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HomeMy WebLinkAboutBIRCH HILLS TERRACE #2 BLK 4 LT 2 Onsite File Birch Hills Terrace # 2 block 4 Lot 2 #050 - 141 - 52 ,C1PAUr.!,.,0, . MUNICIPALITY OF ANCHORAGE tent , On-Site Water&Wastewater Program \o ,, S PO Box 196650 4700 Elmore Road Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997 „ 0 • http://www.muni.org/onsite Dcpartmcnt rroa On-Site Wastewater Disposal System Permit Permit Number: OSP181378 Effective Date: 10/23/2018 Work Type: SepticTank Upgrade Expiration Date: 10/23/2019 Tax Code Number: 05014152000 Site Legal Address: BIRCH HILLS TERRACE#2 BLK 4 LT 2 G:0153 Site Mailing Address: 17850 TEDROW DR, Eagle River Owner: HOFFBAUER DIANE Lot Size in Sq Ft: 54122 Design Engineer: C & M Engineering Total Bedrooms: 3 This permit is for the construction of: ❑ Disposal Field 0 Septic Tank 0 Holding Tank 0 Privy 0 Private Well 0 Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By: 7 Date: •- Issued By: et A ' _ei // Ili Date: /0/23/20/eY PLiNS MUNICIPALITY OF ANCHORAGE • ' "Amie Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section -- Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. aa-1-1-32 p 5C - Property owner(s) Diane Hoffbauer Day phone Mailing address 17850 Tedrow Site address 17850 Tedrow Legal description (Sub'd., Block & Lot) Birch Hills Terrace#2 Block 4 Lot 2 Legal description (Township, Range & Section) Lot Size 54,122 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (El all that apply) Absorption Field E Initial [ Single Family (SF) (w/wo ADU) Septic Tank Upgrade 0 Duplex (D) ❑ Holding Tank [ Renewal ❑ Multiple Dwellings [ Privy U (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: none Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. Charles Balzarini, C&M Engineering (Signature of property owner or authorized agent) Permit/Rush Fees: o2�J Waiver Fees: Date of Payment: /00/iVi Date of Payment: Receipt Number: O 3tiO Receipt Number: Permit No. OsP'8/3W Waiver No. G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc C&M ENGINEERING SERVICES Ph: 907-854-5558 Municipality of Anchorage Onsite Water & Wastewater Program 4700 Elmore Rd Anchorage, Ak 99507 10/10/2018 RE: Proposed Septic System Modification for Birch Hills Terrace #2 Block 4 Lot 2 Dear Reviewer, The above referenced property is currently served by a 3 bedroom septic system installed in the late 1970s. The 1000 gallon tank has failed and is in need of immediate replacement. We are proposing that the existing tank be replaced with a new 1000 gallon (minimum) tank constructed and installed in accordance with MOA requirements. A polyethylene tank is recommended. As shown on the plan, the tank will be greater than 10’ from the house foundation. The tank shall be covered with a minimum of 2” moa approved insulation and 3’ of cover. The repair shall be performed by a moa certified installer in accordance with MOA requirements. The engineer will inspect the tank before backfilling. Repair of the proposed system will not negatively impact adjacent lots. Upon completion of the installation, a record drawing will be submitted showing the location of the new tank, leachfield, well, and other applicable features. Thank you for your time in reviewing this permit request. Please do not hesitate to contact me at 907-854- 5558 or by email cgbalzarini@gmail.com with any questions or concerns. Sincerely, Charles Balzarini, PE Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP181378, Rebecca Carroll, 10/23/18 TED / 181378, Reb C2 541l�Z(j . Row ""•y* LEGEND 10' .. o CLEANOUT EgSEME NT N r CHARLES G BALZARINI • MONITOR TUBE . \ �+��'F�,,�j,, • •CE -13854 • •.��`��i ® TEST HOLE / l F� . ; o/zo��s• �� i „ �� . „�� ..,,,.. r„e • I \ 111��PR0FESS10�P� r BIRCH HILLS TERRACE#2I 3 BR HOME x BLOCK 4 LOT 2 \_J� DECK welvilre SEPARATION DISTANCE NOTES: THE PROPOSED SEPTIC TANK IS GREATER THAN: 100' FROM ANY PRIVATE WELLS EXISTING 200' FROM ANY PUBLIC WELLS DRAINFIELD 100' FROM ANY SURFACE WATER 10' TO ANY PROPERTY LINE OR FOUNDATION SCALE: 1 " = 30' LEGAL DESCRIPTION: BIRCH HILLS TERRACE#2 BLOCK 4 LOT 2 C&M ENGINEERING SERVICES OWNER: DIANE HOFFBAUER I DATE:10/10/18 REV: I DRAWN: CBJ REF: 907-854-5558 SITE PLAN REPLACE EXIST TANK REPLACE 0 WITH NEW 1000 FCO IF 0 GAL OR 1250 GAL TANK. NECESSARY DEMOLISH OLD TANK PER MOA REQUIREMENTS I APPROX INSTALL (2) WATERLINE NEW AFTER TANK LOCATION. CLEANOUTS VERIFY PRIOR TO CONSTRUCTION SEPARATION DISTANCE NOTES: THE PROPOSED SEPTIC TANK IS GREATER THAN: 100' FROM ANY PRIVATE WELLS EXISTING 200' FROM ANY PUBLIC WELLS DRAINFIELD 100' FROM ANY SURFACE WATER 10' TO ANY PROPERTY LINE OR FOUNDATION SCALE: 1 " = 30' LEGAL DESCRIPTION: BIRCH HILLS TERRACE#2 BLOCK 4 LOT 2 C&M ENGINEERING SERVICES OWNER: DIANE HOFFBAUER I DATE:10/10/18 REV: I DRAWN: CBJ REF: 907-854-5558 SITE PLAN ¢~~, MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT MAILING ADDRESS LEGAL DESG~I PTION LOCATIO~~~ ~ ~ . N~I OF B~DRO0~8 ~ DISTANCE TO: ]Wel~-i~' [Absorptionarea/~, Dwelling/~ I PERMIT~lg Width Liq. cap~gallons. IF HOMEMADE: Inside length Liquid depth ~ ~ ~ DI~ANCE T~ Well .. Dwelling PFRA~IT NO~ O Z ~ Manufacturer ~ Liquid capacity in . .oun .tio ~ DISTANCE TO: ~ ~ ] ~ ~ ~ Z ~ No. of lines Length of each line ~ Total length of lines Trench width Distance between lines ~ / ~ ,~0 ' ~ inches ~ ~ Top of tile to finish grade ~ , Material bene~{h til~,, ,nches Total effective a~or~area Length Width Depth PERMIT NO, ~ Type of ' Crib diameter Crib depth ~ effective absorpti ~ ~ation Nearest lot line m DISTANCE TO: ~h ~~ ~Driller Distance to lot line PERMIT NO, ~ ~ ~ B ng foundation - ~ DISTANCE TO: u~di ~ewer line Septic tank Absorption area(s) OTHER REMARKS F'ERMI'T' NO. L, EGf::IL. :!'.~:';~: ~ .... L" '..'.:] T I:;.". E 1:.::_' T., I'=It'.,I C H 0 ~:;:.'. R Cji E., Ft K. :.E.~ :i;,.]!;i::~ :j .... · i/-~ ].~LL~.~ .[ , E'. I". ..::, ..' ~,1 ]':FIN'JSTRI.ICT I ON F:'. 0. E::C ~:':: ;~::].2 E.R. E';:!i)4 ]"E:.[:,ROH DR Z VE LOT ~: E:LK 4 L=::IR(:::H HILL TEF.:R. C': LOT :E:~Z;E 54J..2;7. 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I ]"h-' TO I NF:'OI:;.:M 'TH 19; [)EF'FIF.:"H"IENT E:,I...It';:: l' I",IG THE Z t'-,I~;TF:II..~LF:tT Z O1",! t NfJ!;I::'ECT t ON'ii!; OF f:~lqh" I.,-I['.:.]...I....~:~; F:I[:,Jf=tCENT TO "['Fi I '.:J: F:'.r.;::OF:'ER'T".r' I:::llqE:, "l"l...lli!!: I'-,IUM[':'~EI:;?. OF I:;?.E%IDEI'.~CE:.'Z, THFFr THE 14EI....L.. HILL E:;ERVE. li!i:l.".:tCl<i:: ILL I NG OF: F'IN'-r' S"r'::":';TEM I.,.I t THOLI"[' F I I'.,II:::IL I N'_:.i;PEr3T I CH'.,t FII'.,I[:, I:::IPf='R©'v'F:fL. 8"/ TH I S DEPF:IRTMEN"I" H I I....1... E:E SUB..TE:.'C"I" TO F'F.'.O::¥EC:U"I"I O1'-,t. M]CI'.,IIMIJM [:,t2".';"['FtI'.,tC':E BE"I'HEEN I:::t HELL. I:::IN[:, Fltq"r' OI'.4'...'::=;I'TE :E;E!].,.IF:IC.:iE [:,I:~i;PO':':":;I::IL. :!.:.;"r'S'T'Et"! J_e~f3 FI!EET FOR Ft PF~:'.I',,,'F:ITE I.,.IELL.~ ::L. 5~3 TO ;:J:~3ei FEET I:::RI]li'q f::l PL.IE:L. ZC HEI....L.. [:,EPENE:,ING I..II:::'L')[-,I THE T"r'PE OTHI:!:]:;;: RI~£(;:!L.I I R[EI'"IENT:!~ I'qFl'~" f:IPPL"r'. SPEC: I F I CI=tT I Ol'qS F:tI",ID C:OI",I~ii;TI:'UJCT I ON E:' I F:IGRI::It'tS I:::Hr;.:E I:::l","f::t I L.F:IBL..E TO Z I",ISUF'.E PROF'E':R I 1"4'_".~.;]"F:IL.L.F:IT I ON. I C: E I:;?. "I" I F"? THf:IT :L: t FIM F=l:::lMILIf::lf~.: H ITH THE REL:.!IJlREMEI'.,IT:~!; I:::'OF.: ON-:E;I"f'E I=ORTH [."".',~'r' THE P'IL.IN I C Z I::'I::IL l' 'l""r' OF F:INCHORf:IGE. ',i:J:: I HILL IN'='~;Tf:II...I... THE '='ii;"r'::"'J;]"EM IN F:IC(]:OR[."FINC[::J HI'TH THE CO[:,E:i!i;. ::ii:: I IJI"~[:,EI'7~i;TI::II",I[.':' TFIFIT THE: ON-:E;ITE ::".'!;EHER '.:ii;"r':']::"l"EM Mf:l"r' REQI...IIF.:E ENLF:II:;?.Gt~':]'"tliii]",IT Il=' THE I:;UiE:iii;I[)EI",ICE I:i~; F;.'.EMO[:'ELE[:' TO Z I",ICL. U[:'E MOI';::E THFtI",I ii::: E',E[:'I~7OO!'"I:~!;. !:::II:::'F'I... I C:FINT I ',,,'ER'.E;ON COI"4:!i!;TRUC:T I 08-E GEO ZCHNICAL 8 DEVEL Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 PMENT CO. Russell Oyster Earl Ellis 694-2774 SOIL LOG M8-2280 Soils Et Foundations Land Development Performed for: N&me: Matltng Address:~:~?~.~/~; Depth (feet) Sotl Ch&rqcterlstlc; 4 5 6 7 8 9, .71.0 11 16 Ground Water Encountered: Yes__ NO Proposed Installation: Seepage Coments: yes, what depth Drain Field Performed by: MUNiCIPAUTY'OF ANCHORAGE-' '"'~"~ .... DEPARTMENT 0 F HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska '99519-6650 1.. GENERALINFORMATION Complete legal description CERTIFICATE OF HEALTH AUTHORITY. APPROVAL FOR A SINGLE FAMILY DWELLING Lot 2; "Block 4; B~rch Hill~ T~rrac~ #2 /' Location (s!.te adaress or directions) 17850 T~drow Eagl~ River, AK Ea~l~ Riv~r~ AK Day phone 99577 696-1980 NOTE: .- If commun/~ we// system, provide wr/~en conf/rmat/on from State ADEO a~est- : ;;~ . lng to the legali~ and status of system. ~ ~:~' :': ~ ~ , NOTE: If communi~ wast~water s~,tem, provide wd~en confirmation from S~a~ ~D~. - . a~est/ng to the legali~ and status of system ....... .~ ...... >~.~:,;:~, STATEMENT OF INSPECTION As certified by my seal affixed investigation of this Health and/or wastewater disposal and type of structure indicated hereir~,'l the Municipality of Anchorage files and from supply and/or wastewater dis ordinances, and regulations in effect o Name of Firm s & s ENGINEERIN 17034 Eagle Address Engineer's signature 10w, I verifythat my n-site water supply ~umber of bedrooms ~f0'rmation obtained from )n'and inspect!On, the on-site water and State codes, ~ DH.c~.GNATURE ' Approved for DiSapproved.' ~, Conditional approval for ~the following,:stipulations: Additional Comments 'The M~nt~ipality :o~?66horage O.ePartment~ ApprOval ~Certlfld~{~'~"based' only iupOn the re 'professional en~i~'~r regi~te"!ed in the and their lendthg'inS{Itutions ih'o conduct Inspections or analyze data responsible for errors or omiss~oi~s ~n the 72-025 (Rev. 1,~1) Back MOA #21 :h Authority bY'an independent )umhasers of homes. Ioyees of DHHS do not is not Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: A. Well Data O'~-,Z.- Log present (Y/N) Date completed Driller Total depth Cased to Casing height Well type ~-~ C:>/k~ If A, B, or C, attach ADEC letter. ADEC water system number Sanitary seal (Y/N) Wires properly protected (Y/N) ,~ FROM WELL LOG AT INSPEC Date of test Static water level Well flow g.p.m, g.p.m SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot acent lots Absorption field on lot ,~ ; On adjacent lots Public sewer main J Public sewer manhole/cleanout Sewer service line J Petroleum tank WATER SALTS: Coliform~~ Nitrate Other bacteria Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Date installed Tank size Cleanouts f[~l~l) ¢ Foundation cleanout (~N) High water alarm (Y~:) /-J Date of pumping '"7 -~. b, -cI L~ o Compartments 7_.- Depression (Y~ /'-/ Alarm tested (Y/N) '/'J~ Pumper ~"~ ~'~--~.~ :¢0',v%¢ ~ SEPARATION DISTAN(~ES FROM SEPTIC/HOLDING TANK/TO: Well(s) on lot ~{/~ On adjacent lots To property line / O [ '/ Absorption field /c, I Sudace water/drainage /~o r~~?~'~'i~''~: Foundation Water main/service line 72-026 (3/g3)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) Manhole/Access (Y/N) "Pump off" Level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Sudace water D. ABSORPTION FIELD DATA Date installed Length Total absorption ama Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y(~ Width -z~ Gravel thickness ~ ~ o ~ Cleanout present(~N) y System type Total depth ¥'7._~ Depression over field (Y/~ for ~ Bedrooms After test .~-~ If yes, give date ~/h SEPARATION DISTANCE FROM ABs0~RpTION FIELD TO: Well on lot ~/.~ To building foundation On adjacent lots ~ Surface water Curtain drain On adjacent lots ~1 ~ Property line \ ~ ~ ~ T~) existing or abandoned system on lot Cutbank ~' ~ Water main/service line Driveway, parking/vehicle storage area '~ E. ENGINEER'S CERTIFICATION I ce~'fy that I have checked, verified, or conformed to all MOA and HAA guidelines in eff~~a, te of this [n'spection. H~ Fee $ ~0~ ~ c/~ Waiver Fee $ Date of Payme~ ~ ~ ~ ~'¢~ Dato of Paymo~ Recei~ Numar 7~6- ~ S fi Recei~ Numar 72-026 (3/93)' Back MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # (-'3 ~-%/~3 - ~.L\ \ ~ ~ ,~ HAA # ,t\Q.o% fj ~flo~ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include 10t, block, subdivision, section, township, range) Lot 2, Block 4, Birch Hills Terrace ~2 Location (address or directions) 1 7R50 Tc.d~ow Dr. (b) Property owner Margaret' C.c)~h~ . T~elephone: (home) ~ Business .562-7653 Mailing Address ~¢)r¥~ A ,qt -., ~'i t'¢~ 1C~1: Anr-hnr'ag¢.. A]~. C)C)SQ.q (C) Lending Institution Telephone Mailing Address (d) Real Estate Company and Agent Foctune Properties- Margaret Goche 3000 A St., Suite 101, Anchorage, Alaska 99503 Address Telephone 562-7653 (e) Mail the HAA to the following address: (or check herR, if hold for pick up.) List contact person and day phone number below: S & $ ENGINEERING 17034 Eagle Ri~er Leop R~ad No. 20~ Eagle River, Alaska 995:77' 2. TYPE OF RESIDENCE Single-Family I~ Number of bedrooms 3 3. WATER SUPPLY Individual Well [] Community [] Public ~ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and statu~--~ 4. SEWAGE DISPOSAL On-site ~ 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. 72-025 (Rev. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION 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 shows that the on-site water suPply and/or wastewater disposal system is safe, functional end 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 S & S ENGINEERING 17034 Eagie Ri~er L~.,~p ~.~.6 No. 20~ Telephone ~ ¢~z~ Z ~;;::~7 ~ Address Eagle River, Alaska Date 6, DHHS APPROVAL Approved for ~p Approved ~" Disapproved Terms of Conditional Approval /~///- Conditional Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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. 7/88) Back Page 2 of 2 ~ MUNICIPALITY OF ANCHORAGE (MOA) (~,~[~/~/ Health Authority Approval (HAA) MUNiCIPALI~.'~HORAGE CHECKLIST- FEBRUARY 1984 ENVIRONMENTAL-"~TI~ICEo'""'"""" DIVISION 343-4744 MAR 2 8 1989 A. WELL DATA RECEIVED Well Classification Well Log Present (Y/N) Total Depth Cased to Static Water Level Casing Height Above Ground Electrical Wiring Jn Conduit (Y/N) __ Date Completed Depth of Grouting SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot '2~.-~<~ To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments )~"~, (~, ~-'-, ~'~_)~::~L~ Legai Description: '~,~,,'v' 2-- '~....,~ ~ If A, B, C, D.E.C. Approved (Y/N) ~/~ Yield Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) · Adj , On oining Lots --~ I ~ ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole ; Date B. SEPTIC/HOLDING TANK DATA Date Installed ~'/"/,/"/a) '__ Size StandPipes~N) ~' Depression over Tank (Y/~ Air-tight Capsd~N) To Wat~,r-Supply Well To PrOperty Lin~~ To Water Main/SerVice Line Pumping/Maintenance Contact on File (Y/Ni~/~.. Holding Tank High-Water Alarm (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Building Foundat.i.o,n \ ~ To Disposal Field To Stream, Pond, Lake or Major Drainage Course \ Comments ~'-/~S ~::~-~::~C::>L...- '~Ot'~ No, of Compartments '2..- Foundation Cleanout ~5~N) ~'/ t~D~t,~e Last Pumped ~ 'Z... - ; for '-'"-'-- Temporary Holding Tank Permit (Y/N) 72-0~6 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~"'" "/'" '? ~ Width of Field "B I Square Feet of Absortion Area Depression over Field (Y/~p Results of Last Adequacy Test Length of Field Depth of Field \ Gravel Bed Thickness ~c::::> ~'/ Statndpipes Present4:gTN) p,~ Date of Last Adequacy Test -- To Property Line '~ -Jo f~ To Existi~ng or Abandoned System on ; On Adjoining Lots ~ W-' J To Cutback (if~present) ~//'~/ SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Found Lot To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date Installed ~ns "Pump On" L~ High Water Alarm Level at ~ Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at - ~VVent (Y/N) equacy Test. Signed Company Date MOA No. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines-ineffect on the date?f..tJ0.j,s., inspection. ' ':'~ $ & $ ENGINEERING 17034 F,.a ,~ r, ............ Ena. le River, Alaska 99577 ~. / Receipt No. ('~ .-~ ~-/'~¢) ?'.~'-'" Date of Payment Amount: $ 72-026 (Rev, 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2