HomeMy WebLinkAboutTANAINA VALLEY LT 20Municipality of Anchorage
On -Site Water and Wastewater Section - (907) 343-7904 Page 1 of 3
ON
-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP231113
PID Number: 011-051-95
Dwelling: X Single Family (SF)
El with ADU Fj Duplex (D) F-1 Two Single Family Project: M New A Upgrade
Name
Karen Matthias
A RPTION FIELD
�Trench r_1 Wide Trench M Bed r-1 Mound
E] De Tr c
!
Site Address
6306 Tay Circle
Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
(907)301-1022
Four(4)
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original e
Gravel depth beneath pipe
k.- Ft.
Subdivision
Block Lot
Tanaina Valley
20
Fill added above original grade
Ft.
G h
NZ Ft.
Township Range Section
Gravel width
Ft.
Beds: Number of Lines
Dist between lines
N� Ft.
SEPARATION
DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between ches
From
Tank
Field
Tank
Line
Ft2
Well
> 100'
N/A
N/A
N/A
>25
TANK ❑p Septic ❑ S.T.E.P. E] Holding E] Other
Manufacturer
Greer
Capacity
1,250 Gal.
Surface Water
> loo,
N/A
N/A
N/A
Material
Plastic
Number of compartments
Two(2)
Lot Line
>5,
N/A
N/A
N/A
NA
Foundation
91*
N/A
N/A
N/A
TATION
I
I
Manufacture Capacity
Remarks *See profile drawing
Z_ Gal.
Alarm location
Electra
PIPE MATERIAL House to tank D3034 drainfieldTankto D3034
Installer
A.C.E.S.
Drainfield D3034 CO/MT D3034
Inspector B Schiller
BENCH MARK (Assumed elevation) 100 ft
Inspect
Inspection 1-6121/23
Location and description
rd
2 nd
Corner of siding 0 East Burnpout
3
401
ON -SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
Conditional Approval:
Date
Ago,
.A9 TH
Septic System
Benjarkrg�,-,�chiller
CE 12592
AW
Approved
Date
4/21/26 \�
Note: this approval does not include well permit requirements.
(Rev ub/uz/lu)
TNN�U���U U ��»u� 0 ���� ^���
U��U���UU��� ������_ 8 ��� U ���
PERMIT ^ ^~~~^"-='''°
��|Fl��M11_M|�1J���
' '`~^ ~'' �^~' °°
�=
^�
vsvv1
:XIS7fNG TRENCH
,2519 GAL SEPTIC TANK
/
/
~~ '
~~ | \ TANAM
--
H11-8U
\
( \ \
( L_
| GENERACUTILITY
sxasmENn
� Co
I��
SEPTIC
PLAN
FEET
1"=6O
ALL LOTS UNTHE TANANAVALLEY S8]ARE SERVED 8YACOMMUNITY
WATER SYSTEM,
LEGEND
CO-CLEAN0UT
2CO-DOUBLE CLEANOUT
FCO'FOUNDATION CLEAN(
FS'FLOW SPL|TTERVALVE
MH'MANHOLE
MT - MONITORING TUBE
SV-SEPTiCVENT
TH'TEST HOLE
0
TANAINA VALLEY, LOT 20
PERMIT # OSP231113
PID # 011-051-95
�
B�
TANK TO FOUNDATION PROFILE r� Fc;.CE1292Schii"e`.:�`�,
1 = 4 ,�ls�FgF� • .�5• •'����r
1\�_PROFESSIO�P ,�"'
522-7773
677-7766 (FAX)
March 19, 2024
MOA Development Services, On -Site Water & Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
Subject: Tanaina Valley L20 - 6306 Tay Cir
Waiver Requests, tank to foundation and field
Dear On -Site Services Engineer:
The replacement of this septic tank was particularly challenging due to the tight area and limited
fall of the pipes. The design shifted the tank away from the trench and foundation, but that turned
out to be unfeasible in reality. Forge was on -site during the installation and verified that the
contractor was unable to place the tank in a way as to achieve separation distances per current code
and still get gravity flow to the trench.
The contractor was able to achieve a 4' separation from the trench, and Forge was able to verify
that there was no disturbance of the field or septic rock in the excavation of the old tank.
The contractor was able to place the tank 10' from the major foundation walls of both the home
and garage, but the interior corner `bump out' of the foundation measures only 9' from the edge
of the tank. This is a significant improvement from the previous tank, which was located 5' from
the foundation (meeting code at that time). As the bottom of the tank is 10.1' below grade, and the
bottom of the foundation was verified during installation as being several feet below grade, the
tank is located outside the soil -bearing prism of the foundation and does not affect it in any
structural manner.
We are requesting waivers for 4' separation from the tank to the field, and 9' separation from the
tank to the foundation. These approvals will not have any negative consequences on the home or
property.
Sincerely,
s
Benjamin Schiller, PE�
V,
Municipality of Anchorage
,_�rj
t puitmeex
_... P.O. Box 196650 s 4700 Elmore Road
Anchorage, Alaska 99519-6650 0 (907) 343-7904 * Fax (907) 343-7997
hftp://www.muni.org/Onsite
Development Services Division
On -Site Water and Wastewater Program
* * * * VARIANCE/WAIVER REVIEW * * * *
Waiver#: OSV261016 COSA#:
P I D#: 011-051-95
Legal Description: TANAINA VALLEY LT 20
Engineer: Forge engineering
Permit#: OSP231113
Your request for a waiver of the required 5 feet horizontal separation from the septic tank to the
FI F-L-,D has been approved. The approved separation distance is 4 feet.
This waiver approval applies to the existing septic tank only. Any future upgrade to the on -site
wastewater disposal system will require all separation distances be met or another approval from
this department.
Waiver is Granted: X Waiver is not Granted:
Date: Approved by:
Name of Reviewer
**** VARIANCEMAIVER REVIEW ****
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP231113
Work Type: SepticTank Upgrade
Tax Code Number: 01105195000
Site Legal Address: TANAINA VALLEY LT 20 G:2122
Site Mailing Address: 6306 TAY CIR, Anchorage
Owner: SWARTZ ANDREW W &
Design Engineer: FORGE ENGINEERING
This permit is for the construction of:
Effective Date
Expiration Date
�»cnr
�J
J
Department
Lot Size in Sq Ft:
Total Bedrooms:
6/1/2023
5/31/2024
33511
❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Received By: ✓� =� 'TO F - Q P -C, ( Date:
I /Issued By: ��" Date: lP /2
4
UH C PALO 77 OO F _` HCH0PRA G E
ID
Community Development Department Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
On -Site Water & Wastewater Program
ON-SITE SEWERIWELL PERMIT APPLICATION
Parcel I.D. 011-051-95
Property owner(s) Karen Matthias
Mailing address 6306 Tay Circle, Anchorage, AK 99502
Site address 6306 Tay Circle
Day phone (907) 301-1022
Legal description (Sub'd., Block & Lot) Tanaina Valley Lot 20
Legal description (Township, Range & Section)
Lot Size 33,511 Sq. Ft. Number of Bedrooms 4
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF) ❑X
(w/wo AD U)
Septic Tank
19Upgrade
❑X
(D) El
Holding Tank
ElRenewal
ElDuplex
Multiple Dwellings ❑
Privy
❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: � 2.2 ' Waiver Fees:
Date of Payment: 3 Date of Payment:
Receipt Number: 067VC D Receipt Number:
Permit No. 0.5P 2 2J 1 I 13 Waiver No.
PermitApp_::-:• :'-.,:c;
May 23, 2023
MOA Development Services, On-Site Water & Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
Subject: Tanaina Valley Lot 20 – 6306 Tay Circle
Septic system design
Dear On-Site Services Engineer:
The owner of the above lot has a septic tank that has reached its end of useful life, so we are
submitting this permit application for its replacement. The attached site plan identifies the location
of the home as well as the wells and septic location. We are replacing the septic tank with the same
size designed for 4 bedrooms.
The new septic tank will be a minimum of 100’ fro m all wells and surface water. Please refer to
the attached plan for the septic design. If this design is followed, there will be no adverse impacts
to adjacent properties.
Sincerely,
Benjamin Schiller, PE
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP231113, Curtis Townsend, 06/01/23
Benjamin Schiller
CE 12592REGISTEREDPROFESSION A L E N GINEER
1"=50'
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEANOUT
FS - FLOW SPLITTER VALVE
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
LEGEND
TANAINA VALLEY LOT 20
FEET
0 50 100
FCO
NOTE:
ALL LOTS IN THE TANAINA VALLEY S/D ARE SERVED BY A COMMUNITY
WATER SYSTEM.
3-BDRM HOME
SEPTIC PLAN
5/23/23
TAY
CIRCLE
10' TELE, ELEC AND
GENERAL UTILITY
EASEMENT
10' T&E EASEMENT
DECOMMISSION AND
REMOVE EXISTING
SEPTIC TANK
NEW 1,250 GAL SEPTIC TANK.
MAINTAIN 5' SEPARATION
FROM EXISTING TRENCH
AND 10' SEPARATION FROM
HOUSE FOUNDATION
CO
CO
MT
2CO
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP231113, Curtis Townsend, 06/01/23
MUNICIPALITY OF ANCHORAGE
DEPARTMEN'r OF HEALTH AND HUMAN SERVICES
Environrnental Health Division U,/ ! O"5"~
825 "L' Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SI'rE S[-'WAGE DISPOSAL SYSTEM AND/OR WELl= INSPECTION REPORT
Address
LEGAL DESCRIPTION
Al ~;' ¢ ~.~1
TANKS
SEPTIC I~ HOt. DING
TYPE OF SYSTEM
Lq TRENCH ~-] BED ~g~ W. DRAIN E~ OTHER
~:) F'r ~ FT
(/5 ' F f
WELLS
,~ FT
~ FT
PRIVATE ~[~ OTHER fldentifv)
/
FT
REMARKS:
DISTANCES
WELL
LOT LINE
FOUNDATION
SEPTIC ABSORPTION
TANK FIELD
'7 ' 2 ~'
Scale:
Inspections Performed by:
I ~ t~,~,~,~ ~ ~,~ ~D AJ ~ cedily Ihal this inspection was peHornmed accordinll to ~mm
72 0t3 (3185)
I~:1 U N I C I P A I... I '[' Y 0 F A N C H 0 R ~-/ G E
T El: D E W E R &. E] Iii[ P T I [', T A N K I:::' E R M % T
'ermit. Number: 880046
OwncH', Name." DE~!~iIGNf,~ IIq WOOD
!~,~m.~H" Addpess: '70;~1 DIF<FTWODD L,N.
AN[:H[IRAGE.~ AK 99518
Day Phone~
:349-8014
Papcel :[ cl ,',
I....o'L I....(,.?gal,", Subd:LvisJ. on~ TANA]iNA VALL. EY I.:..o't.~
Sec:tic)n: 4 'l"ownsl~ip~ :t~?.N Range~ Zl.N
Lc)t 8:Lze :'3:3E~ :L :L (sq,,ft,, op acm'e~D
Max Bedpoomsu This f::'G)r'mJ.'t.n 4 Tota]. C',al:)ac:tty~ 4
iEWER 8Y!~Ff'EM,C:],',
I.J.t~it. el::l be:l.l:lw ape the op't, ion~ availab].e 'Lo you
Choose 't. hc.) op'Lii:)n 't. ha'L best J' i'ks your' s J.'J.~,
W. ]} R a :[
Dept. h t,o Pil:)~;.~ Bo'L't. om (Ft,) .' ~5.0
Gpaw~::l. Dept;.h (f'l:.): Z4. 0
'l"c:H'..a~l Dep'Lh (f't): D.()
Gpavel Nidth (ft)~ [5,,0
Drav~l Leng'Lh (Ft) n 94..,C) .~.
Gpav(.?)l golunm) (cubic yds): 61,,()
Sc)il Ra'k:i, ng Used (sq Ft/brm): 200
in designing youp
.~. Gpave]. length > ~50 feet I'eqLliP(;,H~ mu],tiple.~ so:Lis
.~.~' Gr. ave] leng'Lh > 7,5 Feet PeClU:i. pes mul'L:i, pJ, e r'ur~s (no't. ex(::eecl:Ll-~g 75 F'L each),,
.II:::'T 8'I"A'I"I[)NI~ If a :Lift. !.-:itat:i. on i!.-:i :i. ns't.a:Ll~cl, a high water' alapm must be
ffEF"T'IC', TANK," I~l:Ll"~imum 't, otaZ septic t, ank capac::i,Lya .1.~[;:t50 gallons. Each sep'l:.ic
artk IJiLtS't. have a'L ],e~s'L :~ compap'Lments. Deptl"~ to top of sep{:[c 't. ank (s) < 4.,C)
f:'~f::e~:, r'((tqL,lJ.r'l,z~ :LI"I~[~I,.I~L~I'[.~(:)I"I I]v~:{.]P tank (s).
'ER 1E, LI::.I,,,UII WITH W. MI::;F'ADDEN TRENCIJ TO BE TIED IN B I[~ NDT TD
:X[;EED '75~ OF' L,C)iJJ.I. NUL)Uc~ P~PE L..E. IlbfH, PHONE DHIq~J I:::'I~C[OR TO :I. EFI'
'.ND Zi~SF~EC]'IDN~. 'l"H~ I:~)ERMIT E:XP[RES
I';I U N I C I F' A I,,. I ]' Y O F R N Ct H L] R A G
Depar, tment of' I,.lea],th & Human Se.l,v:ice!~
82',[2J L, S'l:.r, ee'l:,, Ar~c::i'H::mag6~., A:l.a~,:d<a 99L~O:1
0 N - S Z T ~Ji ~'; E W E R & S E P 'F I [', T A I',1 K F:' E R M I T
Number,~ lil8()046 F'age 2
BERT];FY 'f'H~T
1., :[ am familiar'
.
;i gned:
(O~ner')
s.sued By."
w:i. th the. 1'6!ql.lJ, l'~l~lE~l']'(.!F~ ~'(]1' (:iFl'-r'SitlD ~E)~DP!i~ ~f]d ~)2].1~
For'th by 'l',.he Mun:i. cipalit, y of Anchorage (M(:]A) and the State ur' A:l. aska.
]: ~:i.].:l. ir]s'~',a]l. 1 the ~y~!it, em in acc:~r, dance ~f:i.'(.h all MOA c:clEl~:)s and
and in compliarlce w~.'fJ'l the destgrl cvi{(.~r'ia ~¢ 'f..h:i.s
I w~].l adhere '~:.o all MOA and State of Alasl(a peqLt:i. Pel~len]gs l'(;)p the set, b;:d:::k
f~eNel*aJi;Je system on this (:11' arly ad,ja(::en'[, oP f]eal"by
any en;[ar(;jement ~i:L~ r'equ:i, ve art additionat
~ D A T E:
DE.,:d:GI~ ]:13 WOE.E) ,
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
{ENGINEER'S SEAL)
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
5
6
7
8
9
10
11
12
~//
13
15
16
17
18
19 4301
20
Township, Range, Section:
SLOPE
SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
YES, AT WHAT
IF
DEPTH?
Oeplh lo Water After
Monitoring? f o_~LO~,LJ~ Date:
Reading Date Gross Net Depth to Net
Time Time Water Drop
t It Z ~?. 5, 7d-' , :%"
PERCOLATION RATE .
TEST RUN BETWEEN .
/~.--- (mlnutes/~nch) PERC HOLE DIAMETER ~ '/
~'-- FT AND (~ FT
ACCORDANCE WITH ALL STATE AND MUNICIPAL GU DELNES N EFFECT ON THIS DATE DATE.
72-008 (Rev. 4/85)
I
~l~?ll
32,
3 .
$'/'~$~ e.f. lO' lt~.,
4.
I ~,oa? ..f."
§ ii. ~o.4~'
6 . I
)' ?,ela~'e~T,',~,., ( IN
~lt. ~emt.
,' (~le~. &
I
7
~4,660 &f.
I
14
~l,OlOtt
E. Andorson
15 ~.ee
13
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONNIIENTAL HFALTH
CERTIFICATE OF INSPECTION FOR I-lEAr. TH AUTHORITY APPROVAL
Of: ON-SITE SEWER AND WATER FACILITY
264-4720
Applica,tion Date
GENERAL INFORMATION
(a)
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name .~ S__/_~ ~ 5
Applicant Address
(c) Applicant is (check one): Lending_lustitution []; Owner/builder,J~'; Buyer r'l; Other [] (explain);
(d) Lending Institution ~'/,~?/¢,,/J 4'Y~0~
Address __~./~,~ ~fid/')c~/~.
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family~ Multi-Family ~ Other
Number of Bedrooms ._
WATER SUPPLY
Individual Well [] Communityj~ Public I'.'J
Note: If corn munity well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite ~1~ Public [] Community [] Holding Tank [-]
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page I of 2 72-025 (11/84)
g ~o g
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~ql u! suo!ss!tuo ~o s Joico ~o~ alq!suodso~ ]ou s! o6~oqouv Jo ,~!led!o!un~ Oq.L 'panss! s! ol~oU!~oo ~ o~oloq ~p OZAl~Ue
~o suo!loodsu! ~onpuoo ~ou op d3HQ jo soo,~old~U3 's~uotuoJ!nbo] m~s pue I~J@Pal u!m~ao ,~ls!~s ol JapJo u!
§u!puel J!eq~ pu~ sewoq l.o sJas~qoJnd ol ,~sa:!Jnoo ~ s~ s!q~ s@op dE)HO eq± 'miS~lV ~o el~l~ eq~ u! peJels!§eJ Jeau!6uo
leUO!SSejoJd luepuedepu! uB Xq e^oqe ~ qdeJ§eJed u! ueA!6 suo!j81uasaJdeJ eql uodn ,{lalOS pes~q sa),~OU!lJaa leAoJddv
,~lpoqlnv qll~eH sanss! (dEIHC]) uo!joeloJd IBlUaWUOJ!^u~) pu~ qlleeN Jo luewpBdea e~Joqouv Jo /~i!lBd!ounlAI eql
NOI.Ln¥O
I~^oJddv 18UO!l!puoc) Jo SLUJe/
I~UO!l!puoc) p@AoJddBs!C] ,, ])~ poAoJddv
'9
I~es s,Jeeu!l~u~
.g
~UNiCIPALITY OF ANCHORAGE
' ENViRoNMENTAL S~RVICES DIVISION
AUG 1 5 1988
RE'CEIVED
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
264-4720
Legal Description: L~?'-'
WELL DATA
Well Classification ~z/~~
Well Log Present [Y/Ni _
Tota Depth _ Cased to
Static Water Level
Casing Height Above G 'ound
Electrical Wiring in Conduit (Y/N)
Seearation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest PUbliC Sewer Line
Cleanout/Manhole
Water Sample Collected py
Water Samole Test Results
Comments
Date Con- pleted Yield
Depth ct Groutin9
Pump Set A1
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
On Adjoining Lots
: On Aejoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
Date
B. SEPTIC/HOLDING TANK DATA
Date Installed 7/~"~!
Standpipes (Y/N) _ %
Depression over Tank (Y/N)
/~ Size /~,,5'~ No, of Compartmerlts
Air-tight Ca~ps (Y/N) / Foundation Cleanout (Y/N)
~ Date Last Pumpea
~N~ ; for
Pumping/Maintenance Contract on File (Y/N)
Holding 'Tank High-Water Alarn. (Y/N) ~
Separation Distances from Septic/Holding Tank:
To Water-Su ~ply Wel .~)~) *
To Property Line
To Water Main/Service Line
Course
Comments '-'T~"/',/I/'-
Temporary Holding Tank Permil (Y/N)
To Building Founaanor
To Disposal Field
To Stream. Pond, Lake, or Major Drainage
Page ' of 2
ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~'/'~/,:~ ~
Width of Field ..~'-', I
Depression over Field (Y/N) /'~
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of East Adequacy Test
I
To Water Main/Service Line '~5' ' )
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area 7~' 'q'"'
Comments ~'.V' ~"r" ~-.-''~ f.,O ~).~' ,P.,6" C_A~I~J'"/"
s V -r- 'TO PlA
/
~,~
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
D, LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent {Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA an¢ HAA guidelines in effect on the date of this inspection.
Signed '~. f~l~,~.-~ E ~ate ~/~'/,~ ~
MOA No.
Company
Receipt No.
Date of Payment
Amount: $
Page 2 of 2
72-026 (11/84)
ANCHORAGE, ALASKa 99503
STEVE COWPER, GOVERNOR
563-6775
PUSID #: _.._~_~_~j~_6_ ........
To Uhom It May Concenn:
Accordinq to the records on ?ile in this o??ice, the _Co¢0~C~ ......
.~,--~.~_~_-~.~TS~,~¢~,~=~OWater System is in compliance with the
State o¢ Alaska Drinking Water Regulations,
Sincenely0
¢~ Ronal d S,
Environmental Field O??icer