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Home My WebLink AboutSUN VALLEY NORTH BLK 5 LT 1 Municipality of Anchorage Page / of ¢ DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 ® Anchorage, Alaska 99519-6650 · Telephone: 343~4744 On.,Site Wastewater Disposal System and/or Well Inspection Report Permit Number: S(J'J'~O~J PID Number: Name: ~V."Ai%l ~A~ET ~'EIN~US~- Wastewater System: ~ New ~ Upgrade *d~,,,: 8~0 Co~ 4~. ¢1 ff~So~ ABSORPTION FIELD Phone: ~%" ~[1~ ]No. of Bedrooms:~ D Deep Trench ~ Shallow Trench ~Sed ~Mound ~Other LEGAL DESCRIPTION so,, Rating: O. ~ GPD/S,. Ft. Total Depth froml ' original grade: Lot: Block: Subdiv~ion: Depth [o pipe bottom from odgin81 grade: Gravel depth beneath pipe Township: ~ Range: ~ Section: ~ Fill added above original grade: Gravel length: WELL: ~New ~ Upgrade Gravelwidth: [%' Ft. Number of lines:~ IDistancebetweenlines:~,5-' Ft. Classification (Private, A,B,C): Total Depth: Cased TO: Total absorption area: Pipe material: AST ~ TANK SEPARATION DISTANCES u Septic U Holding ~S.T.E.,. TO Septic AbsorpUon Lift Holding Publ~c/Priw[e Manufacturer: Capacity in gallons: From Tank Fie[d Station Tank Sewer Lines ~(~ ~ Material: Number of Compartments: Surface ~ Water I~'~ ~OO+ ~O¢ ---- -- LIFT STATION Lot ~ Size in gallons:~ Manufacturer:A ~ "Pump on" level at: ~ "Pump off" level at: ~ High water alarm Curtain ~-- ~O~E ~)~ ~ PumpMake&M0del JE~ctricallnspectionsperformedby: ' BENbH I~ARK Location and Description: Assumed Elevation: Inspections performed ~o~ Eaala Elve~ Eeop Eoa~, Nm 2~ates: 1st. ~" / - ~ Eagle River, Alaska 99577 2nd. ~ - ~ -~ ~ ,-~ ...... -- ...... ' Reviewed and approved by: ~ /~ ~ Date: 2 -~ ~ ..... ~r.-~.' ...... ,~ 72~013 (Rev. 9/91) MOA 25 PermltNo. SW950164 Page 2 of 2 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 995'19-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report LOT 1, BLOCK 5, SUN VALLEY NORTH 05065205 Legal Description: PID No · MT C~ ~1102.8,C0 MH / -102.9'///_FINAL GRADE~..% 108,8' .......... qSU~TiON ~ ~g~O GA~ ~g,7 S.~.~,p. ~0g.~' 100.5~ SYSTEM 106.0' A lO0/ ~ATER FOUND W~LL N w ST1 12' 4~" /~ ST2 17' ~. ~ MT1 58' 9(~' MT2 55' 8~' MT3 95' 12~" NEW 1,~50 GAL~ ~ MT4 92' 12~" S.T.E.P SYSTEM LT. I TE ~ scab . = 40' ~r.~ ¢= ~n · :, ~ 72-013 A (Rev. 9/91)MOA 25 N~ Valley Gravel lille, Al~mka~ 99687 .......~!,,.,. 8ubJooL 01eve Anal¥si~ The fl)llowing I~ tho sieve m'mly~l, ct' lho ~,end om?'iplo ~ul>mllled on 4141B§ Sieve % I::'a~slng % Required for DEC 8~ptlc Filler g,,'oilp A ~roup B Coefficient. of Uniformity C. 3,9 4 max Co~ffloJerlt. of Curvature C~ . 1,0 1 Ma)< ' The Submitted ~ampln contorms lo group B speolflcmlon¢, bul doe8 nol conform to group A. tf you have ~ny queBtJons, please do not hesitate to call, , ,' Blnoerely, M~rl{ Hm'mon January 16, 1996 To Whom It May Concern: This letter certifies that the electrical hook-up of the septic system located on Lot 1, Block 5, Sun Valley North (Janet and Evan Steinhauser, property owners) has been installed according to the municipal codes by the certified electrician named below. signature SULLIVAI WATER WELLS P,O, BOX 670272~ CHUG1AK, ALASKA 90567 ,, TELEPHONE 688,3759 ADDRESS STATIC LEVEL OF W~TER FI'. ~ ~ ..... DRAW DO~N FT DA~E. gtaned Ended ~~ GAI~. PER HR ~ PERMIT NUMBER KIND OF CASING , ~ ~ KIND OF FORMATION: ~'rom O __Ft. to '~' From=. -'~ Ft. From (~ Ft. From ¢~} _Ft. ~'rom. F~om~FL Ftoa, 1 (~ Ft. From Ft, to__. Ft From. Fl. lo_- Ft._ Yrom~Ft. to 1Ft.. From,__Ft. to Ft., From Ft. to_ Ft.~ From Ft.~o_ ~ -Fl., From____~ FI, to Ft. From__FL to,__ From__ Fl fo.__Fl __ Fro~n____Ft.~o_ From From~Ft. Froo! ___FI, to_ From--___Ft. F[bm__ Fl. to~FI From ~.Ft. to_ Fl. Dom____.Ft. to___ Ft. From .Ft. to Ft. From Fl, to.__Ft Fl. ~FI, _~ Fl. Ft. Fl. MISCL, INFORMATION: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-66!50 PAGE 1 OF ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW950164 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:STEINHAUSER EVAN & JANET OWNER ADDRESS:8820 CORDELL CIRCLE #1 ANCHORAGE, ALASKA 99502 DATE ISSUED: 7/14/95 EXPIRATION DATE: 7/14/96 PARCEL ID:05065205 LEGAL DESCRIPTION: SUN VALLEY NORTH BLK 5 LT 1 LOT SIZE: 153422 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL 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 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS {18AAC80) . 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER 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. SPECIAL PROVISIONS: THE SAND USED IN THE FILTER LAYER MUST BE A CLEAN COURSE SAND WITH 4% OR LESS PASSING THE #100 SIEVE AND 2% OR LESS RECEIVED BY: ISSUED BY: ~1, ~VE. A SIEVE ANALYSIS MUST BE PROVIDED >M AN A~PS~ED SOURCE. ROBERT C. COWAN, RE. ROBERTA. SHAFER, RE. HEALTH AUTHORITY APPROVALS SEWER&WATER INSPECTION ENGINEERINGSTUOIES ANDREPORTS WELL INSPECTION & FLOWTEST SITE PIJ~NS ROAD DESIGN SOILTEST PERCOLATION TEST STRUCTURAL & MECHANICAL iNSPECTiONS June, 19, 1995 CIVIL ENGINEERS (907) 694-2979 FAX (907) 694~1211 MUNICIPALITY OF ANCHORAGE Department of He~th and Human Services P.O. Box 196650 Anchorage, AK 99519 REFERENCE: Lot I; Block 5; Sun Valley North Subdivision Recuest ~ou issue a p~it to ~ a we~l and ,~ns~ ~ septic s~st~m to 6eru~ the p~opoee~ Test holes were excavated and pe~¢ola~on tests performed. The approximate locations o~ the test holes are located on the at~ached site plan. At the t~e of excavation, water was encountered at four fe~t in test hole #I and three feet in test hole #2 and after seven day ground water monitoring water was found at four fe~t and fo~ fe~t respectivezy. This property has enough ~cea for a future septic upgrade which can be seen on the at~ached site plan. We do not anticipate any adverse effects on n~ighboring wells, septic systems or drainage patterns by the installation of the proposed septic system. There, are no points of contamination within the proposed w~Z rad~ which can be seen on the attached site plan. If you require add~onal informa~on, please contact Sincerely, Robert C. Cowan, P.E. RC¢/gk Enclosure 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 Z NVId Ills 3SNOH ~08 ~ O3SOdO~d o~ NOIS3G ,09 = ,,~ 3AI~G N~OH)II3 ~ql-'lOHd [ 0 ~Ox 0 a::] ~.. o 'S'.L'N m~ Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST DATE PERF' LEGAL DESCRIPTION:. b"Ol"' / '~-~- 50 ~ ~i~'t~C.~Township, Range, Section: ~Di...¢i~~ SLOPE 2 3-/~ 5- t5., 7 g 10 14 ~7 2O COMMENTS WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Depth Io Water After Mnnitoring? ¢ Date: SITE PLAN Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE ~__ (minutes/tach} PERC HOLE DIAMETER TEST RUN BETWEEN FT AND FT ACCORDANCE ~ITH~--LL ST~NIClPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: __ (; /'"~3 /¢, ~-- 72-008 (Rev. 4/85J {ENGINEER'S SEAL) //a~'k"~l~,, ~ ~ ROBERT C. COW~, RE. K <~/ (007)694-2970 LEGAL DESCRIPTION;~f ~ ~ S~.~4 Townsh,~, Range, Sect,on. ~[ SLOPE EITE PLAN 2 3 4 § 10~ 13 14 15 16 17 18 19 20 WAS GROUND WATER ~j ENCOUNTERED? ~'~ IP yes, AT W,AT 5-- SL DEPTH? pO E Monitoring? Date: Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE -~', t~. tmlnutes/mch) PERC HOLE DIAMETER 'rEST RUN BETWEEN ~-- FT AND .~..__ FT PERFORMED BY: ' '0 I .... CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINFS IN EFFECT ON THIS DATE. DATE: ~ ~/"~-~ (/~ ,.~ 72-008 (Rev. 4/~5) \, HEALTHAUTHORITY APPROVALS SEWER&WATER INSPECTION ENGINEERING STUDIES ANDREPORTS WELL INSPECTION &FLOWTEST SITE Pt~,NS ROAD DESIGN SOILTEST PERCOLATION TEST STRUCTURAL& MECH/d4[CAL INSPECTIONS ONSITE WASTEWATER DISPOSAL SYSTEM BESIGN ' ¢neemn ROBERTC. COWAN, RE. ROBERTA. SHAFER, RE. ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-12'1 '1 REFERENCE: Lot 1, Block 5, Sun Valley North S/D June 16, 1995 GENERAL: The scope of this project includes the installation of a 1250 gallon wastewater S.T.E.P. system (septic tank) and a pressurized absorption bed to serve the three bedroom residence located on the referenced property. Construction shall be in accordance with the approved site plan and design drawings, Municipal permit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. The contractor shall be responsible for obtaining any necessary underground utility locates. Unless specifically agreed otherwise, 'the property owner shall be responsible for final grading areas subsequently depressed from soil settling. On all leachfield mound systems, the property owner shall be responsible for ensuring a satisfactory vegetation growth over the mounded area. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. SEPTIC TANK INSTALLATION: A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. e The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. 17034 NORTH EAGLE RIVER LOOP . SUITE 204 . EAGLE RIVER, ALASKA 99577 Page Two Lot 1, Block 5, June 16, 1995 Sun Valley North S/D Ail standpipes on the septic tank shall extend a minimum of 12 inches above final grade. Septic tanks installed with less than 4 ft. of cover shall be insulated. A foundation cleanout shall be installed one to four feet from the building foundation° In the line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10 ft. from the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. PRESSURIZED MOUND SYSTEM INSTALLATION: 1. Any peat or organic matter must be removed from the elevated mound site. The bottom of the basal bed area as well as the top of the sand filter is to be within two inches of level. The distribution piping is to be of PVC (ASTM D3034 or equal). All joints are to be solvent cemented. The side slopes of the top layer of the mound system must not be steeper 'than 33% (3:1). The top of the mound shall be covered with a minimum of 6 inches of topsoil and vegetated sufficiently to prevent erosion· The distribution pipes are to be embedded in sewer rock. Care should be taken to backfill in such a way as to prevent damage 'to the piping system. Silt barrier material must be installed between the final grave], layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill. Page Three Lot 1, Block 5, June 16, 1995 Sun Valley North S/D Backfill over the final gravel ].ayer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. MINIMUM ~ATERIAL SPECIFICATIONS: Any septic tank proposed for installation must be constructed by a Municipally approved septic tank manufacturer. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Type of Pipe Perforated Solid Cast Iron Yes Yes ASTM D3034 (PVC) Yes Yes ASTM F810 (HDPE) Yes No ASTM D2662 (ABS) Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal)· Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed between the final leachfield grave], layer and the native soil backfill. Ail leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the II200 sieve. When sand is being used as a filter material, its gradation specifications must conform to current M.O.A. or D.E.C. requirements. Page Four Lot 1, Block 5, June 16, 1995 Sun Valley North S/D INSPECTIONS: Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before this inspection. e The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. The final inspection is to occur upon final grading of the property. Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to 'the start of construction. If necessary, a pre-construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or control in any way the contractors activities. The owner shall contract with the contractor to perform the work outlined in these specifications and plans and in accordance with the attached M.O.A. permit. There will be no contractual arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be the owner's representative and will inspect the work as stated above to document the contractors activities. Final acceptance of the contractors work rests with the owner and the M.O.A. Page Five Lot 1, Block 5, June 16, 1995 Sun Valley North S/D S & S Engineering shall have no liability to the owner or to others for acts or omissions of the contractor or any other persons performing work on this project or the failure of the contractor to carry out the work in accordance with these construction documents. S & S Engineering's inspecting engineer will not be responsible for the construction means, methods, techniques, sequence, procedures or the safety precautions incident to this project. CONTRACTOR/INSTALLER MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environrnental 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. # L.'J'6 -¢:¢':> -6 ~ 1. GENERAL INFORMATION Complete legal description HAA#_ ~ ,I~.,~ Lot I; Block 5; Sun Valley North Location (site address or directions) Property owner . Mailing address Lending agency Mailing address NHN Elkhorn DRive Evan & Janet Steinhauser 8820 Cord~.&~ Creek #I Anchora.qe, Eag~6_Riw~, AK Day phone AK 99502 Day phone _ 245_-6116 Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: Individual well XXX 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,: Individual on-site ',~" Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 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. ] 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. S & S ENGINEERING Phone Name of Firm 17034 ~.agJe River I. oop J~oad Eagle River, Alaska 99577 Engineer's signature DHHS SIGNATURE Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date 2 - ~'- ~',~'? 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. Municipality of Anchorage DEPARTMENT OI-- HEALTH & HUMAN SERVICES Environmental Se~Mces Division 825"L" Street, Room 502 # Anchorage Alaska 99501e (907) 343-4744 Health Authority Approval Checklist LegalDescriptiou L--cfr- \ ~w¢-~,j' ~o~ N.~x,t.r~,./ ~ParcelI.D.: A. WELL DATA Well typc LO§ prcscnt Total depth __ If A. B. or C. attach ADEC lelter. ADEC water system number q Date completed -? - Z7 ~ Cased to ~1 ' Casiug height (above ground) Suuitap., seal ~-'~N) FROM WELL LOG Wires properly protected {~N) AT INSPECTION Date of test Static water level Well productioo g.p,m. WATER SAMPLE RESULTS: Coli£orm Date of sample: __ y/{-4¢/q & B. ~HOLDIN~ TANK DATA Nitrate Collected by: r~/L_ Other bacteria $ & S ENGINEERING 17~-t I~a~l~ i~lvc, r Eagle RlYar, Alaska Date installed ~,-2.-¢'1~~' Tank size IL.¢''t::> Number of Compartmeots ~ Clcanouts ~N) '¢ __ Foundation clcanout {~lq) ~ Depression (YBSi~ ~ High wuter alarm iY/N) ,..L I/~ Date of Uumpmg )[A--~.~.[ Pumper. ¢' la C. ABSORIrFION FIELD DATA Date iastalled {t - 2- Leugth ~t~,, Width Effective absorptioa area Date of udcquacy test __ ri/A, Soil ratiag (g.p.d./ft2 or fl2/bdrm) O, 7 System type /'4a ,..)~;a /¢' ' Gravel thickness below pxpc o, ~- ' Total depth ~ / Mollitoring Tube prcscnt~lq'q) -./ _ Depression over field (Y~ ~ __ ~e~ Results [Pass/Fail). -- For --- bedrooms Fluid depth in absorption field belbre test (in.): ~ hnmedi~ttel5 ,alter ~gal. water added (in.): Fhfid dcpt[1 ~.(nls.) Minutes later: ~ Absorption rate = ~-- g.p.d. Peroxide treatmenl (past 12 moaths) (Y/N) ~ If yes, give date D. LIFT STATION Date iustalled B - 2- - qq' Size iii gallons Manhole/Access (~N) x/ "Pnmp off' level tit* t//2, ~ "Pump off' level High water alarm level tit* t/~/. *Datuln OF- ~ {3 o r'm ,~4 Cycles tested 59 SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: L~p~holding tank on lot /o 2. J Absorption field ou lot /~o t Public sewer main '"//~ Sewer/septic service line Z~ ~ p : On adjacent lots /oo : On adjacent lots Pabfic sewer manhole/cleanout Lift station / Oo SEPARATION DISTANCES FRO~HOLDING TANK ON LOT TO: Building fouadation / o t Property line ,,~ a- ~ Absorption field Water lnain/service line /o ~ ~' Surface water/drainage /oo ' ~ Wells ou adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation Surface water Curtain drain z~//,~ Water main/service line /~ t ~- Driveway, parking/vehicle storage area ,~ ~ Wells Oil adjacent lots /o o t g" Property line F. ENGINEER'S CERTIFICATION I certify that i have determined thrufield inspections and review of M'unicipal records that the.~.~_l~l~- yas are ~ co ~Jbrtt ance with MOA ll~gttideli~es in effect on this date ~ O~ A / ~./~ ~ ~b ............... .............................................................................................................. t~-~-~a~r .......... ~-~x~ HAA Fee $ ~ OD ~ ~ ~ Waiver Fee $ Date of Payment / ' 2~ ~ ~ & Date of Paymeat Receipt Nunlber /&// ~ff~ 37ff Receipt Nanlber Rev. 8/95 OSS: Ma.wk.doc