HomeMy WebLinkAboutAUDUBON HILLS BLK 2 LT 2Audubon Hills Block 2 Lot 2 #015-231-52 Municipality of Anchorage On -Site Water and Wastewater Section - (907) 343-7904 Page 1 of 2 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP231041 PID Number: 015- 231- 52 Dwelling: INN Single Family (SF) n with ADU n Duplex (D) [] Two Single Family Project: ❑ Nqvv X Upgrade niarne ABSORPTION FIELD ATKINS Site Address El Deep Trench El Wide Trench El Oed 171 Mound i 12321 AUDUBON CIR n Other Phone Number of Bedrooms 3GPD1,5F Soil Rating JTotal depth froT original grade Ft. -_ -_ - LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel do ! pth beneath pipe Subdivision Block Lot AUDUBON HILLS BILK 2 LT 2Fill added above original grade Ft. le;gth Ft. Ft. Township Range Section SEPARATION DISTANCES Gravel width Ft. Beds: Number of Lines l?istance between lines Ft, To From Septic Tank Absorption Field Lift StationTank Holding Sewer Line Total absorption area Ft2 Number of trenches 5ist. between trenches Ft. Well 100'+ F; 0' + TANK N Septic ❑ S.T.EP. [3 Holding E:1 ther Manufacturer ANCH TANK Capacity 1000 Gal. Surface Water 100'+ NA Material Number of PLASTIC 2 LIFT STATION icompartments Lot Line 104+ Foundation *81+ [Remarks TANK DEMO PER UPC, Manufacturer Capacity Gal. SONOTUBE SUPPORT BELOW TANK LEVEL Alarm location Electrical i stalled by Installer PIPEMATERIAL House to tank 3034 MIKE N ANDERSON, P.E. Drainfield Inspector MIKE N ANDERSON, P.E. BENCH MARK (Assumed elevation) 100 Inspection AIA1111) Location and description dates: 2nd 3 d 41h ITOP OF MANHOLE 1C Tank to drainfield 3034 CO/MT 3034 ft ' res_Stamp En . ON-SITE WATER AND WASTEWATER SECTION APPROVAL .. — nditional Approval: Septic System Approved Date Note: this approval does not include well permit requirements. O 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 hftp://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP231041 Work Type: SepticTank Upgrade Tax Code Number: 01523152000 Site Legal Address: AUDUBON HILLS BLK 2 LT 2 G:2739 Site Mailing Address: 12321 AUDUBON CIR, Anchorage Owner: ATKINS JAMES & JUDITH ALASKA Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING This permit is for the construction of: Effective Date: Expiration Date � gent ` Is, � t. J 5 1. Department Lot Size in Sq Ft: Total Bedrooms: 3/31/2023 3/30/2024 49363 ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ 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: q, 0 Date: Issued By: Date: J 31 20 t 3 MUNICIPALITY OF ANCHORAGE r�;�,c Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 015-231-52 Property owner(s) ATKINS Mailing address 12321 AUDUBON CIR Site address SAME Day phone Legal description (Sub'd., Block & Lot) AUDUBON HILLS BLK 2 LT 2 Legal description (Township, Range & Section) Lot Size 49,363 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: (N all that apply) Absorption Field ❑ Septic Tank 0 Holding Tank ❑ Privy ❑ Private Well Water Storage ❑ APPLICATION IS AN: TYPE OF DWELLING: Initial ❑ Single Family (SF) 0 Upgrade Q (w/wo ADU) Renewal Duplex (D) E]❑ Multiple Dwellings ❑ (SF and/or D) 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. (Signature of property owner or authorized agent) Permit/Rush Fees: 0 Waiver Fees: _ Date of Payment: 3 Z y Date of Payment: Receipt Number: .Z Receipt Number: Permit No. _r5/023 ►D L Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc March 31, 2023 Municipalities of Anchorage On-Site Water and Waste Water Section 4700 Elmore Rd Anchorage, Alaska Phone 343-7904 Re: New septic tank permit Legal: AUDUBON HILLS BLK 2 LOT 2 To whom it may concern: This is a request for a septic tank permit on the above referenced lot. This tank replacement will not impact any of the neighbors or encroach on any wells, septic or open water issues. The tank will be decommissioned per the Uniform Plumbing Code (UPC). Sincerely Michael N. Anderson, P.E. 4661 Natrona Anch, Ak 99516 Ph 727-8864 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231041, Curtis Townsend, 03/31/23 S O S S S 1"=50' RETAINING WALLEXISTING HOUSE INSTALL NEW 1,000 GALLON PLASTIC SEPTIC TANK W/ 20" RISER, DOUBLE CO EACH SIDE. DECOM. OLD TANK PER UPC, MAINTAIN 5' FROM FIELD AND 10' FROM BLDG. SCALE: DJRDRAWN: DATE: AUDUBON HILLS BLK 2 LT 2 Anchorage, Alaska TOM ATKINS 3/26/2023 CARPORT NO WALLS WELL WELL WELL WELL ALL CO'S TO BE FOUND AND CONNECTED A U D U B O N C I R Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231041, Curtis Townsend, 03/31/23 MUNICIPALITY OF ANCHORAGE MEMORANDUM 91-015 (Rev, 1/81) NAME 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 [] UPGRADE MAILING ADDRESS LEGAL DESCRIPTION LOCATION I Well - DISTANCE TO: v ~ z I Manufacturer I [Liq. capacity in ~alions ~ DISTANCE TO: Iwell ~ ~ ~ Manufacturer ~ ·m~ ~ ~o. of lines Een~th of each line ~ ~ I Top of tile to finish grade ~ Length ~ ~ ~ ~ Type of crib Crib diameter ~ DISTANCE TO: ~ell ~ Class Depth ~ DISTANCE TO Building foundation IAbsorption area Dwelling NO, OFBEDROOMS PERMIT NO. Trench width .~ ~. inches Material ~ ~ No. of compartments Inside length Width Liquid depth Dwelling PERMIT NO. Material Liquid capacity in gallons Foundation Nearest lot line PER~IT~NO. Distance between lines Total length of lin, es Material beneath tile inches Depth PERMIT NO. Crib depth Total effective absorption area Building foundation Nearest lot line Driller Distance to lot line PERMIT NO. Sewer line Sept c tank Absorpt on area(s) Total effective absorptipn area OTHER PIPE MATERIALS SOIL TEST RATING INSTALLER REMARKS *3O APPROVED~Y DATE 2/85 72-013 (Rev. 3/78) LEGAL ,x~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION I ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL DESCRIPTION LOCATION NO, OF BEDROOMS I Wel Absorption area Dwelling PERMIT NO. ~ ~ Manufacturer~ Material No. of compartments Liq. capacity in gallons IF HOMEMADE: Inside length Width Liquid depth  Dwelling PERMIT NO, DISTANCE TO: Well ~ Manufacturer Material Liquid capacity in gallons ~ Well Foundation Nearest lot line PERMIT NO, ~ DISTANCE TO: ~ ~ No. of lines Length2 each line Total length of lines Tren~th Distance between lines ~ -- ~Z inches ~ Top to grade ~ Total effective absorption area of tile finish Material beneath ~ ~ -- ~ ~ 7S ~-~ s, inches Length Width Depth PERMIT NO. ~ ~ Type of crib Crib diameter Crib depth Total effective absorption area m Well Building foundation Nearest lot line ¢ DISTANCE TO: ~ Class Depth Driller Distance to lot line PERMIT NO. ~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS SOIL TEST RATING / REMARKS :~,'~&-".. 2248 E o-'- 5610 Silverado- Suite A7 , (907) 274-9397 ~ , AP~ ~ DATE LEGAL 72-013 (i 3/78) PERM'I T NO. I-'1 IIJ F.I I C: I F' R L I 1'- "'r' ,] F R I'--I F: H mi F-: R mi E [:,EF'FIRTMENT ~.-zE' HEALTH AWE:' EN',,,'IRONMENTAL F:ROTEC:TION o.-'5 STREET., RN]:HOF.'R~SE, RE. '~' 264-4720 PIELL Rf4E.':, CmF4--S T Ti SEPIEE: F'EF-:F1 [ T 82-:(1427 .':, APPLICANT LOCATION LEGAL L.H. CONSTRUCTION 62~0 A STREET, LOT 2-BK 2 AUDUBON HILLS SBDV. ANCHORAGE., AK. 562-2~54 LOT SIZE 999999 SQUARE FEET 'TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH t"tANIMLIH NUMBER OF BEDROOMS = 2-: SOIL RATING (S6! FT,..'BR)= t82 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: [:,, E F' T H = -'--.=: L E f-4 mS T H = 5 5 mS E: R 'v' E L [:, E F" T H = 5 THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENC:H OR DRAINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXC:RVRTION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOf'i OF THE EXCAVATION (IN FEET:). F-: E 6! Li I F-: E [:, S E F' T I C: T F~ 1'-4 ~::; S I Z E = -1 ~--:~ ~.-'-:'~ F'-, ~.3 R L L C' F4 S PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE T i-4 Em ( 2 ) I F4 S P E C: T I Cm f-4 '_S R E: E F-: E C-! LI I F-: E [:, BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSF'ECTION AND APPROVAL 89 THIS DEPARTMENT WILL 8E SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN A WELL fiN[:, ANY ON-SITE SBqAGE [:,ISF'OSAL SYSTEM IS ±00 FEET FOR A PRIVATE WELL OR ±50 TO 2E4~:~ FEET FROM A F'UBLIC WELL DEPENDING UPON THE TYF'E OF PUBLIC WELL MINIMUM DISTANCE FROM R PRI?ATE WELL TO A F'RI?ATE SEWER LINE IS 25 FEET AN[:, TO A COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS ARE REL.]UIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 2-:E~ [:,AYS OF THE WELL COMF'LETION. OTHER RE~}.LIIREMENTS MAY APPLY. SPECIFICATIONS AN[:, CONSTRUCTION DIAGRAMS ARE R',.,'AILABLE TO INSLIRE PROPER INSTALLATION. F'EF-:f-1 I T E:=-:;F' I F-:ES [:,EI]:Ef'IE:EF-: '"~:: J_.. J_L:-~- :--:__~--: I CERTIFY THAT ±: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. 3: i UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN ~ BEDROOMS. S I GNED,: AF'PL I CANT L.H. CON':, RUCT I 0N ,-- ~CBy ~~ I -6UED V4. 0 ptg~l~l [ 1' NO. RPPL[ C~N T LOCR T I ON L. H. CONSTRUCTION 6230 Ft U]T 2-BK 2. RUOIJGON-HILLS SGOV. LOT SIZE r~'PE OF SOIL ABSORPTION S~'STEH IS; TRENCH THE REL~UIREO SIZE oF THE SOIL ABSORPTION SYSTEH IS: DEPTH--' 8 LENGTH= 55 L]RI::IVEL DEPTH-" THE LENGTH OI¢tEN~[ON IS THE LE~GTH (IN FEEr) OF THE T~,ENCH OR DRFi[t~FIELO. THE OEPTH QF R TRENCH QR PIT IS THE O[STRNCE 8ETNE~J THE SURFFp~E ~3AOUND ANO THE BOTTO~ OF THE .~CAVATION (IN FEET). · -THERE ~ NO ~Er~'WIOTH FOR TROCHES. THE GRAVEL DEPTH [~ THE ~[NIPIUH DEPTH OF GRflVEL 8ETI~EEH THE-~OUTFRLL PIPE- ~NO THE 80TTOH OF THE~EXCRVRTIO~ (IN FEET>. ~N~T~LLRTION ~N~PECTIO~IS OF ~N~ ldELLS flDJRCE~Ir TO THIS PROPERT~ RNO ------ TI,JO ( ;2..', T 1'-,I?5PE~=; T I 01'-,15 lIRE BACKFILLING OF F~IY S~TE-]~ WITHOUT FINRL INSPECTION RNO APPROVAL BY THI~ C, EPRRT;'~E~T WILL ~E SUBJE,;r FO PROSECUTION. ~-t~[NIt'IUt~ oI3rRNCE 8ETI~EEN ~ WELL FIND RfIY ON-~tTE SEWAGE O['~PO~:Ii_ ~STEM [~ ~ 'L~ FEar FOR R'~PR[VRTE IdELL OR i5~' rD 2Go FEET FROH R PUBLIC ~ O~E~INO .~ UPON THE TYPE OF PUgLIC (4ELL. .~ TO ~ ,;O)4~llJ)JIt~ SEWER LINE [S ~ FEET. ~ ~ELL LOG~ ARE REQUIRED ~HO HUST BE RETU~HEO TO THE DEP~RT~EHF. H[TH[N 3~ DRY~.~ OF THE NELL O]HPLETION. ~ OTHER RE~U[REHENT5 HAY APPLY. ~PECIFICRTION5 RHO CONSTRUCTION OI~RR~ ARE .~ RVRILR~E TO I~ISUR/ PROPER ~N3TRLLRTION. ~ PEF:M t T R.F'PL ! E:,q.N T LOC:R~.' I ON L. EGRL ROGER F iEL[:,ON SR BOF,; 82-H HUE:,RBON C:IRCLE LOT 2 BLK 2 RUDRBON HILLS SUB LOT 8; I Z'E 34,4-6424 4Z.':5EO SQURF.:E FEET T'T'PE OF SI:IL R..BSORPT!ON S'¢S'TEM tS: TRENCH MRXIMUM NLiME=ER OF E:EDROOMS = 3 SE IL RRTING ,::L=;6! FT,.-"EF.::)= 226 THE RES!UIF.:ED SIZE OF THE SOIL RDSORF'TION S'T'STEH IS: THE LENGTH [:, I MENS I ON IS THE LENGTH ,'iN FEET::, OF THE TRENCH OR [:,F:P..INFIEL[:,. THE DEPTH OF R TRENCH OF.: PIT IS THE D ISTRNC:E E',ETHEEN THE SLIRFRCE OF THE GF.:OUND RND THE BOTTOM OF 'THE EF,;CR',..,'RTION ,:; IN FEET;:,. THERE IS NO SET !.4I[:,TH FOR TRENCHES. THE GRR',,,'EL [:,EPTH IS THE MINIMUM DEPTH OF GRRVEL BETHEEN THE OUTFRLL PIPE RN[:, THE E',OTTOM OF THE E::-,;CR',,,'R. TION ,::IN FEET). PERMIT RF'PL!CRNT HRS THE RESF'ONS!BILIT'9 TO INFORM THIS DEPRR'FMENT [:,UF::!NG THE INSTRLLRTtON INSF'ECTIONL=; OF RN? HELLS R[:,JRE:ENT TO THIS PREPERT'9 RND THE NUMBER OF RESIDENCES THAT THE 1.4ELL HILL SER',,,'E. BRCKFILLING OF' BN.'T' SVSTEM NITHOUT FINRL INSF'EC:TION RND RPPRO',..,'RL B? THIS DEF'RRTMENT .tq ILL E,'E SLIBJEC:T TO PF.:OSEE:L!TION MINIMUM D!S'FRNCE BETHEEN R HELL RND RNY ON-SITE SEWRGE r:,!SPOS~L SYSTEh! tS; ±0~ FEET FOR R PRt',,,'RTE WELL OR &50 'TO 298 FEET FROM R PUBLIC: ~4ELL £.',EPENDING LIF'ON THE T'WPE OF F'UBLIC WELL. HI.N!MUH DISTRNCE FROM R PRI',,,'RTE WELL TO R F'R!',,,'RTE SEI4ER L_iNE IS; 25 FEET RNE:, TO R COMMUNIT'T' SE!.,.IER LINE IS 75 FEET. HELL LOGS RF.'.E RES:!U!REE:, RN[:, MUST BE RETURNED TO THE DEPRRTMENT !.4ITH!N. SO DR?S OF 'THE HELL COMF'LET!ON. EITHER RES!UIREMENT':; MR'T' RPF'L'9. SPEC!FICRTIONS RN[.', C:ON'=:TRUCTION DIRGRF~,MS R.RE R'v'RILRBLE TO INSURE PROPER INSTRLL. RTION. I C:ERTIF°T' THRT ±: I BM F'RMILIBR HITH 'THE RES!UIREMENTS FOR ON-SITE SEWERS ~.ND HELLS RE; SET FORTH B'¢ THE MLINIE:I PRLI'T'.¢ OF RNCHORFtGE. 2: ! HILL IN~;TSLL THE S'¢~TEM !N fiCCORDRNCE WITH THE E:O[:,ES. ~:' I UN[)ER:STRN[:, THRT THE ON-SITE SEI.,.!ER S?%TEM f,l~ RESCJIRE ENL. RRGEMENT IF THE RESI[:,ENC:E I% REMODELE[:, T] It',~CL JDE MORE 'FHFt ... .........- · ~SOI LS LOG '~e~ MUNICIPALITY OF ANCHORAGE ~', DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (i~''~1~'-~)) 825 L. Street, Anchorage, Alaska 99501 264-4720 _.S~,ILS LOG - PERCOLATION TEST LEGAL DESCRIPTION: ~PERCOLATION TEST DEPTH ~.F.E ET) 2 4 7 10 -~' 11 12 13 14 15 16 17 18 19 20 COMMENTS/L~/~' PERFORMED BY: 72-008 (6/79) SLOPE SITE PLAN WAS GROUND WATER ~ ~ ENCOUNTERED? O P E IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop ?_. q/~ Io' /,fF o ,/o PERCOLATION RATE ~;~ y (minutes/inch) TEST RUN BETWEEN '~- ET AND 5'~"~'~)'"- FT DATE: /0~ _,tUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SOILS LOG PERCOLATION TEST PERFORMED FOR: ~-Y, o~,,/¢,'t-,'o ~ Corn DATE PERFORMED: LEGAL DESCRIPTION: f~u)J~on H[1('~ [r'~)~. L~.- SLOPE SITE PLAN DEPtl 5 III ~ l~l 12 ' 13 14 15 18 ~. 2251-E 19- 20 COMMENTS WAS GROUND WATER S 'l ENCOUNTERED? ~o L 0 P E IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop 517.-I Zzo -- /-/. ~/ -- 250 ~o ~.oo . ¥? 51~ ,o H. Z8 3~3 - H. 3B - PERCOLATION RATE //7l (minutes/inch) TEST RUN BETWEEN ':} FT AND -~ '/& FT 18 Z ~://=,,~,~ .('~,~ ~ -lo ,~-' PERFORMED BY: ~)~t4~rX$ CERTIFIED BY: DATE: 72-008 (6/79) '- i 4 1I 13- C. b4~, ,lt. Nil. M-W DRILLING, Inc. P.O. Box '10-378 ,, 10300 Old Seward Highway ANCHORAGE, ALASKA 99511 Well Owner Location DRILLING LOG L.H. CONSTRUCTION ~Use of Well ~t'.zc (address of: Township, Range, Section, if known; or distance main road Lot 2 Block 2 Audubon Hills 1 ! Size of casing Depth of Hole Static water level 14 ft. (~) Screen ( ); Perforated ( 41 feet Cased to /-i). 5 feet Describe screen or perforation Well pumping test aL_LS:k_gallons per of drawdown from static level. Date of completion July 13, 1983 (below) land surface. Finish of well (check one) ). None open end ( xx ); (minute) for I hours with 1007o WELL LOG Depth in feet from ground surface Give details of formations penetrated, size of material, color and hardness 0 TO 2 Casing stickup 2 TO. 38 Brown clay and gravel 38 TO 41 Waterbearing gravel MUNiCiPALi[y OF ANCHOEAOE DEPT, OF HEALTH & __ TO ENVI~C~-~-ENT?£ P.a. OT~-~T, ~C~ .TO. OCT f') .1 TO. TO. TO. TO. ~' ~'~' TO. , .TO, 1 -- CUSTOMER MUNICIPALITY OF ANCHORAGE Development Services Department = 1T Phone- 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval 015-231=52 -- - _ Parcel I.D. Expiration Date: I Legal description AUDUBON HILLS BLK 2 LT 2 Site address 12321 AUDUBON CIR Current property owner(s) ATKINS X The On-site system(s) is/are approved for 3 bedrooms Conditional approval for Comments or advisories: im bedrooms, with the following stipulations: Original Certificate Date: 5/2/2023 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory Other COSA ApprovMjune 2022 1�1IiUHJCJ°L � 7 Y OF HCH0F,A37 04 Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Application __GENERAL INFORMATION Parcel I.D. 015-231-52 Complete legal description AUDUBON HILLS BLK 2 LT 2 Location (site address) 12321 AUDUBON CIR, ANCH AK Current property owner(s) ATKI NS 2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS Day phone 3. TYPE OF WATER SUPPLY: ®❑ Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units ❑ Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: ❑® Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel X Plastic ❑ Concrete ❑ Fiberglass Age NEW - See advisory if steel older than 20 years 6. ABSORPTION FIELD: X AWWTS ❑ Bed IN Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: ❑ Distance: By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $ -5 5 c0./Waiver Fee $ Date of Payment f� A,22' Date of Payment COSA # Waiver # COSA Application—June 2022 COSA Checklist Legal Description: AUDUBON HILLS BLK 2 LT 2 ParcellD: 015-231-52 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this A. WELL DATA H Well log is filed with Onsite (or attached) Date drilled 7/13/83 Total depth 41 ft Cased to 40.5 ft ❑� Sanitary seal is functioning correctly ❑� Wires are properly protected Casing height (above ground) 12 in. Date of flow test for COSA 3/14/23 Static water level at beginning of test 12 ft. Comments B. TANK DATA Measured operating fluid level in septic tank NEW Date of pumping NEW ❑ Required maintenance completed, ifAWWTS Comments: NEW PLASTIC TANK INSTALLED D. ABSORPTION FIELD DATA Which system tested (date installed) 6/2/83 V ALL standpipes present per record drawing Total measured depth from grade 10 ft (max) Measured depth to pipe invert from grade 5 ft (min) ❑ N/A — pressurized field. ❑ Per record drawings, field is insulated. X Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) If yes, enter date COSA Checklist June 2022 Well production at time of test 3+ Water storage tank volume Well disinfected for coliform test? M Coliform bacteria is Negative Nitrate mg/L X Nitrate le Arsenic ug/L 0 Arsenic I Collected by Date 4/24/23 MNA C. LIFT STATION ❑ Required maintenance coml Age of lift station _ years Lift station material Comments: Adequacy test date 3/14/23 Results Q Pass Fluid depth prior to test 4 in Water added 450 gal New fluid depth 56 in Elapsed time 1440 min Final fluid depth 4 in Absorption rate 450 gpd FIELD STATUS — POST RECOVI Effective depth (per record drawin Effective depth used 4 in Effective depth remaining 56 ] Yes ❑ti No than MRL (ND) than MRL (ND) 60 in E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) Septic Tank/Lift Station on Lot > 100' ifNo_ft ❑� Yes Community Sewer Manhole/Cleano Fi Yes if No _ ft 1E Neighboring Tank > 100' Yes if No _ ft Private Sewer/Septic Line > 25' Q Absorption Field on Lot > 100'❑ Yes if No _ ft Holding Tank > 100' U Neighboring Absorption Fields > 100' Animal Containment > 50' Q Q Yes if No ft _ Manure/Animal Excreta Storage > 1 Community Sewer Main > 75' ❑� Yes f No _ ft Q ❑ N/A — Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than r Building Foundations > 10' ❑ Yes if No .$ ft Surface Water > 100' 0 Tank to Property Line > 5' Field to Property Line > 10' Water Main > 10' Water Service Line > 10' QYes ifNo_ft ❑� Yes if No_ ft DYes ifNo_ft ❑� Yes if No ft Wells on Adjacent Lots: Private Wells > 100' Community Wells > 200' If tank or field is under driveway �' 0 F. ENGINEER'S COMMENTS " CARPORT FOUNDAITON IS A SONO -TUBE NO CONFLICT WITH N SONO -TUBE BELOW BOTTOM OF TANK. > 100' :s if No _ ft ,s if No _ ft as if No _ ft )s if No _ ft I, is if No _ ft ired) !s if No _ ft �s if No _ ft s ifNo_ft ent below TANK G. CERTIFICATION & STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my in estigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines, indicates tha the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal nd State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm 1Ake A] /stn Ley4VWf (�E Phone 727 Engineer's Printed Name 'i v vr.G_ Date .0 �r frSNSaP�O... `. /� S^• MICHAEL N. AKCEREC,% CE 99 9 Ilk 49 • Z+f ro'` COSA Checklist June 2022 V Municipality of Anchorage Development Services Department Yom: Building Safety Division On -Site Water and Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING//pp Parcel I.D. 015-231-52 COSA # le5 C i Qt&0 Expiration Date: / C - /42-' / --2- 1. GENERAL INFORMATION Complete legal description Lot 2, Block 2, Audubon Hils Subdivision Location (site address) 12321 Audubon Circle Anchorage, AK 99516 Current Property owner(S) Garry and Kathleen Houghton Day phone 246-6067 Mailing address 12321 Audubon Circle Anchorage, AK 99516 Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address Unless otherwise requested, COSA will be held by DSD for pickup 2. NUMBER OF BEDROOMS: Three (3) 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ✓❑ Individual On-site ✓❑ 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 sample results. (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 Anderson Engineering Address P.O. Box 240773 Anchorage, AK 99524 Engineer's Printed Name Michael E. Anderson, P.E. 5. DSD SIGNATURE Approved for bedrooms. Disapproved. Phone 522-7773 Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other By: 1 =�-- Original Certificate Date: 7 —I VL -2Z (Rev. 11fi15) Municipality of Anchorage • Development Services Department r Building Safety Division ` On -Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: Lot 2, Block 2, Audubon Hills Subdivision Parcel ID: 015-231-52 A. WELL DATA Well type Private If A, B, or C provide PWSID # _ Well Log (YIN) Y Date completed 7/13/83 Sanitary seal (YIN) Y Wires properly protected (YIN) Y Total depth a1 ft. Cased to 40.5 ft. Casing height (above ground) >18 in. FROM WELL LOG AT INSPECTION Date of test 7/13183 7/5/2012 Static water level 14 ft. 11 ft. Well production 15 9,p -m. 3.45 g.p.m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 mL Nitrate 5.52 mg/L Arsenic: N/D ugA Date of sample: 8/1812012 Collected by: J. Berkrem B. SEPTIC/HOLDING TANK DATA Tank Type/Material SepffclSteel Date installed 801983 Tank size 1,000 gal. Number of Compartments TWO Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (YIN) N Date of pumping 7/812012 Pumper Around the Clock Pumping C. ABSORPTION FIELD DATA Date installed 601983 Soil rating (g.p.d./ft or ft2/bdrm)182 SF/BDRM System type Deep Trench Length 59 ft. Width 3 ft. Gravel below pipe 5 ft. Total depth 10 ft. Eff. absorption area 590 ft2 Monitoring tube Y Depression over field N Date of adequacy test 7/5/2012 Results (Pass/Fail) Pass For 3 bedrooms Fluid depth in absorption field before test 0 in. Water added 470 gal. New depth 9 in. Elapsed Time: 1440 min. Final fluid depth 0 in. Absorption rate >= 450 g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at _ in. "Pump off level at _ in. High water alarm level at in. Datum Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankllift station on lot >toc' On adjacent lots >100' Absorption field on lot >100• On adjacent lots >100' Public sewer main N/A Public sewer manhole/cleanout N/A 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 >5' Property line >5' Absorption field >5' Water main >19 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 >10' Water Service line >10' Surface water >100' Driveway, parking/vehide storage - >10' Curtain drain None Noted Wells on adjacent lots >100' F. COMMENTS: 4 G. ENGINEER'S CERTIFICATION (7: 49M* I certify that 1 have determined through field inspections and ,0 �' •• •••••• review of Municipal records that the above systems are in 00,• •�•. . conformance with MOA COSA guidelines in effect on this date. 0 �3 pCkH�1 8 JU sOr I 6' • ;=*4381 : 2 Engineer's Printed Name Michael E. Anderson, P.E. ,� f '�• _ Lr'w�s I��gFB DlESSIbw� Date 716/2012 �h_��! COSA Fee $ `fq6 Date of Payment �17Z �f o Receipt Number r)1 23 (Rev. 11105) Waiver Fee $ Date of Payment Receipt Number Municipality of Anchorage s `\ O Community Development Department sr _ 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 # 121262 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 2, Lot 2 of Audubon Hills subdivision. This inspection revealed a nitrate concentration of 5.52 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. Z. Me%nete Municipality of Anchorage Development Services Department 1 ": Building Safety Division Onsite Water 8 Wastewater Program 4700 South Bragaw SL P.O. Box 196650 Anchorage, AK 99519-6650 www.cf.anchorage.ak.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 015-231-52 HAA# 1!050w7j 1. GENERAL INFORMATION Expiration Date: /0 -7 -049 - Complete D-7-OS Complete legal description AUDUBON HILLS SUBDIVISION: LOT 2, BLOCK 2. ❑ Mailing address . 12321 AUDUBON CIRCLE • Location (site address or directions) 12321 AUDUBON CIRCLE • ANCHORAGE. AK. 99516 Current Property owners) FRANK AND DOROTHY HILL Day phone (907) 349-7780 Community Class Well ❑ Mailing address . 12321 AUDUBON CIRCLE • ANCHORAGE. AK. 99516 Lending agency Mailing address Real Estate Agent Mailing address Day phone BETH WEISER w/ PRUDENTIAL JACK WHITE Day phone 727-4488 3801 CENTERPOINT DRIVE, SUITE 200 • ANCHORAGE, AK. 99503 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well IN Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ TYPE OF WASTEWATER DISPOSAL: Individual On-site IN Individual Holding tank ❑ Community On-site ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority 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 HAAs upon request to homeowners. Certificates of Health Authority 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 certifiod by my seal affixed hereto and as of the validation date shown below, I verify that my Investigation, based on procedures outlined in the Health Authority 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 Tilos 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 JEFFREY A. GARNESS, P.E. Engineer's Comments: 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 d 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 readilyldentiflable features. The operational life of all 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(IE-Zp 0S Conditional approval for bedrooms, with the following stipulations: Note: The well for this property meets existing State and bfunicipal Codes. There are nitrates present. -it is suggested that periodic testing be performed to insure the wells continued suitability. Current nitrate concentration is 5.22 mg/l. EPA maximum concentration is 10.0 mg/l. more information on nitrates is available from the On -Site Services Program, at 343-7904. Attachments: / HAA Checklisty Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineers Report Other By:� ovl Original Certificate Date: -7— 7 —0Z (R". 12101) Municipality of Anchorage ' Development Services Department Building Safety Division OnSke Water & Wastewater Program 4700 South Bragew SL P.O. Box 196650 Anchorage, AK 995196850 www.ciAnchorage.ak.us (907)343.7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: AUDUBON HILLS SUBDIVISION: LOT 2. BLOCK 2. Parcel ID: 015-231-52 A. WELL DATA Well typo PIRIVAYE If A, B, or C provide PWSIDN N A Well Log (Y/N) YES Date completed 7/13/1983 Sanitary seal (YIN) YES Wires party pretecW (Y/N) YES Total depth 41 ft. Cased to 40.5 ft. Casing height (above ground) 12+ in. FROM WELL LOO AT INSPECTION Date of test 7/13/1983 6/21/2005 Static water level 14 ft. 11 ft. Well production 15 g.p.m. 3.2 g.p.m. WATER SAMPLE RESULTS: Conform __a, colonies/100 ml. Nitrate 5�mgA. Other bacteria colonie3/100 ml. Arsenic; N/A mgA. Date of sample: 6/21/2005 Collected by: GEG, LtD. e. SEPTIC/HOLDING TANK DATA Tank Type/MateriW STEEL Date installed 6/2/1983 Tank size 1000 981. Number of Compartments 2 Cleanouts (YM) `ES Foundation cleanout (YM) YES Depression over tank (YIN) NO High water alarm (YIN) N/A Date of pumping 6/22/2005 Pumper McDONALD's PUMPING C. ABSORPTION FIELD DATA Date installed 6/2/1933 Soil rating .p.d ft%drrn) 182 System type TRENCH Length 59 ft. Width 3 ft. Gravel below pipe 5 ft. Total depth •10 ft. Eft. absorption area 590 ft' Monitoring tube YES Depression over field NO Data of adequacy test 6/21/2005 Results (Pass/Fak) PASS For 3 bedrooms Fluid depth in absorption field before test 37 in. Water added 550 9ht. New depth 40 in. Elapsed Time: 1140 min. Final fluid depth 37 In. Absorption rate k 450+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date — D. LIFT STATION Date installed "Pump on" level at _in. E. SEPARATION DISTANCES Size In gallons High water alarm level at Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tanklliR station on lot 1000+ Absorption field on lot 100'+ Public sewer main N/A Sewer /septic service line 25'+ On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout N/A Holding tank - N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main N/A Water service line 109+ Surface water 1006+ 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 100+ Surface water 100'+ Driveway. parking/vehide storage 5'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION I ceRify that I have determined through field inspections and +�• review of Municipal records that the above systems are in conthrmance with MOA HAA guidelines in effect on this date. / Engineer's Printed Nme JEFFREY A. GARNESS Date 6- os HAA Fee S 4W -OD Date of Payment 11!5/06 Receipt Number It Woo (rtrv. 12101) Waiver Fee $ Date of Payment Receipt Number �vUUB0N CIRCLE THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SHOW ANY CONFLICTS BETWEEN EXISTING STRUCTURES AND PLATTED LOT LINES AND/OR EASEMENTS; AND IS NOT TO BE USED FOR POSITIONING ADDITIONAL STRUCTURES, IMPROVEMENTS, OR FENCELINES. EASEMENTS OF RECORD, OTHER THAN THOSE APPEARING ON THE RECORD PLAT , ARE NOT SHOWN HEREON ( UNLESS INDICATED) NOTE: FENCELINES THAT MAY APPEAR ON THIS DRAWING ARE NOT TO BE USED TO DETERMNE PROPERTY LINES OR POSITION ADDITIONAL IMPROVEMENTS. ANY PAVING SHOWN HEREON MAY BE APPROXIMATE DUE TO EXCESSIVE SNOW AND/OR ICE. _o opppop OF At 49 TH SHANEA.HOLTO LS -6914 y�®O /e s sic net iso ASBU/LTSURVEY 111 =401 NO CORNERS SET THIS DATE I HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY OF THE FOLLOWING DESCRIBED PROPERTY LOT 2 BLOCK 2 AUDUBON HILLS ANCHORAGE RECORDING DISTRICT, ALASKA, AND THATTHE VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS EXIST OTHER THAN NOTED. DATED AT ANCHORAGE,ALASKA THIS _10 TH DAY OF _APRIL , 2023. 9794 -9-7 231-9 HOLT LAND SURVEYING 9309 GROVER DRIVE ANCHORAGE,AK 99507 JA DECK DWELL / / / 0000 0y �• / `d CM ONt `t,FA J1�t (� e e•1A0 tYAO oo.s iU EPAM a c DECK m N O o� a a m $ 46D5�,4jKE �80.3gI AUOUSON CIRCLE THE WFORIMTIOII HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIDCALLY TO SNOW ANY CONFLICTS BETWEEN EXISTING STRUCTURES AND PLATTED LOT LINES OR EASEMENTS AND IS HOT TO BE USED FOR POSITKMENO ADDITIONAL STRUCTURES OR FENCELINES EASEMENTS OF RECORD. OTHER THAN THOSE SHOWN ON THE RECORDED MT. ME NOT SHOAN HEREON. NOTE ANY FENCEUNES SHOWN ME LOCATEDAPPROXIWTELY MD ME NOT TO BE USED TO DETERMINE F OR LOCATE STRUCTURES. ANY PAVING SNO'MI MAY BE APPROXIMATE WE TO SNOW COI D=OMS AS -BUILT SURVEY SCALE: 1' K 40' I HEREBY CERTIFY THAT I HAVE PERFORMED A MORTGAGEE'S INSPECTION OF THE FOLLOWING DESCRIBED PROPERTY. LOT 2. BLOCK 2. AUDUBON HILLS SUB ANCHORAGE RECORDING DISTRICT, ALASKA AND THAT THE VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN THE PROPERTY LINES AND THAT NO VISIBLE ENCROACHMENTS EXIST OTHER THAN NOTED. DATED AT ANCHORAGE. ALASKA THIS 247H DAY OF _JUNE RODS HOLT LAND SURVEYING 9794, FB 119.7 TEL 7455511 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. # CERTIFICATE Of HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Day phone ~P ~/- ~- ,5'$ Lending agency Mailing address ' Agent ~-~ cz~j~.. / Address Day phone . Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well 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: NOTE: Individual on-site Holding tank Community on-site Public sewer AUG 2 C 3998 MUNICIPALITY OF ANCHORAGE 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 C~,,lf., If~e. T~me.XJ Phone Address 732(~S~-~F~ er~Ci ~cle · ..~ En~ineees signature ( 6. DHHS SIGNATURE ~ Approved for Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: ¢/~¢'~ ~¢-~' /~;>~ 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 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. 72-025(Rev. 1/91) Back MOA~I Municipality of Anchorage AUG 1998 DEPARTMENT OF HEALTH & HUMAN ,~~a_F~o~ Environmental Services Division,-~,~c~,- 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Legal Description: ~-¢ 7/ 2. Health Authority Approval Checklist /~/o¢]~ ¢-,, /~tr._,~,~c~/~¢~ /,~1/5 Parcel I.D.: 0/2- 2~'.5 / - A. WELL DATA Well type Log present (Y/N) \/ Total depth /~ / ~ Sanitary seal (Y/N) y If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to /-~O, .~' ' FROM WELL LOG '7-/5 Casing height (above ground) Wires properly protected (Y/N) AT INSPECTION Date of test '7 ~ / Static water level ! '-/ Well production 1 .~' WATER SAMPLE RESULTS: Coliform (~ Date of sample: ~ ~ / ~ ~ ~/ Nitrate /¢, / g.p.m. g.p.m. B. SEPTIC/HOLDING TANK DATA Date installed ~ ~ ~ ~' ~ Tank size Foundation cleanout (Y/N) F Date of Pumping '7- z,L- ~ F ), ¢- c~. c~ Number of Compartments 2-- Cleanouts (Y/N) . Depression (Y/N) /~ High water alarm (Y/N) Pumper ~--~ C. ABSORPTION FIELD DATA Date installed ~ ~- 2 - ~:' ~ Soil rating (g.p.d./ft2 or ft~/bdrm) Length -~ ~' / Width ~ [ Gravel thickness below pipe Effective absorption area ~c/o -~ ~Monitodng Tube present (Y/N) \/ Date of adequacy test ~c .- l # - ,~ ~ Results (Pass/Fail) ,~ ~ ~ System type ~ ~'~'/'~ Total depth 1.~ Z '~ · Depression over field (Y/N) /~ For ~ Fluid depth in absorption field before test (in.); -~ '~ I~ediately after '75;.dgal. water added (in.): Fluid depth / ~¢. ~¢ //(ins) Minutes later: -~.1 :ll/~. j~ Absorption rate = ~0 +~ q.p.d. Peroxide treatment (past 12 months) (Y/N) A~E~ If yes, give date ~ bedrooms 72-026 (Rev. 3/96)* LIFT STATION Date installed Manhole/Access~~ High~larm level atc.~.yc, les tested * 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 /'v//~ On adjacent lots ? On adjacent lots / Public sewer manhole/cleanout /~/,4 Sewer/septic service line Lift station ~//) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation / ~3 f ~l-~ <'-~ ©, Property line /C/"~ Absorption field 2.,~' Water main/service line '2_-5 t,- .Surface water/drainage / cO ~' Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line /~ ~ Building foundation /~ ~ '~ Water main/service line / ~ ~ ~ '~ Driveway, parking/vehicle storage area Wells on adjacent lots /~ ' /'~-,'~ ~'~-~./~- Surface water Curtain drain ENGINEER'S CERTIFICATION~/~ I certify that I in conformanc~wi~. ~~uid__. Signature l~ Engineer's Name ~ld inspections and review ines in effect on this date. HAA Fee $ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Alaska Water & Wastewater Consultants, Inc. 7320 East Chester Heights Circle — Anchorage — Alaska 99504 Phone (907) 337-6179 — Fax (907) 338-3246 August 25, 1998 Municipality of Anchorage Department of Health & Human Services Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 � -d Vtu AUG 2 G 1998 MUNICIPALITY OF ANI tj q,;l. "'T0NMEN"I SEEVICES brvi i Subject: HAA for Private Well & Septic System. Lot 2, Bk 2, Audubon Hills To whom it may concern: The subject lot has a 3 bedroom house on it which is served by a private well and septic system. The results of the field investigation and adequacy tests are summarized as follows: A. WELL: The static water level on 8/18/98 was 13' BTC. Water was pumped from the well at an average rate of 7.19 gpm for a total of 105 minutes (755 gallons). Within the fust 7 minutes of the pumping period the water level dropped 2.25 feet, to 15.25 feet BTC. The level stabilized at that level throughout the rest of the test. In short, the well was recovering as fast as the water was being pumped out. Based upon our test results, it was determined that the capacity of the well exceeds the Municipal requirements for a 3 bedroom house (.31 gallons per minute), and will continuously produce greater than 3 gallons per minute (as required for FHA financing). B. SEPTIC TANK: The existing septic tank was installed in June of 1983 (approx. 15 years old). According to the M.O.A records, it is 1000 gallons, has two compartments and is made of steel. Most tanks of this type typically have a structural life of approximately 20 years. No warrantee is made regarding the future life of the septic tank. C. SEPTIC SYSTEM ADEQUACY TEST: The drainfield is a 3 foot wide trench, which is 59 feet long, and has an effective depth of 5 feet (per the 1983 inspection report). On the day of the inspection (8/18/98), the liquid depth in the sump was 3 inches deep. Water was introduced into the sump at an average rate of 7.19 gpm for 105 minutes (755 gallons), which caused the liquid level to rise 42.75 inches, to a total depth of 45.75 inches. This corresponds to 17.7 gallons per inch. The level was checked 21.75 hours later and it had dropped 26.75 inches, indicating that approximately 473 gallons had been absorbed. Based upon this data, it was determined that the absorption rate of the trench exceeds 450 gallons per day, as required for a 3 bedroom house. NOTE: The adequacy of a septic system is influenced by numerous factors, including, but not limited to, seasonal surface water infiltration, groundwater variations, septic system maintenance (frequency of septic tank pumping, usage of biological additives), condition of drain pipe and pipe joints (which can be damaged by seismic activity and deteriorate with age), type of substances deposited in septic system (cigarette butts, sanitary napkins, mise. objects), and the amount of water being introduced on a continual basis. Consequently, the results of this adequacy test are only valid for the specific day of the test. Furthermore, because of the limited nature of this investigation, it is possible that there are hidden defects which may not have been detected. No warrantee is made regarding the future performance of thisiVell or septic system D. SEPARATION DISTANCE FROM ABSORPTION SYSTEM TO WELL ON LOT A-2, AUDUBON S/D: According to the 1983 inspection report for Lot 2, Bk 2, Audubon, dated 6/2/83, the septic system is 100 feet away from the "neighbor's well", which is believed to be the well on Lot A-2, Audubon. Upon reviewing MOA and ADEC records it appears that there is a class "C" well on Lot A-2 that was approved on 8/13/84, after the septic system on Lot 2, Bk 2 was installed. In short, there appears to be an encroachment on the subject class "C" well; however, due to the fact that the septic system was in place prior to approval of the well, it would be the responsibility of the owners of Lot A-2 to obtain the necessary waivers. E. DISCREPANCY WITH INSPECTION REPORTS: In reviewing the MOA files for Lot 2, Bk 2, Audubon Hills, it was noted that there arc two inspection reports for the septic system installation This first is dated 10/20/81 and the second is dated 6/2/83. A previous HAA was issued 11/29/84, which is based upon the 6/2/83 inspection report. Based upon our field measurements, it appears that the 6/2/83 report is the correct one. If you have any questions, please contact us at 337-6179. Thank you for your assistance. Sincerely, / , :tIVLU AUG 2 - 1998 ALY.11.1590 SI01Pt1 FORTUNE FP,O=ERTIES h0.4V P.7/7 r - • \ TRACT A •10' GTILITY ESMT9. 1O•N 10' GUY WIRC E5MT. y H —' X00' X19! CEN'rCR&V CN•I Fv1wR Lima -- LOT 1 ,. �r ,sLT•d•� ar.�T "5G. Aadrew F, Polls No. 35148 . ohs tw A'r.•/r • AJl L!1 / � :nrn `�.SJJ• sUNVETOR't ` NS TIMM#TLdN I wSnyN Cra r.PT TROY 1 "Awe sonvSTeo Twe 000014DCACNgeD ON Tw•O PIAr Ano Tot A PAOVErsN iO O•Tv.rcg }"LOCO" OAC Isiq EO � •wArw Ow rw1A PINT. DATED TRIP OOT OF eA IIY� 9 LOT •Z) LeaeFlo rWl•�+ ���� 0 LOT =RNER3 l�QtnOTR'E FOUNDATION DRAINAGE ARROWS NOTE91 I, IT s"b.L DC rwt OSVOTOIOIIITT GP Tot SUn.01N On OrNss TO vO01Pv THAT DUILDINO Lr OATIOK O"OrN ■CSTS ALL SVODIVIOIOA COVENANTS AND EONINO OAO10A"LEO. t. rTIt Tot P91PONSIl ILlTV 00 Tot IMUM611% TO V/RIFT ALL RLlVa?IONA WIT" AEvtev TO ALL Ur1.IT199. t. '"Is NL.1' etrwtlenrt Tot FANCCL OF FNOFSNTT OetslUsee DeLOv TAKEN Iwsr n ArDe Ntu •`•T Pty DNI1Ue T-" PKnee L. INf Tel.Nfnrt Kuuwee0 ToIS0 TopA Ar TCN TNF PILING OI' TN}CyyIILOOOOtO /LAr ARE Par snOON Go A• JPTAIFu: 6TfISM 04 101"01 ANT �iNFLI- laUTn •e TO " ■-M` lne 0tIN.I.%,I DOeIs ANO r"1100 601 Imes 011 GAs0ltNNe PLAf M NOT TO It Vs[O POn FOOITIONIITs OOOITIONAL sTROCTVAta 00 Pt OCCO. Aa - bUI LT LOT 2 T ft -0-- A -,Z AU9abO9 HILLS 04jbAYlzlbhl Gnu" A e-a4s+ 10/10 'd '08 VA Rd VIET NMN Ee-LZ-Int DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE/WESTERN PUBLIC SERVICE AREA OFFICE 555 CORDOVA STREET ANCHORAGE, ALASKA 99501 September 18, 1995 TONY KNOWLES, GOVERNOR (907) 269-7519 Mr. Jim Duggan 200 West 34th, ~435 Anchorage, Alaska 99503 SUBJECT: Lot A-2 Audubon Subdivision, Anchorage, Alaska, Class C Public Water System and Wastewater Disposal System, ADEC Project Number 9621-WVV- 256-123, Review Dear Mr. Duggan: I have reviewed your September 13, 1995, submittal regarding the upgrade of your four bedroom single family home into a three bedroom Bed and Breakfast. Based on this review, I have the following comments: From the submitted information and my review of this office's files, it appears that the existing water system was approved as a Class C Public Water System by this Department on September 13, 1984. Based on this information and the fact that the demand on the existing water system will not be increased, it appears that the water system will be able to meet the demand without modifications. Therefore, the existing Class C Public Water System serving the three bedroom Bed and Breakfast and the one bedroom single family home located on the above-referenced property is approved for the concerns of this Department. The final Operation Certificate issued by the Department on September 13, 1984 is still valid. The existing four and two tenths (4.20) milligrams per liter (mg/I) of nitrate (as nitrogen) is above ambient levels for nitrate (.4 to .9 rog/I) normally found in groundwater in the State of Alaska. Although the nitrate level is above ambient conditions, it is below the maximum concentration level for nitrate (10 mg/I) set in the State Drinking Water Regulations, but the existing level does show degradation of the water quality of the aquifer that you are withdrawing water from for drinking. Due to the possibility of continued degradation of the aquifer's water quality and to ensure the public health will be protected, annual analytical results for nitrate (as nitrogen) and total coliform bacteria will need to be submitted to this Department. I recommend that the water samples be collected during February - March of. each year. If nitrate levels remain over eight (8) mg/I for more than two consecutive STATE OF ALASKA DEPARTMENT OF ENVIRONMENTAL CONSERVATION CONSTRUCTION AND OPERATION CERTIFICATE for PUBLIC WATER SYSTEMS APPROVAL 1'0 CONSTROCT Plane for the construction or modification pub'll¢ wat®~ ~ystem located in , Alaska, submitted In accordance with 18 AAC 80.100 by .have been reviewed and are [] approved. ~ conditionally app~d (see attached conditions). J' ~ ~ - ~., t w O,- ,' ~ ~ -, ~ [ "c ~ ', If construction has not sta.~ within ~o years of the approval ~ate, this ce~lflcate Is ~ld and new plans and' .-~:~ specifications must ~ submitt~ for review and approval ~fore construction. Be APPROVED CHANGE ORDERS Change (~o~ ~ ~ ~ ~,~ ~) W A_I: L~ e' /-IO RR Approved by Date 5oZt. Tio;O 5'rS',TE " TO. C. APPFIOYAL TO OPERATE The "APPROVAL TO OPERATE" section must be completed and signed by the Department before any water Is made aveilableto the public. The construction of the (~-t~$.~' public water system was completed on' ! ?, F'; (lV / ~ ?~" (date). The system is hereby granted interim approval to operate for 90da~s following the completion date. BY TITLE DATE As-built plans submitted during the Interim approval period, or an Inspection by the Department, has confirmed the system was constructed according to the approved plans. The system ia hereby granted final approval to DISTI~BUTION: 1. WHITE - ItNGINEER We Se~tlee C) 2. YELLOW - WATER SYSTEM FILE (Complete W C) 3. FINK. EN~INEEFMMUNI-eOROUGH (Coml~e(e Section CI 4. GOLDENROD. MUNI-eOROt~H (Complete Sectkm A) MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) [% ~o i.,~: -~ ct' , .'-,- \~ (b) Applicants Name Applicants Address Telephone - Home Business (c) Applicant is (check one) Lending Institution ~; Owner/builder ~-~ ; Buyer ? ; Other ~-~ (explain); (d) Lending Institution Telephone Address (e) Real Estate Co. & Agent Address Telephone (f) Mail the HAA to the following address: 2. T~?e of Residence' Single-Family~-~% Number of Bedrooms Multi-Family ~--~ Other (describe) 3. Wa.ret Supp1M Individual Well Community Public.~. Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. Sewage Disposal Onsite ~ 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. [Page i of 2] e En§ineerin~ Firm Providing Inspectio.ns~ Tests~ File Search~ Data and Information As certified by my seal affixed hereto and as of the validation date sho~ below, I verify that my investigation of this Health A~thority Approval sho~ that the on-site water supply and/or ~stewater disposal system is safe, functional and a~eq%~ate for the number of bedrooms and type of structure indicated herein. I further verify that, based on the information obtained from the ~nicipaltty of Anchora§e files and from m~ investigation and inspection, the on-site ~ter supply and/or %rastewater disposal system is in compliance ~rlth ~.ll Municipal and State codes, ordinances, and re§ula- tions in effect on the date of this inspection. Name of Firm /~l~s~, e:~,~~ro~\,~c.r+z~_l C,,~'-~c~I ~,x,,'~ !,~.~_ Telephone Address !'~ ,::-c: ~-~ 3 M~'d Aw< Date DHEP Approval Approved for Approved bed rooms Disapproved Terms of Conditional Approval CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN ~EDER~LL ~ND STATE REQUL~E- MEN~$. EMPLOYI~ES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. 1~4E MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERI{0RS OR OMISSIONS IN TRE PROFESSIONAL ENGINEER'S WOR~. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84 ae MUNICIPALITY OF ANCHORAGE (MOA) HEALTH ALrlIqORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Well Classification ~ ~z Well Log Present ~N) ~P Total Depth ~ \~ Cased to Static Water Level i ~ Casing Height Above Ground 2 Electrical Wiring in Conduit/(~Y~N) Separation Distances from Well: Legal Description: _~o~0~ t+,t~ If A, B, or C, D.E.C. Approved(Y/N) Q~ Date Completed ~'~ ~3) ~q~3 Yield ~o, 5~ ~pth of Grouting~.~~ ' Sanit~y ~al on Casing ~) ~Q) ~ession ~ound ~l~ead (Y~) C leanout/Manhole Water Sample Collected By Water Sample Test Results To Septic/Holding Tank on Lot ~5 3. S ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot I~-~ ~ -~ · On Adjoining Lots To Nearest Public Sewer Line ~/~ To Nearest Public Sewer i~I~ To Nearest Sewer Service Line on Lot B. SEPTIC/HOLDING TANK DATA Date Installed O ~ Z 8'5 Size l ooo NO. of Compartments Standpipes!~/N) ~(~ Air-tight Caps (~_~N) ~ Foundation Cleanout P~ing~intenan~ ~n~act ~ File (Y~) ~; for Holding Ta~ High-Water Ala~ (Y~) N~ Te~rary Holdi~ Tank ~it (Y~) Sep~ation Distan~s ~ ~ptic~olding Tank: To Water-Supply ~11 I 5 5' ~ ~ ~'~ TO ~Jllding F~ndation It. To ~o~rty Li~ ~ O~ ~'~ To Dis~al Field '~ ~ To ~ter Mai~rvi~ Li~ Ig/~ To S~e~, ~nd, ~e, ~ ~jor ~aina~ Course Receipt Date Paid: Amount: [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 18 2_ U'/g Type of System Design Date Installed d~ne Z i~3 Length of Field Width of Field 3g Depth of Field 1 Gravel Bed Thickness Square Feet of Absorption Area ~ ~O I"~L Standpipes Present ~/N) Depression over Field ~ r~O Date of Last Adequacy Test Results of Last Adequacy Test ~j ;~ Separation Distance from Absorption Field: To Water-Supply Well {~, ~'.~ tO To P~operty Line ~ ~L To Building Foundation ~ ~, ~'-F f.) To Existing or Abandoned System cn Lot l,,3k ; On Adjoining Lots ~ ~ ~ To Water Main/Service Line ~ To Cutbank(if present) ~ A To Stream/Pond/Lake/or Majo~ Drainage Course {oo'~ To Driveway, Parking Area, or Vehicle Storage Area ~ ~y''' D. LIFT STATION Date Installed ~ Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for ~ ~ Electrical Codes(Y/N) ~ Din~nsions ~//r Manhole/Access (Y/N) ~ "Pump Off" Level at /~^ ~ Vent (Y/N) ~ ~ Pumping Cycles du~ing Adequacy Test. Meets MOA Con~ents Check Permitted Bedroom Rating Ax~ainst HAA Pequest I certify that I have checked, verified, or conforn~d to all MOA HAA Guidelines in effect on the date of this inspection. Signed ~%;'-~L~ ,/~"'~""'~ Date il'- Zq-fe~ Company ,~C~ /~, MOA NO. ~q ~2.~f KB1/d5/s [Page 2 of 2] 2-15-84