HomeMy WebLinkAboutT12N R3W SEC 15 LT 51AMUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section
Septic System Owner -installer Agreement
The On -site Water and Wastewater Section (On -site) may issue an approval for a homeowner
to perform work on an on -site wastewater disposal system to serve that individual's owner -
occupied, single-family or duplex home if the homeowner meets and agrees to the following
requirements:
1. The property owner and excavation equipment operator may perform work on no more
than one owner -installation project in a 12-month period.
2. Owner's projected active involvement witht the installation: / J
? �--t-i0 ,J4,r //
zlti
3. The name of the excavation equipment operator: Ptd 4 J
4. 1 agree that there will be no monetary compensation for installation services rendered.
9 �;�
5. The name of the inspectingen engineer:
6. 1 agree to discuss the following items with the inspecting engineer:
a. Permit design criteria and specifications.
b. Inspection requirements set forth in AMC 15.65.070.
c. Advance notice given to the On -site Water & Wastewater Section for all required
municipal inspections (AMC 15.65.070A).
7. 1 agree to have the project -specific On -site Wastewater Disposal System Permit available
at the construction site for the duration of all related work.
8. 1 agree that if the system is an advanced wastewater treatment system (AWWTS), I will
obtain additional installation instructions and approval from the equipment distributor.
As owner of (legal description) l2 t W'L IS LT S 1,
I agree that the information above is true and accurate.
Owner's printed name: 9—d; l L� 5e,,,y
Owner's signature Date: qhl A6
11
IVlaling Address P Q Bc�x'�9�650'Anchorage, A,Iaska 995�9 6650 * www nnun� o�g .
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: OSP241397
Work Type: SepticTank Upgrade
Tax Code Number: 01505247000
Site Legal Address: T12N R3W SEC 15 LT 51A G:2436
Site Mailing Address: 9401 CARLSON RD, Anchorage
Owner: LARSON PHILIP N & IRENE T
Design Engineer: TRIAD ENGINEERING
This permit is for the construction of:
Effective Date:
Expiration Date:
Lot Size in Sq Ft:
Total Bedrooms:
12/27/2024
12/27/2025
49528
❑ 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
Special Provisions:
1. Alignment of new sanitary service line is to be shown on record drawing.
2. A COSA is to be approved for this property in order to close out this tank permit.
Received By: 1 S S ?`mot A- a
Issued By:
Date:
Date: / 2-2 7/2a 2 `/
ON -SITE SEPTIC/WELL PERMIT APPLICATION
015
Parcel I.D. QYI -052-47
Property owner(s) Philip Larson
Mailing address 9401 Carlson Rd, Anchorage, AK 99507
Site address 9401 Carlson Rd, Anchorage, AK 99507
Legal description
T12N R3W SEC 15 LT 51A
Number of Bedrooms 3
Engineering Firm Triad Engineering, LLC
Building Permit Number R24-1783
Day phone 907-632-2995
Not Applicable F-1
APPLICATION IS FOR: APPLICATION IS AN:
(Z all that apply)
Absorption Field
D Initial El
Septic Tank
F] Upgrade R.
Holding Tank
❑ Renewal El
Privy
❑
Well
❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
Permit/Rush Fees: -#2-25
Date of Payment: 2--Y
Permit No. 03 P-,7_y]S cj:Z
Waiver Fees:
Date of Payment:
Waiver No.
Distance:
EXCELLENCE IN CIVIL ENGINEERING SINCE 1982 • SITE PLANNING • CIVIL ENGINEERING DESIGN • PROJECT MANAGEMENT
ENGINEERING, LLC PHYSICAL MAILING OFFICE WEB
615 E 82nd Ave #101 P.O. Box 111989 907-561-6537 triadak.com
Anchorage, AK 99518 Anchorage, AK 99511
December 27th, 202 4
Municipality of Anchorage
Development Services
4700 Elmore Rd.
Anchorage, Alaska 99519-6050
Attention: MOA On Site Water & Wastewater Program
Subject: T12N R3W SEC 15 LT 51A
Parcel ID 015-052-47
On Site System Upgrade
Project Scope
The homeowners of the subject property are permitting a residential reconstruction that will require
upgrades to the existing well & septic system. The existing system includes a 1250 gallon steel STEP septic
tank and one deep trench absorption field, 54-ft long, 2 -ft wide with 7-ft of effective depth. The system was
permitted and installed in 1993. The field was tested by Pannone Engineering in 2023 and found to be
performing adequately. However, the tank is more than 30 -years old and is in need of replacement. The
well was originally drilled in a pit but was recently converted to pitless by Anchorage Well & Pump Services.
The proposed scope of work includes replacing the existing steel tank with a 3-bedroom plastic septic tank.
The existing absorption field is currently sufficient and no upgrade to the field is proposed.
Site Conditions
The area of the proposed and existing septic system is on the edge of the yard and is vegetated with gently
sloping topography. No surface water was observed or is known to exist within the vicinity of the system.
Soils
A test hole dug in 1992 for the original septic design indicates sandy silt (ML) down to 16 -ft below grade
with no groundwater encountered.
Material Specifications
The proposed septic tank shall meet the specifications of AMCR 15.65.205.
Insulation (if provided) shall be 2” of rigid foam board, expanded closed -cell with a minimum R-value of
4.5/inch.
Construction Notes
The contractor shall be responsible for utility locates.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP241397, Curtis Townsend, 12/27/24
December 27th, 2024
Subject: T12N R3W SEC 15 LT 51A
On Site System Upgrade
Page 2 of 2
EXCELLENCE IN CIVIL ENGINEERING SINCE 1982 • SITE PLANNING • CIVIL ENGINEERING DESIGN • PROJECT MANAGEMENT
The existing septic tank shall be decommissioned in accordance with the current Uniform Plumbing Code.
The bottom of the tank excavation shall be level and the tank shall be set in undisturbed material.
The finish grade above the excavation shall be raised 6” to allow for settlement. The area shall be graded
for a smooth transition into the existing terrain.
The contractor will be responsible for establishing final grade. The homeowner will be responsible for top -
soil and seeding disturbed areas, unless otherwise stipulated in the contract.
Minimum Slope Requirements
Waste Line from residence to septic tank = 1/4 inch per foot
Waste line from tank to absorption field = 1/8 inch per foot
Inspections
Two (2 ) inspections shall be required in accordance with AMCR 15.65.70.
1. An inspection shall be conducted after the tank is set in place with distribution pipes and cleanouts but ,
prior to backfill.
2. An inspection shall be conducted after the tank has been backfilled to verify final grading, electrical
equipment installation, and the locations of all standpipes.
The contractor shall notify the engineer at least two (2) hours in advance of each required inspection.
Waivers
None requested.
Notes
The upgrade to this septic system will not prevent the installation of on -site water and wastewater systems
on adjacent lots.
If you require additional information, please call (907) 720-6128 or email me at
grantmathews@triadak.com.
Sincerely,
Triad Engineering, LLC
Grant Mathews, P.E.
E N G I N E E R I N G, LLC
GRANT W. MATHEWS
CE 135444REGISTEREDPROFESSIONALENGINEER
12.27.24
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP241397, Curtis Townsend, 12/27/24
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
Pump Installation Log
Well Drilling Permit Number: _______________ Date of Issue: ____-____-____
Parcel Identification Number: ____-____-____
Legal Description Block Lot Property Owner Name & Address:
Pump Installation Date: _____-_____-_____
Pump Intake Depth Below Top of Well Casing: __________ feet
Pump Manufacturer’s Name: ___________________________ Pump
Model: _____________________________________
Pump Size: ____________hp
Pitless Adapter Burial Depth: _________ feet
Pitless Adapter Manufacturer’s Name: _________________________
Pitless Adapter Installer: ____________________________
Well Disinfected Upon Completion? XX Yes No
Method of Disinfection: _____________________________
Comments:
Pump Installer Name: __________________________________
Company: ___________________________________________
Mailing Address: ______________________________________
City: ___________________ State: __________Zip: _________
Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation.
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PREPARED BY:
FRONTIER SURVEYS, LLC
650 W. 58th AVE. SUITE E, ANCHORAGE, AK 99518
907-460-1686
DRAWN BY:
CHECKED BY:
DATE:
SCALE:
DRAWING ID:
SHEET 1 of 1
1.Excepting for gross negligence, the liability for this survey shall not
exceed the cost of preparing this survey. Dimensions to property lines
are plus/minus 0.1ft.
2.This document is created by Frontier Surveys for the purpose of an
as-built survey for Philip Larson, only.
3.This document is based on Plat No. 93-95, Anchorage Recording
District.
General Notes DisclaimerLegend
1. This survey complies with the ASPLS Mortgage Location Standards. The survey represents visible
improvements and conditions at the time of the survey. This document does not constitute a boundary
survey and is subject to any inaccuracies that a subsequent boundary survey may reveal. It is the
responsibility of the Owner to determine the existence of any easements, covenants, or restriction
which do no appear on the record plat. Under no circumstances should this document be used for
construction or for establishing a boundary or fence line.
PS 1" = 25ft
1/13/2023 23-001KC
Scale 1" = 25'
AN AS-BUILT SURVEY OF
BLM LOT 51A
SEC. 15, T12N, R03W, S.M.
9401 CARLSON ROAD
CONTAINING: 49,528 Sq. Ft. +/- (RECORD)
RECORD PLAT: 93-95
Gas Meter
Electric Meter/Outside Power
Deck
Septic
Telephone Pole
Fence
Overhead Utility
Water Well
G
E
S x
W -DQ 1 0
R
E
GISTEREDPROFESSIO N A L L A N D S U RVEYORPierre M. Stragier
No. L.S. - 9812
Found Alum. Cap Mon.
Found Rebar w/ YPC
Pannone Engineering Services, LLC PO Box 1807
Consulting Engineers Palmer, AK 99645
Ph (907) 745-8200 Fax (907) 745-8201
www.panengak.com
SEPTIC SYSTEM ADEQUACY INVESTIGATION
Legal: T12N R3W SEC15 L51A
Address: 9401 Carlson Rd
Owner: Philip Larson
Number of Bedrooms: 3
Septic System Private
Well Private
Tank Size: 1250-gallon STEP
Absorption System Type: Deep Trench (54 linear feet)
Absorption Area: 756 ft2
Soil Rating: 0.6 gpd/SF
Installation Date: 8/11/1993
(All info found from MOA records)
Date of Investigation: 5/12/2023
Septic System:
The Septic System was inspected visually and measured. The septic tank was found to have 4.0’+ of ground cover. The
drain field was found to have 3.0’+ of ground cover.
Effluent levels in the tank are well above the normal operating range. It appears the lift station is not operational PES
recommends having the tank pumped and the lift station serviced and replaced if necessary. There is a large depression
over the STEP tank. This should be filled to prevent ponding above the tank.
450 gallons of clean water was added directly to the drain field monitor tube at a sustained rate of 4.7 gallons per
minute. The monitor tube was dry prior to the start of the test. Water levels in the drain field returned to dry shortly after
the completion of the test.
Based on historical documentation all separation distances meet MOA requirements.
Conclusion: Based on observations and measurements the drain field is operating as designed and may be used as a 2-3
bedroom system until more bedrooms are added to the system. The STEP Tank should be inspected before normal
operation of the system resumes. If the tank is found to be in working order fill should be added on top of the tank to
prevent ponding of water.
If you have any questions or concerns, please contact me at (907) 745 -8200.
Sincerely,
Steven R. Pannone, P.E. F. ASCE
Owner/Civil Engineer
SPECIAL NOTE:
In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in
accordance with MOA guidelines and regulations. The reported results describe the performance of the system under the
conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The
operational life of all wells and septic systems depend on the local soil condition, ground water 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 this system. All systems eventually fail, and satisfactory test results do not guarantee future
performance of the system, nor do they guarantee that there are no hidden defe cts or encroachments. Therefore, we
cannot provide any warranty for future performance, nor can we estimate the remaining life of the system. The content
of this report is for the sole benefit of the owner listed above.
Inspector’s Qualifications
Mr. Pannone is a registered Civil & Environmental Engineer specializing in the planning, design and construction of
sanitation facilities. He is a lifelong Alaskan with more than 2 4 years of engineering and construction experience. Mr.
Pannones background includes experience in survey, design, construction, testing, and monitoring of engineered
projects. He has worked all over the state of Alaska, including extensive time in the arctic and remote regions. He takes a
practical approach to design, taking into account how and who is going to be doing the construction. He has hands on
experience in the construction of water and wastewater systems, buildings and large earth works projects. Mr. Pannone
is a certified ADEC water/wastewater designer and sanitary surveyor.
Mr. Pannone is the founder of Pannone Engineering Services, LLC., this privately-owned company was founded in
February of 1991. The company specializes in the design, testing and installation of on-site water and wastewater
systems. Pannone Engineering Services, LLC have performed engineering designs, analysis and evaluations of water and
wastewater systems throughout Alaska. The types of systems have ranged from small single -family wells and septic
systems to large commercial systems serving greater than 250 people daily.
Municipality of Anchorage Page
DEPARTMENT OF HE!ALTH 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
N~me: Wastewater System: ~ New ~pgrade
~dress: ~OI ~[S~ ABSORPTION FIELD
Phone: ~No. of BeSoms: ~eep Trench ~ Shallow Trench [3 Bed ~ Mound ~ Other
Soil Rating: Total eepth from original grede:
LEGAL DESCRIPTION ~o~s~. ~ I
Bloc~: Subdivision: Depth to pipe 5ottom from or[ginsl grade: Gravel deplh beneath pipe
Fill added above original 9rads: Gravel length:
Township: I Range; ~ Tsecuon: -" ~ ~ Ft.
WELL: ~ New ~ Upgrade Gravel~ ~ I Ft. [ ¢ Ft.
--;lassification (Private, A,B,C): Tota~ Depth: Cased To: Total a~sorption area: Pipe material:
Yield: Ft. , ~t. TANK
- ' GPM Pump Set at: C~sing Height Above Ground:
SEPARATION DISTANCES ~ s..tic ~ Ho,di.. ~,T.E.P,
Number of Compartments:
Surf.o. ..... -~ LIFT STATION
Water
Lot Size in gallons: [ Manufacturer:
¢0
'Pump on" level at: "Pump el at:
C~t~in ~ ~ ._ Pump Make & Model ~ Electrical In pecti ns performed by:
- BENCH MARK
Remarks:
Inspections performed by: ~=S. Dates:lst ~ ~'~':"/' ~, ,:
Department of Henlth and Human Services approval -%
Reviewed and approved by: 4°Hcq- %~"¢t* Date: ~6J/¢fJ ~ L
72-013 (1/91) MOA25
SCALE: i' -- SO FT.
203 ~/ ~STH. AVENUE ] ! ~rc ~ rl£N RSW I ~ ])ATE ,4UG. 13, 1993
ANCH, AK, 99501 ! I ~,/~0) ~RLSEN ROAD ! I SHEET, 2/3 GRI]), 24361
£tondord Trenchem 1250 6AL STEP TANK
2' ~/ide
5~' Lon9
10' Deep
7' Sewer rock under pipe
3' Cover
MimoPi 140
89.5
7 Pt o£ £ep-~ic
UNDER PIPE'
Cleonou~5
I JO0±
NO SCALE 82
I I .I 85,4
I250 OAL STEP TANK
Ave ' ! ] ~ mu r~r^~SEN I I ]]ATE AUG. 13~ 1993
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW930237
DESIGN ENGINEER:TOBBEN SPURKLAND, P.E.
OWNER NAME:EVENSEN JANICE V
OWNER ADDRESS:9401 CARLSON 8
ANCHORAGE, ALASKA 99507
PARCEL ID:01505222
DATE ISSUED: 7/20/93
EXPIRATION DATE: 7/20/94
LEGAL DESCRIPTION: T12N R3W SEC ].5 LT 51
LOT SIZE: 32238 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PLRMIT. 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD / 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 (iSAACS0).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4329 OR 343-4681 AFTER BUSINESS HOURS
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
RECEIVED BY:
iSSUED
DATE:
DATE:
S F~LJ~t~CL-~B~> F~ - ~
205 W 15th. Avenue, Suite 206
ANCtt0RAGE, ALASKA 99501
(907) 279-5916
SEPTI~ SYSI-EI~ DESIGN
~AN EVENSEN
No Ground Water' or Impervious Layer 'to 1.~ ft.
Use Standard Trench
Soil Rating. From test Oct. 23, 1992
30 mill/in = ~6 gal/sin ~
Requir-~_~d Area per [~edroom:
150/.6 = 250 sq. ft...
Testhole Total
Less 6 feet.
Less 5 Cover
Rock Depth
Depth
16 ft
10 -f t
5 ft
5 ft
Number- of Bedrooms .'~ /
Length of 'i're~ch 250 x 3 / 10 -= 75
STANDARD TRENCH
TO'rAL LENGTH 75 F-r.
TOTAL [~!DTH 3 FT.
TOTAL DEPTH i0 FT.
ROI]K DEPTH 5 FT.
COVER 5 FT.
SEPTIC TANK 1OOO BAL.
ABANDON EXISTING S¥STEI~
PUHP AND ~BUGH EXISTIbIG TANK
PU~P~ CRUSH~ AND BACKFILL
E×ISTING PIT
The installation o-F this septic system will not prevent wells
from b~. installed on the adjacent l~ts.
There are no devfsloped or ~]aturat SLit"face / SU[1 sLir'face drainage
£:our-ses on this or the adja~zent lots.
The proposed septic system will not chanqP~ the general si ope of
the area. Pooding and/or concentration o~ surface runo~4: will not
result ~rc~m this instal!atior.
]
Municipality ol Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERPORMEO EO~:_ ym
(ENGINEER'S SEAL)
DATE PERFORMED:.__ ~**,~ ·
TOWRShipl Range, Section: T I~).~%~ I ~' SLOPE SITE PLAN
1
2
3
4
5
6
7
8
9
10
11
12
13
14-
15
16
17
18
19-
20-
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTFI?
Oepth Io Water A[ler
~oniloring? -[~ ~-~
Reading Date Time
Net /Depth to Net
Time ~ Water Drop
PERCOLATION RATE
}ESTRUNBETWEEN .~ ~ FTAND -~
tmlnutes/mch) PERC HOLE DIAMETER
_F]
COMMENTS
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDEUNES IN EFFECT ON THIS DATE DATE:
72-008 IRev 4/851
Municipality o! Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
(ENGINEER'S SEAL)
PERFORMED EOR:__
LEGAL DESCRIPTION:
3
4
5-
6 .~.~. ~¢.¢.~
7
8
13
14
15
16-
17~
18
19
2O
WAS GROUND WATER
ENCOUNTERED?
Township, Range, Section: "~.,,~ / ~'~ ~ ~.~--1 ~
SLOPE
S
IF YES, AT WHAT ~}
DEPTH? P
E
Oeplh ti) Water Alter
Menitering? __ Dale:
SITE PI AN
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE --
(mmules/mch) PERC HOLE DIAMETER
TEST RUN BETWEEN ____ F ND
'J i m
FT
__ CERTIFY THAT THIS TEST WAS PERFORMED IN
GAS
1000 GAL SEPTIC TANK
~ote
75 FT. LONG TRENCH
0 ?5 50 7,5 100 185 15"0
SCALE~ I' --. 50 FL
e03 ~/ 15TH, AVENUE I I SEC 15 [IBN R3W ! I DATE JUL Y 18, 19.
ANCH, Al<, 99501 I I 9401 CARLSEN ICDAD ~ ~ SHEET,.~/3 GRID, £436
£tondord Tren es, 0 gol £ep~ic ~ank
3' !Vide
7,5' L o~9
10' ~eep
5' Sewer rock under plpe
5' Cover
Cleonouts
4' Topsoil
5' Cover
Monitor
£xisf:, Oround
4' Min Cover
Tonk
Mima£1 140
5 Pt o£ Septic Rock
UNDER PIPE
NO SCALE
1000 9ol. ~eptlc ~onk
LZ}T 51
£ECHfl/V 51 Ti£N
JAN EVENSEN
9401 CARLSON ROAD
[ SEPTIC SYS'fEH DESIGN
])^~£' JUL Y '18 1993
SHEET, 3/3 6Ri~, 2436
,' /
(~/,'~ - (~.~' ?_ 2- '2~INVOICE No 2300
M.-W DRILLIING IN(:.
UNIT
ANCHORAGE. ALASKA 99511 QTY. MATERIALS PRICE AMOUNT
OWNERS
DESCRIPTION OF WORt<
Ali charges shall be paid in full within ten
days unless other arrangements are made
pr/or to dh?/lng. The customer sha// pay
~erest at the rate o[ ~ ~ % per month on any
amount not paid within ten days, Failure to
p~y m~y result in ~ lien against the propert!/,
WORKMAN {~ATE
IN OUT
I '730
OTHER CHARGES
HOURS J ~ATE
MATERIALSIF~OM ABOVEI
PAY THIS AMOUNT
/'~ oo,.g. OoO N,
u') ¢ 1.4
o l
00¢
S 874 500T 05 ~g~
