HomeMy WebLinkAboutCLEARY TR AI"""rYOT MUNICIPALITY OF ANCHORAGE
/ On -Site Water & Wastewater Program
' PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP201109
Work Type: Septic Upgrade
Tax Code Number: 05110278000
Site Legal Address: CLEARY TR A G:1359
Site Mailing Address: 22808 HOMESTEAD RD, Chugiak
Owner: TORRISON SCOTT & CLARA
Design Engineer: NORTH RIM ENGINEERING
This permit is for the construction of:
Q Disposal Field 0 Septic Tank ❑ Holding Tank ❑ Privy
Effective Date
Expiration Date:
�l�enr S'
`�•
0 id V
Department
Lot Size in Sq Ft:
Total Bedrooms:
5/15/2020
5/15/2021
103879
❑ Private Well ❑ Water Storage
All construction shall 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 wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Received By: &AAL
Issued By: Lelj:,�
Date:
Date: ZO 00
10
MUNICIPALITY OF F ANCHORAGE
Development Services Department��"`"= 'r;! Phone: 907-343-7904
On -Site Water & Wastewater Section -43-7997
ON-SITE SEPTICM/ELL PERMIT APPLICATION {a.
Parcel I.D. 051-102-78
Property owner(s) Torrison Day phone
Mailing address 22808 Homestead Rd
Site address same
Legal description (Sub'd., Block & Lot) Cleary Tract A
Legal description (Township, Range & Section)
Lot Size 103,879 Sq. Ft. Number of Bedrooms 4
77
Ar0 Y, Cu
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(N all that apply)
Absorption Field
Q
Initial ❑
Single Family (SF) El
(w/wo ADU)
Septic Tank
ElUpgrade
RXDuplex
(D) ElHolding
Tank
❑
Renewal ❑
Multiple Dwellings ❑
Privy
❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
v
(Signature of property gwy(er or authorized agent)
Permit/Rush Fees: s75 UWo-2y
Date of Payment: Jl l /0-10 ay
Receipt Number:
Permit No. Qsp //o
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client FormsTermit Application.doc
ENGINEERING I�
Date: 5/8/20
To: MOA On -Site Services
Subject: Cleary Tract A
Septic System Upgrade
SteveEng.com
Steve Eng, PE, PH
907-694-7028
SteveEngPE@gmail.com
Number of Pages:
During an inspection it was discovered that all the drain -field cleanouts had standing water,
indicating failure. A new design is submitted to mitigate this damage. A previous soil test reveals
GM w/Sand and no groundwater; no bedrock at depth. The design calls for a new trench and a new
septic tank. The existing trench to be connected via diverter valve. Slopes and easements are
depicted on the drawing. The terrain is generally a flat slope at the trench site, and the remainder of
the area. The system design size is a single family at 4 bedrooms.
Please review the wastewater system design for the existing single family home. I have included
design plans & specs, design guidelines, & soil test. If there is need for additional information or
clarification please give me a call.
Thanks -Steve
I�-
ENGINEERING
SteveEng.com
SPECIFICATIONS & DESIGN GUIDELINES
Wastewater System Sizing: This is an existing 4 -bedroom single family home. This is a
developed subdivision. This is a very large lot with no conflicts. A new trench is planned +
new 1250 gallon septic tank. The existing trench to be connected via diverter valve. No
adverse impacts are expected from trench/tank upgrade. No conflicts to the other lots will
take place by this septic system construction upgrade. A previous soil test reveals GM
w/Sand. An application rate of 1.2 GPD/FT2. Trench Length = 500 FT2/5'x 2 = 50' trench,
5' effective. A new 1250 gallon septic tank will be installed; Decommission old tank per
UPC. Public water keybox depicted on drawing.
Specification Requirements: All components and work must comply with the
Municipality of Anchorage Specifications (AMC) & State of Alaska Drinking Water
Regulations and Wastewater Regulations.
• Two compartment, New 1250 gallon septic tank. Install Double Cleanouts.
Decommission old tank per UPC. MOA -Spec Material Under Tank.
• 10' minimum between the tank trench, tank to house. 10' to property lines,
• 3' of cover or insulation is required for trench; 2" Minimum thickness for insulation
can substitute for 1' cover.
• Tank & solid pipe must be set on well compacted, stable soil.
• 4 inch diameter cleanouts with airtight caps are required 1' to 4' from foundation
wall, prior to any 90 degree bend in 4 inch line, in each tank compartment, and two
adjacent opposing cleanouts between the tank and the absorption field, not more than
10' from the tank positioned to provide cleanout access towards the tank and towards
the absorption field.
• All cleanouts must extend to at least ground level.
• In solid pipe runs, ASTM D-3034 may be used in lieu of cast iron.
• Trench to be placed level, minimum of 4' to groundwater, 6' to bedrock from
drain -rock.
• Drain rock to be '/2 inch to 2 inch screened. Drain rock to be distributed uniformly
throughout the trench.
• Perforated pipe to be installed level with perforations down.
• Silt barrier (filter fabric) to be installed above the drain rock.
• Smeared trench sides must be raked or scarified before drain rock placement.
• The finish grade must be mounded to promote drainage away from trench.
• Insulation must be placed over any pipe installed under driveways or parking areas.
• Approved pipe materials include cast iron, PVC ASTM D3034, PVC ASTM F789,
ABS ASTM D2661,
• Sewer Service Line is minimum 2% slope.
• Septic Tank to be pumped every two years or when required.
0 Insulation board to be extruded direct burial polystyrene (Dow Styrofoam HI/equal)
DESIGN NOTES:
1. Total Depth of Trench is 9'.
2. Sewer Service Line minimum 2% slope.
3. Diverter Valve To Old Trench.
4. Decommission Old Tank Per UPC.
5. Locate Sewer Service Line— Replace If Necessary.
6. If No FCO Found, Add DCO Before The Tank.
Homestead Rd
\ \ Flat Slope
Flat Slope
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4 Bdrm
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Diverter
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Decommission Old
Septic Tank
PER UPC &
Replace w/ 1250 Gallon
Septic Tank
w/ Double Cleanouts
Flat Slope
NOR THRIM
ENGINEERING
SteveEng. com
PO Box 770724
Eagle River, Alaska 99577
907.694. 7028
Flat Slope
No
Conflicts
Flat Slope
No
i Conflicts
Flat Slope
m 1' 50 i
:�P ...., CL EARY
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DESIGN
TRACT TRACT A
LAYOUT
►,n�/�� WASTEWATER
'
Date:
UPGRADE SEPTIC5/15/20 12 of 3
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EAGLE .RI VER t
SCALF-
ENGINEERING SERVICES ASBU/L. T SURVEY f'=6o' 6/3t/rn . 1 N r 1
P. D. Box 773294
10421 VFW Orlvc Oti�iNr R: C�EARY EKES Project Number. 97-080
Cagle River, ,41ask� 99577 DESCRIPTION; CLEARY SUB. TRACT A Con File hams: 9 Sl> oAa.OWC
(9DT7 es4—STy.S ��k r907) 60,9—=97_ ��-
I heraby certify that I have surveyed the following dsterlbed property. ARY SUB, TRACT A
Anchorager Reeardlnq Precinct, Alanko, and that no encrobemmenta exl; ' sept tis
the reSOOM51011(ty of tho owner to determfree the existence of any e�.sarnent:;. covenOrtb. or
restrietlang which do net appear on the recordbd subdivIslan plot. Under no dream-i3tancet should
Lamy data hereon be used for constructlon of lance limes, or for establishing boundary lines.
Municipality of Anchorage Page
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
Name:
~,./~_ ~ ~,~ ~/~y Wastewater System: ~New D Upgrade
Address:
Phone: ~_ ~_//~ ~No. of~rooms: ~DeepTrench ~ Shallow Trench ~Bed ~Mound DOther
Total Depth from original grade:
Township: I Range: I S~tion: Fil, add~ above ~a, grade: Gravel ~ength:
WELL:~N'~ D New ~ Upgrade Gravelwidth: ~/ Numberoflines:
SEPARATION DISTANCES ~Septi~ ~ Ho~in. ~ S.T.~.P.
* ' Material: Number of C~pa~ments:
WelF . ~
su,==ew=te~ ~ .......... ~ '> LIFT STATION
~rain
BENCH MARK
ENGINe, S SEAL
Depadment of Health and Human Se~ices approval
Reviewed and approved by: ~/~ ~ Date:/2 2 -?~
72-O13 (Rev. 9/91) MOA 25
Permit No. SW980136
Page 2 of 2
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 * Anchorage, Alaska 99519-6650 Te~phone: 543-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: CLEARY SUB TRACT A
PID No.: 05110204
All Wells
All Septics
·" All Wells
6-C = 49.4'
250 Gal A-D = 92.5'
Septic Tank B-O = ~7.6'
SWING TIE5
Troct A
115,522 SF
- TEST HOLE
- MONITOR TUBE
- SEWER CLEANOUT
- K EYSOX
aao.a~' SCALE
ELEVATIONS
(NDT TO SCALE)
ORIGINAL
GROUND
LEVEL AT,
1" =60'
8/14/98
MUNICIPALITY OF ANCHORAGE
DEPART~iENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, 3%LAS KA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW980136
DESIGN ENGINEER:EAGLE RIVER ENGINEERING SERVICES
OWNER NAS~E:CLED-R¥ MICFJ~EL F & JANICE L
OWNER ADDRESS:22813 DALLON CT
CHUGIAK, ALASKA 99567
LEG~ DESCRIPTION: ~O~ ~O~ ~ ~
T15N R1W SEC 9 W2~4NE4NE4
DATE ISSUED: 5/27/98
EXPIRATION DATE: 5/27/99
LOT SIZE: 115522 (SQ. FT.)
~VurMBER OF BEDROOMS: 4 THIS PER~IT: 4
THIS PEP~MIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK SYSTEM
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 D-ND 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 343-4744 ( 24 HOURS ) . (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEMUNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECI~ PROVISIONS:
RECEIVED By: ~~ ~~
DATE:
DATE:
Eagle River Engineering Services
P.O. Box 773294
Eagle River, AK 99577-3294
(907) 694-5195 tel
(907) 694-3297 fax
March 24, 1998
Jim Cross, P.E.
Manager, On-Site Services
Municipality of Anchorage
P.O. Box 196650
Anchorage, AK 99519
Re: Cleary Sub. Tract A
Narrative & Permit Application
Dear Mr. Cross:
The proposed well and septic system will have very limited impact on adjacent properties for the
following reasons:
1. The surrounding lots are large, allowing sufficient room for septic sites.
2. Immediate neighboring septic systems are all +30' distance.
3. Reserve space is adequate, due to absorption capacity and a public water source.
4. Drainage will not be affected and is not a major consideration in our design.
If you have any questions please call our office at 694-5195.
Sincerely,
Louis Butera, P.E.
\1997\97-080-NA~
_ __ 55' ~OW
NO ~
CONFLICT]N~ ~ 2
WELL5
m.
Tract A
550.07'
~ - TEST HOLE
· - MONITOR TU~E
o - SEWER CLEANOUT
+ - WELL
NO SURFACE WATER EASEMENT
NO KNOWN CURTAIN DRAINS ~ PROPOSED LEACHFIELD
WELL/SEPTiC SITE PLAN
LEGAL: Cleory Subdivision Tract A
CONTRACTOR: N A
EAGLE RJVER ENGINEERING SERVJCES
EAGLE RIVER, A~. 99577
(907) 694-5195 FAX: (907) 694-329?
EAGLE RIVER
ENGINEERING SERVICES
P.O. Box 773294
Eagle River, Alaska 99577
(907) 694-5195
ERES Project No.: 97-080
Calculated By: LB
Date: 10/24/97
Legal: Cleary Sub. Tract A
Single Family 4 Bedroom Dwelling
TEST HOLE
Deep Trench Subsurface Wastewater Disposal Field
Water use at 150 gallons per bedroom = 600 gallons
Percolation rate = 3.6 minutes perinch
Wastewater application rate = 1.2 gallons per day per square foot
Required absorption area = 500 square feet
Trench width ON) = 3 feet
Gravel depth (D) = 6 feet
Required length = Required absorption area / 2 / D
Required length = 500 / 2
Required length = 42 feet
Total Excavation Depth = 9.0 feet
/ 6
~... ~
LOUIS A. BUTERA .:~
.~... ...~
Eagle' 'Aver Engineering ervices
Louis Butera, P.E.
P.O. Box 773294 (907) 694-5195 tel
Eagle River, AK 99577-3294 (907) 694-3297 fax
LEGAL:
SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM
Cleary Sub. Tract A
10/30/97
A. GENERAL
I. The well and septic plan are for a single family residence only.
2. The drawing and or site plan shall be a part of this specification.
3. All materials and workmanship shall meet the Anchorage Department of Health and State
Department of Environmental Conservation requirements.
4. All soil tests are advisory to the design and are to be verified or modified in the field by the engineer.
5. All excavations and depths are advisory and are to be verified in the field by the contractor to meet
Municipality of Anchorage, Department of Environmental Conservation requirements.
6. It is the responsibility of the owner to obtain all necessary permits or easements and to locate any
adjacent multi-family wells.
7. The excavation is to be exactly in the area shown on the site plan, any deviation requires engineer
approval.
8. It is always recommended that a surveyor locate the nearest lot line position and the location of any
easements.
9. Any remaining open test hole excavations shall be filled.
B. SEPTIC TANK
1. Septic tank shall have a minimum capacity of 1250 gallons and be of MOA approved design..
C. TRENCH
1. The trench is to follow the natural land contour to maintain uniform total depth of the trench bottom.
2. The bottom of the trench shall be level, plus or minus 1.5".
3. The total depth of the trench excavation is not to exceed 9' at any point.
4. The effluent line within the trench shall be laid level within 0.03'.
5. The trench gravel is to be covered with typar fabric material.
6. Soil or combination of soil and extruded board insulation to a depth of Y or equivalent is to be placed
over the leachfield.
7. The area over the trench is to be finish graded to prevent ponding of surface water runoff.
8. The septic tank and leachfield must not be closer than 100' to any existing private well, 150' to any
Class "C" well, or 200 feet to any community well.
RECOMMENDED LEACHFIELD DIMENSIONS:
TOTAL DEPTH -- 9' GRAVEL DEPTH = 6' under pipe, 2" over pipe
TRENCH LENGTH = 42' TRENCH WIDTH = Y
SOIL RATING = 1.2 GPD/ft2 BEDROOM CAPACITY = 4
SEPTIC TANK = 1250
Twenty-four (24) hours notice required for all inspections.
\199%97-080-spc.doc
Municipality o! Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR: ~"~/~
LEGAL DESCRIPTION:
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
DATE PERFORMED:
dle,,r ~, ~ v. Township, Range, Section:
SLOPE
SITE PLAN
r ~or ~,
WAS GROUND WATER /.//-)
ENCOUNTERED?
DEPTH?
Oepth to Waler After
Moflil0riflg? o Date:
Gross Net Oepth to Net
Reading Date Time Time Water Drop
.~ I /~,'/¢ ~3 ~//~
PERCOLATION RATE ~° O/ (minutes/tach) PERC HOLE DIAMETER
TEST RUN BETWEEN ~ FT AND ~' FT
COMMENTS
PERFORMED BY; ~'/"~t'-~'5'- ~~ CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ~ ~'~
72-008 IRev. 4/85)
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. # ~")~-/-- /~._~ - ;7,~ HAA #
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency ~-'d~--J i~-~ ~'~,?<' 'i¢ ..'~c~ ~ Day phone
Mailing address
Agent ~ ~/ Day phone
Ad dress
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
NOTE:
Individual well
Community well
Public water ~<
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site ~,v,.
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm Eagle ver Eng ee ' Se ce
~ .......... zd.n~ Phone
~ .~. ~ox ZIOZ~, ]Za~le J~ver, Ax~ 99522~294
Address
Engineer's signature
Date
DHHS SIGNATURE
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of 'Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-O25(Rev. 1/91) B~ck MOA.#~
RECEIVED
Municipality of Anchorage MAR 0 9 199!
DEPARTMENT OF HEALTH & HUMAN SERVICF~NiCiP^Li~, OF ANCH
Environmental Services Division ~NVIRONMENTALSERVICE$
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Legal Description:
Health Authority Approval Checklist
,,~ ~ ~'~',-~ r~ ~'~, .,4.~./,,, Parcel I.D.:
A. WELL DATA
Well type If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) Date completed
Total depth Cased to ,/
/
Sanitary seal (Y/N) ~ /
Date of test
Static water level
/
FROM WELL ~LOG
Well production
WATER SAMPLE~ULTS:
oo,.o
D~of ~ample:
Casing height (above ground)
Wires properly protected (Y/N)
AT INSPECTION
B. SEPTIC/HOLDING TANK DATA
Date installed '~ - ? <~ Tank size
Foundation cleanout (Y/N) /v
Date of Pumping
C. ABSORPTION FIELD DATA
g.p.m.
Nitrate Other bacteria
Collected by:
g.p.m.
i ,_.'2 ~-~ .~ Number of Compartments ~ Cleanouts (Y/N) .
Depression (Y/N) /q High water alarm (Y/N) .~,,2~
Pumper ~
!
)/
Date installed ~' - ?-'¢' Soil rating (g.p.d./fF or-fF-,q~) /,
Length -¢-~ ' Width L~ / Gravel thickness below pipe
Effective absorption area 5-,~ '~ Monitoring Tube present (Y/N)
Date of adequacy test /v'//1 ,,u~,~.~ Results (Pass/Fail)
Fluid depth in absorption field before test (i~ Immediately after
Fluid depth (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N) ,
. Depression over field (Y/N)
For
~ gal. water added (in.):
Absorption rate = g.p.d.
~lf yes, give date
System type
" Total depth
.bedrooms
72-026 (Rev. 3/96)*
LIFT STATION
Date installed ~ Size in gallons
Manhole/Access (Y/N) ~ "Pump on" level at*
High water alar~el at* *Datum
Cycles~ed
E. SEPARATION DISTANCES
"Pump off" level at*
F.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation ~' ~ Property line ~/ / Absorption field ~ /
Water main/service line ~/'~ / Surface water/drainage ~-/~" Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line G' ~ ~ Building foundation ~ 3- ~ Water main/service line
Surface water -/-t,.~,~ ' Driveway, parking/vehicle storage area ~ / ~
Curtain drain
Wells on adjacent lots
ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review
in conformance with MOA HAA guidelines in effect on this date.
Signature ~-~ ~~
Engineer's Name ,,~ .~r ,,~ ~'~,-<.
Date ~-~/~/'~ '~
HAAFee $ "~'~ ~ ' ~
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number