLY. SPECIFICFtTIONS RND CONSTRUCTION DIRGRRMS RRE RVRILRE,'LE TO INSURE PROPER INSTRLLRTION. ! CERTIFY THFtT ±: I BM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND I.,.IELLS RS :BET FORTH BY TWE MUNICIPRLITY OF RNCHORRGE. 2: I WILL INSTRLL. THE SYSTEM IN RCCORDRNCE HITH THE CODE'_:;. 3: I UNDERSTFtN[:' THFtT 'THE ON-SITE SEWER SYSTEM MRY REQUIRE ENLRRGEMENT IF' THE RESIDENCE IS REMODELED TO INCLUDE MORE THRN i": BEDROOMS. PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 ~':'~-~ 9 10 11 12 13- 14- 15 16 17 18 19 2o COMMENTS PERFORMED BY: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Pouch 04~50, Anchorage, Almic,, g9602 276-222'l SOILS LOG - PERCOLATION TEST PERCOLATION TEST Gary Stromber9 p ,]%~- ~ ._T-.~_ ~ DATE PERFORMED: April 7:lgR1 Lot 9, Block l~ Northwood Subdivision Organics and organic silt, dark brown, top frozen. (Pt-0L) Gravelly-sandy-silt, brown to red-brown, stiff, moist, with some organics, rounded gravels. (GM-ME) Silty-gravelly-sand, gray, compact to dense, moist, rounded to sub rounded particles to cobble size, contains some thin silt lenses at depth. (GP-SM) SLOPE SITE PLAN ~OAb ~FR TTC;T'~ ~--~i") TT:qT i WAS GROUND WATER S L T---F- I ENCOUNTERED? No o~- I DEPTH? i ....... Gross Net Depth to Net Reading Date Time Time Water Drop 2 4-8-81 320 Min. l0 Min. 47½ ½ 3 4-8-81 330 Min. 10 Min_ 4R ½ 4 4-8-81 340 Min. 10 Min_ 48½ ½ 5 4-8-81 350 MiD, 10 Min. 49 ½ 6 4-8-81 360 Min. l0 Min. 49½ ½ PERCOLATION RATE 20 (minutes/inch) TEST RUN BEl~EEN . F'~I~ ~-..::~-J---~-.--~" ..... Howard Grey & Assoc.~ Inc. CE,T~EDaY: V~ [~ ~ ~E: y~t'' 8, 1981 P.O. ,.._~X 196650 ANCHORAGE, ALASKA 99519-6650 (907) 264-4~k 4744 TONY KNOWLES, MA YOR DEPARTMENT OF HEALTH & HUMAN SERVICES January 23, 1987 Leo and Nancy Williamson SR 3 Box 7589 Chugiak, Alaska 99567 Subject: Lot 9 Block 1 North Woods Subdivision The Department of Health and Human Services wishes to take this opportunity to thank you for your cooperation and assistance with the septic system related problems facing the North Woods area. With your help we have been able to ascertain which areas of Phase I are most likely to have a shallow groundwater problem. Our next step in this process is to determine to what extent the shallow groundwater has affected your neighbors throughout North Woods Phases II through V, as well as the surrounding area. We will then proceed along a similar course in those areas where groundwater contamination is a definite possibility. After reviewing the specific tests and the results provided by our engineering consultant relating to your lot, we have drawn the following conclusion: your septic system is not constructed so as to maintain the required four foot separation above ground water. However, since your system does not actually extend into the groundwater but is constructed approximately one and one-half feet above, the department will not require immediate action. It will be necessary, however, to arrange for upgrading upon resale or refinance. Please call our office for any further information or questions you may have at 264-4744. It is our sincere hope that we will be able to insure a clean and safe community in which you and your neighbors can live. To this end we wish to once again express our gratitude for your under- standing and unselfish cooperation. Dan Bolles Engineering Tech On-site Services - " ~.ot .-~..~'"B"-~ MUNICIPALITY OF ANCHORAGE ..~,'~O O¢'5 .~'~'~ Department of Health & Human Services O< ~%;O© k~tl DIVISION OF ENVIRONMENTAL SERVICES 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 9; Bloc~ I~ ~orth Woods Sub~vision~ Location (address or directions) 22656 North Woods D~ve (b) Property owner Mailing Address A.H.F.C.#29291 Telephone:(home) _Business 75290 5~0 East 34th Avenue Anchorage, Alaska 99503 (c) Lending Institution Mailing Address Tel.ephone (d) RealEstateCompanyandAgent RE/MAX ¢)F'EA¢IE RIVER ATTN~ Sbaro. Mi~h Address 16600 Centerfield Drive #201 Eagle River, Alaska 99577 Telephone 694-4200 (e) Mail the HAA to the following address: (or check hereY~, if hold for pick up.) List contact person and day phone number below: S & $ ENGINEERING 17034 Eagle RiYer Loop Ro~ EagJe River, Alaska 99577 2. TYPE OF RESIDENCE Single-Family E~x Number of bedrooms 3. WATER SUPPLY Individual Well [] Community [~X Public [] Note: If community.well system, must have written confirmation from the State Department of Environmental :Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site ~( Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72 025 (Rev. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, i verify that my investigation of th is 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 Address Date 6. DHHS APPROVAL Approved for~_¢ Approved bedrooms -'" Date Disapproved Conditional Terms of Conditional Approval The Municipality of Anchorage Department of Health and Human Services(DHHS) issues Health Authority Approval cerificated based only upon the representations given in paragraph S 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 DHHSdo not conduct inspections or analyze data beforeacertificateisissued. TheMunicipalityofAnchorageis not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 7/88) Back Page 2 of 2 ~'~ELL<~)~TA..~\ Well Clas~tion Well Log Present (Y/N) Total Depth Cased to Static Water Level Casing Height Above Ground MUNICIPALITY OF ANCHORAGE (MOA) ~ Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343-4744 Legal Description: ~ ~ ~' Date Completed Depth of Grouting Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot--- To Nearest Edge of Absorption Field on Lot If A, B, C, D.E.C. Approved~N) Yield Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining L'ots ; On Adjoining Lots To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments ~' ~,~'j _/-2. \ ~'~- "~ '~/l~d-~o~, To Nearest Public Sewer Cleanout/Manhole ; Date SEPTIC/HOLDINGZANK DATA Date Installed ~'/40 Size Standpipes ~;)N) Depression over Tank Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well "~,/ To Property Line ?> t''~ To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course [ c;~4:?(::::> ' No. of Compartments Air-tight Caps ~) T F°undati°n Cle~n//~t (~) /X/V'~ ~pa/~e Last PumpecY /',/--~ ;for / Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field ~ / Comments 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Type of System Design Length of Field Depth of Field-- Gravel Bed Thickness Square Feet of Absortion Area ~:~ ~''''~t~' Stat nd pipes Presentz::C~N) /~.~/~ Depression over Field (Y~P ,~ Date of Last Adequacy Test Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation Lot ~ ~ To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area "'~,--tc;,~:~t-'~ To Property Line To Existing or Abandoned System on ; On Adjoining Lots ~ t_.~ To Cutback (if present) ~' Comments D. LIFT STATION Date I~ed Dimensions Size in GalR:rrt~ Manhole/Access (Y/N) "Pump On" Level at '~.. "Pump Off" Level at Water Alarm Level at ~ ~_Vent High (Y/N) Tested for Meets MOA Electrical Codes (Y/N) Comments **Check Permitted Bedroom Rating Against HAA Request** -. I certify that I have checked, verified, or conformed to all MOA and HAA guidelines Tn effe of this inspection. Signed .:.. ~ Company '17034 [:~..~gio [~.iver Loop [~oad Ne. 204 Receipt No. 'z/~O //~--~ ~-~,,~'~,,~.----. Date of Payment z/',~ --~ ZTL - ~ LO Amount: $ /ff,,'~') , ._~.E 72-026 (Rev. 7/88) 8ack Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE WESTERN DISTRICT OFFICE 3601 C STREET, SUITE 322 ANCHORAGE, ALASKA 99503 STEVE COWPER, GOVERNOR 563-6775 November 26, 1990 FOR: S & S Engineering Attn: Ray PWSID: 9213001 According to the records on file in this office, the Chuqiak Utilities Northwood Deerhorn Subdivision Water System is in compliance with the State of Alaska Drinking Water Regulations. Sincerely, WRA E. CRAIG ( / Environmental S'p'ec i al is t VEC:pf ~" D~-.~,-<-:R EC El V E D INSPECTION APPOINTMENTS TIME I TIME ~ ~'%,. TIME DATE DATE ~ ~. ~.)(~ J~/'~ DATE INSPECTOR I NSPE / INSPECTOR / MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL PROTECTION  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 825 LStreet-Anchorage, Alaska 99501 JUL 3 0 I981 ENVIRONMENTAL SANITATION DIVISION · R E C E ! V D REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing, 1, PROPERTY OWNER PHONE MAILING ADD~ESS PROPERTY RESIDENT (If different from above) - PHONE 2, BUYER PHONE i MAILING ADCRESS 3. LE~DINGJNS~ITUTION [ PHONE MAI LING ADDRESS 4. RE.OR/AGEnT PHONE MAI LInG ADDRESS/ 5. LEGAL DESCRIPTION STREET LOCATION 6. TYPE OF RESIDENCE NUMBER OF BEDROOMS  E~ One [] 'Four SINGLE FAMILY ,[~----Tw o [] Five [] MULTIPLE FAMILY [] Three [] Six [] Other 7. WATER SUPPLY INDIVIDUAL* [] COMMUNITY PUBLIC UTILITY * ATTACH WELL LOG. A well Icg is required for all. we s drilled since June 1975. For wells drilled prior to that date, give well depth (attach Icg if available.) 8. SEWAGE DISPOSAL SYSTEM J~--INDIVIDUAL/ON-SITE** /~c~2/ YEAR ON-SITE SYSTEM WAS INSTALLED. E~] PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SiX ~ERMIT NUMBER 2, WATER SUPPLY [~] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified_ LOG RECEIVED 3.' SEWAGE DISPOSAL SYSTEM ~ERMIT NUMBER [] INDIVI DUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER []Septic Tank or [~3 Holding Tank Size: _ . If Tank is homemade SOl LS RATING give dimensions: -- TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL ' 4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line WELL TO: Absorption Area to nearest Lot Line 5, COMMENTS [~3-~APp RQV E D FOR '-~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany cortificate) [] DISAPPROVED DATE BY