HomeMy WebLinkAboutEKLUND BLK 2 LT 2Eklund
Block 2
Lot 2
#050-531-06
August 5, 2002
Municipality. of Anchorage
George P. Wuerch, Mayor
Btdlding Sa/cry Division
P.O. Box 196650 · 4700 S. Bragaw Strcct
Anchorage, Alaska 99519-6650 · (907) 343-8301
http://www.ci.anchoragc.ak.us
.rio
Gary Kuchinka
PO Box 770521
Anchorage AK 99577-0521
Subject:
On-Site Water and/or Wastewater Permit.
Permit Number: SW010394
~_.~e]g~llDescriptio..n: Eklund Block 2 Lot 2~
Dear Gary Kuchinka:
An On-Site WaterAVastewater Permit, number SW010394, issued by this office for a single-family
system, will expire on September 26, 2002. This permit was valid for 365 calendar days.
If this was a well permit and the well has been drilled, a well log must be sent to this office for
documentation of the installation and to close the permit.
If this permit was for a wastewater disposal system, an original as-built inspection report must be sent to
this office for review, approval and documentation. This as-built inspection report must be signed by
the licensed Professional Engineer who inspected the installation of the system. As-built inspection
reports are required to be submitted within 30 days of the completion of the system.
If no System was installed under this permit, and you are still planning to install a well or wastewater
disposal system, a new permit must be obtained from this office. A new permit for a second year may
be issued for a fee of $100.00 if the renewal application is received on or before the expiration date of
the original permit.
When applying for a new permit, the fees are: $400.~)0 for a wastewater permit and $150.00 for a well
permit.
If you have any questions, please call this office at 343-7904.
lvl anage, Jaj~nes CrrO ss, P.E. ·
On-Site Water and Wastewater Program
Enc: Copy ofpermit
MUNICIPALITY OF ANCHORAGE
Development Services Department
On-Site Water & Wastewater Program
4700 Soufh Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM I WATER SUPPLY PERMIT
Renewal
Date Issued: Sep 26, 2001
Expiration Date: Sep 26, 2002
Permit Number: SW010394
~Legal Description: EKLUND BLK 2 LT 2 '
Design Engineer: 0041 AK Water & Wastewater Consultant
Owner Name: GARY KUCHINKA
Owner Address: P.O. BOX 770521 Total Bedrooms: 3
ANCHORAGE, AK 99577-0521
Parcel ID: 050-531-06
Site Address:
Lot Size: 95587 SQ. FT.
Permit Bedrooms: 3
This permit is for the construction of:
r~ Disposal Field [] Septic Tank [] Holding Tank [] Privy
Private Well
Water Storage
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 DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day,
B. Covered, sealed, and heated to prevent freezing.
Date:
Parcel I.D.
Municipali.ty of Anchorage
Development Services Department
Building Safety Division
On-Site water & wastewater program
4700 SOuth Braga~' St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak, us
(907) 343-7904
ON-SITE SEWER/WELL PERMIT ~,PPLICATION
FOR A SINGLE FAHILY DWELLING
Permit Number
Property owner(s) GARY KUGHINKA
· Day phone 522-1006
Mailing address (1)
Mailing address (2)
P.O. BOX 770521 * ANCHORAGE. AK
Zip Code 99577
Legaldescription (Lot, Block&Sub'd.) EKLUND SUBDIVISION: LOT 2. BLOCK 2,
Legal description (Section, Township & Range)
Lot Size 35.587 Acres/Sq. Ft.
Number of Bedrooms
THIS
THIS
APPLICATION IS FOR:
Sewer Only
Sewer and Well
Sewer Upgrade
PROPERTY CONTAINS:
Hot Tub
Swimming Pool
Therapy Pool
[3
Well Only
'Water Storage
. Jacuzzi
Water Softening Unit
'[3
I certify that the above Information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal codes.
ALASKA WATER &: WASTEWATER CONSULTANTS, INC.
Permit Fees:
Date of Payment:
Receipt Number;,
~ ~_~ X,[ ReceiptNumber:
August 10, 2001
MunicipaliW of AnchOrage
George P. Wuerch, Mayor
Btfildhlg S,-uCc~, Dixqsion
P.O. Box 196650 · 4700 S. Bragaw Street
Anchorage, Alaska 99519-6650 · (907) 343-8301
h ttl)://www.ci.anchoragc.nk.us
Department of
Public Works
Gary Kuchinka
PO Box 770521
Anchorage AK 99577-0521
Subject:
On-Site Water and/or Wastewater Permit.
Permit Number: SW000396
Legal DeSCriPtion: Eklund Block 2 Lot.2
Dear Gary Kuchinka:
An On-Site Water/Wastewater Permit, number SW000396, issued by this office for a single-family
system, xvill expire on September 26, 2001. This permit was valid for 365 calendar days.
If this was a well permit and the well has been drilled, a well log must be sent to this office for
documentation of the installation and to close the permit.
If this permit was for a wastewater disposal system, an original as-built inspection report must be sent to
this office for review, approval and documentation. This as-built inspection report must be signed by
the licensed Professional Engineer who inspected the installation of the system. As-built inspection
reports are required to be submitted within 30 days of the completion of the system.
If no system was installed under this permit, and you are still planning to install a well or xvastewater
disposal system, a new permit must be obtained from this office. A new permit may be issuedj'bee of
charge for a second year if the application for the renewal is received on or before the date &expiration
of the original permit.
When applying for a new permit, the fees are: $320.00 for a wastewater permit and $120.00 for a well
permit.
If you have any questions, please call this office at 343-7904.
Since~
Jl~l am:aS//r°ss' mE
On-Site Water and Wastewater Program
enc: Copy of permit
MUNICIPALITY OF ANCHORA GE
Department of Health and Human Services
On-Site Services Program
825 L Street, Room 502
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM I WATER SUPPLY PERMIT
Initial
Date Issued: Sep 25, 2000
Expiration Date: Sep 25, 2001
Permit Number; SW000396
Legal Description: EKLUND BLK 2 LT 2
Design Engineer: 0041 AK Water & Wastewater Consultant
Owner Name: GARY KUCHINKA
Owner Address: P.O. BOX 770521 Total Bedrooms: 3
ANCHORAGE, AK 99577-0521
Parcel ID: 050-531-06
Site Address:
Lot Size: 35587 SQ. FT.
Permit Bedrooms: 3
This permit is for the construction of:
[] Disposal Field r~ septic Tank
Holding Tank [] Privy
Private Well
Water Storage
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
(907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By: ~ ~____~_....~=~-
Issued By: ~/~-'~,~~-~
Date:
Date:
ALASIG WATER & WASTEWATER
August 26, 2000
Municipality of Anchorage
Department of Health & Human Services
Division of Environmental Services
On-Site Services Section
P.O. Box 196650
Anchorage, Alaska 99519-6650
Reft Well and Septic Design for Lot 2, Block 2, Eklund Subdivision
To whom it may concern:
The proposed 3 bedroom house will be served by a private well and septic system. Test holes
were excavated on the property. The proposed septic system will be designed around the 30 foot
radii of test hole gl and #2. We are proposing that a 1500 gallon Advantex septic tank and
filtration system and a five foot wide drainfield be installed. Comments regarding the proposed
design are summarized as follows:
1. SOILS: Attached are logs which shows the soil classifications, groundwater monitoring, and
the percolation test results. The soils below the organic layers are a SM/ML material to a depth
of 10.5 feet in TH#1 and to a depth of 8.0 feet in TH#2 (bottom of test holes). No groundwater
was encountered during the excavation of the test holes. A percolation test for TH#1 was
performed between the depth of 3.5 feet to 4.0 feet which had a percolation rate of 10.4
minute/inch. A percolation test for TH#2 xvas performed between the depth of 3.0 feet to 3.5 feet
which had a percolation rate 6f 13.3 minute/inch. It is our opinion thai due to the overall
appearance of the soils, a application rate of 3.0 gallons/day/ft2 should be used for installation
with an Advantex system.
2. TRENCH DESIGN:
a. Percolation Rate: 10.4 & 13.3 minutes/inch
b. Allowable Application Rate: 3.0 gallons/day/ft2 for Advantex
c. NumberofBedrooms: 3
d. Design Flow: 450 gallons per day
e. Minimum Absorption Area: 150 ft2
f. Total Depth: 4 feet (max.)
g. Sand Filter: 2 feet
h. Effective Depth: 0.5 feet
i. Width: 5 feet
j. Minimum Length: 30 feet long
6901 Debarr Road, Suite 2B * Anchorage, AK 99504
Ph: (907)337-6179 * Fax: (907)338-3246 * Website: akwxvc.com
k. Effective absorption area = 150 ft2
3. SURFACE WATERS: There is a stream which runs from east to west approximately 110
feet away and down hill from the proposed trench. The 100 foot offset is to be flagged by a
registered land surveyor prior to beginning construction.
4. TOPOGRAPHY: As can be seen on the attached topography site plan, the average
topography of this property is a 30 to 35 percent slope running from approximately northeast to
southwest on the northern half of the lot. There is a cutbank that runs from approximately
northwest to southeast in the middle of the lot. The trench is to be installed on a 30 to 35
percent slope that is naturally vegetated and will not allow for the surfacing of effluent. The
trench is designed 50 feet from the specified cutbank. We are requesting a waiver be granted for
a separation distance of 40 feet from the proposed road/driveway cutbank to the proposed reserve
site. Because of the natural vegetation of the slope, and the percolation rate which would
encourage effluent to move quickly downward through the soils we foresee no problems with
this separation distance.
We are unaware of any adverse impacts this installation would have on adjacent wells or septic
systems. If you have any questions, please contact us at 337-6179, or 244-9612. Thank you for
your assistance.
., M.S.
President
NOTE: Attached is a site plan drawing, a design drawing, a profile drawing, a topography site
plan, 2 soils logs, and a 7page construction specification letter which are all part of the design
package for this septic system.
6901 Debarr Road, Suite 2B * Anchorage, AK 99504
Ph: (907)337-6179 * Fax: (907)338-3246 * Website: akwwc.com
I KIRK SUBDMSION; /
'~ ~ ~ ,'- ~ LOT 4. BLOCK 2 ~ I LOT 1
/
.- ~--~ ~ ~.-~c--~' , /
, x~~. ~ .... Z ..... . vi: ,, ,
'~'~~ ~"~ ~ / ~ ', ,,I ~"
~OT 7, BLOCK 4 ~ ~ ~ ~ ~ '. ~.,~7~ / ~ II //' '~9~]///
----..~ ~. -~ ~ ',,
I
~ ///~ x, ,
I NORTH S~PE SUBDI~SION;
I ~T 14, BLOCK 5
. I
I
EKLUND su~p~)~L~; / / / ~ ) J /
LOT~..LOCK1 /// .............. / ~ , m
. ,~/ / EKLUND SUBDNIS ON; / J I I
/// LOT ~. .LOCK ~ J ,/ / m m
///........ . , ~ , ,
~~/ ~_ / ~ [/~T l..~OCK ~ I
I
1
8/14/2000 .~='
.... a.w.~. ~'1 rl ll ~' ~'~%
----~ CONSULTANTS, INC. ~ .~(:~ .
6901 DEBAR RO~, S~TE 2B ' ~CH~GE, ~ 9950~ ' ~ONE (907~37~179 ' F~ (907)338~2~6 1" = 1 oo'·
PREPAEED FOR PHONE NUMBER: P~E NUMBER:
OA~Y KUCH~KA (907) 522-100e ~ oF 3 'o~t~ ~ff~ey;9.
LEo~ ~SC.[~O.: ~;~ [.. CE~]7953 ,..'
EKLUND SUBDIVISION ; LOT 2, BLOCK 2 '~J~{[e~_' ....... ".~%~;
SITE P~N FOR NEW SEPTIC SYSTEM (ADVANTEX) ·
/ / \ I
/ / / I
/ I I
' EXCNATE A ~CH ~T IS 4 ~ DEEP r / / I
~ ~ ',~%.~*o~%~,~~ ~/ ' . ....... L ............ L~.. ) /
~ h ~co,,~o~ / ~/'m
~ . -X, ./"- '
...... .....
AIAS~ WATER & WASTEWATER
PREPPED FOR: PHONE NUMBER: PAGE NUMBER: .......
GARY KUCHINKA (907) 522-1006 2 OF 5 ~ .i re ~ ss~:'"~
EKLUND SUBDIVISION LOT 2, BLOCK 2
DESIGN DRAWING FOR, NEW SEPTIC SYSTEM (ADVANTEX)
AdvanTex Treatment stem
'~*, e ~'
AX Series - Mode la
Three (3) 34x48 Pods
NOTE: THE BOARD INSULATION IS TO
BE INSTALLED OVER THE SEPTIC TANK
& 4" BEYOND ON ALL SIDES EXCEPT Pxs~w ~ VmT--~
UNDER THE ADVANTEX FILTER. THIS
WILL ALLOW FOR THE HEAT TO
ESCAPE FROM THE TANK & RISE TO
THE FILTER ABOVE IT.
INSULA1ED FIB~R~ UDS
m ~ ~ ~ r~.~.~=a =~,
OR£N¢O
t_ LJ Illll I BIOTUBE
- I.~oo ~.~u.~ Illlt / SCREE~qED
. ,Iff L VAULT
EFFLUENT
i SHALL BE AS SHOWN ON THE All'ACHED DRAWING PUMP
i PREPARED BY ANCHORAGE TANK & WELDING.
PROPOSED DRAINFIELD, EXCAVATE A
TRENCH THAT IS 4- FEET BELOW
. /.- IqNAbt:~.Al~ ORGNAL GRADE, BY 5 FEET WIDE,
2 ,~A"LIM :: ~ / BY 30 FEET LONG. ADD 1tNO FEET
2~""qh'~C'OVFr'R~ / MINIMUM OF LEVEHNO SAND, AND 6
~ ~ 2" "SU. AIION / INCHES OF' CLEAN, WASHED SEWER
'~ 'N~ " -~ / /--FL1T-~fA.'.'.'.'.'.'.'.'.~ DRAINROCK. SEE PAGE 2 Of 3 FOR
'~._~ \ / / LOCATION. INSTALL TRENCH PARALLEL
,.:;:'... :-';*;:"-'.:'~ :,;. '~~.
.,-"' : .:.';:..'-;~-,'.';:"-'.:.'-';~' 7~' ',3¢ ~, .........
· , '.'~' ~.;,,.'.'*~.":' °'...'".i." 'tv ,
~ ~,tl'"J I'I,11~R t,~lEl~Vt,. · ""? -. -:. ":~ % i :' ';*":' '-' ~ .,t.:/-. 12~
,.,,.,;. :...,., :-, · .,..'~.~,.. ~ ..,:: ¥', ,..,.:.
DATE:
' '~'"'~:": : '~" 8/26/2000
,__ .~? "~'"?"'~' o~w, .,: ~x~.... ....... ~..~ ~,~
,.w.,.
WATER & WASTEWATER
PREPARED FOR: PHONE NUMBER: PAGE NUMBER: ;....~.~
GARY KUCHINKA (907) 522-1006 $ OF 5 ~h.~
£KLUND SUBDIVISION -; LOT 2, BLOCK 2 'lJ~'~Joj-,.. I ..-"'~*_~
PROFILE VIEW OF PROPOSED TRENCH AND ADVANIEX SEPTIC TANK
spocI 8gx'~£ (£) ug opoIAI osfl IU!Oocls
Iii'Il
!
ALASKA WATER & WASTEWATER CONSULTANTS, INC.'
6901 DEBARR ROAD. SUITE 2B * ANCHORAGE, AK. 99504
PHONE (907)337-6179 '" FAX (907) 538-3246
J SOIL LOG - PERCOLATION TEST J
LEGAL DESCRIPTION: EKLUND SUBDIVISION ~ , LOT 2, BLOCK 2,
PERFORMED FOR: GARY KUCHINKA
DATE PERFORMED: 5/4/00
ORG*N,CS I TEST HOLE #11
w,~M/ML
SOME
GRAVEL
BEDROCK
SOIL CLASSIFICATIONS
JGW
GM
GC
SW
~SC
ORG
NL
CL
OL
NH
CH
OH
DEPTH TO
SROUNDWATER DATE
DRY 5/4/00
6.25' 5/11/00
DRY 9/14/00
.100" WELL RADIU~
LOT 3, BLOCK 2,
\ EKLUND S/D ~1
\
CREEK
LOCATION)
/ I
I
I
I
DATE READING CLOCK NET TINE WATER LEVEL NET DROP
TINE (NINUTES) READING (INCHES)
5/5/2000 PERC. HOLE WAS PRESOAKED 4+ HOURS PRIOR TO TESTING
I 5:25 6"
2 5:55 30 2 3/4" 3 1/4"
3 5:55 6"
4 6:25 30 3 1/8" 2 7/8'
5 6:25 6"
6 6:55 30 3 1/8" 2 7/8"
PERCOLATION RATE 10.4 (HIN./INCH) PERC. HOLE DIA. 6 (INCHES)
TEST RUN BETWEEN 3.5 FT. AND 4.0 FT.
CONMENTS:
PERFORMED BY ALASKA WATER & WASTEWATER. i, JEFFREY a. GARNESSo CERTIFY THAT THIS
WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON
DATE: c///C'/oo
ALASKA WATER & WASTBWATBR CONSULTANTS, INC. ~ OF
~o, o~ ~o~. ~.~ ~. ~o~. ~. ~o~ ~...~ "7/: ..
I soil LOG - PERCOLATION TEST I ~.~/~,o...' ~/<, Ib'///~L ".?.
PERFORMEDLEGAL DESCRIPTION:FoR: GARyEKLUNDKucHINKASUBDIVlSION ~?'. LOT 2, BLOCK 2,~'%'"' 'j~i ~,~Z--~ ~ ]~/~v~jv~,. g~';;:...
..........
~ GP ~ NL EKLUND S/D ~1 / j
~JlNIII~I)IIi w/ SOUL~~ CRE~K (~PROX~
EL GC OL LO~ON) ~ ~ / i I
SP CH
SM OH
SC
GROUNDWATER DATE ~ ~ /j+~/' ~ I
~~ ,DROCK DRY6, 5/15/4/001/00 ~ ~x~ -// ~¢~>'/ ~ '~ll
DRY 9/14/00 ~ '~~// [ I I I
10
~1 DATE READING CLOCK NET TIME WATER LEVEL NET DROP
TIME (MINUTES) READING (INCHES)
12 5/5/2000 PERC. HO~ W~ PRESOAKED 4+ HOURS PRIOR TO TE~NG
15 1 5:26 6'
2 5:56 50 55/8" 25/8"
14 5 5:56 6"
4 6:26 50 55/4" 21/4"
15 5 6:26 6"
16 6 6:56 ~0 55/4" 21/4"
17
18
19 PERCO~TION RATE 15.5 ,(HIN./INCH) PERC. HOLE DIA. 6 (INCHES)
20 TEST RUN BETWEEN 5.0 FT. AND 5.5 FT.
COMMENTS:
PERFORMED BY A~SKA WATER ~ WAST~ATER. I, JEFFR~ A. GARNESS, CERTI~ THAT THIS
WAS PERF~M~ IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON
DATE:
DEPTH TO
GROUNDWATER DATE
DRY 5/4/00
6' 5/11/00
DRY 9/14/00
;ent,'By[ MLA;
PLASTIC COLLAR
IBE AT TF~'"T HOLE
I 907 694 8965; Jul-28-00 2:12PM;
Page 4/4
I
I
I
oo
t'13'35"
80.og'
L-41.57'
(,'.-,la
(L"41.56'.)
!
I
S i I~l~tll I1~_ I/~R I
UL~L~I V l~l~Jl V
I
I
I
I
I
en~' By.: ULA; 1 907 694 8965; Jul-28-O0 2:11PM; Page 2/4
~.~1.~I.0 ;)
$
..... 2 ~ ~'u'E- -~- - -~ZU-n :~
..............
/ '-. ./~ ~ -- /~ ..
,/. ~.~ ~ . . ..
, .:/ / ~ ~, · ~ .......
/ .- . ,,~ ~ ......
~ ~ ~//~ / //. ,, · .... _.,-
~ ~ / ~/Z,..~ _. .......' /
. ~ a :~"' '. ~ /
~ ....'/ ,
./' '- ..' ~~ *.- ~,~ ~ I''~ :~ ~-f~.~
.. , , . . .... ~ ~ ~ ~_ g-~ . . =~:. =~.= =.
~ ~ , ~ . N ' ;-=~ Z~.~ ~-=- -'-- - ~
. ~'~ ..: ~.~[~ *~;'- ~ ~:~ .,~ ~ '~.
i " ~ ~ -
Municipality of'Anchorage.
Department of Health and Human Servu:e
· 82,5 'L" Street
P.O. Box 1966S0 Anchorage, Alaska 99519-6650
httlr.//w~wv, ci~ nchomgo.ak.u~
Dear Homeowner/Pw~five Buyer:
The on-site wastcwater disposal system you are purchasing/installing is an "alternative" wastewater
disposal system. This system, known as an AdvanTex Trcatment System Septic System:, is
undergoing testing v~thln thc Municipality of Anchorage Under the Alternative System section of the
Wastewater Disposal Regulations (AMC 15.65). There arc certain risks involved with the ownership
of one of these systems:
The technology used in this system has been shown to bc effective in other areas. The system
is currently Undergoing a two-ye;= testing period in Anchorage under thc gu/dance of the
Department of Health & Human Services. (DH[-IS) and the State of Alaska Department of
Environmental Conservation (ADBC) to determine its effectiveness in a subarctic environment.
2. The system for this property receded a vertical Separation distance waiver from both the State
of Alaska and Anchorage Mnn;cipal Codes to ground water. This waiver was granted due to
thc system's expected p~rformance with;~ the site conditions on this property.
I (we) certify that I (we) have read thc at,)ye statements and am(arc) aware of the risks outline. I (we)
also certify that, I (we) am (am) in the process of purchasing (property legal description):
(P~rchsser ~ame) (Purchaser Name)
srsm tu e) (Purchaser signore)
· Notarize Below
. personally appeared before
who is personally known to me
__ whose Identity [ prov-.A on thc oath/affirmation of .., ,
a credible wimess to 1~ lhe slgaer of the above document, a~d he/she ack~owl,~..~ he/she s/~ned it.
(Not~
(Notary l~bllc Printed Name)
PROPERTY OWNER MAINTENANCE AGREEMENT
ON-SITE WASTEWATER DISPOSAL SYSTEM
This agreement, dated ,~7- 2~'''~ ,2000, is made between the Municipality of
Anchorage D.epartmen. t of He~Ith and Human Services (DHHS) and the prOperty owner(s) of
This agreement is made for the purpose of maintaining an on-site wastewater disposal system
on the subject property.
The property owner(s) agree to the following:
The property owner(s) will have an annual inspection of the system' performed by a registered
professional engineer. This inspection shall verify that all effluent and air pumps, timers, and
alarms are functioning as designed. Any deficiencies shall be corrected and the engineer's
statement that the system is functioning as designed shall be filed annually with the DHHS.
Prop~ty Owner Name
Property Owner Name
(Notarize Here)
~,(~.Judicial District ~ SS.
On th~ 'z~ day of'~/~;- ,'~ ~- in the
year P_.O~9~9., before me, the undersigned notary
public, personally appe, ared.:
~,.rt~ t~ fi::~t~/~. ,~ ~.,~. known to me to be
the pearson(s) whose name(s) is/are subscribed to the
within instrument and acknowledged that he/she/they
executed the same for the purposes therein
contained.
In witness whereof, ]4hereunto set my hand and
~o~lic {si~'n~.~e> -,,. -
(Notary s printed name)
My c~i7 expires: