HomeMy WebLinkAboutVALLEY VIEW TERRACE BLK 1 LT 2B
i % 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
NAME PHONE E~NEW
MAILING ADDRESS
~ ~ DISTANCE TO: Well Dwelling PER~IT NO.
TO:
~ ~ ~ No. of lines Length of each line lota, length of mines Trench widtb Distance between mines
inches
· ~ ~ ~ Type of crib ~o~c r. Crib diameter Crib depth,. Total effective absorption area
Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Building foundatioo Sewer line Septic tanE Absorption area(s)
OTHER
SOlINSTALLERL T~rpEST RAT'NG
APPROVED DATE LEGAL
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAl. PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LO(] - PERCOLATION TEST
[] PERCOLATION
TEST ~2
SLOPE
SITE PLAN
~ 1
~,..- 2
3
4
5
6
7-
8
9-
10-
11
13-
ENCOUNTERED? ~/&/~ ~- -
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
15-
16-
17-
18-
P .......... N RATE
COMMENTS
TEST RUN BETWEEN
, ET AND
(minutes/inch)
-- FT
PERFORMED BY: ,~%~ ~;~ ~/~-~J' ) ~ ¢~ ~'~ CERTIFIED BY:
72-008 (6/79)
poIj...~ 6 650
ANCHORAGE, ALASKA 99502-0650
(907) 264 4111
TONY I(NOWI ES.
MA YOR
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Permit #: 840534
January 31, 1985
TO: Permit Applicant
SUBJECT: Lot 2 Block 1 Valley View Terrace Subdivision
A permit issued by this Department for an individual well
and/or on-site sewer system has expired as of December 31,
1984.
Permits are issued on a calendar year basis by authority
of Municipal Ordinance. A new permit must be obtained from
this Department for any well and/or on-site sewer system not
installed by the expiration date.
If you have drilled the well, a well log needs to be sent
to this Department for documentation of the installation
and to close the permit.
If a private engineer inspected the installation of the
on-site sewer system, the original as-built inspection report
and the yellow copy must be sent to this office for review
and approval, and for documentation.
If there are any further questions, please call this office
at 264-4720.
Sincerely,
orKeith E. Bandt, SupeYvis
Environmental Engineering Program
KEB/ljw
enc: Copy of Permit
SW?/057
MUN-][C I F'AL I TY OW= ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L STREET, ANCHORAGE~ AK 99501
264-4720
ON--S I ~TE SEW. EZR ~ WE~-_ L PERMIT
PERMIT NO:
DATE ISSUED:
07/02/84
APPLICANT: C/O S & S ENG'G. JAKE CHRISAFULLI
ADDRESS: GRB 196X
EAGLE RIVER, AK 99577
CONTACT PHONE: 694-2979
LEGAL DESCRIP:
LOT SIZE:
MAX BEDROOMS:
SUBDIVISION: VALLEY VIEW TERRACE LOT: 2
SECTION: 22 TOWNSHIP: 12N RANGE: 5W
20000 (GQ.FT. OR ACRES)
BLOCK: 1
Listed below are the options available to you in designing your septic
system. Choose the option that best Fits your site.
W. I}RA ][ N
DEPTH TO PIPE BOTTOM (FT.)
GRAVEL DEPTH (FT.) 0.5 1.0
TOTAL DEPTH (FT.) ~.0 3.0
GRAVEL WIDTH (FT.) 17.0 5.0
GRAVEL LENGTH (FT.) 54.0 77.0
GRAVEL VOLUME (CU.YDS.) 21.4
TANK SIZE (GALS) 1~000.0
SOIL RATING (SQ. FT./BR) 125 146
DEPTH TO PIPE BOTTOM < 3.5 FT. REQUIRES INSULATION
DEPTH TO PIPE BOTTOM < 4.0 FT. MAY REQUIRE A LIFT STATION
GRAVEL LENGTH > 75 FT. REQUIRES MULTIPLE RUNS (NOT EXCEEDING 75 FT. EACH)
TANK MUST HAVE AT LEAST TWO COMPARTMENTS
I certify that:
1. I am £amilimr with the requirements ~or on-site sewers and wmtls am
~orth by the Municipality of Anchorage (MOA) and the Gtate o£ Alaska.
2. I will install the system in accordance with all MOA codes and regulmtio~s,
and in compliance with tqe desig~ criteria of this permit.
3. I will adhere to all MOA and State o~ Alaskm requirements for the set~ ba~k
distances £ro~ any existing well, wastewater disposal system or public
sewerage system on this or any adjacent or nearby Iot.
4. I understand that this permit is valid ~or a maximu~ of 3. bedrooms and
any enlargement will require an additional permit.
IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES~
THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTG
WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE
ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN.
SIGNED ~/ ~ DATE:
APPLICANT: C/O S & S E~G'G. JAKE CH~ISAFUL[I
PERFORMED FOR:
7
8
9
10
11
12
13
14
15-
17,
18.
19-
20-
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTIVlENT OF HEALTH AND ENVIRONMENTAL PROTECTION_,d,~./~ ~) ~E~TCOLATION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
DATE PERFORME~
/ SLOPE SITE PLAN
6
COMMENTS
/
t
Reading Date Gross ,~et Depth to Net
k Time j Time Water Drop
RERCOL.~T!C~.JRATE J~ ~ ~ (minutes/inch)
TEST RUN BETWEEN '"~FTAND -- FT
PERFORMED BY: ~'~r-~
CERTIFIED BY: ~'~ DATE:
72-008 (6/79)
- O & E E EERING & DEVEL'C MENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
Russell Oyster Earl Ellis
694-2774 SOIL LOG 688-2280
Performed for: Name: ~"~/~'~ ~'~/-//~ / 5' ,~FU~! Tel. N0 [~" ~
Mailing Address: ~ ~'' ~ ~/ ~ ~/ ~'
Legal Description: L~2, ~/~/,. ~V ~/~'~ ~~ ~-
Depth (feet)
Soil Characteristics
0
1__
2__
3
4__
5__
6__
87 ~]] ~-'~'~.~'w~;,~~
9__ /--4
10 /~o ?-'r~
7--0
11__
PLOT PLAN
12__
13__
14__
15--
16__
Ground Water Encountered: Yes ~ No
/~O/t~/~/ ~c~ TLY ~E=
If yes, what depth
Proposed Installation: Seepage Pit
Drain Field
Comments:
PERC. TEST
Performed by: ~. ~4~_/.~
Date'
· GR E4Y"~",, AN C H 0 RAG E AREA
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME //~/f}/¢~'~'/) /~1~;-/~'" MAILING ADDRESS
SEPTIC TANK:
DISTANCE
FROM WELL
INSIDE LENGTH
PHONE
~ . [ , ~_./j~,~c.yCi_~Z.' NUMBER OF
MANUFACTURER (~'~ [ ~' ~{~ ~/ MATERIAL COMPARTMENTS
INSIDE WIDTH LIQUID DEPTH .LIQUID CAPACITY /(~) GALLONS.
SEEPAGE PIT:
NUMBER OF PITS __
LINING MATERIAL
BUILDING FOUNDATION__
DIAMETER ~ OR WIDTH LENGTH DEPTH 131
CRIB SIZE: DIAMETER /~' DEPTH (~.1 DISTANCE FROM:
TOTAL EFFECTIVE
NEAREST LOT LINE __
WELL
ABSORPTION AREA (WALL AREA) ~]L/
.SQ. FT.
ADDITIONAL ABSORPTION
WELL:
BUILDING NEAREST NEAREST
FOUNDATION LOT LINE SEWER LINE
DEPTH DISTANCE FROM:
SEPTIC ¢(~t SEEPAGE (~2~
TANK SYSTEM
CESSPOOL
OTHER SOURCES
APPROVED DISAPPROVED
REMARKS
DISTANCES:
DIAGRAM OF SYSTEM
INSTALLED BY:
PIPE MATERIAL:
LOT SLOPE:
REMARKS:
Form No. EQ~031
GrEATEr ANCHORAge Area BOrOUgh
DEPARTMENT OF ENVIRONMENTAL QUALITY
SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT
PERMIT NO,
TYPE AND SiZE OF FACILITY TO BE SERVED
PHONE .
., OTHER.
NOTE: TMIS PERMIT IS NOT VALID WITHOUT SOIL TEST
FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCES, REQUIREMENTS
FOUNDATION TO SEPTIC TANK
FOUNDATION TO SEEPAGE PIT ~
/~-~
SEPTIC TANK TO SEEPAGE PIT WALL
SEPTIC TANK -, SEEPAGE PIT
TO NEAREST LOT LINE.
W~LL TO SEPT'C TANK
DRAIN FIELD
WATER MAiN TO SEPTIC TANK
DRAIN FIELD
SEPTIC TANK, , SEEPAGE PIT
TO RIVER, LAKE, STREAM.
DRAIN FIELD
CAST iRON INTO AND OUT OF SEPTIC TANK AND iNTO CRIB CROSSING GAP OF
EXCAVATION 5 FEET INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIO TANK AND SEEPAGE PIT
F~TTED WITH AIRTIGHT REMOVABLE CAPS.
DIAGRAM OF SYSTEM
CONFORM tO BO~O~E~O~TION$ REGarDING INSTALLATION.
i CERTIFY THAT [ AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE
08`EGEOTECHNICAL 8' DEVELOPMENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
Earl Ellis
Russell Oyster 688-2280
694-2774
Soils 8- Foundations Land Development
SOIL LOG
Perfomed for: Name:
Tel. No.
Matling Address:
'Legal Description:
Depth (feet)
So11 Characteristics
12
Ground Water Encountered: Yes No ~
If yes, what depth
Proposed Installation: Seepage Pit ~ Drain Field
'Oi.A)[:I< ~ L
Ii
I
WILL.
tZI .EiC I
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
GENERAL INFORMATION ~' ~/¢c,K I
Legal Description (include?t, block, subdivision, section, township, range)
Location (address or~irections)
(b)
(c)
Applicant Name ,.7-~ ¢ o A (' ~-'~' ¢'* //' ' Telephone: Home /~./~ Business
Applicant Address /~,O. z~,.>r ,~-~' '3 L:~sz~ ,,'¢~,.~c~, .~,;(
Applicant is (check one): Lending Institution [] Owner/builder ~; Buyer []; Other [] (explain);
(d)
(e)
Lending Institution ~ /¢'r ~'~
Address ,¢~,¢, z~o~ '~ 7~
Real Estate Company and Agent
Address
Telephone
Telephone -~' ,2 ~, _ ~'~C' 2/
(f) Mail the H,AA to the following address:
TYPE OF RESIDENCE
Single-Family~ Multi-Family []
Number of Bedrooms ~
Other
WATER SUPPLY
Individual Well~' Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environ mental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite~ Public [] Community [] Holding Tank [] /
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
72-025 (11/84)
Page 1 of 2 ¢,
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATioi,~
As certified by my seal affixed hereto and as of the validation date showo below, I verify that my investigatioo ~ ~
Authority Approval shows that the on-s te water supply and/or wastewater disposal system is sate fUnCtior~ah
for the number of bedrooms and type of structure indicated herein. I further verify that based on the ntormatio~ ¢
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and~'~f
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 F~..~ IF RIVIFR FN{~INEt:Rt~' Telephone
EAGLE RIVER, AK §9§;I
Address [', O. ~
Engineer's Seal
6. DHEPAPPROVAL
Approved for "~'~
Approved
?
Disapprove/t~/' ' /' Conditional
Terms of Conditional Approval
Date
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their [ending
institutions in order to satisfy certain federal and state requirements. Employees of [:)HEP 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.
Page 2 of 2 ~
DEPT. O~ ~NVlRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA 99501
BILL SHEFFIELD, GOVERNOR
274-2533
Mr. Lou Butera, P. E.
Eagle River Engineering
Services
P. O. Box 773294
Eagle River, Alaska 9957 7
July 1, 1985
Horizontal Separation Waiver Between Well and Leach Field,
Lot 2-B, Block 1, Valley View Terrace, Eagle River, Alaska
8521-WA-176
Dear Nr. Butera:
The Department has reviewed the subjectwaiver request and hereby waives
the horizontal separation between the well and leach field to 90 feet
on the subject property for a 2 bedroom single family residence only.
Sincerely,
Steve Eng, P.E.
District Engineer
SE/dd
WELL DATA
Well Classification /4:) ~, ~
Well Log Present (Y/N)
Total Depth /o ~
Static Water Level ~=~' /
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4728
~ ~NVIRONMENTAI. PROT£C~ION
Legal Description:
M , ~ ,.~ T~ r' r'-, ¢ ,c
IfA, B, C, D.E.C. Approved (Y/N)
Date Completed ? ~ ~ q Yield
Cased to ~'z~' v- Depth of Grouting
Pump Set At
/~" Sanitary Seal On Casing (Y/N)
.)/ Depression Around Wellhead (Y/N)
JO0 / ; On Adjoining Lots /~ ¢
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line /~o'-',-'-~
Cleanout/Manhole
Water Sample Collected by /:~ ~ ,~ e ~ ,-
Water Sample Test Results
,,~ z ; On Adjoining Lots /~ ~'-
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
;Date ~'//' ¢/~ i-
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed /~'~5- Size /,¢~¢~:~ No. of Compartments
Standpipes (Y/N) ~' Air-tight Caps (Y/N) ~' Foundation Cleanout (Y/N)
Depression over Tank (Y/N) /t.) Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) "~ · ; for
Holding Tank High-Water Alarm (Y/N) /~.,~ Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well
To Property Line ~/~ /
To Water Main/Service Line ~ &~ '~ Course
To Building Foundation ~- ~ ?
To Disposal Field /d_) /
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed /¢) 75-
Width of Field //~"
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test .~,
Separation Distance from Absorption Field:
To Water-Supply Well 7°9 ' ~"~'
To Building Foundation --'4-',2
Lot
To Water Main/Service Line /o
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storag? Area
Comments
Type of System Design
Length of Field /9"
Depth of Field / '3
Gravel Bed Thickness ~ r
Standpipes Present (Y/N)
Date of Last Adequacy Test
.Y
To Property Line Y/E2 /
To Existing or Abandoned System on
; On Adjoining Lots ..~o ~-
To Cutbank (if present) ,/Vcr~
LIFT STATION
Date InstalleO
Size m Gallons
"Pump On" Level at
High Water Alarm Level at
'rested 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 and HAA guidelines in effect on the date of this inspection.
Signe~~¢:¢~ Date '7/°-,/ac&-
Company ~'/~"~"/~'£' MOA NO. ff~ ~ ~ ~-
Receipt No. ~4~1 ~
Date of Payment ~ ~' O~
Amount: $ q- ~ - ~ ~
Page 2 of 2
72-026 (11/84)
Engineer's Seal
n!
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 L Street-Anchorage, Al"$"a ~0~01 ,
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10} days for processing.
P PERTYOW.ER ~l~I PHONE
· BUYER ~ PHONE
I
MAILING ADDRESS
4, REALTOR/AGENT / PHONE
MAI LING ADDR ESS
E, LEGAL DESCRIPTION
STREET LOCATION ,
6. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] One [] Four
SINGLE FAMILY ~Two [] Five
MULTIPLE FAMILY [] Three [] Six
[] Other
7. WATER SUPPLY
~ INDIVI DUAL* * ATTACH WELL LOG. A well log is required for all wet[s drilled
[] COMMUNITY since June 1975. For wells drilled prior to that date, give well
[] PUBLIC UTI LITY depth (attach log if available.)
8. SEWAGE DISP. OSAL SYSTEM
~. INDIVIDUAL/ON-SITE**
[] PUBLIC UTI LITY
**If individual/on-site, give installation date
If system is over two (2) years old an adequacy test is required
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72~)10(3/78)
. THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR I NSP ECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[]INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBUC UT.ITY &
Connection Verified INSTALLER
[]Septic Tank or [] Holding Tank
Size: ]O~O IfTankishomemade SOILS RATiNG
give dimensions: ~,~ (~-)
TYPE OF TANK
MANU FACT RER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
dP
[:;]'/'APPROVED FOR ~).~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[Z~-"~D I S A P P R O V E,.~/D
DATE ~ .- (/~'"r~ -'? i~Y BY (Title)
LEGAL DESCRIPTION
72-010 (Rev, 3/78)
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C" Street, Anchorage, Alaska 99503 274-4561
Date Received 3/12/75
Time of Inspection
Date of Inspection 3/14/75
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
FOR
VA
1. Approval requested by:
Mailing Address:
2. Property Owner:
~ailing Address:
3. Legal Description:
Selective Realty
Harold Haeg
Eagle River AK
Phone:
Phone:
Lot 2, Blomk 1, Valley View Terrace Subdivision
4. Location: Eagle River Road
5. Type of facility to De inspected
6. Well Data:
A. Type Drilled
o
C. Construction
Sewage Disoosal System:
A. Installed
C. Septic Tank: 1.
D. Seepage Pit: 1.
Well Pit
Single
No. of bedrooms 2
B. Depth 107'
D. Bacterial Analysis Satis£acto~.~'
3/17/7s
See Comments.
B. Installer
Size 2. Manufacturer
Absorption Area 2. Material
E. Disposal Field:
Distances:
A. Well to: Septic tank
Nearest lot line
B. Foundation to septic tank
Total length of lines
, Absorption area
, Other contamination
, Absorption area
C. Absorption area to nearest lot line
, Sewer Lines
EQ-034 (1/74)
Page 1 of two ,,~ac~e~
Legal Description
LO'C 2~ Block 1~ Valley View Terrace
Comments Approval pending escrow funds for upgrade of sewer system and well
prior ~o July 1~ 1975.
e~ ~ ~'~'. Disapproved
Approv Date
Approval:Valid for one year from date signed~
Greater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
certify that the information contained in this request for approval to be a true and
accurate representation of the subject sewer and water facilities and these facilities
are operating satisfactorily.
SIGNED Date
EQ-034 (1/74)