HomeMy WebLinkAboutKNIK VIEW ESTATES BLK 3 LT 21 Municipality of AnchoragePage _ 1
~ 1.F ) DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVlSIO'N
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: sw980080 PIDNumber: 05104323
Name:
Waldec Enterprises Wastewater System: ~5~New [] Upgrade
Address:
22647 Judd Dr. Anc., AK 99567 ABSORPTIONFIELD
Phone: NO. of Bedrooms:
344-5678,~ ~DeepTrench r-i Shallow Trench ~Bed ~Mound DOther
LEGAL D ESCR I PTi ON so,, ~.ting: Total Depth ,rom original grade:
.45 GPO/Sq, Ft. 1 3 '
Lot: Block'. SubdN~ion: Depth (o pi~e bo~om from odginal grade: Gravel depth beneat~
21 3 KNIK VIEW Ests. 3 ~. 10
Township: Range: S~tion: Fill added above original grade: Gravel length:
1 - 2 ~t. 72 ~.
WELL: Q New ~ Upgrade G~v.~ width: Number of lines: 01s~cebe~eenlin~:
3 ~t. 1 1 ~.
C~ifl~tion (Private. A,B.C): Total Depth: C~ To; Total aOsorpt[on area: P~pe material:
Ciasa A System ~t ~. 1 ,440 se.~. ASTM D3034 PVC
Orillec Date Odll~: S~cwater Level: Installe~ Oate installS:
~ Sanders & Sanders 4/29/98
SEPARATION DISTANCES ~s~,c s Ho,~,~ ~ S.T.~.~.
To Septic Abso~den Uff ~ldlng ~bl~Pdva~e Manufacturec CaPaciW in gallons:
From Tank Reid Station Tank ~r Lin~ Anc, T~nk ; 1 / 250
Material: Number of Compartments:
Well >200' >200' H/A H/A ~/~ Steel
Sudace 0 ~
w~.~ >~0 >~00 ~/~ ~/~ u/~ LIFT STA~'ION
Line Lot >5~ ~ ~ ~/~ ~/~ ~/~ Size in gallons: Manufacturer:
Foundation > 5 ' > 1 0 ' N/A N/A N/A "Pump on"level at: "Pump off" level at: High w~ter alarm at:
CudaJn Pump Make & Mouel Electrical Ins0ections pedormed by:
Drain None on Let
Remarks: See Lot Line W~iver for BENCH MARK
Absorption Trench. Location and Description:
Garage Floor Slab
~umo~ ~lovation:~ 0 0 · 0 g~,
ENGIN~E~SEAL
Inspections pedormed by: A. Harala Dates: 1st 4/29/98 : ~ / ~':' :~
2nO 4/29/98_ ~ ~ ~
Department of Health and Human Se~ices approval ":?/'~;: ~'~
Reviewed ~nd approved b _ ~~ Date: ]0-~.~¢ ~:.;',':',)F,":.';
72~O13 (Rev, 9/91) MOA 25
August 11, 1998
Municipality of Anchorage
Department of Heath & Human Services
825 "L" Street
Anchorage, AK 99502-0650
Subject:
Lot 21, Block 3, Knik View Estates Subdivision
Lot Line Waiver Request
Dear On Site Services Engineer:
RECEIVED
Municipality of Anchorage
Oept. Floalth & Human Servicos
The absorption trench on Lot 21, Block 3, Knik View Estates Subdivision was constructed within
5' of the northern lot line. This was apparently done to allow additional room for placement of the
septic tank and to maintain required separation distances fi'om the house foundation. House
placement was critical due to the topography of the lot, steepness of the driveway and the size of
the house.
Lots in this subdivision am served by a connnunity water system eliminating any conflicts with
adjacent wells. The septic system on the adjacent lot is more than 60' away. Underlying soils
have an absorption rate of .45 gallons per square foot per day and consist of fairly silty gravel with
some sand. No groundwater has been noted in the area and any risk of contamination seems
remote. We therefore recommend a waiver be issued to allow construction of the absorption trench
to within 5' of the northern lot line.
Please let me l~mw if you have additioual questions.
Sincerely,
Michael E. Anderson, P.E.
2 3
Permit No. SW980080 Page of
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICi~S
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorsge, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Legal~ Description:
LT 21, BK 3,
KNIK VIEW ESTATES S/D PIDNoi: 05104323
!
/
,/
A B C
C1 3.9
S1 -32t,~ 7 t 0.5 - -
S2 3.8'5 13.3
C2 14.8 25.0
-C3 ..... 15~9 24~7
_c4 ..... o
M2 : 39.6 38.6
-C5 ......... ~7-- . -52-;2 .... 45-.-1----
/
/
/
/
%
SP1 Se,p, tic Pump, compa,r, tment 1
SP2 " 2
C Clean Out
C2~
r$2
4 BR
House- C
PLAN AS-BLT
1" = 20'
M1
Permit No, SW980080 Page 3 of '~
Municipality of Anchorage
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
i i !
Legal Description: LT 21, BK 3, KNIK VIEW ESTATES S/D__ PIDNo.: r)~ln4'~?3
I I ' , ' ' · ~
I i6/\ ' * ' ' I ' '
I__ I I lo. pc_ ~',~..~_~J.~~ : ~ ~
f;~-'b r i c ~
R~O C K
LEGEND
SP1 Septic Pump, compartment 1
SP2 " " " 2
C Clean Out
MT
ELEVATION
1" = 10'
AS-BLT
Monitor Tube
PERFORMED FOR:.
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG ~ PERCOLATION TEST
LEGAL DESCRIPTION:
OL
3
4
9
10
11
12
13
14
15
16
17
18
~ r~ (E~'GINEER'S SE~L),
Township, Range, Section:
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED7
IF YES, AT WHAT
DEPTH?
L
Reading Date Gro~ Net Depth to Net
Time Time Water Drop
~1 z.: l~' -- ~ 'h." ~ ,,
I _
PERCOLATION RATE ~__ Iminute~nch) PERC HOLE DIAMETER __
TEST RUN BETWEEN ~-' FT AND ~' FT
PERFORMED BY:
AOOORDA.OE W,T~*LL S'~^~'~ A,~O,.,UN,O,P*L ~,,,D~.,NES ,. E~EO~' ON ~'H,S 0^'~_ O^TE' ~/l. lq~'
72.,008 (Rev. 4/85)
Rick M?strom.
Mayor
MtmicipaliDT of Anchorage
Department of Health and Human Services
825 "k" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
hllp://www.ci.anchorage.ak.us
October 29, 1998
Michael E. Anderson, P.E.
Anderson Engineering
PO Box 240773
Anchorage, Alaska 99524
Subject: Waiver Request for Lot 21 Block 3 Knik View Estates
Waiver Request #WR980049, PID #051-043-23, HA980229, SW980080
Dear Mr. Anderson:
Your request for a waiver of the required 10 foot separation
between an on-site wastewater disposal system and a lot line has
been approved. The waived distance is 5 feet from the absoroti6n
field to the north property line.
This approval applies to the existing on-site wastewater disoosal
system lot line separation only. Any future upgrade to the on-site
wastewater disposal system will require all separations be met:or
another approval from this department.
If there any further questions or concerns regarding this waiver,
please call our office at 343-4744.
Sincerely,
Engineering Tech
On-site Services
ljw #7
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On-site Services Section
Waiver Review Werksheet
Date Received: AuKust 12, 1998
Legal Description: Lot 21 Block 3 Knik View Estates Subdivision
Engineer: Michael E. Anderson, F.E., Anderson.En~inesrtnK
PO Box 240773, Anchorage, Alaska 99524
Applicant: Waldec Enterprises
Waiver Requested: Lot line waiver of 5 feet from the absorption t~ench to the
northern lot line,
Criteria:
1. Geology:
A. Water Table
B. Soil Sorption
C. Permeability
D. Water Table Gradient
E. Horizontal Separation
TOTAL:
Special Conditions:
Points:
3. Other:
is Granted: ~ Waiver ~s NOT Granted:
Waiver
/.
List Conditions or Reasons for above:
Date:
Rec ~: 4110~4184
By:
N~e/~f- R~iewer
Amount: $ 115.00
Date Paid: Aqg 12, 1998
DATE:
October 8, 1998
MEMORANDUM
TO: Jeff Poet
FROM: Mike Anderson, P.E.
SUBJECT: Lot 21, Block 3, Knik View Estates Subdivision
CmXificate of Health Authority Approfval
On August 26, 1998, a testhole was dug at the extreme east end of the completed
absorption trench to verify that no groundwater was present 4' below the bottom of the
trench and no bedrock was present 6' below the bottom of the trench. The total depth of
the trench was in excess of 26'. In order to get to this depth the backhoe was required to
bench down approximately 6' and then excavate the testhole an additional 20'. No
groundwater was encountered nor was any noted during the monitoring Period. In
addition, no bedrock was found.
A testhole log is attached for your review. Soil materials encountered were identical to
those encountered during construction of the system and in Testholes No. 1 and 2.
Municipality of Anchorage
DF..PARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502'-0~50
SOILS LOG -- PERCOLATION TEST
2
3
5
7
8
9
10
11
13-
14-
15
16
17
18
19
2O
COMMENTS .
SITE PLAN
I
' I
WA~ GROUND WATER
ENCOUNTERED? S[ I '
iF YES. AT WHAT
DEPTH?
I
I I
t Gross ] N~ Deism ~o Net
Reading ~1;e '~rn~ T~me Water Drop,
I J
I
I
PERCOLATION RATE __ {m~nute~mci~} PERC HOLE DIAMETER
TEST RUN B~'TWE-'N FT AND FT :
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW980080
DESIGN ENGINEER:ANDERSON ENGINEERING
OWNER NA/~E:WALDEC ENTERPRISES INC
OWNER ADDRESS:22647 JUDD DR
ANCHORAGEf ALASKA 99567
DATE ISSUED: 4/27/98
EXPIRATION DATE: 4/27/99
PARCEL ID:05104323
LEGAL DESCRIPTION:
KNIK VIEW ESTATES BLK
3 LT 21
LOT SIZE: 21864 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK 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
ISSUED BY: ~J.
DATE:
April 9, 1998
Municipality of Anchorage
Department of Heath & Human Services
825 "L" Street
Anchorage, AK 99502-0650
Subject:
Lot 21, Block 3, Knik View Estates Subdivision
Septic System Design
Impacts to Adjacent Properties
Dear Onsite Services Engineer:
We hereby apply for a permit to construct an onsite septic system on Lot
21, Block 3, Knik View Estates Subdivision. The attached site plan and
backup documentation identify the size and location of the new septic
system to serve the four bedroom home to be constructed on the lot. The
subdivision is served by a community water system and al! required
separation distances are easily met. No conflicts exist with other septic
systems in the area.
Testholes placed on the property revealed gravelly silts which percolated
between 30 and 60 minutes per inch. We have designed a deep trench
absorption system with 10' of effective depth because of:the slow
percolating soils and the small area available on the lot for a syStem. The
total depth of the system will be 13' below the surface. Insulation may be
required to provide sufficient cover above the system.
The surface of the lot slopes from east to west at varying grades. The
back half of the lot is fairly steep and probably not acceptable for system
placement. The area designated for the system is fairly flat, but this
location has also been identified as the home site restricting the
available surface for the septic system and replacement site. oufficient
room is available, however, if the lot is developed as shown on the site
plan.
Lot 21, Block 3, Knik View Estates
April 9, 1998
Page Two
If the system is constructed as designed the following statements apply:
The system, if constructed as designed, will have no adverse impact
on the wells in the area or those to be constructed in the future. The
subdivision is currently served by a community water system.
The system, if constructed as designed, will have no adverSe impact
on existing septic systems in the area or those to be constructed in
the future.
The system, if constructed as designed, will have no adverse
impact on reserved space, either surface or subsurface, on any lots
located in the area.
The system, if constructed as designed, will have no adverse impact
on drainage patterns in the area. The current drainage pattern will
be maintained.
Sincerely,
Michael E. Anderson, P.E.
Attachments
LOT 21, BLOCK 3, KNIK VIEW
ESTATES
SITE PLAN
SCALE 1" = 30'
LOT 21, BLOCK 3, KNIK VIEW
ESTATES
1,250 GALLON
SEPTIC TANK
TH NO. 2
FLOW SPLITTER~
VALVE
3' WIDE X 10' EFFECTIVE DEPTH
ABSORPTION TRENCH
SYSTEM PLAN
SCALE 1" : 10'
EN 18 (10/78~
LOT 21, BLOCK 3, KNIK VIEW ESTATES
SUBDIVISION
DESIGN FACTORS:
Four Bedroom Home
Perc. Rate: 40 Min./Inch
Application Rate: .45 GPD/SF
4 Bedrooms X 150 GPD = 600 Gallons Per Day
600 GPD/.45 GPD/SF /20 SF/LF = 67 LF Trench
SYSTEM REQUIREMENTS:
Deep Trench System
1,250 Gallon Septic Tank
10' Gravel Beneath Dist; Pipe
Therefore: Construct a Deep Trench System with Two Laterals Each 34'
in Length. Distribution Piping to be Placed at 3.0' Below Original Ground
Level. Mound over Trench to Provide Minimum of 3.0' Cover Over Pipe.
Flow Splitter Valve Required to Distribute Flow to Trenches.
NOTE:
/0'--0"
Grade Area to Drain Away, ~2'~'~')~, ......,,;,x~;~, 77'
3 Cover Requ red Over System or 2' nsuaton
.1
4
15'
14
17
·
'~b-'T RUN ~ ~' FTAND ..-...~_. F'r
PE~'FORMF.~ IN
3
4
10-
14
15
16
SrTE PLaN
WATER
' t t t~ t !_
ON-SITE WAST'EWATER DISPOSAL SYSTEM
CONSTRUCTION AND MATERIAL SPECIFICATIONS
SUBJECT: LOT 21, BLOCK 3, KNIK VIEW EST. SUBDIVISION
GENERAL:
1. The scope of this project includes furnishing and installing
a new 1,250 gallon septic tank. It also includes the
construction of a new 68' total length by 3' wide by 1 0'
effective depth absorption trench. The distribution piping
must be placed at 3.0' below the ground surface. MOunding
over the trench may be required to provide a minimum of 3'
of protective cover.
2. Construction shall be in accordance with the approved site
plan, design drawings, Municipal Permit with any special
provisions or conditions, and all applicable State and
Municipal Wastewater Disposal Regulations.
3. The Contractor .shall be responsible for obtaining all
underground utility locates and for the layout of the septic
system and verification of the location of all lot lines.
4. Unless specifically agreed otherwise, the contractor shall
be responsible for final grading areas subsequently
depressed from soil settling. Property owner shall be
responsible for revegetation of affected areas unless
specifically agreed otherwise.
5. Contractors installing wastewater disposal systems must
be certified by the Municipal Department of Hea!th and
Human Services for system installations. Owners inStalling
their own systems must receive prior approval from:D.H.H.S.
before beginning system installation. :
SEPTIC TANK INSTALLATION
1. A new 1,250 gallon septic tank must be procured from an
approved source and installed at the location shown: on the
plans.
Lot 21, Block 3, Knik View Estates
April 8, 1998
Page Two
2. A septic tank is to be constructed by a certified septic tank
manufacturer. Construction shall include two 4" cleanouts
for pumping access.
3. The septic tank shall be sufficiently bedded to prevent
settling or shifting of the tank.
4. All standpipes on the septic tank shall extend a minimum of
12 inches above final grade.
5. Tanks installed without 4' of cover shall have a minimum of
2" of direct burial insulation.
6. A foundation cleanout shall be installed one to four feet
from the building foundation. Two cleanouts are required
between the tank and the drainfield.
7. Final grading over the tank shall be such that a Positive
slope exists away from the septic tank.
DRAINFIEL. D CONSTRUCTION:
1. The drainfield shall be constructed to the dimensions shown
on the design. The bottom of the trench shall be within 2"
of level.
2. Distribution piping must be placed level with perforations
down atop alevel bed of drainfield rock. Rock should then
be placed over the pipe to provide a minimum of 2" of cover.
3. A silt barrier or geotextile fabric must be placed between
the drainfield rock and the natural soil backfill.
4. Monitor tubes must be 4" in diameter and installed at the
locations shown on the design. The portion below: ground
must be perforated.
Lot 21, Block 3, Knik View Estates
April 8, 1998
Page Three
5. Contractor shall verify the septic tank and drainfield are a
minimum 100' away from any private water wells in the
area, 150' from a Class "C" Well or 200' from any con~munity
well.
6. Direct bury insulation must be placed over the distribution
system if less than 3' of backfill depth is available. :Finish
grade over the trench must be mounded to prevent
settlement or depressions.
7. Grade area surrounding the absorption trenches
away.
to drain
8. A minimum 2' of accepting soil is required below the
drainfield rock for a 5' wide trench. Contractor shall verify
this condition prior to placement of the rock. All pockets of
unacceptable materials must be removed and replaced.
MATERIAL. SPECIFICATIONS:
1. Septic tanks must be constructed by a Municipally approved
septic tank manufacturer.
2. The following pipe materials are approved for use in septic
system installations in the Municipality of Anchorage:
Cast Iron (perforated and solid), ASTM D3034 or P.V.C.
(perforated and solid), ASTM F810 or H.D.P.E. (perforated,
but not solid) and ASTM D2662 or A.B.S. (perforated and
solid).
3. Insulation shall be at least 2" thick extruded direct burial
polystyrene (Dow Chemical Co. Styrofoam HI or equal).
4. Septic tank inlets and outlets shall be fitted
watertight couplings (Caulder, Fernco, or equal).
with
Lot 21, Block 3, Knik View Estates
April 8, 1998
Page Four
5. A permeable geotextile fabric (Typar, Mirafi or equal)must
be installed between the final drain rock layer and the
native soil layer.
6. All drain rock shall be .5" to 2.5" in diameter with less than
3% passing the #200 sieve.
INSPECTIONS:
A minimum of two inspections are required by Municipal
Ordinance. These inspections must be conducted under the
supervision of a professional engineer registered in the State
of Alaska. The first inspection must be conducted after the
excavation of trenches, beds or pits and before the installation
of any gravel. A septic tank may be set in place, but may not
be backfilled.
The second inspection must be conducted after the placement
of the geotextile fabric, gravel, distribution piping,
standpipes, cleanouts and insulation. No backfill should be in
place at the time of inspection.
Contractor shall provide acopy of all field survey layout and
construction notes for use in preparing the certified as-built
of the completed system.
Municipality of Anchorage P~ F CEil V F. [) ~
DEPARTMENT OF HEALTH & HUMAN SERVICES :
Environmental Services Division AUG l'r2 1998
825 L ¢' · OM7)nic~pality 0f Anchorage
otreet, Room 502 Anchorage, Alaska 99501 · (90 343-47~..4
C)ept. Health &Human Services
Health Authority Approval Checklist
Block 3~ Knik View ParcelI,D,: 051 04323
Estates
Legal Description: Lot 21 r
A, WELL DATA
Well type ~__ IfA, B, or C, attach ADEC letter. Ar)EC water system number
Log present (Y/N) Date completed
Total depth Cased to
FROM WELL LOG
Sanitary seal (Y/N)
Date of test
Static water level
Well production g.p,m.
WKTERSAMPLERESULTS:- Public Water System
Coliform Nitrate
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Date installed 4/29/98 Tanksize 1 .. 250
Collected by:
218409
Casing height (above ground)
Wires properly protected (Y/N '
AT INSPECTION
Foundation cleanout (Y/N)
Date of Pumping
C. ABSORPTION FIELD DATA
Date installed 4/29/98
Length 72 ' Width
Number of Compartments
Depression (Y/N)
Pumper Construction
Y
_ Soil rating (g,p.d./ft~ or fF/bdrm)
.45
3 ' Gravel thickness below pipe
Effective absorption area 1 , 440 S F Monitoring Tube present (Y/N) Y
Date of adequacy test New Const, Results (Pass/Fail) Pass
Fluid depth in absorption field before test (in.); Immediately after
Other bacteria
__ g.p.m,
2, Clean0uts (Y/N) y
High water alarm (Y/N) ! ~
_ System type~Dc_c_p q~T'~nc.h
10' _ Total dePth 13'- 17~'
__ Depression over field (Y/N) ~,1 _
For 4 ' bedrooms
gal. water added (in.): __
Fluid depth (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
72-026 (Rev. 3/96)*
Absorption rate =
If yes, give date
.g.p.d.
LIFT STATION - None
Date installed
Manhole/Access (Y/N)
High water alarm level at*
on Lot
Size in gallons
"Pump on" level at*
*Datum
"Pump off" level at*
Cycles tested
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
No Well on Lot
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation > 5 ' Property line > 5 ' Absorption field
Water main/service line > 1 0 ' Surface water/drainage > 1 00 '
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
>5'
Wells on adjacent lots > 200 '
Property line
Su trace water
Curtain drain
5' ww Building foundation > 10 ' Water main/service line
> 100 ' D~iveway, parking/vehicle storage area > 10
None on Lot Wells on adjacent lots >200'
F.
ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review of Municipal re~s~that th~ a~o~e systems are
in conformance with MOA HAA guidelines in effect on this date.
S,gnat.re
Engineer's Name Michael E. Anderson: P.E.
Date 8/11/98
HAA Fee $ ~
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number ((~,L.I \\~)
72-026 (Rev. 3/96)*