HomeMy WebLinkAboutCOLONIAL PARK BLK 4 LT 14A
Name
Address
Phone(s) I P_~ermit No.
LEGAL DESCRIPTION
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
DISTANCES
F RO M-'~"'"'""~ SEPTIC ABSORPTION '
~:~~ TANK FIELD WELL
I No. of Bedrooms WELL ,~:::>1 ~1,.~ ~ IJd
~ LOT LINE \ ~1 j~ ~ c:;, I..{.~ ~
FOUNDATION \~. I .j.j.~ ,~i~t ~ ~
AS-BUILT DIAGRAM (Show location of well. septic system, property lines, foundation,
driveway, water bodies, etc.)
Township, Range,(Section
EPTIC [] HOLDING
Manufacturer Capacity in gallons
No. of Compartments
TYPE OF SYSTEM
~'~RENCH [] BED [] W. DRAIN [] OTHER
Depth to pipe bottom from Total depth from original grade
original grade ~ FT ~
Fill added above original grade
Gravel depth beneath pipe
FT I I
~th i Gravel width
'Z., FT
Total absorption area between lines j~j
'~'~ SQFT
Soil rating Pipe material
_ ~/ Date Instm~ed
WELLS
[] PRIVATE [] OTHER (Identify)
Classification (A,B,C) I Total Depth / Cased to
Installer I~te Installed:
REMARKS:
FT
I 17034 Eagle River Loop Road No.
Eaale RJver~ Alaska 99577
Municipal and StatO'guidelines in effect on this date:
Health Department Approval:
certify that this inspection was performed according to all
~ Date:
No, 1~57-E ,
72-013 (3/85)
DeS :i,
Par'ce :1. Id: 050-:30 :l.....-4.q.
Lcli:. L.~,.?..~ga .I.: Subd :i. v J, s :[ (51"'~ II C;OL. ON I Al .... PAl:U< L..,:::~t.:
Sect :i. on ~ 7 "F,::,~,.~nsh :i. p: :t. 4N Range:
L,(::)t, S :i. ~: ~,:,:,:, :1. 17 19 ( s q ,,' F 'L ,: c) P a ~::: r' e s )
Pla'x B,:~.'.,d r' o,:::,ms: 'Th i s I:::'er' m i i'.. :: :]; 'T'o't:. a ], Capac :i. 'L y ',',
B 1 c) c k :: 4
SEP'T I C "FANI< :', M :i. r"~ :i. mum "(")" a 1 sept :i. (::: t an I< c:apac :i. 'Ly: .1.., 0()0 ga 1 1 (::)n s ,, E!:a,::::h sept. :i. ,::::
........... !il-:: must have at ].east 2. ,.'::c, mpar'tmer'~ts,, .De?pth 'Lo 'Lop oF sep'Lic t. ank r:: ~ < 4,0
~' (,:.:,: e,', t F' e q u i r' e s i n s u :1, a t :i, (:.)no v e r' t a n 1< ( s ).
DEV ]: AT I C)N I:::'FIOM AI::'F:'ROVED I~.:.':I',.IG i NEER ' S DES I GN RE(:',!LJ I RES [)I.,.IHS APF:'RC)V ....
A! .... F::'F:;::[ OR Ti:) CONSI"RUCT ION,, NOT :I:I:::'Y DHHS BEFORI!!i: ALI .... II'~ISPECT :I:C)I',IS, THE
)!!i: X :[ S'T :I:NG SEF::']" :I:C TANK MUST BE lii!:XF:'C)SED 'T'O VER I F'Y I NTEC,)R Iml"Y,, EXCAV-
AT:I:ONS MUST BE OF::'EN/CI....OSED 1'HE SAME DAY [)F:;: BE HEATE:D OVF.:!:RNIGHT,
'I"H]:S F::'Iiii]:;.'MIT IS F::'OI::t A .3 BEDFtDOM !31::' RI.:!:SIDEIqCE ONLY, AND N]:t...,I .... E×-
1:::' ]: RE ON 12./:3 1/9(),,
'Fc, F. th by the Mur"~:i.c:i. pal:i~'l:.¥ oF Anchc~r. age (MOA) and the Stat,:.:.:..~ oF A'.l.a~!.~l.::a,~
4,, 1[ ur"~(::)er'.smt, ar"~d 'Lhat th:i.s p(.:...":r'.m:i.t :i.s va].J.d Fc.:~r' a ma;,':i, mum (:)f' 3 bedr'c)c)rns,,
SCALE
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
Township, Range, Section: .-~
SLOPE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
WAS GROUND WATER
ENCOUNTERED?
SITE~ PLAN
S
L
IF YES, AT WHAT O
DEPTH? p
E
Depth lo Wate~ .
Monitoring? ~ Date: ~* ~, ~ ~ ~'-.~<~
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE
__ (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN __ FTAND FT
COMMENTS
PERFORMED BY: ~ / :34 Eagle River Loop ~,~ ~<~. CERTIFY THAT T/,,~IS TES~-_ WAS
Eagle li[jver~r AJa~ka
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUID DATE:
72-008 (Rev. 4/85)
PERFORMED IN
GREAJ'ER ANCHORAGE AREA BORudGH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME Executive Realty
Eagle River
LOCATION Colonial Park
MAILING ADDRESS 2810 C Street PHONE
St]bdivi~io~lLEGAL DESCRIPTION T,(3~-_ ]4A R]ock 4
276-7777
SEPTIC TANK:
DISTANCE TD.C. NUMBER OF
FROM WELL N./A MANUFACTURER Sunset Plas~_~ C~ATERIAL Fibreglass COMPARTMENTS
INSIDE LENGTH 7'-8" INSIDE WIDTH 5'-2" LIQUID DEPTH 4'-] 'LIQUID CAPACITY ] OhO GALLONS.
SEEPAGER~ Trench:
Trenchs
NUMBER OF~ ].
LINING MATERIAL N/.A
BUILDING FOUNDATION 18'
ADDITIONAL ABSORPTION
DIAMETERN/A OR WIDTH_2~, LENGTH 24,' DEPTH 12 '
/
CRIB SIZE: DIAMETERN./ADEPTH N./A DISTANCE FROM: WELL N/~
TOTAL EFFECTIVE
, NEAREST LOT LINE 20___~_'.. ABSORPTION AREA (WALL AREA) 416
SQ. FT.
WELL: Community System located to the West approximately
TYPE .CONSTRUCTION Drilled & Cased DEPTH
BUILDING NEAREST NEAREST SEPTIC
FOUNDATION ~/A , LOT LINE ~]/A , SEWER LINE N/A , TANK N/A
CESSPOOL N/A , OTHER SOURCES N/A
APPROVED DISAPPROVED REMARKS
550 feet.
DISTANCE FROM:
SEEPAGE
SYSTEM N/A
DISTANCES:
DIAGRAM Of SYSTEM
INSTALLED BY: MR~m
Excavating
PIPE MATERIAL: PVC
LOT SLOPE:
REMARKS:
Level
Form No, EQ-031
DATE
11/23/76
APPROVED
~A%X~ Moening-Grey &
Associates, Inc.
PERMIT NO.
MUN I C I "'~AL I TY OF ANCP"3RAGE
DEPARTMENT ~ HEALTH AND ENVIRONMENTAL ROTECTION
~510 E. TUDOR RD., ANCHORAGE, AK. 9950?
276-222i
ON--S I TE SEWER PEArl I m
76i19 >
APPLICANT
LOCATION
LEGAL
_FOREMOST SERVICE[ 2523 BROOKWOOD
E.R. RD
L~4A B4 COLONIAL PARK SUBD LOT SIZE
278-3644
ii7i9 SQUARE FEET
TYPE OF SOIL RBSORBTION S~STEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS
SOIL RATING
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
DEPTH= 12 LENOTH= i9 ORAVEL DEPTH= 8
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIELD.
THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND fiND THE BOTTOM OF THE EXCAVATION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFRLL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
REQU I RED SEPT I ¢ TANK S I ZE= iOOO GALLONS
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR R PRIVATE WELL OR 200 FEET FOR A PUBLIC WELL.
SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER
INSTALLATION.
PERM I T VAL I D FOR ONE YEAR FROM ISSUE
I CERTIFY THAT
l: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS RS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
~: I UNDERSTAND THAT THE ON-~~EWER SYSTEM MAY REQUIRE ENLARGEMENT
RESIDENTS. ~..M_O~;O ~L~.~E THAN 3 BEDROOMS.
SIGNED:-~~~__~_~ ........... 8P~NT 'FOREMOST SERVICES
, ........
IF THE
Performed For
Leaal ~escrintion: Lot Z~A.Block
This ;orm Renorts Soils Loq
"On~ test is worth a thousand opin;ons"
2204 Cleveland Anchorage, Alaska 99503'
Foremost Construction Date Performed
4/21 /7~
4,Subdivisi0n Co1QDial. Park Suhd. ~.~gl~ River
Percolation Test
.nenth
J. Feet
6--
8~
10---
14--.
16_
T°ps°il S°i 1
Sandy Gravel
(GP-GW)
Characteristics
Bottom of test hole
18-~No ground water or bedrock
encountered
20
Was Ground Water Encountered? No
I~ Yes, At what Depth? ......
Readinq
Date
Net Time
Depth to H20
Net Dron
Percolation Rate Hinute
Proposed Insta'i'llation: Seenaoe Pit Drain Field
Deoth of Inlet Depth To Bottom Of Pit Or Tr'ench
C~MPENTS: 100 Square fee~ Orainage ar~a 'required per bedroom
~EST
Data Certified B~/:_ T~?i~Tj -
Date: 4/23/76
MOENING-GREY & ASSOCIATES, INC.
GEOLOGISTS AND ENGINEERS
715 L STREET, SUITE 8 ANCHORAGE, ALASKA 9950~
TELEPHONE 274-2314
December 2, 1976
~unicipality oF Anchorage
Dept. of Health and Environmental Protection
2510 E. Tudor Road
Anchorage, Alaska 99507
Attention: Mr. John Kennedy
Re:
On Site Sewage Disposal, Lots llA, 12A, 13A, & 14A,
Block 4, Colonial Park Subdivision in Eagle River.
Gentlemen:
As reported to you bY telephone this morning, the depth of
screened gravels in the seepage trenches on the subject
Lots is as follows:
Lot llA - 9 feet
Lot 12A - 9 feet
Lot 13A - 8 feet
~ot 14A - 8 feet
Please call if you require further information.
Very truly yours,
MOENING-GREY & ASSOCIATES, INC.
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lOt, block, subdivision, section, township, range)
LOT 14A; BLOCK Lt; COLONIAL PARK SUBDIVISION
Location (address or directions)
19838 FIRST STREETJ EAGLE RIVERJ ALASKA
(b) Property owner
Mailing Address
F,]}.I.C_
ATTN: KAREN CARs°N
3000 C STREET
TelePhone ' (home)
ANCHORAGE; ALASKA
99503
Business 786-6365
(c) Lending Institution
Telephone
Mailing Address
(d) Real Estate Company and Agent
Address
Telephone
(e) Mail the HAA to the following address: (or check here~ if hold for pick up.)
List contact person and day phone number below:
S & S ENGINEERING
17034 E= -~ ~; .... L-cop '"
Eagle River, Alaska 99577
2. TYPE OF RESIDENCE
Number of bedrooms
Singl.e-Family ~9/(
3. WATER SUPPLY
Individual Well []
Community E~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 legality and status.
72-025 (Rev. 7/88) Page 1 of 2
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A. WELL DATA
Well Classification
Well Log Present (Y/N) Date Completed
Total Depth Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
Comments ~',~
--~ MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
Ll'i'Y OF AI'~,~IST. FEBRUARY 1984
E~i~ENTAI. SE,V,CES D,V,$,ON 343-4744
MAR 2 7 1.990
RECEIVED
Legal Description: ~ \~ ~"
If A, B, C, D.E.C. Approved {~/N)
Yield
Depth of Grouting
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
~ t jO ; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
;Date
B. SEPTIC/HOLDING TANK DATA
Date Installed I~ /"~' Size
Standpipesd~N) ~ Air-tight Capsq~TN)
Depression over Tank (Y~J)
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
To Water Main/Service Line
No. of Compartments 'Z.---
7 Foundation Cleanout((.~N) ',/
Date Last Pumped ~ -'~"~-"- ct ~:>
I'~ ;for -
/
Temporary Holding Tank Permit (Y/N) ~//~
To Building Foundation
To Disposal Field
To Stream, Pond, Lake or Major Drainage Course
Comments
\ c~::>1.&
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Instal led
Width of Field
Square Feet of Absortion Area
Depression over Field (Y/~
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line
Type of System Desigh~"~~¢
I
Depth of Field ~
Gravel Bed Thickness '~'
Statndpipes Present ~:ETN)
Date of Last Adequacy Test
Length of Field
To Property Line
; On Adjoining Lots
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
To Cutback (if present)
To Existing or Abandoned System on
Comments
D. LIFT STATION
Date I nstalle~....~ Dimensions
Size in Gallons ~ Manhole/Access (Y/N)
"Pump On" Level at ~ "Pump Off" Level at
High Water Alarm Level at ~'~..~._~t (Y/~N) _
Tested for ~--..,.~mping Cycles during Adequacy Test.
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 in effect
inspection.
Signed
Company
Date
MOA No.
& S ENGINEERING
7034 Eagle River Loop Road No. 2~04
: O~~t~of thi'~!:~;):;',
....
Receipt No.
Receipt No.
Date of Payment
Amount: $
72-026 (Rev. 7/88) Back
Waiver Fee: $
Date of Payment
Page 2 of 2
SENT BY:Xerox TelecoDier ?020 ; 3-23-90 ; 2:26PM ;
DEC $CROw$&$ ENG~NEER~NO ;~ 2
DEi~T. OF ENVIRONMENTAL CONSERVATION
/
STEVE COWPER, GOVERNOR
ANCHORAGE W~STERN DISTRICT OPPICE
3601 C STREET, SUITE 322
ANCHORA~E, ALASKA 99505
$63-6775
March 23, 1990
S & S ENGINEERING
PWSID,
A~¢ordtng to the ¢eeords on file in ~hts offioe, the Colonial Park
~Water System is in oompliance with the State of Alaska
Drinking Water Regula~ion~.
Richard u~ndet
Environmental Pteld Officer
RS~ba$
1. Approval requested by:
Mailing Address: 645
2. Property Owner:
Mailing Address:
Legal Description:
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C" Street, Anchorage, Alaska 99503 274-4561
Date Received February 3, 1977
Time of Inspection
Date of Inspection
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
FOR
Conv.
United Bank Alaska
9:00 a.m.
2=4=77 Friday
Pratt
G Street Phone:
Terry J. Fielderf Fielder Const. Phone:
Post Office Box 851, Eaqle River 99577
278-9526
694-9253
Lot 14 Block 4 Colonial Park Subdivision
Loc~tion:
Type of facility to be inspected Sinqle Family
Well Data:
A. Type Community
C. Construction
!.s.t .street, between Eaqle River Lane & Hillcrest Lane
No. of bedrooms 2
B. Depth
D. Bacterial Analysis
A. Installed
~C. Septic Tank:
D. Seepage Pit:
E. Disposal Field:
Distances:
Sewage Disposal System: On-site system, Permit #76119
1976 B. Installer
1. Size 2. Manufacturer
1. Absorption Area 2. Material
Total length of lines
A. Well to: Septic tank
Nearest lot line
B. Foundation to septic tank
, Absorption area
, Other contamination
, Absorption area
C. Absorption area to nearest lot line
, Sewer Lines
EQ-034 (1/74) Page 1 of two pages
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
2510 East Tudor Road, Anchorage, Alaska 99504 276-2221
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER and WATER FACILITIES
,MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAl. PROTECTIO~q
FEB 3 1977
RECEIV_F.D
1. Type of Inspection:
2. Property Owner:
Mailing Address:~.~,
3. Name of Buyer:
VA FHA. CONV
Mailing Address: .~.Ls)~Y-. ~q~,/ ~¢~../~/L~'~ ~ Day Phone: ~Y-E~'5'S
Name of Lending Institution: 2_/(. L~.,/~ ,(:~' '
Mailing Address:
Name of Realtor or Agent:
Phone:
Mailing Address: --- Phone:
Legal Description:
Location: -Z'-~-
7. Type of Facility to be Inspected:
8. Water Supply
No. Bdrms. c~
Type of Supply: Public Utility
If Individual, number of dwellings presently served
If Individual, depth of well
Sewage Disposal System
Type of System: Public Utility.
.Individual
Individual (on-site)
If Individual, date of installation
72-003(3/76)
Page 2 of two pages Re( ~t for Approval of Individual ~ Jr & Water Facilities
Legal Description Lot 14 Block 4 Colonial Park Subdivision
Comments
Approved ~ < ~Disapproved Date ~/6/r/~
Approval Valid for one year from date signed
Greater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
I Certify that the information contained in this request for approval to be a true and
accurate representation of the subject sewer and water facilities and these facilities
are operating satisfactorily.
SIGNED
Date
EQ-034 (1/74)
1. Approval requested by:
Mailing Address:
2. Property Owner:
Mailing Address:
Eagle River Area
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C" Street, Anchorage, Alaska 99503 274-4561
Date Received November 10, 1976
Time of Inspection
Date of Inspection
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
FOR
Cony.
Roger Fielder
Phone:
Phone:
694-9894
Legal Description: Lot 14A Block 4 Coldnial Park Subdivision
Location:
First Street
5. Type of facility to be inspected
6. Well Data:
A. Type Community
C. Construction
7. Sewage Disposal System: On-site system
A. Instal]ed
C. Septic Tank: ].
D. Seepage Pit: l.
E. Disposal Fie]d: Iota] length of lines
8. Distances:
A.Well to: Septic tank
Nearest lot line
B.Foundation to septic tank
C. Absorption area to nearest lot line
Single Family No. of bedrooms 2
B. Depth
D. Bacterial Analysis
1976 B. Installer y~)/)~j
Size ~ 2. Manufacturer
Absorption Area .. £///~qx~, ~ 2. Material
, Absorption area
, Other contamination
, Absorption area
, Sewer Lines
EQ-034 (1/74) Page 1 of two pages
2510 East Tudor Road, Anchorage, Alaska 99504 276-2221
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER and WATER FACILITIES
1. Type of Inspection: ~ CMRO VA
2. Property Owner:
3. Name of Buyer:
FHA .CONV
Day Phone:
Mailing Address:
Name of Lending Institution:
Day Phone:
Mailing Address: , Phone:
Name of Realtor or Agent:
Mailing Address'~'~_/~' ,/'~ L-~ ,~'"/)~ Phone:
Legal Description: ~------¢~
Location: '~ _ ~~ ~~,, ~---
7. Type of Facility to be Inspected:
8. Water Supply
Type of Supply:
~' /;~.~) No. Bdrms.
Public Utility ]_~"'"/ .Individual.
If Individual, number of dwellings presently served
If Individual, depth of well
Sewage Disposal System
Type of System: Public Utility
If Individual, date of installation /
Individual (on-site)
72-003(3/76)
Page 2 of two' pages - Re( st for Approval of Individual S ~r & Water Facilities
-Legal Description Lot 14A Block 4 Colonial Park Subdivision
""'' -~ ,~ ~ F~ ' / ' ' .- ' /
Appr°ve~"~-~Y~/F ~" , -.~ ~ Disapproved Date //-~-7~
~- Approva~ ~Valid for one year from date signed
Greater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
I certify that the information contained in this request for approval to be a true and
accurate representation of the subject sewer and water facilities and these facilities
are operating satisfactorily.
SIGNED. Date
EQ-034 (1/74)