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T12N R3W SEC 15 LT 133
TI R3W 15 Lot 133 #015-48 - 11 ,.vww.muni (907] Pump instatiation Log ?m-eel Idendfic,~don Number: piflesa Adap~r Bm~ Dep~: /O~ feet Disinfected Upon C~om~Le~,o~'? ~ ~fes Pump InstxLler }[azne: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL E. NGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WFLL INSPECTION REPORT ~"A'M E PHON~ - []r~sw [~PGRADE ~ILINGADDRESS LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS ~ Z Manufacturer Msterial ~ No. of compartments Liq. capacity in gallons IF HOMEMADE: Inside length Width i Liquid depth ~ ~ ~ DISTANCE TO: Well Dwelling PERMIT NO, O ~ ~ Manufacturer Material Liquid caeaciw in gallons ~ We I Foundation Nearest lot line P~RMIT ~O. ~ No. of lines Length of each line ~ f lines Trench width~ ¢ inches Distance between lines Top of tile to finish grade Material beneath tile Total effective absorption area Length Width Depth PERMIT NO. ~ ~ Type of crib Crib diameter Crib depth Total Mfective absorption area ~ Wall 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 b 3oa N ~PPROVED DATE LEGAL ................. 72 013 (Rev, 3/78) PERHIT NO. FIPF'L I CFIN'F LOC:FIT I ON LEGRI_ ROBERT BRKER x.:r. CRRNRHF:I ~¢I~.:ER RERLT"r'-47~4 BUSINESS PK 8 T±ZNR3:W S::L5 I.~13:2: LOT SIZE 999999 %QUFIRE FEET T'¢PE OF SCIIL RBSORPTZON S'T'STEM IS: TRENCH MR'/,IHUM NUHBER OF EaEL':,F.:OOMS = SOIl.. RRTING (SO FT,,"BR)= 173: THE REQUIRED SIZE OF THIS SOIL F. IBSORPTION S'¢STEM IS: THE I._ENGTH DIMENSION IS THE LENG'rH (IN FEET) OF THE ]"RENCH OR [:,R~INFIELD. THE I}EPTN OF R TRENCH OR F'IT IS THE DISTRNCE BETNEEN THE SURF'RCE OF "I"HE GROUN[:, RND THE BOTTOM OF THE E::.:;E:RVRTION (IN FEET). THERE IS NO SET HI[;,TN FOF.: TRENCHES. THE GRFi'v'EL DEPTH IS THE MINIMUI'fl DEF'TH OF GR.R',,,'EL BETWEEN THE OLITFRLL PIPE RND THE BOTTOM OF THE E?.,'CFI',,,'FITION (IN FEET). lq: EZ G:., L.I Z ~;: E: £:, E; E P T' Z C:: "F Fl ~-~ I-::: E. :[ Z lie == :]_ i~2n ¢.-:'~ ~E1 ~..3 F~ ~_ L_ C, I1"..,~ :FLY F:'ERMIT RF'F'LICRN"r FIRS THE RESPON'SIE:ILIT'¢ TO INFORIfi THIS I}EF'RRTHEI'.,IT DURING THE INSTFILLRTION INSPECTIONS OF FIN"r' 1.4ELLS FIIi:,JRCENT TO THIS PROPER"r'¢ FINE:, THE NUMBER OF RESIDENCES TFIFIT "]-PIE WELL HILL SER'v'E. DFICKFIL. LZNG OF FIi'.4't' SYSTI:'P1 WITHOUT FINRL INSPECTION RND RPPROVFIL E?'r' DEPRRTHIENT 14ILL BE SUBJECT TO PROSECUTION. I'"III',IiMI..IM DIE, TFINC:E BETNEEN R PJEL. L RN[:' RN'¢ ON-SITE SE:NRGE DISPOSRL. SYSTEM I'S'; :LE10 FEET FOR fl PRI',/flTE I,iELL OR t50 TO 200 FE:ET FR. OM R PUBLIC NELL DEPENDZI"~C~ UPON THIS T'¢I:'E OF' F'UBLZC P.IELL I"IINIHUH DZ'S, TRNCE FREq'"I R F'RZ',,,'RTE WELL TO fl PRiVRTE SEHER LINE IS 25 FEET FINE:' TO FI COMP1UNZT'¢ SEP.IER LINE IS 75 FEET. 01'HER REQUIRE:P1ENTS I"1R¥ FIF'F'L"r1. SF'ECIFICflTIQNS FINE:' CONSTRLIC:'FIC~N [:,IFIGRRMS fiRE R',,,'RILRE~LE TO INSURE PROPER IN':;TRLLFITION. I CERT I F'"r' I'FIRT 1: I FIM FI::IMILIRR WITH THE REL.]LJIRE:MEN'rS FOR ON-.SITE SE[,.IERS FIND NEL. LS FIS 'SET FORTH B'¥' THE HLINIC:IPRLIT'¢ OF RNCHORRGE. 2:: I WILL INSTFILL TFIE S'¢STEH ZN RCCORD~NCE HITH THE CODES. 2:: I LIND, ERSTRND THRI' THE ON-SITE SE[,.IER S'¢STEM IdR'T' REQUIRE IENLFIRGEMENT IF' TFIE RESIDENCE I~ REMODELED TO INCLUDE MORE THFIN ~: E:EDROOHS. s ~ ,s N E D: ....... .~.~ ~ _. ¢ _ _~. 2z~ =~: ..................... HFI L. Zk/RN~ RuE, ER F L, HLLR ,.]. bHRNHIlHN ...... ' -' "- , ; ,, ,. / ¢M,' ,' ' '"": '"' , /~ --/ ¥14, I]1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMEN'TAL PROTECTION ~ PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG -- PERCOLATION TEST PERFORMED FOR:. DATE PERFORMED:... LEGAL DESCRIPTION:__ T 1 4 8 10.- 13 14 15 16 17 18 19 20 COMMENTS SLOPE WAS GROUND WATER S ENCOUNTERED? ~O [ E IF YL:S, AT WHAT DEPTH? SITE PLAN Reading I)ate 'rime Time (~,;^") Water Drop PERCOLATION RATE TEST RUN BETWEEN ~ '}"' (minutes/inch) ~ ~ FT AND ~ '/'~' , FT Subdivision .~_~N A,E,C,S,~ INC, ]220 W, 2~t, AVENUE ~ICHORAGE, ~<, 99501 Supplemental Soils Information. LO7 ~H \ 3 4 5 6- 7 8 9 10 11 12 13~ 14- 15- 16 17 18 19 20 LOl TH 3 5 6 7 9 10 11- 12- 13- 14 15 16 17 18 19- 20- LOT ~H 1 2 4- 6 ? lO 11 12 14 17 18 2O LOT EET) 1- 2 3 4 5 7 8 9 10 11 12 13- 14- 15- 16- 17- 18 19 2O . ,,1UNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENI'AL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephong 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT MAILING ADDRESS LEGAL DESCRIPTIQN ~PHONE/PHONE [~NEW ~.=~'~J.~~-~'"7~.r~/-'-' [] UPGRADE LOCATION NO. OF BEDROOMS Well Absorption area Dwelling PERMIT NO. DISTANCE TO: ~ ,~ ~"~/,~. _~" -- Manufacturer Material No. of compartments Liq. capacity in gallons inside length Width Liquid depdn IF HOMEMADE: Well Dwelling PERMIT NO. DISTANCE TO: Manufacturer Material Liquid capacity in gallons Well Foundation ,st lot line PERMIT NO DISTANCE TO: ~r' "¢',~'~O l ~'~" -- No, of lines of each line lines Trench width Distance between lines Nc//--/ inches Top of tile to finish grade Matedal beneath tile Total effective absorption area Width Depth PERMIT NO. Length Type of crib Crib diam0ter Crib depth Total effective absorption area Well Building fourldation Nearest lot line DISTANCE TO: Class Depth Driller DISTANCE TO: Building foundation Sewer line Distance to lot line Septic tank OTHER PIPE MATERIALS SOIL TEST RATING INSTALLER REMARKS MUNICIPALITY OF ANQi©RA.G',] DEP[. OF HEAL1H & LEGAL LI:)I~i:I:::I'J" t"lJ:::i::.::}il'"il.l~'"J I'.,fLIJ"IE:J:![t:;?. OF 13EPF?X3E~HS!; = 2!: -II-JE LI:!:I'.,IGI-I.I O ): HF:I'.,}5; ]: ON :i]Si; 'I'HfE I_.[!:blGI-H ,::]3'.,I 'l'hJ[i: [)EI::)TI..I Elf::' J:::l I'f:i?.ENC:J.I O1::;: J:::']i"l :[5 THE I}ij:,::OI..Ij,,l[) I::ll",l[)TILE: E!iH:ITTI:II',I I~11::: TILE!] lii::,::l]::l=:['v'l::J-I ]]Iii:H'.,I Tl-II}:i::~l~: ]::!:!: F,IO 5i;1!!3' I,.I):E:,i'lq I:::'il)l:,:: "['1111: (iil:ii:F:l'v'[i:l. [:,l~!l:.:"J'l..J ~[51: 'l't.Jl!iil Iq ]i l'.,J ]: l','tl...ilq [:,~::F:"f'lJ I])1::: J::Jlr-,J[:~ 'iI. JE J!!!:O'l"'i"l:)[q iEIJ::' 'l"l'.tl!~i JiiT,:.:',l::l=¢v'l:::J'[ ]3:JJ'.,t (]iJ",l I:::lii:E3") I:::'E:I:;i:I'I 3: I FII:::'t:::'[ :1: C:t::II',I I" i...IFr='~; THE i,.i :. ;f: O[',l_:; ]: l'; 7: I_. :[ I'() :[ t'.,II::'ORH TI.I :[ ::ii; I)~EI:::'i:::iI:¥1-HEi'.,tT I)1_.11:~,. ]: F,IC:i TI.lIE 3:l',lS!;'/l::lL..I..l:::ff:[ON LiL:I.L... t lll...IL:: O1:::' I:::11%.' 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'I-HE '5"¢5;-t'~][N :1:t",1 i:::l(:;(:;I;)f;'.[)l::l['41:]:¢~Z I.,.I:[I'H THE }~:: :1: I.&,IIZ::,IEI:;~:5.'fF:iI",I[::, FI'tF:fT' TIlE C)I"~-~]:TI~:; 5i~;EZl,.lEf('. :5"¢:E;TE~PI I"~l::fT' ~;;:tE(;:!LIZF?.E[ IEI".II...I:::IJ;:GIEFIEZI',IT Z F::' TI'tIE I:;~:IES; ;1: I:::,I:~:Ir',E:IE :1::5 F;:E:blEOIS}...E%, 'TEl :1: IqE:LIJDE I"IORE THFIN 3: 13EDl:;~:En3fq:~5. FII='I='L. ]; CFIN T R 0 E', E~I?. T GARY PILA¥I zR CONSULTING GEOLOGIST SOILS LOG Performed for. _~-~ Soil Type Water Level Remarks ].2 1l~ 16 18 20 Total Depth of Excavation ~'~o t Reached 'Depth, if Reached Classification Method ( ) Sieve Analysis () Material at: Total Depth Bedrock ~ot Reached Depth, if Reached Gary F. Player, Consult::[ng Geologist DEPT. OF ENVIR~)NMENT,~.t, ~;ONS]BRVATION JAY S. HAMMOND, Governor · SOUTHCENTRAL REGIONAL OFFICE MACKAY BLDG, 338 DENALI STREET ANCHORAGE 99501 July lO, 1975 Mr. Lynn Coad GAAB--DEQ 3330 C Slreet Ancherage, Al( 99503 Subjeck: Lol's 122 and Dear Mr. Coad: 133, Seciion 15, TI2N, R3W, S.M. We have no objection to a well located on Lot 133 serving bo~h the subjecfl lots as long as a 200 foot minimum distance is main- rained between the well and any septic flanks or seepage systems, S i ~cere I y, Cherry, P.~. Regional Environmen~al Supervisor Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www. muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 015-482-11 1. GENERAL INFORMATION Complete legal description COSA # Expiration Date: T12N R3W SEC 15 LOT 133 Location (site address)" 4421 E. 104TH AVE, ANCHORAGE, AK 99507 Current Property owner(s) STEPHEN SOBETSKY Mailing address Lending agency Mailing address- Day phone 442! E. 104TH AVE, ANCHORAGE, AK 99507 Day phone Real Estate Agent LORI HACKENBERGEPJDYNAMiC PROPERTIES Day phone 907-727~??.4 Mailing Address 3111 C Street, Suite # 100, Anchorage, AK 99503 Unles~ otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well ~E] Individual Water Storage Community Class Well [] Public Water System [] TYPE OF WASTEWATER DISPOSAL: Individual On-site [] Individual Holding Tank [] Community On-site [] Public Sewer I--I 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 sewed 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 sewed 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 vedfy 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 Wat~Jns Engineering, Inc. Address p.o. Box 110443. Anchorage, AK 99511-0443 Engineer's Printed Name Cindy W. Ellis, P.E. Phone 907-349-1851 5. DSD SIGNATURE Approved for .-~ Disapproved. Conditional approval for bedrooms. Date bedrooms, with the following stipulation§:' Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory X Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other Odginal Certiticate Date: ~7 - ,,~ "~ - 0 ~' Municipality of AnchoFage Development Services Department Bulk:ling ~afely Dlvtslon On. Site Water & Wastewater Program 47OO 8ragaw b~treet P.O. Box ~g6650 Anctmmge. AK 99519-6650 www.munLorg/onsite (0O7) a43-7~04 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Oesc:dptio~: T12N R3W SEC 15 LOT t3314421 E. 104th Ave. WELL DATA IfA, B, otc provide PWSlD # ~anltary eeal (Y/N) YES Ga~to 168+ fL Well type PRI Date completed 1978 Total depth 168+ It. FROM WELL LOG /J Date of ~m~ple: 7/5/07 Date oftest Static water level Well produclion WATER ~M~IPLE RESULTS: Coliform .0 cok)nie~100 mL Amenic: <0.005 mg/I B. SEPTIC/HOU}INO TANK DATA Tank Typ~ FIBERGLASS Tank lize 1000 gal. Foundalion deanout (Y/N) YES Date of pumping JULY ,10.20O'/ C. ABSORPTION FIELD DATA Date inltall~l 6~J78t'6/13~3 Soil rating (g.P.dJlt't or tt't/lxlrm) t25il 73 Length 2~+44 It. ~ 2.5~ 3.0 f. Number of Compaflments 2 Depre~lo~ over tank (Y/N) NO Pumper Around ~e C3ock Pumpin~ Parcel ID: 015-482.11 wel~ Log (Y/N) NO W~res property protectee (Y/N) YES Casing height (alcove ground) 24 AT INSPECTION 7/10/2007 g.p,m. Ot~or bacterio 0 Co.ected by: Rocky Tralnor Date installed 6/2/1978 Cleanouts (Y/N) YES High water alarm (Y/N) N/A colonies/10O mL System ~ TRENCH Gravel below pipe 7; 5.5 ff. Totaldepl~10.75 [ Eff. ebsot1~onamas94' ~ Monltoflng tube .YES DepmssionoverfleldNO Date of adequacy test 7111/2007 Resub (Pa~FaF0 PAS~ For 3 bedrooms Fluiddept~inabsori:~onfleldbeforetest44.8' in. WateraddlKI621 gal. Newdepth66 in. Elapled Time: 264 min. Final fluid dep~l 66.6 in. Absoq~ rate >= 450 g.p.d. Any rejmmnat~on treatment Cpast 12 m~) (Y/N & type) NO If yes, give date D. UFT STATION Date inatalla(I 'Pump on' lawl at in. Datum, E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WF! I ON LOT TO: ~ tllnlc/l~ stl~on on lot 110.+ Abonf~)bon field on lot 94 waiver issued Public lewer main 100.* Sewer/sel~c ~ewico line 100'+ Animal containment areas 50 Manhole/Access (Y/N) High water alarm level at Meets II~m & cimuit ~quimments? Size in gallons 'Pump off' kwel at in. Cycles lasted On adjacent lots 100. On adjacent ~ 100'~. Public ~ew~r manhole/claanout 100'+ Holding tank 100.+ Manure/animal excrete ~torage areas 25' to barn° SEPARATION DISTANCES FROM BEPTIC~IOLDING TANK ON LOT TO: Building foundation 5+ Water main 100'+ Wells on adjacent lots 100'+ Property line 50+ Water ~rvice line 10+ Al~oq~on field 4 Suff~ce water 100'+ in* over dralnfleld. Septic tank is not under ddvew~. ~... C~. ~a~ ..-" F~ $ Wa~r F~ $ Water main 100.+ C)fi~way, padcmg/~hicle ~ge O' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Properly line 30' Building foundation 10+ Water Service line ~=/4~w~ ~ 01 Surface water, 100.+ Curtain drain none known Wells on adjacent lots 100'+ F. COMMENTS: 'MT I~ 16' off boltma. Initial level in 6eld on 7/10 was 26'. Azld~1459 ~lal$ water on 7110, pdor to on 7111. Al~4xpflon ama raducecl by Lee Reid on 6/83. Barn has concrete flcor ond no menure atorage. Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 So~Jth Bragaw St. P.O. Box 196650 Anchorage. AK 99519-6650 www.ci.anchorage.ak.us (go7) 343-7g04 ON-SITE SEWER/WELL SUBMITTAL COMMENT SHEET To: Cindy Ellis Legal description: TI2N R3W Section 15 Lot 133 E]Permtt []C.O.S.A. I--]inspection Report The attached paperwork has been reviewed and Is being returned for the following reasons: 1. Septictank underdrive 2. Separation distance water service line to septic system. 3. Distance well to animal containment area. Name of reviewer: ,,l~ff Date: July 23, 2007 Please supply the necessary information and re-submit your request. LEA VE THIS FORM ATTACHED TO THE PAPERWORK SGS Ref.# 107317700 I Client Name Watkins Eng~nee6ng Project Name/# 4421E 104~h Cllent Sample ID 4421 E IO4th ~.latHx DrlnkJn.R Water PWSID 0 Sample Remarks: Ar$cnic Total Nitratc/Nit~te-N .Microbiology La,or&tory Total Coliform All Dales/Times are Alaska Standard Thne Printed Date/Time 07/17./2007 10:30 Collected Date,'line 07/05/'2007 14:00 Received Date?rime 07/05/2007 14:20 Technical Director Stephen C. Ede Allowable Prep Analysis Results POL Units Me~od Centainer ID Limits Date Date Init ND $.00 ND 0.1~ ug/L EP200.8 C (<10) 07/09/07 07/13/07 Mil mg/L SM204500NO3-F B (<10) 07/12/07 JDS col/100mL S~120 92221~ A (<1) 07/05/07 DLC LOT 123 LOT 122 LOT 121 EAST 164.95' LOT 152 ~ LOT 153 GREENHOUSE 35.0 LOT 134 WEST 164,93' .~...' 49TH~ ...7.0~ ......................... :..,:.~ qhe~ '... ...' ~.,,,~- _ EXCLUSION NO1T$: It Is the o~rne~' respo~¢blllty to determine LEGEND: SET FND STEVE SOBETSKY which do not oppeor o~ the recorded mubdivl$lon plot. NOTT..: 3,25° SURVEYORS-PLANNERS-ENGINEERS w^ T~', v~u.- (fox) 561-6626 (907) ~62-~29, LOT 135 SEC 15, 2536 627/40.41 440 WEST BENSON BLVD. ~ 103 ANCHORAGE, ALASKA 99503 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division ef Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. ~t ~.--~ ~Z~ _ U,¢.~- '~ ~ NAA ~ _ GENERAL INFORMATION Cornplete legal description Location (site address or directions) Property owner 5~'e~ -Co /¢ e /'-r /'~, Day phone Mailing address _ "?/2-/ /~ Cd,'//~ /~,¢~ ¢ A-/~c/~,r'~¢/ /~ Lending agency _ ,~d_¢,~'/'~ //¢,~¢ hlo,-/-~¢/_~_~,-¢ Day phone Mailing address___ Agent_ Address Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: NOTE: Individual well Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 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 IBY 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 tile 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. NameofFirm ~1~/-/¢~¢ 7-~'c,~i(~[ _~er~/;¢~' Phone Address _ I~f~ o [=-c/~, _C/-? t~r~ c/~o/'~v~__~~_ /+l,~ Engineer's signature ~,J-,.~,,.cZ~,,~_ ~. '~'/'/-~-¢,~_ ___Date DHHS SIGNATURE Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does th is as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DH HS 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~)25 (Rev. 1/9t) B¢Ck MOA#21 Municipality of Anchorage Department of Health & Human Services HEALTH AU'rHORITY APPROVAl. CHECKLIST Legal Description: ~_L/'I /~o~ 13.~.. -~¢c IN TrzN.. i~'u.¢ Parcel I.D. A. WELL DATA Well type _P~' Log present (Y/N) Total depth Sanitary seal (Y/N) Date of test Static water level Well flow Pump level If A, B, or C, attach ADEC letter. ADEC water system number /V. 4. Date completed ~ It '7 ¢. Driller c~,q/~, Cased to ;;> ( EW' Casing height ~ 2" Wires properly protected (Y/N) Y' FROM WELl. LOG g.p.m. AT INSPECTION ~// // ~' 16o~ g.p.m. ,~ SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main /'J. Sewer service line ~ c.o. ; On adjacent lots ~¢X ?/zz,4¢~,); On adjacent lots Public sewer manhole/cleanout Petroleum tank /Vo,~¢, WATER SAMPLE RESULTS: Coliform _~ ~o{ /'too m ~ Dateofsample: fi/t/ ? ~ . Nitrate--/X~tcf¢~''~-c/'¢~ Other bacteria _no,¢~ ~/¢of'/~c,(' "1 /l'Z./¢.~ _ Collected by:__ /~/,~/¢..,/~ '7-ec(~ _¢c,c B. SEPTIC/HOLDING TANK E)ATA Date installed ~',"~ / 7~,i Cleanouts (Y/N) '¢ High water alarm (Y/N) N, 4. Date of pumping I/?/?~, _ Tank size _! ooo ~, ~( Compartments Foundation cleanout (Y/N) _ ~' Depression (Y/N) Alarm tested (Y/N) Pumper _ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s)onlot I1~" ~/,o,,, d.o. Onadjacentlots "~ To property line 7 ¢ ~ Absorption field_ Foundation ¢ ' ~c~.o,~ Watermain/serviceline ~- ?,~ ~ Surface water/drainage ~ r ,-,,,~ ' 72-026 (Rev 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm Jevel "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots D. ABSORPTION FIELD DATA Date installed d'/;z/?~ ~7,~,,-.¢dcd d'/t3feJSoiI rating Length ~%¥~1' =7o' Width Totalabsorptionarea Ito .~ ~f E, y -- Depression over field (Y/N) /¥ Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) /~oo¢ Surface water /7.7 ~lr'eC~r~ System type Gravelthickness ,5-:. S' Totaldepth Cleanouts present (Y/N) Dateofadequacytest 'Y / / / 2 2 for 3 bedrooms I~'.,~o~,~ of If yes, give date I'~. SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Wellonlot 9q' .c¢.¢~,c~ 7rzT~',ee.~Onadjacentlots ~. (oo' Propertyline To building foundation ;> ¢0 ¢ To existing or abandoned system on lot On adjacent lots ;> $o ' Cutbank H, A, Water main/service line Surface water ;> fcc' Driveway, parking/vehicle storage area Curtain drain None 5eeo E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelin~ff~e~er~the date of this inspection. Engineer'sName ~heo~¢~ ~ ~oo~ ~~ ~ ~ Date ~r~] I~/ /¢¢~ * : ...... ' ' HAA Fee $ '/7 Date of Payment Receipt Number 72 028 (Rev 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301 RJ'.PORY oi! C[iant Name :I"[.AfTOP TF. CItiIICIL .SgV Coil. oetad :0'!/01/93 0 [q:O0 hfs, Ordered tly :T~;D ~{00R~ Received :05/01/93 Protect }[ah~ ?lOgK Order :64521 }koJ ect~r Report Completed ?d lowatl] e !IiTRATI',--I! O.lO U ~,,g/1 }',1'~ 3532/3000 10 Soo Specl¢,l in,structlom~ Above UA ,; UnavalLxRle ~ ~S Member of the SGS Group (Socibt* G6n6rale de Surveillance) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICI--S DIVISION OF ENVIRONMENTAL SERVICES ~:~ ""] c-~ CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL ,~,~-~ OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date '~-~lly II/ I2,¢,E GENERAL. INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a} Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) ~YY~.I E.=., IOV (b) Properly Owner /~ ~ ~ ~' Telephone: Home Business (c) (d) Lending Institution ~m~ ¢~ ~ (~ ~¢~ Telephone MailingAddress ~3 De~li., ~c40~ h~ ~03 Real Estate Company and Agent ~(~ (~n~c - ~u[ Address ~0~ ~c~[/ ~,~ ~C4o~%, ~ Telephone ~ Y ~- ¢~¢ / //2.2 Q (e) Mail the HAA to the followine address: or: Check here [~, if hold for pick up. List contact person and day phone number below, TYPE OF RESIDENCE Single-Family [] Number of Bedrooms WATER SUPPLY 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. 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 1 of 2 72-025 fRev 8/861 From '~JOM e,JeaU[~u@ ejep eZ~leUe Jo suo!loedsui lonpuo3 leu op SHHQ 1o seeXoldm~ 'sluemeJ!nbeJ a~eis pub leJepeJ ulePeo Als!les el ~epJo u! suo!lnl!jsu! 8u!pual J!a~l pub sero oq jo sJeseqoJnd el Xsepno3 e se siql seep SH HQ eqZ 'e~SelV jo alel9 eqi u! paJa~si6eJ Jaau!6ua leUO!SSaiOJd luapuedepui ue Xq eAoqe g qdeJB~Jed u] uaA!6 suo!leJuasaJdeJ aql uodn ~lUO peseq leAoJddv Xi!~o~jnv ~lleeH sanss! (SHHG] sao!AJeS uemnH pue ~lleaH Jo jua~pedaa a~eJo~ouv ~o ~j!led!o!un~ NOlin¥O IB^oJddv IBUO!I!pUO0 1o SWJe± IBUOB!puoo peAoJddes!C] ~)? paAoJdd'¢ ~_~/ ~,_~../ elB~ / ~_.(~::~ AqSLUOOJpoq ~ JolpaAoJddyqYAO~dd, SHHa '9 uo leeJJ@ u! suoBBIn6@J pue 'BeOUBU!pJo '9epoo elel$ pub IBd!o!unv~ lie LIl!M eOUB!IdUJo9 Jo/puB Alddn$ J@leM el!s-uo eLI1 'uoBoadsu! pUB UOiIB6!lSeAU! ALU LUOJJ pUB Sel!J ebBJoqeu¥ Jo Al!lBd!o!unV~ eqi uJoJj peu!Blqo UOBBLUJO~U! eLIl UO pesBq 1Bql AJpeA J@qpnj I 'u!eJeLI pelBo!pu! eJnlonJls elenbepe pUB leuo!jounj 'eJB9 S! LUejsAs IBsods!p JelBMelSB~A Jo/puB Alddns JelBM el!S-UO qllBeH sill1 jo UOiIBSBSe^U! ALU leql AJ!JeA I 'MOleq UMOqS eiBp UO!lepflB^ emi jo sB pub oleJaq pex!,tJB Ieee AuJ Aq pe!lipe3 NOI.L¥1~IBO-INI aN~/ytYa 'HC)I~V~$ ~11.-I 'S.LSeJ. '$NOIJ. C):~,4$NI 9NlalAOMd I/~MI_-I -g MUNICIPALITY OF ANCEIORAGE ENVIRONMENTAL SERVICES DIVISI(~,~JNIClPALITY OF ANCHORAGE (MOA) HEALTH AUTHOFIITY APPROVAl. (HAA) J U L ! 2 ]988 CHECKLIST- FEBRUARY'1984 264-4744 RECEIVED Legal Description: WELL DATA Well Classification /'~¢'1 ') ~r/'e. If A, B, C, D.E.C. Appr0~ed (Y/N) Well Log Present (Y/N) N Date Completed ~/"¢ '~-- I,~ 7~' Yield Total Depth ~' 18¥' Cased to ~"~ r~y~ _ Depth of Grouting N,/¢.. __ Static Water Level !~1' Pump Set At _ ~> Casing Height Above Ground '~ 8" Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) Y' Depression Around Wellhead (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot _ I1'¢.' )~' c.,¢. ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot. ~) ¥' __; On Adjoining Lots To Nearest Public Sewer Line N,/I-, To Nearest Public Sewer Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments /V, 41, To Nearest Sewer Service Line on Lot ~> 'e,.¢' f2'/¢,,/~¢, 7~',~c/~ .¢,,,'c.,' ; Date ~"/~71~ B. SEPTIC/HOLDING TANK DATA Date Installed ~/'~/ Standpipes (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank kligh-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well .... I1~ To Property Line To Water Main/Service Line ~/~. Course ~, /.oo ' Comments Size I0O0~,~1 __ No. of Compartments Air-tight Caps (Y/N) ~ Foundation Cleanout (Y/N) }'" Date Last Pumped ~'/~,~ /'~,/& ; for Ah ~, Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~'/8{ 7~' ,.~/oVq, Width of Field ~'~ Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Type of System Design Length of Field Depth of Field I Gravel Bed Thickness ItO '~ ¥<¢¥ : ~-~ ¥ Standpipes Present (Y/N) Date of Last Adequacy Test ~" ! ~-~ / "~ Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation ~ lo ' Lot TO Water Main/Service Line I~hA., To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments To Property Line '~¢' To Existing or Abandoned System on ; On Adjoining Lots _ ,,5TM To Cutbank (if present) ~, to~~, D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Pe~'mitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed '~~ ¢ ~ Date _ Company /~(~/'1~,/¢ ~d~ ~¢~ MOA No. Receipt No. ~0~ ~ ~ Date of Payment /~/~ ~oo ~ . --~[~ ~ / 'J~A% ~ ~%.. ,~- Engineer's Seal ~mount: $ _~_M ~___~_ZTM ~ Z , Page 2 of 2 Tom Fink, Mayor Nlunicipality of A tchorage Department of Health and Human Services 825 "L" Street P.O, Box 196650 Anchorage, Alaska 99519-6650 343-4744 July 27, 1988 Ted Moore, P.E. Flattop Technical Services 14530 Echo Street Anchorage, Alaska 99516 Subject: Waiver Request for T12N R3W Section 15 Lot 133 Waiver Request #WR88-039, #H88-0275, P.I.D. 015-482-11 Dear Mr. Moore: Your request for waiver of the required 100 foot separation of a septic system to a private well has been approved. The approved separation distance is 94 feet. This waiver approval applies to the existing septic system to well separation only. Any future upgrade to either will require all separation distances be met or another approval from this department. Sincerely, Daniel J. Roth Civil Engineer On-site Services DJR/ljw~6 MUNICIPAUEY OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION :J U L 1 2 1988 FLATTOP TECHNICAL SERVIC E I VED CML & ENVffgONMENTAL ENGINEERING · ENERGY CONSERVATION & ANALYSIS TItEODORE F. MOORE, P.E. 14530 ECHO ST. PH: (907) 345-1355 ANCHORAGE, ALASKA 99516 July 11, 1988 M.O.A. Dep't. of Health and Human Services I:).O. Box 6650 Anchorage, AK 99519 Dear Sirs: By means of this letter I am requesting a waiver down to 94 feet from the 100 foot separation requirement between a private well and a soil absorption system, applicable to the residence on BLM Lot 133, Section 15, T12N, R3W, S.M., located at 4421 East 104th Avenue. ^ site plan and copies of pertinent backup documents are enclosed. No driller's log for the well is available, but other Municipal records indicate it was probably drilled in1975. At that time there was some correspondence in the file about having it become a community well to serve both Lot 133 and Lot 122, but the idea was subsequently dropped, and it appears to definitely be a single family well. On June 28 I measured the yield of the well by pumping over 560 gallons of water from it at the maximum pump output of 5.2 gpm. The initial static water level in the well was 181 feet below the top of the casing, and steady pumping at 5.2 gpm caused it to be drawn down to 184 feet, but no further. The water level returned to it,(; original position within a few minutes of cessation of pumping. Water samples taken on June 27 were satisfactory, showing no coliform bacteria per 100 mi, and less than 0.1 mg/l of Nitrate-Iq. I believe the enclosed log for the well on Lot 134 (located near its southeast corner) is representative of the Lot 133 well also. This well has a total cased depth of 211 feet, a static water level of 178 feet and a reported yield of 13 gpm. The log for this well shows several tight silt strata between the surface and the relatively deep aquifer, which should prevent contamination from above from reaching the aquifer. The original wastewater disposal system consisted of a 1000 gallon, two compartment septic tank, followed by 26 feet of soil absorption trench containing 4 feet of gravel. The inspection report indicated a 100 foot separation between the trench and the well, however I measured a distance of only 94 feet between the t. oT t ~$ '5 I..o"i' t~ ~ 16'q,95~ F~att6~5 Technical Services 14530 Echo Street /tnchorage, Alaska 99516 LoT' I~1 Al~ ApP~oX t~'r'~' Mailing Address APPLI(' NT FILLS OUT UPPER HA[ ONLY ~--~{ 'J Zip (;ode Buyer Address Zip Code Lending Institution Address Realty Co. & Agenl Address Legal Description -~- Street Locatic~l Zip Code Phone Zip Code Type of Residence L] Single Family [] Multiple Family [~ Other Water Supply £] Individual ~ Community FI Public Utility Sewer Disposal [] Individual [] Public Ulility (-] Holding Tank AfTACH WELL LOG. A well Icg is required for all wells drilled since June 1975. For wells drilled prior to that date, give well deplh (altacb Icg if available), Year Individual Installed: _ When Connected to Public Utility: NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time [)ate Inspector Time Date Inspector Time Date Inspector Time Date Field Notes: (.~) APPROVED BEDROOMS ) DISAPPROVED ) CONDITIONAL APPROVAL' 'CONDITIONS OF APPROVAL tWell Log Received Septic Ta~k Size Soils Flating Date Sewer Installed Well To Absorption Area Well to Tank APPL' FILLS OUT UPPER H/' ONLY Buyer Address Zip Code Lending Institution Address Realty Co. & Agent (~ · ,,/ v ,.' ,. ,.x, ' //"' /'} ~c ~ // /~ ~-./ t ; ,. ' Address , / ~''/ //d ":i':~- :- /.>1 ,' '~; ';/V~'/. Street Zip Code Zip Code }'~;~, & Z; Phone Type of Residence ~ Single Family 2 , ^ ~ ¢., '(. o 0¢ IO C)-(¥x- .%'1 L~ Multiple Family Nc. of Bedroo~> ~ :.. ,~- _ , ''> ~ ' 'XlndividuaI ~¢¢X 6 ~~'* A~AOH WELL LOG. A well log is required for all wells dd[led since June 1975. "*'LO*~I'Y~ Rublic Utility ¢ ~~*~;~'~¢;- For wells drilled prior to thai date. give welldeplh (attach logit available). Sewer Disposal [PJ' Individual [] Public Utility [} Holding Tank Year Individual Installed: / :/ When Connected to Public Utility: NOTE: THE INSPECTION trEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. ,? Time Time Time ~ '--'-'"' Time /~ Bate Date Date ,- ~ Date Insp~tor lasp~tor Insp~tor Insp~tor ~) CONDITIONAL APPROVAL' ~ h (~ n~-¢~ Soils Rating ¢ Dale~werlnstalled [ We,, T~Abso,ption Area J(, ~ ~WellL.ogReceived August ~4, 1.982 Robert Baker & MarLee Baker c/o Joy Carnahan 47[)4 Business Park Blvd. Anchorage, Ali 99503 Subject: I,ot 133 Sec. 15 T12N R3W Approval for the individual sewer and water facilities cannot be granted u~ltJ, i the following items ]lave been completed: q~'ho septic tank pumped with a receipt submitted to this department. An ~dequaey test needs to be performed on the existing leaching area. This test will determine if the syst. em is adequate according to National Standards. A listing of private firms performing the test is enclosed. This report needs to be submitted to this office for our review. Please eotify this Department fera reinspection when the not. o,d discrepancies have been corrected. If ther~ are any further questions, please call this office at 264-4720. Sincerely, CW24/p/EII Enclosure ALASKA eFIUIROI meFITAL COI TROL S RUICeS, IBC. ~nqineerincI ~ ~nui~'onmentol Studies 11/16/82 ROBERT BAXER SRA 1747-B ANCHORAGE AK 99507 SELLER - ROBERT BAKER BUYER-NELS ANDERSON SUBDIVISION-T12N R3W S15 BLOCK-0 LOT-133 ADEQUACY TEST FOR SEWER SYSTEM THE TYPE OF ABSORPTION SYSTEM IS A TRENCH WITH AN UNKNOWN AREA. THE SYSTEM IS CAPABLE OF ACCEPTING 95 GALLONS OF WATER PER DAY. THE SURGE CAPACITY OF THE SYSTEM IS 60 GALLONS. THE SYSTEM IS UNACCEPTABLE BECAUSE THE SURGE CAPACITY IS LESS THAN 75 GALLONS. THE SYSTEM IS NOT CAPABLE OF ACCEPTING 450 GALLONS OF WATER PER DAY. SEPTIC TANK ADEQUACY THE EXISTING SEPTIC TANK VOLUb~ O1~ THIS 3 BEDROOM HOUSE. 1000 IS ADEQUATE FOR 1220 LU~st 251~ ~ucnu¢ · ~nchoro~l¢, ~lt~s~t~ 99503 · {907) 276-1361 MUNICIPALITY OF ANCRORAGE · ~ DEPARTMENT OF HEALTH IL ENVIRONIVlENTAL PROTEC'rlON S2E L Street - Anohora~e, Alaska BBS01 ENVIRONMENTAL ENGINEERING DIVISION Telephone 264~4720 FIEQUEST FOFI APPROVAL OF INDIVIDUAL WATER AND SEWER FACl L TIES DIRECTIONS: Complete all parts on page 1, Incomplete requests will not be processed· Please allow ten (10) davs for precessinLi. 1' P.,..~B~tI31: ,~.))WNER / ~ PHONE MAILING ADDRESS - PROPERTY RE~MDENT (If d~t from abovel PHONE 2, BUYER PHONE MAILING ADDRESS DI,~G INSTITUTION ~IAI LING ADDRESS ~.'REALTOR/AGENT MAILING ADDREBS PHONE 8. ,.E.A,..EB :R,PT,ON STREET LOCATION 6. TYPE OF RESIDENCE I~( SINGLE FAMILY [~ MULTIPLE FAMILY 7, WATER SUPPLY .[~.. INDIVIDUAL' [~ COMMUNITY [~ PUBLIC UTILITY 8. SEWAGE DISPOSAl-SYSTEM NDIVIDUAL/ON-SITE** ~UBLIC UTILITY NUMBER OF BEDROOMS ~ One ~--- Four ,~ Two ~ Five ~ Three ~ Six Other_.. ' ATTACH WELL LOG, A well log is required for a wells drilled since June 1975. For wells drilled R(~r [9, tha;. date, give well (attach loc if avaih]ble.) depth **if md~weual/on-sm,h give i~sta lat'on date l£E-~'~-Pd:. svstem ~s over two (2) years old an adequaev Lest is required bv this Depar[ment, NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE'.' PROCESSING (;AN BE INITIATED, 72-01013/78) rills SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTI ON APPOI NTM ENTS TIME TIME TIME DATE DATE DATE INSPECTOR I NS P ECTOR INSPECTOR DIRECTIONS:' 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER []INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified, _-- IfTankishomemade INSTALLER ~ '~ ~ []Septic Tank or [] Holding Tank Size: /~ (~ (~ SOILS RATING give dimensions:.----- - ,--~- TYPE OF TANK MANUFACTURER 'OTAL ABSORPTION AREA MATERIAL 4, DISTANCESwE LL TO: Septic/Holding Tank Absorption Area Sewer Line~i I Nearest Lot Line Absorption Area to ~earest Lot Line B, COMMEN~S ~}--'~P R O V E D FOR r~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany cert~cate} [] DISAPPROVED / / ii15c , o 72-010 (Rev. 3/78)