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Home My WebLink AboutLAKE HILL ACRES #2 LT 4A '~ Municipality of Anchorage Page 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: ~.~J,t,/ <~20?~.~ PlO Number: O~/-/~- ~ Name: ~ ~50~ Wastewater System: ~ New ~Upgrade Address~?,~ ~/V~ ~/~ ~ ABSORPTION FIELD Phone: /~ ~?~ . ~ Deep Trench ~ Shallow Trench ~Bed ~Mound ~Other Total Depth from original grade: LEGAL DESCRIPTION s°i' ~.~,: J' ~ GPO/Sq. Ft. Lot' Block: Subdiv~ion: Depth to pipe heroin from original grade: Gravel depth beneath pipe Township: Range: Section: Fill added above original g~de:~ Ft. Gravel/~/length:~ ~/~ ~ ;~x ~ / Ft. WELL: D New ~ ~ Upgrade ~ Ft. ~ ,;~ ~ ~ Ft. Classification (Private, A,B,C): Total Depth: Ca~ Total absorption area: Pipe material: Driller: ~ ~lled: Static Water Level:Ft. Installer:/~/~ ~ ¢~ Date installed:,~ ~/~ y~ ]Pump Set at: Casing Height Above Ground: TANK M Ft. Ft. SEPARATION DISTANCES a Septic ~ Holding ~ S.T.E.P. ~,~ ~ ~/Private Manufacturer: Capaci~ in gallons: From *Tank Field 'Sewer Lines su,~c~ , LIFT STATION Lot ~ / ~ ¢ Size in gallons: Manufacturer: Foundation ~] /~/ /~1 ~/~ "Pump on" level at:~5_" ~ "Pump off' level at:~g, ~- High water alarm at:~ ~, ~ .. /5 / ~5 / ' ,Pump Make & Model Electrical Inspections pedormed b Remarks: ~" ~5P5/ /~/sv~%/~W 0~ BENCH MARK Location and Description: I Assumed Elevation: Inspections pedormed by:' ~ Dates: 1st ~g~/7~ "' *- ~-~ ' - Depadment of Hea!~ ~m~~~es approval ....... Reviewed and approved by'./.~~, D ate ¢~¢¢¢. ~' ........ '~ 72-013 (Rev. 9/91) MOA 25 Permit No, ~,t2 ~ z20 ;7~ Page 2 of 2 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 545-474¢ On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description: LAKE HILL .2 LOT 5 PID No.: 3,500 GAL HOLI)ING ~ ~ LOT 4 i~/ HI]PE ~' ~ PVC MANIFDLD WELL ~ CUrTAiN ~ HDLES ~ l' 0C EASEMENT LINE~ SWING TIES 700 SQFT TRANSITION PIPE A-C = 90.I B-C = 108.9 A-D = 20.14 B-D : 83.14 LDT LDT 5 APPROX, WELL LOCATION ELEVATIONS ~-~ TOP OF STONE FOUNI]ATION, LOT 4 RE$II]EN£~' (NOT TO SCALE) ~ ASSUMEg EL[V = 100,00 MIRROR LAKE SCALE 1"=50' 7/9/96 ENGINEER'S SEAL ~<~-~.~-~,-~,. , , -~ ~"' 49 TH~ ".~, ~.;?..:. .................... ~ ~". LOUIS A. 8UTERA ."~'~ ~ ~.' .......... "~ BioCycle ALASKA WASTEWATER TREATMENT SYSTEMS GUARANTEE AND MAINTENANCE AGREEMENT Between: Mr. John Thompson {Customer) And: BioCycle Alaska (The Company) Address: 17343 Santa Maria Drive 2440 E. Tudor Road, Ste. 162 Anchorage, Alaska 99507-1185 Eagle River, AK 99577 ~ 4- (-.-~{~..(-1:i' ~ (907) 333-1608/(907) 337-9372 Fax (907) 696-5070 {Phone) ,/~(-~q-I~,% ~/'13 ff' ~.. A. GUARANTEE The Company guarantees to repair or replace free of charge any parts of the System requiring repair or replacement due to defective manufacture: a. within five (5) years of this Agreement, except for defects in the ,~eration pump, thu discharge pump, the electrical circuity for which the period of warranty shall be one (1) year. b. and other than under exceptional circumstances, tho company shall respond within 24 hours of the Customer's call for seDtice. B. MAINTENANCE I. On a quarterly basis (once each 3 months) during the period of(l) one year from the date of commissioning of the System,and where necessary, the Company agrees to perform the following maintenance tasks: a. Adjust the air intake in the clarification chamber. b. Clean the inside of the clarification and discharge chambers. c. Replenish the supply of chlorine tablets, if chlorination of effluent is being performed. d. Check the aeration pump, discharge pump, electrical system. e. File a copy of the Maintenance Report with the Department of Health and Human Services, Municipality of Anchorage, and/or with the Department of Envimnmantal Conservation, State of Alaska, or any other local regulatory agency having jurisdiction over the area in which the System is installed. f. Once every throe (3) months the filter in the air blower will be changed. 2. In the event the Customer requests the Company to perform maintenance to the system other than that specified in B.I. above or where the Customer requests work to be performed which is not a part of the above guarantee, the Customer shall pay the Company's reasonable additional charges for the work done as well as for any associated equipment and or supplies. Additionally, the Customer shall pay the Company's reasonable charges where the need for work is a result of the Customer's failure to ensure compliance with the operating instructions, from loading the system in excess of the design flow for the installation, or where the problem is the result of force majeure (i.e. earthquake, flood, lightning, land slip, or from persons not authorized by the Company interfering with the system in any way, or as a result of the Customer failing to comply with this Agreement. 3. Commencing at the end of one (1) year from the date of this contract, the Customer agrees to participate in BioCyale's ongoing maintenance program, as required by the MOA and/or ADEC, and agrees to pay for such maintenance services at an annual rate of $175 which shall be invoiced to the Customer by the Company at or about each anniversary date of this Agreement. with annual renewals of the maintenance conta'act deemed m be automatic. The Company shall be entitled to alter the annual service charge from time to time as reflected in the increase in the national cost of living. C. CHLORINE WARNING 1. Due to the risk and danger involved in the mixing of different chlorine compounds, the Customer hereby agrees to refrain from adding chlorine compounds of any kind directly to the BioCycle system. 2. The Customer is also advised against using and/or discharging compounds to the system, such as chlorine, drain cleaners, insecticides,,I]iocides, medications, ere in amounts that would be harmful to the system and cause it to cease functioning in a normal Da - Cust~mer'~3~n~ure re: '("~/{ ~;t~ ~4~ Date: JULY 12, 1996 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES PoO~ BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 PAGE 1 OF ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW960076 DESIGN ENGINEER:EAGLE RIVER ENGINEERING SERVICES OWNER NAME:THOMSON JOHN E OWNER ADDRESS:17343 SANTA MARIA EAGLE RIVER, AK. 99577 DATE ISSUED: 5/16/96 EXPIRATION DATE: 5/16/97 PARCEL ID:05112232 LEGAL DESCRIPTION: LAKE HILL ACRES #2 LT LOT SIZE: 16900 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 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 (iSAAC80) . 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: 1.) THE WASTEWATER DISPOSAL SYSTEM INSTALLED UNDER / THIS PERMIT IS AN ALTERNATIVE SYSTEM UNDERGOING //~A~ EVALUATION WITHIN THE MUNICIPALITY OF ANCHORAGE. 2°) ENSURE A 4 FTo VERTICAL SEPARATION BETWEEN LEACHFIELD ~ SEASONALLY HIGH GROUNDWA~R. ( 1' MAX. DEPTH ) . RECEIVED BY- ~ ~/~~3 DATE- ISSUED BY: ( DAT~: 06-11-1996 ll:49AM FROM E×I~TING NOL~Nr, EASEMENT L.INF, E.R. Engineering Sucs. TO ~4~4786 P.O1 lT~ ~/~'~ 5/~'z~P°~t'It~ brand f~ tmn~mi~al memoriam 7~ I~'~~ 1""~'~9~ PVC P¥C MANIFDLD PVC 1/8' HDLES ~ 1' DC <TYP) I..E]T 4 WELL 15×45' BE/] PIPE LDT 5 LEACHLINES, BIOCYCLE TA~NK AND BEDS SHALL BE : INSULATED W/ 2" ;35 PSI: FOAM ~PROX. WI LOCATIBN - TEST HOLE · - MONITOR TUBE o - S[WER CLEANO + WELL EASEMENT PROPOSED LEA ~- EXISTINC LEACF SEPTIC LLI PG RADE tTE ' PLAN LEGAL: LAKE HIILL ACRES lOTS 4 & N1 OWNER; JOHN THOMSON .,. CONTRACTOR: N JOB// 95-009A BATE: SCALE 1" = 40' EAGL~ RIVER EATGI1V~'6'RINO SERVICES AP.O. ',~ox 7732,94 EAOL£~ RIVER, AK. 99577 (9o7)1 6.94-5 ~ ~5 LOUIS A. ~UT~R, *, 0E-6736 MIRROR L~,KE :HFIELD FIELD TOTAL P.01 INSULATE]]N,,L / /CARPI]RI / ~ -/..... ,~ / .......... / ~'~ EXISTING / ~ 647'----------__~.~ -/ 3,500 GAL ~ / /,v/F~A / ~ / ~ , ,::x-'--' '~ / ~, LI3T 4 r3 E~' CURTAIN J '~. / J J~/ ....... ~,~3 ?go~ .... / ~ ~ FILTER FABRIC ~ =.0. "/~ / ........ F N SEPTIC UPGRADE S~TE PLAN ~~. LEGAL: LAKE HILL AC~E5 ~ (OT$ 5 & N~/2 5 OWNER: JOHN THOMSON ~w..-' CONTRACTOR: NzA ~ EAGLE RIVER ENGINEERING SERVICES ~ P.O. Box 772294 ~ EAGLE RIVER, AM 99577 (907) 694-5195 FAX: (907) 694-3297 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: ,~'~b/' ~3~ PID Number: ~/- /Z.Z-- ~ N~, ~ ~A~ ~~ ~0~2 Wastewater System: D New ~Upgrade A~,: ~ ?//~ P~/NO~No.o,~oom,: ABSORPTION FIELD P~ D Deep Trench ~ Shallow Trench D Bed ~ ~ Other Total ~m original grade: LEGAL DESCRIPTION so, R~..~: GPD/Sq. Ft, Subdivision: Depth to pipe bollom from original grade: ~el depth beneath pipe ~Lo~ Block: ~ ~//~L ~ ~ ~ Ft. I o,on: ~ Fill addedaboveoriglnal~ra~ Gravel length: Ft. /Ft. Distance ~n lines: WELL: D New ~/~pgrade Gravel depth: Number of lines: Ft. Fi, Pipe material: Classification (Private, A,B,C): Total Depth: Cased To: Total abso~rea: ?~1 VA~ Ft. Ft. SQ. Ft. Driller: Date Drilled: StaticWater Level; Installe~ Date installed: Yield: I Pump Set at: ~ Casing Height Above Ground; TAN K GPM I Ft. Ft. SEPARATION DISTANCES ~ s,ptic ~o~di,g ~ S.T.~.P. TO Septic Absorption Lift Holding ~Private Ma~rer: Capacity in gallons: From Tank Field Station. Tank Sewer Lines ~ ~ Material: Number of Compa~ments: Surface ~/~ ~/~ W/~ ~/m ~ ~/~" LIFT STATION~ Water Line Foundation ~l]~ ~/~ ~/~ /~1 ~/~ ,,Pump on" level a~ ~off" level at: ~ High water alarm at: ~t ~ Electrical Inspections pedormed by: Cudain BENCH MARK Remarks: Location and Description: Assumed Elevation: ENGINEER'S SEAL Inspections performed by: ~ ~ Dates: 1st ~ //~ ~ ' '"~:: %~ ': 2nd -,~ ..... -~ ........... - Department of Health and Human Services approval ~,.~,,.~, . .,..~ Reviewed and approved by: ~' Date: /~-?~ :~ "~:~, ~'~:~' 7243r3 ri/git MOA 25 PermitNo.' SW 93-0325 Page o! Municipality of Anchora§e 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 Lake Hill Acres #2, Lot 4 Legal Description: 051-122-32 PID No.: 3,500 GAL ~ HE]LDING TANK g%/ING TIES A - C = ~4.5 B - C = 29,5 A - D = 30.1 A - E = 33.8 B E = 25,2 ELEVATIBN3 (NBT TB ~CALE) NBRTH "-.~, TD~P DE BLOCK EBUN])AT]~3N ASSUMED ELEV = 100,00' '/.96,8 /BRIG. GRB~JND 100,7 SBUTH 72-013 A (2/91) MOA 25 ~;CALE 1" = 40' o[ - SEWER CLEANOUT ~i - WELL -- -- - EASEMENT ENGINEER'S SEAL ~ .-~-gTH f/~ '. -k ~-~ · ..... T ~^ ' ¢ '.LOUIS A. BU E .' ~ ~ '. CE-6736 . ' ~ ~ 3M~3 ~V3N 'NOIIVO03 33V31BO Z NOIIVDO] NIV~O NI~l~n3 w z J L~ W W W ~6-17-1996 12:05PM FROM E.R. Engineerin9 Svcs. TO J4~4786 P.O1 I~st.lt~ brand fa~ 1 'ansm~l memo 7671 ~'~'~ C~,~ II ,I 3N~9 BV3N 'N011¥009 99~1A0 NOIi¥30] NIV~ NI~£BnD TOTAL P.01 Ea |e River En ineerin Services Louis Bu~te~ca, P.E. P.O. Bo× 77329'~ (907) 694-fi19S tel E~i~ Riwr, AK 99S77-329,~ (907) 694~-3297 ~x April 30, 1996 Jim Cross, P.E. Manager, On-Site Services Municipality of Anchorage P.O. Box 196650 Anchorage, AK 99519 96-04-36 Re: Lake Hill Acres #2 Lots 4 & 5 Permit Application Dear Mr. Cross: On behalf of my client, Mr. John Thomson, owner of the above referenced property, we are applying for a permit to construct a septic leachfield utilizing the Biocycle system. The original system was installed in 1974 Failed and was subsequently replaced by a holding tank in 1993. The Biocycle system will allow sufficient leachfield reduction to allow placement of the system on the limited available area. The clarified effluent should result in an increased lifespan for the system and avoid the use of a holding tank. The Biocycle was chosen as it is an established system with a maintenance contract available, and the owner requires an immediate installation. We are not requesting a waiver to groundwater table or bedrock. We have attached a site plan and profile showing our bed location on Lot 5, which is jointly owned by Mr. Thomson and the owner of Lot 6. This lot is going to be split by the owners and an interim easement will be obtained to allow construction of the field. We are requesting that the existing holding tank be retained with the use of a diversion valve. If you have any questions please call our office at 694-5195. Sincerely, Louis Butera, P.E. \G:\WPDOCS\1996\95-009B-NAR °0%.¢1~0 . ~-v4'.. ~// CAST IRDN./ ~ ~ EX}STZNG / ~ ~'4~ 3,500 GAL ~/ /,W/r//../ / ~ / EASEHENT LINEx / / ' / ,~ / ~., X D .~/~ ~ / ~ ~ ACREAGE ' / · - MONITOR TUBE LEACHLINES, BIOCYCLE TANK ~ ,~/ ~ Z ~%T,ER CLEANOUT AND BEDS SHALL BE ~ ~ iNSULATFD W/ 2" 55 PSI FOAM ~ EASEMENT - ~ ~ ~- PROPOSED LEACHFIELD NO KNOWN CURTAIN DRAINS ~ ~- EXISTING LEACHFIELD SEPTIC UPGRADE S~TE PLAN LEGAL: LAKE HILL ACRES ~2 LOTS 4 & N1/2 5 ~.. .... OWNER: JOHN THOMSON ' ~0~ ¢5-00¢~/¢~1[: 04/30/¢eI SCLC[ ~" = 40' ~.~ EAGLE RIVER ENGINEERZNG SERVICES ~'~ A EAGLE RZVER, A~. 99577 (907) 694-5195 FAX.. (907) 694-3297 i iI J L~ SPECIFICATIONS FOR ON-SITE SYSTEM LEGAL: Ao 1. 2. 3. Lake Hill Acres #2 Lot 4 and N1/2 Lot 5 REVISED - 04/30/96 96-04-30 10. Co 4. 5. 6. 13:~9 RC~/D GENERAL The well and septic plan is for a four bedroom single family residence only. The drawing and/or site plan shall be a part of this specification. All materials and workmanship shall meet the Anchorage Department of Health (MOA-DHHS) requirements. All soil tests are advisory to the design and are to verified or modified in the field by the Engineer. All excavations and depths are advisory and are to be verified in the field by the Contractor to meet MOA-DHHS requirements. It is the responsibility of the Owner to obtain all necessary permits or easements. It is the responsibility of the Contractor to secure all utility locates prior to construction. The excavation is to be exactly in the area shown on the site plan, any deviation requires Engineer approval. It is always recommended that a surveyor locate the nearest lot line position and the location of any easements. Any remaining open test hole excavations shall be filled. SEPTIC TANK/LIFT STATION Septic tank and lift station shall be a 1,500 gallon Biocycle type unit approved for four bedroom capacity with Meyers MFA0 pump and level controls capable of providing a 50 gallon effluent dose, with high water alarm mounted in the home. Biocycle supplier is Pegasus Engineering at 333-1608. Receipt from licensed electrician stating the lift station was wired to applicable codes to be supplied to Engineer upon completion of work. LEACHF1ELD The leachfield is to be located as shown on the site plan, 100' distance to be maintained from the Lot 4 well. Leachfield bed is to be excavated to 4' depth below ground surface and backfilled with pit run sand to 2' elevation below ground. The bottom of the leachfield excavation shall be level, plus or minus 1.5". 1' of sewer rock is to be placed with the 1-1/4" distribution pipe level at 2" below top of rock. Orifice shields to be placed over holes. Reference cleanout detail on site plan. The leach gravel is to be covered with typar fabric material. A combination of soil and extruded board insulation to a depth of 4' or equivalent is to be placed over the leachfield. The area over the trench is to be finish graded and contoured into the slope to prevent ponding of surface water runoff behind the leachfield. RECOMMENDED LEACHFIELD DIMENSIONS: GRAVEL DEPTH = 9" under pipe, 2" over pipe TRENCH LENGTH = 90' total GRAVEL WIDTH -- 7' SOIL RATING = 48 min/inch BEDROOM CAPACITY = 4 ABSORBTION CAPACITY = 2 gpd/ft2 1/8" holes ~ 1.5' spacing, facing up with orifice shields Twenty-four (24) hours notice required for all inspections \1996\95-009B-SPC EAGLE RIVER ENGINEERING SERVICES P.O. Box 773294 EAGLE RIVER, AK 99577 (907) 694.5195 JOB SHEETNO OF CALCULATED BY DATE CHECKED BY DATE SCALE Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: ~-~A~'~ /-'~'.'~50.~ DATE PERFORMED: LEGAL DESCRIPTION: A~ ~/~ Zo/" .g- Z~ /-/,'// /)~,~..~-~Township, Range, Section: . 7"./.~-~'J ,~. /z.~ J'e ~ ,~- SLOPE SITE PLAN 4 ~/5 6 7 8 9 10 11 12 13 WAS ~ ENCC IF Y~ PERC IND WATER ERED? S L ;, AT WHAT O P E Alter 14 15- 16- 17- 18- 19- 20- Gross Net Depth to Net Reading Date Time Time Water Drop )N RATE d,~/~oo (mmuteslinch) PERC HOLE DIAMETER __ TEST RUN BETWEEN z.f, FT AND ,.5-- FT COMMENTS PERFORMED BY: /2_~/'~,T£ I ~~--'~'~ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES I" EFFECT ON THIS DATE. DATE: .~4//'~/~ GRANT made this 5th day of May 1996. John Thomson and John and Patty Peo~;~''f-¥ hereinafter referred to as the grantor and John E. Thomson of 17343 Santa Maria Eagle River, AK. hereinafter referred to as the grantee. WHEREAS, the grantor is the owner in fee simple of the following described realty, Lot 5 Lake Hill Acres #2, according to the official plat NW1562 thereof, filed as Plat NW 1562in the Anchorage Recording District, Third Jusicial District, State of Alaska, and, WHERAS, the grantee is the owner in fee of another and adjoining parcel of land described as follows: Lot 4, Lake Hill Acres #2, according to the official Plat NW 1562 thereof, filed as Plat NW 1562 in the Anchorage Recording District, Third Judicial District, State of Alaska, WHEREAS, the grantee is desirous of enjoying the use of a certain portion of the grantor's land for the sole purposes of ingress and agress to grantee's land for the purpose of installing and maintaining a septic system leech field, and, WHEREAS, The grantor has agreed, in consideration of $10.00 (Ten Dollars and no Cents) and other good and valuable consideration, the receipt of which by grantor is hereby acknowledged, to grant to the grantee an easement soley for said defined purposes and for no other, NOW this grant witnesseth that in return for said specified consideration paid by the grantee to the grantor, the grantor hereby grants unto the grantee, his heirs and assigns, full and free right and authority to install and therafter maintain a septic system leech fiels upon the following described portion of grantor's land: Septic System Easement Description and AS-Built Survey, attached hereto and made a part hereof, dated 4/11/96 and 4/30/96 respectively, by Eagle River Engineering Services. This Grant of Easement is intended to be appurtenant to grantee's above-described land and touches, concerns and runs with said lands. This is not intended to be an exclusive easement. The grantor herein expressly reserves unto himself equal rights of Ingress and egress and all other rights as the owner in fee simple of the desribed premises. Any Dispute or disagreement arising under or in any way concerning this instrument shall be submitted for resolution to the process of binding arbitration in accordance with the Alaska Statutes made and provided for said arbitration. The jurisdiction of the the Arbitrator shall commence 60 days from the onset of the dispute and shall operate to toll all applicable Statutes of Limitation. IN WITNESS WHEREOF the grantor and grantee have hereunto set their hands the day and year first above written. ~,/Johh E. Thomson, John & at~y e~ ~ John E. Thomson STATE OF ALASKA ) ) SS. THIRD JUDICIAL DISTRICT ) THIS IS TO CERT~Y that on this / ~ day of ~ 197~ before me the undersigned, a Notary Public in and for the State of Alaska, duly com~ssioned and sworn, personally appeared John E. Thomson and John & Pat Peck, to me known to be the persons described in and who executed the above and foregoing instrument and acknowledged to me that they signed and sealed the same freely and voluntarily for the uses and purposes therein mentioned. WITNESS my hand and official seal the day and year in this certificate first above written. "Notary Publgc in and for ~lffska -_-.,~ My commission expires: Mttnicipality of Anchorage P.O. ~x 196650 Anchorage, Alaska 99519-6650 Oc~ Hom~wnelYProspccfive Burr: ~ ~ ~e on-sRo w~ntcr dis~ ~u Rrc iutcr~t~ in purci~ing is an "aRcmafi~" w~er d~ sy~n. ]~is systmt~ k~vn ~ a "Biocycle Aerated Was~ater T~b~cnt System", within the M[micipality of Anchorage m~&r the Altcn~fivo System s~fio~ ff~e W~t~tcr Di~s~ Re~latim~s (AMC 15.65). l'h~rc am ~in fis~ ~lv~ wi~ the m~emhip of one orfl~m sys~nm: I. 'i'h~ sys~ ~ been ~hown to be e~tivo in off,er are~. '[l~e s~tem is currently unde~olng a two y~r Wstit~fl p~iod in Ancho~e u~ t~ ge~ of the ~ran~nt of ~ ~ Hum~ Sc~i~ (DJa4S) ~d th~ State of Ala5~ Dcpa~t~t & Environmcnt~ Consc~adon (ADEC) to d~cnninc iL~ eff~tivcn~ ~ a ~tbar~c ~vi~. T~ting ~ui~ on ~ta ~tallcd lmv~ bc~n vo~ m~mgilg. Copies ofinifi~ t~ r~u[~ ~ available flora flt~ 2. Th~ B~cle system has not been tcs~ and approv~ by thc Nafonal Sani~tion Foundation (NS~. Currently, Aacho~ge Munidp~ C~ f~ W~tcr Di~al ~l~iol~ pmpri~ ~uipm~tt m have NSF approval. ~s approv~ or d~mgos ~ fl~ W~tc~cr Disposal R~ulafions fl~rm~h Munici~ Ass~bly ~tion will ~ n~s~g~ pri~ being ~provcd ~ a stat~dard sync. 3. If~fis s~m hils to tn~ thc ~uironcl~s scl for it to b~tnc a s~txd~'~ ~ approv~ ~a/er dis~os~ ~gm, it may ~ to be ~ov~ m~ ~1~ by d~ = holdhg ~ or (if p~ible) o~cr was[~ disp~ s~g~n flint m~ M~icipali~ of A~om~ r~uircmenm. ~c co~ of~y conversim~ ~fircd ~ t~ct ~ ~uir6~cn~ will ~ tim r~onsibi[i~ homcown~ ~ fltc fimo of I (we) ccrtifij that I two) Isavc read thc above statements mid am (arc) aware of thc risks outlined. ,,. /E- ..'__~e ~ ~..?-'5 ....... (Purchaser Name) . ~(Purci~ascr Si~atutc) ............. (Ih,,cl,a~er NamtO (Purch~cr Siglmtnm) Notarize Hcre §lOr~l b~ffore t~[e, a Notary Public, in and for {ho Stoto of Aloska Third Judicial District, APR--~O--96 PROPERTY OWNER A(;REi'iMENT FOR THE MAINTI~NANCE {)F AN ON-SITI*~ WAS I LWA FER DISPOSAl, SYSTEM / This a~c¢~ll~lt, datcd~ /$ ........ 19'~.., b mad< between tho Mutl~ipality Ail¢horagc Dcp;trtlllgnl Of ['IeiLIlII anti Httlllilll se~iccs (DI I,I IS) itlld Ihg property This agr¢crncnl is tnad¢ fi:r tim purpose of muiatainiag an ua-site sysle, n't on thc subject properly. The property o. wllei'$ agree to the Allow tt~ Municipa}ity of Aa<borage the perpetual right of Cntl'y to thc i>rope~y dm'ing flocfl~al working hours, to allow for effluent samlAing or cv;thutling thc gcnctltl stat< tff repair Or fl:ncliOll of lbo sysle;n, Submit to thc Mtmicipality o1' Ailchoragc, Oll an anmml hanis, im in~mclion all(I operation statement fi'om a rcgialered prol~ssional engineer. This inspcclion and operation statengnt sMdl yin'fly that the cngincmr has inslmclcd all effluent ami air t>utaalX~, timers, ami alunlls, alld Ilull a;{y (leficicacics have he<, repaired and Illal IbC system b functioning as deaign~l. (Sigllature} (Sigmttur<] (Printed Name} (l')rinlccl Name) Signed before Me, a Notary Public, in ~nd for the Stat~ 9f Alaska Third Judicial Dislrict, Eag!e./l~_~f', Al.o~k~., .,, ,, v ~ ' IIN(IIIiI'IZ'~. rl.C. Jl'lJl Rick Mystrom, Mayor Mtmicipality of Anchorage Department of Health and Human Services $25 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 November 15, 1994 Federal Home Loan Mortage Corp. P.O. Box 9114 Van Nuys, CA 91409 Subject: Lt. 4 Lake Hill Acres Permit #SW930325, Parcel ID #051-122-32 Dear Federal Home Loan Mortage Corp.: The subject permit, issued August 25, 1993 by this office for a single family well and/or on-site wastewater system, has expired as of August 25, 1994. A new permit must be obtained from this office for a well and/or on-site wastewater system NOT installed by the expiration date. If you have drilled the well, a well log must be sent to this office for documentation of the installation and to close the permit. If the on-site wastewater system has been completed and a licensed Professional Engineer has inspected the installation of the on-site wastewater system, the original as-built inspection report must be sent to this office for review, approval and documentation. All inspection reports must be submitted within 30 days of construction completion. When applying for a new permit, the fees are: $320.00 for an on-site wastewater permit; $120.00 for a well permit and $440.00 for a combined on-site wastewater and well permit. If you have any questions, please call this office at 343-4744. ~/~/3rely' James Cross, P.E. Program Manager On-Site Services JC/kb cc: Louis Butera, P.E. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 PAGE 1 OF ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW930325 DESIGN ENGINEER:EAGLE RIVER ENGINEERING SERVICES OWNER NAME:FEDERAL HOME LOAN MORTGAGE COR OWNER ADDRESS:P.O. BOX 9114 VANNUSE. CA 91409 DATE ISSUED: 8/25/93 EXPIRATION DATE: 8/25/94 PARCEL ID:05112232 LEGAL DESCRIPTION: LAKE HILL ACRES #2 LT 4 LOT SIZE: 16900 (SQ. FT.) NUMBER OF BEDROOMS: 4 T~I$--~PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTIO~ OF: HOLDING 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 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: DATE: DATE: Louis Butera, P.E. Registered Civil Engineer August 11, 1993 John Smith, P.E. Municipality of Anchorage Dept. of Health & Human Services 825 L Street Anchorage, AK 999502 Re: Lake Hill Acres//2, Lot 4 Dear Mr. Smith: At the request of our client, Mr. John Thomson, we are applying for holding tank permit for the above referenced property. The subject lot presently is served by an undocumented septic system. We propose to properly abandon the existing system and replace it with a 3,500 holding tank. Attached is a report from Mr. D.R. Dayton, P.E. attesting to the unsuitability of this lot for a conventional on-site septic system. The soils in the area are described as impermeable silts with a high water table. If you have any questions please call our office at 694-5195. Sincerely, Louis Butera, P.E. SPECIFICATIONS FOR ON-SITE HOLDING TANK SYSTEM LEGAL: LOT 4, LAKE HILL ACRES//2 GENERAL 1. The wastewater plan is for a single family residence only. 2. The drawing and or site plan shall be a part of this specification. 3. All materials and workmanship shall meet the Anchorage Department of Health and State Department Of Environmental Conservation requirements. 4. All excavations and depths are advisory and are to be verified in the field by the contractor to meet Municipality of Anchorage, Department of Environmental Conservation requirements. 5. It is the responsibility of the owner to obtain all necessary permits or easements and to locate any adjacent multi-family wells. 6. The excavation is to be exactly in the area shown on the site plan, any deviation requires engineer approval. EXISTING SEPTIC TANK 1. Existing septic tank are to be pumped dry, the tops removed, and tanks filled with compacted gravel material, or tanks completely removed and disposed of properly. 2. The existing septic tanks & area surrounding them are to be disinfected with chlorine or lime applied to the exposed area. NEW HOLDING TANK 1. The holding tank excavation is to be over~excavated 1' depth and backfilled with compacted NFS Type II soil. 2. The tank is to be anchored by four, 2,200 lb. concrete blocks, two on each side of tank with ~.6" galvanized cable straps over the tank. Each pair of blocks located at 1/a the length of tank from each end of the tank. These blocks are available at Klondike Concrete. 3. The tank is to be installed level. 4. The tank is to be a tank that is approved by the Municipality of Anchorage with corrosion prevention standard, for septic tank as per Uniform Plumbing code. 5. Holding tank must have two-six (6) inch diameter standpipes with airtight caps to provide pumping access. The standpipe must extend at least twelve (12) inches above the surface of the ground. 6. Holding tank must have a watertight manhole to provide access to the interior of the tank. The manhole must be at least twenty (20) inches in diameter. 7. A holding tank must be equipped with a high water alarm which registers both visually and audibly inside the dwelling. The alarm must be positioned to allow at least three hundred (300) gallons per bedroom of additional storage after the alarm has been activated. 8. Alarm and wiring to be to Municipality of Anchorage code. 9. The tank is to be installed with 4' earth cover. EXISTING SEWER LINE 1. The existing sewer line is to be removed and replaced with 4" PVC 3034 to the house foundation with 4" cleanout and mechanical water tight connections at foundation connection. 2. The trench for the entire sewer line is to be over-excavated 1', and backfilled with 1' of NFS. Type II material compacted to 95 %. 3. Sewer line is to be insulated with 2" burial foam, 2' wide centered over sewer line. BEDROOM CAPACITY = 4 HOLDING TANK SIZE = 3,500 gallons Twenty-four (24) hours notice required for all inspections. \I993\93-052A.SPC LnT ~ TANK: PUNP, X / / ~ ~ 7 o ~,~_ ~ / q/ / o - SEWER CLEANOUT ~ - WELL EASEMENT S E P T J C S I T E P LA N LEGAL: LOT 4, LA~E HILL ACRES ~2 ~''~' OWNER: JOHN THOMSON ~" .... ~'~:~"" ~ '-~' CONTRACTOR: JOB ~ 95-0521 DATE: 08/10/95I, SCALE 1" : 40' i EAGLE RIVER ENGINEERING SERVfCES EAGLE RIVER, AK. 99577 M~s, Betty Fields 12801 Old Glenn Hwy. ~agle River, Alaska 99577 696-2417 Dear Mrs ~ields~ As toques%ed by your cite,ti Hr. John Smart, we have dug test holes, Installed 9round ware[ monitorln~ tllb~a ~nd performed Fercolat!on The he,es were dug on Mafch 3, 1993. The f~$~ hole, located near the Northwest corne~ of the carpor~, showed a tlgh~ Sil~ ~oi~s ~0 a de~h of 8 ft.'(the exten~ of the hole) w/ch a wate~ table at 6 it, The ~econd hole wa~ near'the $outhwea~ corne~ of the carport. This ho!~ was p[imaclly gravel which ~¢~ the gravel backfill around the old septic ~yste0! seepage pit. The aide of ~he hole was ~he llatlve ~o!l which was the name material ho!~ ~1. The percolation ra~e was 116 minutes pe~ inch. on March l?, 1993 we did a ~econd parc te~t on the ~oil~ at the 1 f~..lavel. The re~ult~ were the 6ama as the flint tes~, and in additio{) old seepage pi~ was also at 4 ft. ~ inches, Fitldln9 this ~ituat[on with ~he soils l~rcolating slowe[ ehan probably be higher about the flrl~ week in Mayl, it is my opinion ~hat thi~ lot Call only be ierved by in, tailing a seca:Se holding ~ank. If there are ~ny quem[!ons, pleameOntact me. Sincerely, _ t?avid R. Dayton Tom Fink, Mayor MuniCipality of AnchOrage Department of Health and Human Services 825 %" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 October 7, 1993 Lou Butera, P.E. Eagle River Engineering Services PO Box 773294 Eagle River, Alaska 99577 Subject: Waiver Request for Lot 4 Lake Hill Acres Subdivision ~2 Waiver Request #WR930063, PID ~051-122-32, SW930325 Dear Mr. Butera: Your request for waiver of the required 10 foot separation between a septic system and a lot line has been approved. The waived distance is 6 feet from the holding tank to the property line. This approval applies to the existing septic system lot line separation only. Any future upgrade to the septic system will require all separations be met or another approval from this department.~ Sincerely, Daniel J. Roth Civil Engineer On-site Services ljw#7 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-site Services Section Waiver Review Worksheet WR# WR930063 PID~ 051-122-32 HA9 Permit # SW930325 Date Received: September 29, 1993 Legal Description: Lot 4 Lake Hill Acres 92 Engineer: Lou Butera, P.E., Eagle River Enqineering Services PO Box 773294, Eagle River~ Alaska 99577 Applicant: John Thomson Waiver Requested: Lot line waiver - 6 feet from holding tank to property line Criteria: 1. Geology: Points: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation TOTAL: 2. Special Conditions: 3. Other: Waiver is Granted: ~ Waiver is NOT Granted: List Conditions or Reasons for above: ~f ~/mg£R; M~C~ED Date: ~a~f Reviewer Rec #: 25243/350 Amount: $ 115.00 Date Paid: 9-29-93 Louis Butera, P.E. Registered Civil Engineer MUNICIPALITY OF ANCHORAGE t:NVIRONMI::NTAL SERVICES DIVISION September 23, 1993 John Smith, P.E. Municipality of Anchorage Dept. of Health & Human Services 825 L Street Anchorage, AK 999502 Re: Lake Hill Acres #2, Lot 4 S£P 2 9 199 RECEIVED Dear Mr. Smith: At the request of our client, Mr. John Thomson, we are applying for a waiver of lot line setback to 6' actual distance of lot line for a holding tank. This should not create a conflict due to the fact that it is a holding tank system, and the lot line fronts the Glenn Highway frontage road so there are no conflicts with neighboring lots. If you have any questions please call our office at 694-5195. Sincerely, Louis Butera, P.E. \1993\93-052B.NAR ,:~GRE'~R ANCHORAGE AREA BOF~qGH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME ~1//'~'1 LOCATION .,/'~/~F//(~//' Z/__..( ~ '~ SEPTIC TANK: DISTANCE FROM WELL INSIDE LENGTH MANUFACTURER-~ ~- ~-~/z~ ~/~/~-~ MATERIAL INSIDE WIDTH LIQUID DEPTH __ C~?~.~ NUMBER OF 3 ~ COMPARTMENTS _LIQUID CAPACITY /~<C~ GALLONS. SEEPAGE PIT: NUMBER OF PITS / DIAMETER OR WIDTH /~ LINING MATERIALCg~'~C ~")~'~ CRIB SIZE: DIAMETER BUILDING FOUNDATION__ NEAREST LOT LINE '~ ~ . ADDITIONAL ABSORPTION LENGTH ~, DEPTH / DEPTH <~ DISTANCE FROM: WELL TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) SQ. FT. WELL: BUILDING FOUNDATION __ CESSPOOL APPROVED CONSTRUCTION NEAREST LOT LINE OTHER SOURCES DISAPPROVED DEPTH~/~/~/ DISTANCE FROM: NEAREST SEPTIC SEEPAGE SEWER LINE TANK SYSTEM DISTANCES:/4 -- l~ %) INSTALLED BY: ~]a.)~,(;'Y' PIPE MATERIAL: LOT SLOPE: REMARKS: C~_:...~ f DIAGRAM OF SYSTEM GrEATer ANCHORAGE ArEA Borough DEPARTMENT OF ENVIRONMENTAL QUALITY 3330 "C" STREET ANCHORAGE, ALASKA 99503 TELEPHONE 274-4561 SEWAGE DISPOSAL SYSTEM m APPLICATION AND PERMIT PERMIT NO. 'NSTALLAt,ONLOCAT,ON INSTALLATION OF: SEPTIC TANK TYPE AND SIZE OF FACILITY TO BE SERVED FINANCED THROUGH SOil test reSULTS PNONE SEEPAGE PIT ~ ., DRAIN FIELD TO BE INBTALLED BY I OTHER. NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST COMPLETION DATE ANTICIPATED FINAL INSPECTION: 2~ HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEPTIC TANK SIZE ~.~0~qll TYPE MINIMUM DISTANCES, REQUIREMENTS FOUNDATION TO SEPTIC TANK FOUNDATION TO SEEPAGE PIT SEPTIC tank tO SEEPAGE PIT Wall DRAIN FIELD SEPTIC TANK ., SEEPAGE PIT TO NEAREST LOT LINE. f DRAIN FIELD WATER MAiN TO SEPTIC TANK DRAIN FIELD DRAIN FIELD SEEPAGE Pit ALSO CONSIDEr AREA WELLS. SEEPAGE PIT TO RIVER, LAKE, STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING G~P OF ~EXCAVATION ~ FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS. GRAVEL BACKFILL CONFORM TO BOROUGH R ULATIONS REGARDING INSTALLATION. Y. TiCZT/O ~/r-~/,r'TYPE DIAGRAM OF SYSTEM I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE DEscrIBED SYSTEM IS iN accOrDANCE WITH SAID CODE. ~r~.~~~ ~r~/~'~ ~ Performed for Legal Description: This fOrm reports: 3330 "C" Street Anchorage, Alaska 99503 SOILS LO(] - PEROLATION TEST Mr. William Magnusson Date Perfomed L6~'~, La~ Hiii A6res, Deoond' Additi0~l Soils log Y'es Percolation test 7/12/74 Depth Feet 1 - 3- 4- 5~- 6- 10~ ll - 12- Moist gray sandy silt 350S.F./ B.R Damp gray silty sandy gravel 225 S.F./B.R. 13- 14- Slightly damp gray silty sandy gravel 200 S.F./B.R. Bottom of test hole 14' Was ground water encountered? No_~ If yes, at what depth? Reading Date Gross Time Net Time Depth to Water Net Drop Percolation rate -Proposed installat-i-~'n7 .... minute. Seepage Pit Drain Field Depth of Inlet . Depth to bottom o¥-])it or trench COHHEItTS: No bedrock or gr'ound wa~er encountered. Certi fi ed By :~r~ Performed Dy: N..eal A. Hausam ..... EQ-040 (6/74) "One test is ~,orth a thousand opinions" i5829 TUDOR ROAD, ANCHORAG£, ALASKA 991507 · TELEPHONE: 333-8472 DATE July 13, 1974 PROJECT Bill Magnuson SIEVE 4' - 5' o.E.ATo. ANALYSI S 8PECIFI CATI~ SIEVE WEIGHT ~INED PERCENT RETAINED % P&SGING LIMITS ~IZE ~ '4 MIN~ '4 SIEVE CUMULATIVE 3/8" '4 mo ~5 a 98 ~o g7 7 93 Sandy Si~t 35O 40 90 ~3 87 60 · 8o .65 24 76 IO0 140 TOTAL 393 SOl LS L,~. ,o. o~'r~ July 13, 1974 ~i~_ Ma:~n~on $1E V E , PROJEGT. 9 ~ ~0 ~ OPERATOR ANALYSI S SIEVE WEIGHT ~INED PERCENT RETAINED % PA~ING ~PECIFICATI~ REMARKS LIMITS ~IZE K~ "4 MIN~ '4 SIEVE CUMULATIVE ~" I-I/2" 118 3 97 I" 311 8 92 3/4" ~o5 ~2 88 I/2" 776 19 81 3/8" 9~9 23 77 Silty Sandy "4 .413 ~727 34 66 G~avel aa5 ~o ~5 ~7 83 '4o zTo 25 75 ~o 60 so ~o 38' ~2 140 PAN ~ ~,.~. y~ ~ TOTAL ~.[gO 66g I IA �.t1` : ,, � • Municipality of Anchorage On-Site Water and Wastewater Program (907) 343-7904 ate T� Certificate of On-Site Systems Approval Parcel I.D. 051-122- Expiration Date: , �^l 1. GENERAL INFORMATION Complete legal description Lake Hill Acres #2 L4 Location (site address) 22643 Mirror Lake Dr. Chugiak, AK 99567 Current Property owner(s) Charles Redmon Day phone Mailing address P.O. Box 266 Bandon, OR 97411 Real Estate Agent Day phone 2. TYPE OF DWELLING: Single Family (w/wo ADU) ❑ . Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Q Individual Individual Water Storage ❑ • Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Distance: 7 > 1 Received b • ` l Date: /,F777-c9l c:) COSA to be released to the engineer,unless otherwise requested by the engineer. COSA Fee $ 5a C Waiver Fee $ Date of Payment R I 5l/$ Date of Payment Receipt Number (15Receipt Number COSA# 050 ?LS-07 Waiver# • • 5. STATEMENT OF INSPECTFON BY ENGINEER As certified by my seal affixed hereto and as of the validation dale shown below, I verify that my investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-sile 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. In conducting an adequacy test,I attempt to provide a thorough,conscientious engineering analysis of the system in accordance with MoA COSA guidelines and regulations.The reported results describe the performance of the system under the conditions encountered at the lime 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 defects or encroachments.Therefore we cannot provide any warranty for future performance, nor can we estimate remaining life of the system.The content of this report is for the sole benefit of the owner listed above. Name of Firm Pannone Engineering Services LLC Phone (907) 745-8200 Address P.O. Box 1807 Palmer, AK 99645 Engineer's Printed Name Steven R Pannone Date 9/24/2018 OF AL,�k 6. DSD SIGNATURE f•••• hoar.. System#1 Approved for y bedrooms :%Steven `•ririone . System#2 Approved for bedrooms � 4y • CE-8149 s �r Disapproved 1kq�q -� Conditional approval for bedrooms, with the following stipulations: yrHNCy0,tt9•. °P�ENT s-9 By: \e.„ �`— Original Certificate Date: , 1 The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the Stale of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheet° - If more than 1 septic system is on the lot: COSA Checklist# 1 of 1 Structure served by this system I Certificate of On-Site Systems Approval Checklist Legal Description: Lake Hill Acres #2 L4 Parcel ID:051-122-32 A. WELL DATA Well type Private If A, B, or C provide PWSID# Well Log(Y/N) N Date completed 1976 Sanitary seal (Y/N) Y Wires properly protected(Y/N) Y Total depth 72 ft. Cased to 72 ft. Casing height(above ground) 24 in. FROM WELL LOG AT INSPECTION Date of test 1976 9/14/2018 Static water level UNK ft41 ft Well production 25+ g.p.m. 5.0 g.p.m. WATER SAMPLE RESULTS: Coliform Neg colonies/100 mL Nitrate 0.199 mg/L Arsenic ND ug/L Date of sample: 9/17/2018 Collected by: PES B. SEPTIC/HOLDING TANK DATA Tank Type/Material S.T.E.P/Fiberglass Date installed 7/3/96 Tank size 1500 gal. Number of Compartments 2 Cleanouts(Y/N) Y Foundation cleanout(Y/N) Y Depression over tank(Y/N) N High water alarm (Y/N) N/A Date of pumping N/A Pumper See Maintenance Report C. ABSORPTION FIELD DATA Date installed 7/3/96 Soil rating (g.p.d./ft2 or ft2/bdrm) 1.0 G.P.D/SF System type Bed Length Varies 17'-22'-40 ft. Width Varies 13'-15'-18' ft. Gravel below pipe 0.8 ft. i it" ar 3•t (A,' Total depth SPCfrflEff. absorption area 700 ft2 Monitoring tube Y Depression over field N Date of adequacy test 9/14/18 Results(Pass/Fail) Pass For 4 bedrooms Fluid depth in absorption field before test 0/O in. Water added 600 gal. New depth 0/0 in. Elapsed Time: 135 min. Final fluid depth 0/0 in. Absorption rate >= 600+ g.p.d. Any rejuvenation treatment(past 12 mo.)(Y/N&type) N If yes, give date 2cc 2(611-D 7.-tisaL oldL Ft a- 1--2=. • • D. LIFT STATION Date installed 7/3/96 Size in gallons 1600 Manhole/Access (YIN) Y "Pump on"level at in. "Pump off'level at in. High water alarm level at in. Datum Cycles tested �( Meets alarm&circuit requirements? v ,moi 1N-PiE t `j�VN �,�e -- E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot 1001+ On adjacent lots 1001+ Absorption field on lot 100'+ On adjacent lots 1001+ Public sewer main 75'+ Public sewer manhole/cleanout 1001+ Sewer/septic service line 25'+ Holding tank 1001+ Animal containment areas 50 + Manure/animal excrete storage areas 100'+ SEPTIC/HOLDING TANK ON LOT TO: Building foundation 10i+ Property line 10 + Absorption field 101+ Water main 25'+ Water service line 25'+ Surface water 100'+ Wells on adjacent lots 1001+ ABSORPTION FIELD ON LOT TO: Property line 101+ Building foundation 10 + Water main 101+ Water Service line 25 + Surface water 1001+ Driveway,parking/vehicle storage 10'+ Curtain drain 50'+ Wells on adjacent lots 1001+ F. COMMENTS Tf\IL\(\rACV\ �(-\\OL L5 b„ -2.Cama-\•\ss;)\'LQ ray (c•C Q;w_ct --.\r\ C O c-eA--e . G. ENGINEER'S CERTIFICATION (�G9F cgAkk I certify that I have determined through field inspections and 9'<P' �i �. .. �� review of Municipal records that the above systems are in ��; .,• I. _ /\ conformance with MOA COSA guidelines in effect on this date. ��' ! 6 g Steven Pannone �A��,, . Engineer's Printed Name i 1 Steven R. 'onrione:.. CE-8149 d Date 9/24/2018 ¢��s. ��® COSA canary sheet_2-6-15.doc ✓/V✓ I>1 .11. L1Y3 ✓1J b) cc YCLE "Alaska Anchorage AK 99503 Email: crbioak@gmail.com (907) 274-0314 3rd Quarter Inspection Report 2018 Homeowner Info Customer Name: Mike and Barbara Redmon Tank#: 16 Install Date:July 1996 Address: 22643 Mirror Lake Dr. Area Chugiak Initial Inspection: Alarms Tested: Air 7 High Water U Battery Tested: Yes n No n N/A 71 (Please make sure alarm is on "normal", not"mute") Does system have a septic tank ? No I Yes ❑ (Recommend pumping tank every 2 years) Is System Lid Locked? Lid hardware in working order? Is there any noticeable odor? Yes U Repaired ❑ Yes r✓ Repaired n Strong [ I Mild n None 7 System Inspection Inlet plumbing in working order? Solids pillow normal? Yes Replaced Yes [71 Requires Pumping Are all aerators functioning? Any buildup of solids? Yes 71 Replaced [ [ Yes n No Clarification return system operating? Any buildup of solids? Yes ❑✓ Adjusted n Yes n No 7 pH Reading: Dissolved Oxygen PPM Turbidity of discharge (in FTU) (pH of 6-8 is ideal) (2-5 is ideal) (Under 35 FTU is considered compliant.) 7.4 4.0 3.99 Pump float operating? Alarm float functioning? Any buildup of solids? Yes [✓ Replaced n Yes [A Replaced n Yes n No A Filter cleaned? Discharge line condition: Yes [7` NA Li Good [✓1 Replaced I 1 Comments: Has emailing or mailing of form been requested? - Inspected By: Chris Date: 9/04/2018 (contact office to request...) Yes No f 8431N J 30 1f Lot 3 1 S79°34,0 , j ;.,;1 (6 21E 171.18 64.0 E ° i `Wood fence 111 ° c\i0 2 Sto �, / o ry Frame House‘.5049 �2/ O o Lti f ..`o� .. 64.0 1 2 ,. deck ./\ Cn - O j' eptic tank oWell \ 0) J J Asphalt e. 11-1 p 3 u N o h 60.3 O7. -o vs. /' 4 ° r\ a) j ; Boat ram• Y LUo Hangar w I " OM � o .b•••••-' c). w • 60.3 ' tlpCk O rtC r � 1 o o Shed 1 30 N87°02'27"E 165.37sn / Lot 6A / h i a- 1 MEANDERS OF WATERS EDGE Z L1 S30°35'W 17.50 L2 S58°09'W 9.76 L3 S10°07'W 6.50 L4 S24°31'E 16.69 ' L5 S13°45'W 94.84 RECERTIFIED 9-20-2018 / .) `N.N.N. '‘,% AS-BUILT NO CORNERS SET THIS DATE OF — .Kc_ . 4 '# I hereby certify that I have performed a Mortgagee's inspection ....�Q. .S\ 1 of the following described property: LOT 4A.BLOCK 2. C'7' 49th -� .-9 j/ LAKE HILL ACRES SUBDIVISION. ADDITION Np.2 ]l� .4.A /� t � Anchorage Recording District,Alaska,and that the 4 ` •`. ��•e. -7 improvements situated thereon are within the property lines / '' Eli2obeth L. Wojcik():; / and do not overlap or encroach on the property lying „— / € • , adjacent thereto.that no improvements on the property lying SCALE: 1 — 40 sr�•••• 8036 – 15 •�e �. adjacent thereto encroach on the premises in question and Rfo ' . • . • , • a• `' that there are no roadways,transmission lines or other ° t" . visible easements on said roe except as indicated R�FFSSiON A'r � property rty P ` 1 k "`fir. hereon. ii Dated at Anchorage.Alaska EASEMENTS OF RECORD,OTHER THAN CV 24 ''6 3 this 19th day of JANUARY .2016. THOSE SHOWN ON THE RECORDED FB 18-7, pg 40 FRED WALATKA&ASSOCIATES.L.L.C. PLAT ARE NOT SHOWN HEREON. Seward Engineers and Surveyors UNLESS OTHERWISE NOTED FB 15-14, pg 65-66 BE 907-248-1666 ADVANCED WASTEWATER TREATMENT SYSTEM MAINTENANCE AND REPAIR AGREEMENT BETWEEN CIPALITY OF ANCHORAGE AND 1 ' ' 2bII !KZI THIS MAINTENANCE AND REPAIR AGREEMENT made d entered into as of this ra- Day of * e, of 201? by and between ,e,i herein the"OWNER,"and the Municipality of Anchorage,herein the "MUNICIPALITY." In consideration of the mutual covenants contained herein,the parties to this Maintenance and Repair Agreement agree as follows: 1. Advanced Wastewater Treatment Systems. Municipality grants permission to Owner to utilize and operate an Advanced Wastewater Treatment System (AWWTS),described as 22.(x- -�.t rrCr lak ocated at(legal description). 4\ \s Ao S 4.2 Le 2. Definitions. Alteration. Any change to the design or function of an AWWTS that includes the installation or removal of any parts,components or pieces not included in the original construction permit and design. Certificate of On-Site Systems Approval(COSA). An approval by the Municipality of existing water and wastewater disposal systems given at the time of property sale and title transfer in accordance with Anchorage Municipal Code(hereinafter,"AMC") 15.65.These approvals certify that the systems are adequate for the homes that they support and meet the codes that were in place at the time of system construction. Damage. Any man-made or natural change in a system that would inhibit the system from performing as designed. Maintenance and Repair. The scheduled and as needed replacement of existing parts,components and pieces of an AWWTS that were included in the original design which would allow the AWWTS to continue to perform as designed. Permit.An On-Site Wastewater Disposal Permit as required by AMC 15.65 to construct and operate an AWWTS. 3. Term. The term of this Maintenance and Repair Agreement shall begin on the date of approval by the Municipality to operate the installed system or issuance of a COSA, and shall continue while the AWWTS is in use or is operational or until the property is sold or title is transferred by the owner and a new COSA is issued to the new owner or transferee of the property. 4. Alterations,Installation and Removal of Additional Equipment. Prior to performing any alterations to an AWWTS,the owner agrees to obtain an On-site Wastewater Disposal Permit from the Municipality in accordance with AMC 15.65. 5. Maintenance and Repairs. A. Throughout the term of this Maintenance and Repair Agreement,the Owner shall maintain their AWWTS in a satisfactory condition capable of producing treated septic effluent in accordance with the equipment's approval for operation in the Municipality. The owner shall enter into a service agreement with an AWWTS service and maintenance provider approved by the municipality and the manufacturer of the AWWTS for the entire term of the AWWTS. In addition, it shall be the responsibility of the Owner during the term of this Maintenance and Repair Agreement,and any renewals thereof,at the owner's sole expense,to pay for any and all: (1)repair(s),(2)maintenance, (3)adjustment(s), (4)replacement costs,and(5)inspection costs. B. Owner agrees to comply with all applicable ordinance,laws,regulations,rules and orders for the AWWTS. C. Upon request by the Municipality,the owner agrees to provide the Municipality a written schedule of routine maintenance and repairs which have been performed on the system. When a record of maintenance is documented and maintained by the system vendor,the owner agrees to allow the Municipality access to this information. D. Owner acknowledges that the fine for failing to maintain and repair an AWWTS may be assessed in accordance with AMC 14.60 for improper discharge. E. Owner agrees that only maintenance and repair personnel approved by the Municipality will inspect and make any necessary maintenance,repairs or permitted alterations to the system. F. Owner agrees to grant the Municipality reasonable access to test and inspect the AWWTS upon 24 hours written notice. G. Owner agrees that any sale or transfer of title of the property will not occur without a new Certificate of On-Site Systems Approval. H. Owner agrees that the AWWTS installation and maintenance requirements as provided by the AWWTS vendor/installer and approved by the Municipality are the governing guidelines for the construction,maintenance and repair of the Owner's AWWTS. I. Owner agrees to provide and maintain a telephone connection to the AWWTS as required by the AWWTS approval. 6. Nonwaiver. The failure of either party at any time to enforce a provision of this Maintenance and Repair Agreement shall in no way constitute a waiver of the provisions,nor in any way affect the validity of the Maintenance and Repair Agreement or any part hereof,or the right of such party thereafter to enforce each and every provision hereof. 7. Amendment. A. This Maintenance and Repair Agreement shall only be amended,modified or changed by a writing,executed by authorized representatives of the parties,with the same formality that this Maintenance and Repair Agreement was executed with,and such writing shall be attached to this Maintenance and Repair Agreement as an amendment. B. For the purposes of any amendment modification or change to the terms and conditions of this agreement,the only authorized representatives of the parties are: a. Owner: -rettia b. Municipality: Director,Community Development or designated authority C. Any attempt to amend, modify,or change this contract by either an unauthorized representative or unauthorized means shall be void. 8. Jurisdiction: Choice of Law. Any civil action arising from this Maintenance and Repair Agreement shall be brought in the Superior Court for the Third Judicial District of the State of Alaska at Anchorage. The laws of the State of Alaska shall govern the rights and obligations ofthe parties under this Maintenance and Repair Agreement. 9. Severability. Any provisions of this Maintenance and Repair Agreement decreed invalid by a court of competent jurisdiction shall not invalidate the remaining provisions of the Maintenance and Repair Agreement. OW .ER: - 11 By:_ ', ,�. (signature) Date: I G� ,;Z i)0( (7( �(1:,{,L K b L (print name) STATE OF ALASKA ) ) ss. THIRD JUDICIAL. DISTRICT The foregoing instrument was acknowledged before me this 'Z day of Oc.Voloe r . 2014g. by :1''^"0.1 .q-o4ae -4OTARY PUBLIC FOR ALIASICA �. Ft My Commission expires: % 1 aG2. 1 ; : 1.4 isTOTAR Va,9.it s: Fff 'Y/rtranto F �C MUNICIPALITY: - !9—1 By: (signature) Date: f __--_ (print name) Title: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D.# 051-122-32 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING NAA# GENERAL INFORMATION Complete legal description L~ke Hill Acres #2, Lot 4 Location (site address or directions) 22643 Mirror Lake Drive Property owner Jo}m E. Thomson Day phone 696-5070 Mailing address 17343 Santa Maria, Eagle River, AK 99577 Lending agency N/A Mailing address Day phone Agent Eva Loken/ReMax of Eagle River Day phone 694-4200 16600 Centerfield Drive, ~201, Eagle River, AK 99577 Address Unless otherwise requested, HAA will be held for pickup. 4 '4 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: x 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. NOTE: 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site × Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. NOTE: 72-025 (Rev. 1/91) Front MOA.~21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Eagle River Engineering Services Address P.O. box 773294, Eagle River, AK Engineer's signature DHHS SIGNATURE Approved for Disapproved. Conditional approval for Phone 694-5195 99577 bedrooms. bedrooms, with the following stipulations: Additional Comments By: Date //- ~¢' ¢3 The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72*025 (Rev. 1191) Back MOA #21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: /~/qY-£ H/bi.- /~CF-.E.~ # Z-- Parcel I.D. 0 ~/- / Z Z A, Well Data Well type ~./V/~'~ If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Total depth Sanitary seal (Y/N) Date of test Static water level Well flow Pump level1 ?~,' .% FROM WELL LOG + 7..5 SEPARATION DISTANCES FROM WELL TO: S~ic/holding tank on lot / Absorption field on lot /,/ Public sewer main /,,///I Sewer service line //~) Date completed /~b Driller C.O ~'7'~/~ Cased to ?~' ?'E-~ asing height 7.- / Wires properly protected (Y/N) ~'~-~ AT INSPECTION RECEIVED ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ~ Date of sample: Nitrate 0.0: m~///_._ Other bacteria Collected by: B. S~I~/HOLDING TANK DATA Date installed ~ 7/¢//~ ~ Cleanouts (Y/N) ~/~ High water alarm (Y/N) Date of pumping /V'/~ ~ Tank size Foundation cleanout (Y/N) Compartments Depression (Y/N) Alarm tested (Y/N) y Pumper ./'4 lA y~5 SEPARATION DISTANCES FROM E, EP-T-t~/HOLDING TANK TO: Well(s) on lot / ~ O' On adjacent lots ¢- l O0; TO property line ~ '(l,¢fllV£[')'~ Absorption field Surface wateddrainage /L~O ' Foundation Water mah~/service line 72-026 (3/93)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level Manufacturer Manhole~ "Pump on" level at ~ "Pump off" Level at Meets MOA electrical codes (Y/N),lb, tested SEPARATION DISTA. b~gE~ROM LIFT STATION TO: Well 9~r¢''~- On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed Length Width Total absorption area Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) SEPARATION DISTANCE FROM~ON FIELD TO: Well on lot J On adjacent lots Soil rating (GPD/FF) System typ~r"~'~ Gravel thickness ..-T'dtal depth Cleanout present (Y/N) ~...-~epression over field (Y/N) Results (pass/fail) for After test If yes, give date To building foundation. On adjacent Io~~ S_~a.ter //6~ rtain drain Prope~yline Bedrooms To existing or abandoned system on lot Cutbank Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION Signature Engineer's Name Date I certify that I have checked, verified, or conformed to al~ MOA and HAA guidelines.~8~e,.~t~A' [t~'~:.~ate of this inspection. HAA Fee $ C¢0¢ ~¢~- Date of Payment //~/¢- ~L::~; Receipt Number ~.,0~% ~ Waiver Fee $ Date of Payment Receipt Number ' MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 825 L Street - Anchorage, Alaska 99501 i ENVIRONMENTAL ENGINEERING DIVISION Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES 31RECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.~-~"~7~ PROPERTY RESIDENT (If different fro abo ) U/] PHONE 2. BUYER ~ P., PHONE MAILING ADDRESS 3, LENDING INSTITUTION PHONE MAI LING ADDRESS 5. LEGAL DESCRIPTION ./' / /3 /~/' .4 '~ ;TREET LOCATION ~/'} .~ ~. ~'- . */ 6. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] One [] Four ~ SINGLE FAMILY [] Two [~ Five [] MULTIPLE FAMILY [] Three [] Six [] Other 7. WATER SUPPLY INDIVIDUAL~ [] COMMUNITY [] PUBLIC UTILITY INDIVIDUAL/ON-SITE** *ATTACH WELL LOG. Awell log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) **If individual/on-site, give installation date . If system is over two {2) years old an adequacy ~st is quired 8. SEWAGE DISPOSAL SYSTEM [] PUBLIC UTI LITY by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOINTMENTS I TIME TIME TIME DATE DATE DATE ~'NSPECTOR INSPECTOR i INSPECTOR I 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 [] COM/MUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [~NDIVIDUAL/ON -SITE DATE INSTALLED Connection Verified INSTALLER []Septic Tank or E~Flolding Tank Size: If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTALABSORPTIDN AREA 4. DISTANCES Septic/Holding Tank AbsorPtion Area Sewer Line I Nearest Lot Line I WELL TO: Absorption Area to nearest Lot Line 5. COMMENTS ~!~/~PROVED FOR ,~ BEDROOMS [] CONDITIONAL APPROVAl_ {letter must accompany certificate) [] DISAPPROVED DATE 8Y(T:~ ~ :/~ LEGAl_ DESCRIPTION 72-010 (Rev, 3/78)