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Home My WebLink AboutGATEWAY TO THE PARK BLK 1 LT 22Gateway to the Park Block 1 Lot 22 #067 - 611 - 06 Municipality of Anchorage �UBMI'' On -Site Water and Wastewater Program • (907) 343-7904 • a ON-SITE WASTEWATER INSPECTION REPORTlPli JAN 13 2014 Permit Number: OSP131394 PID Number: 067-611-06 Dwelling: // Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ■ New /4 Upgrade Name: ETHAN BENSON TRUST... ABSORPTION FIELD - EXISTING Address 1835 MOUNT YUKLA CIR. EAGLE RIVER, AK a Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound ❑ Other Phone Number of Bedrooms 3 Soil Rating -- GPD/SF Total depth from original grade -- Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe Subdivision Block Lot -- Ft. -- Ft. GATEWAY TO THE PARK 1 22 Fill added above original grade Gravel length Township Range Section -- Ft. -- Ft. Gravel width Beds: Number of Lines Distance between lines SEPARATION DISTANCES -- Ft. Ft. To From Septic Tank Absorption Field Lift Station Holding Tank Sewer Line Total absorption area -- Ft' Number of trenches -- Dist. between trenches Ft. Well 100'+ -- -- __ 254. TANK El Septic ❑ S.T.E.P. ■ Holding ❑ Other Manufacturer Capacity Surface Water 100'+ -- -- __ ANCHORAGE TANK 1000 Gal. Material Number of compartments Lot Line 5'+ -- -- -- NA STEEL 2 Foundation 5'+ -- -- -- LIFT STATION Manufacturer Capacity Curtain Drain NA -- NA -- Gal. Remarks Existing septic tank decommissioned Pump on level at Pump off level at High water alarm at per code & new tank reconnected in. M. in. to existing system. New tank insulated. Pump make and model Electrical Inspections performed by nstaller JRs PIPE MATERIAL House to tank D3034 drainTank to D303I4 Drainfield -- Co/MT D3034 Inspector ARCTERRA BENCH MARK (Assumed elevation) 100 ft Inspection dates: 1" 11/4/13 20d 12/3/13 Location and description 3rd 41h Bottom Of Siding COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL Conditional Approval: Date y 11.,1a� Air 4 /,/ Approved id Date 1 -/3-/ 471 saki '. AS—BUILT TANK DETAILS/SITE PLAN GATEWAY TO THE PARK S/D El L22 APPROX. LOC. SEPTIC REMOVED / 0 EXISTING S. NEW 1000 -GAL OMMI & INSTA S.T. IN SA COVERED ENTRY ONED ED E LOC. CANT •0 ac APPROX. LOC. SEPTIC i:\°-.3 :\ 0041 ®WELL LL Permit: ❑SP131394 PID# 067-611-06 10' DRAINAGE EASEMENT S88'07109"E 171.39' (171 24' R) APPROX. LOC. WELL LOT 23 A -C=13.6' U B -C=18.8' A -D=20' 5B -D=19.5' a i� Su F- O 099.66 2 4F.Y1111i rcI 4a 0 Ms uTmx o 4 7100^ 0 GAL ti / SEPTIC em TANK 95.49) 0 V o ` / *11y KE M D L 1 3 0 A N N SCALE: 1' = 50' SUMP SCALES NTS EXISTING TRENCH PREPARED FOR: ETHAN BENSON TRUST 1835 MOUNT YUKLA CIR EAGLE RIVER, AK 99577 FIELD BOOKS COMPUTED: eauNDARr. BOUNDARY DRAWN: BMW STARING: STAKING cHEcKED: KMD ASBUILT: JLS DATE: 12/3/13 DWG. FILE: GRID: SE1005 ACRD FIlL FILE JG6 No.: 13-215 1 Gd ati WCTER 4 On -Site Wastewater Disposal System Permit MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water & Wastewater Program 4700 Elmore Road, PO Box 196650 Anchorage, AK 99519-6650 Telephone: (907) 343-7904 Permit Number: OSP131394 Tax Code Number: 06761106000 Work Type: Septic Permit Effective Dates: October 28, 2013 to October 28, 2014 Design Engineer: ARC TERRA CONSULTING INC Subdivision: GATEWAY TO THE PARK Site Legal Address: GATEWAY TO THE PARK BLK 1 LT 22 G:1005 Owner/Address: BENSON ETHAN R DECLARATION OF TRUST BENSON ETHAN R / TRUSTEE 1835 MOUNT YUKLA CIR EAGLE RIVER AK 995779729 Site Mailing Address: 1835 MOUNT YUKLA CIR, Eagle River Lot Size in Sq Ft: 71444 Total Bedrooms: 3 This permit is for the construction of: N Disposal Field Y Septic Tank N Holding Tank N Privy N Private Well N 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 wastewater code requires inspections during the installation. The engineer must notify the Development Services Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either: A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing. Special Provisions: The existing field is in a drainage easement. Prior to Inspection Report approval, please resolve with ROW if a letter of nonobjection is required. Received By: Issued By: MUNICIPALITY OF ANCHORAGE Community Development Department Development Services Division On -Site Water & Wastewater Program Phone: 907-343-7904 Fax: 907-343-7997 ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 067-611-06 Property owner(s) ETHAN R. BENSON DEC. OF TRUST... Day phone Mailing address 1835 MOUNT YUKLA CIR, EAGLE RIVER, AK 99577 Site address 1835 MOUNT YUKLA CIR, EAGLE RIVER, AK 99577 Legal description (Sub'd., Block & Lot) GATEWAY TO THE PARK BLOCK 1, LOT 22 Legal description (Township, Range & Section) Lot Size 71'444 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: (El all that apply) Absorption Field ❑ Septic Tank Holding Tank ❑ Privy Private Well Water Storage APPLICATION IS AN: Initial Upgrade Renewal TYPE OF DWELLING: Single Family (SF) (w/wo ADU) Duplex (D) ❑ Multiple Dwellings (SF and/or D) 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 . o Permit/Rush Fees: Date of Payment: Receipt Number: Permit No. Permit App_9-1-12.doc owner or authorized agent) Zoo. /a/tB/!_3 (95P /313V Waiver Fees: Date of Payment: Receipt Number: Waiver No. October 15, 2013 ARCT ERRA CONSULTING, INC 212 E. 51g Ave, Anchorage, AK. 99503 Office (907) 868-3791, Fax (907) 868-3793 Municipality of Anchorage Development Services Department On -Site Water & Wastewater Program P.O. Box 196650 Anchorage, AK 99519-6650 Subject: Septic Tank Upgrade Permit — Gateway to the Park B1, L22 The owner has requested we proceed forward to obtain a septic permit to upgrade the failed septic tank on the subject lot. The proposed upgrade will serve the existing 3 -bedroom house. The adjacent lots are served by private water as noted on the design. There is no surface water within 100' of the proposed tank. We do not expect there to be any adverse effect on adjacent lots by the development of this tank. If you have any questions, please contact me at 868-3791/ FAX 868-3793. Respectfully submitted, ArcTerra Consulting, Inc. Kenneth M. Duffus, P. Attachments: On -Site Sewer Application Wastewater Absorption System Details/Site Plan 20441 PTARMIGAN BLVD • EAGLE RIVER, AK 99577-8736 • PH (907) 868-3791 • FAX (907) 868-3793 WASTEWATER DISP❑SAL SYSTEM DETAILS/SITE PLAN S/D B1 L22 GATEWAY TO APPROX. LOC. WELL THE PARK •u FIREWOOD LEANTO APPROX. LOC. SEP11C D CANT DECOMMISSI INSTALL 1000 POST TANK 5'+ FROM FOU & EIOS FLAG ALL WELL RADII, EASEMENTS & LOT LINES PRIOR TO CONSTRUCTION N0 PUBLIC WELLS WITHIN 200' OF PROPOSED SYSTEM. N0 PRIVATE WELLS WITHIN 200' OF PROPOSED SYSTEM EXCEPT AS NOTED. N0 SEPTIC SYSTEMS WITHIN 200' OF PROPOSED WELL EXCEPT AS NOTED. (1... 0) 00 E143. LOT 22 BLOCK 1 ITV ®WELL 0. 10' DRAINAGE EASEMENT 988'07109`E 171.39' (171 24' R) APPROX. LOC. WELL LOT 23 1N34'13SV3 31411 NOLL33S 141 c Z (n C CO O r I .A. Scale: 1"= 60' PAGE 1 OF 2 DESIGN DETAILS DECOMMISSION EXISTING SEPTIC TANK PER CODE INSTALL NEW 1000 -GALLON SEPTIC TANK INSTALL FCO AND POST TANK COs - CONNECT TO EXISTING SYSTEM NOTES1 1. INSULATE TANK IF <4' COVER. 2, CONTRACTOR WILL ENSURE MINIMUM 2% SLOPE INTO SEPTIC TANK. 3. CONTRACTOR WILL ENSURE ALL SEPARATIONS TO ADJACENT WELLS & SEPTICS. PREPARED FOR' ETHAN BENSON TRUST 1835 MOUNT YUKLA CIR EAGLE RIVER, AK 99577 HELD BOOKS BOUNDARY: BOUNDARY STAMINR STAKING ASBUIT: JLS DW0. FILE: AGD FW FILE COMPUTED: DRA"w BMW CHEC1a KMD DA1E, 10/16/13 Goo: SE1005 aD K^': 13-215 a a. 5 K Ivo C‘‘YENSOLTING YN6 R, AK, 99577-w tatS 1 ERR4 ii1 WASTEWATER DISPOSAL SYSTEM DETAILS GATEWAY TO THE PARK S/D B1 L22 APPROX. LOC. SEPTIC DECOMMISSION INSTALL 1000 POST TANK 5'+ FROM FOU & EXIS /ax25E5kf r *Ye ver; fIcd d W ecc I XISTI GAL. S. . OS&MAIN ATI3N/SON G %EPTIC FI 7 0 6, 15.0 FIREWOOD LEANTO 33sO 780• 4is 2g0• 6 yoc ry� k"SF 9S• o 0 y O ^ry. COVERED ENTRY AVEL Fs /W 0 S.T. W/ AIN TUBES D Spot co 7 NOTE: DESIGN BASED ON ELECTRONIC CANT FCO `EW TANK /cos NCO OO �1 ,�10• SCHULLER AS -BUILT 0 10' DRAIN, S88`07'09"E APPROX. LOC. WE LOT 23 FLAG ALL WELL RADII, EASEMENTS & LOT LINES PRIOR TO CONSTRUCTION Scale: 1"= 30' PAGE 2 OF 2 PREPARED FDR: ETHAN BENSON TRUST 1835 MOUNT YUKLA CIR EAGLE RIVER, AK 99577 FIELD BOOKS MUMMY' BOUNDARY STMCM STAKING ASSUILT: JLS CWvuim: DRANK: BMW aca®: KMD 0E1E: 10/16/13 DWG. RE: ACRD FILE' FILE m l0: SE1005 JOB Ne.: 13-215 6y SWCTERk r¢ co 'Pryea S—LT I NO +�6 � AK, 99571 MUNICIPALITY OF ANCHORAGE Community Development Department Development Services Division November 14, 2013 Ethan Benson Declaration of Trust Ethan Benson, Trustee 1835 Mount Yukla Circle Eagle River, AK 99577-9729 Mayor Dan Sullivan Right of Way Section Phone: 907-343-8240 Fax: 907-343-8250 RE: Encroachment: Septic Leach Field and Monitoring Tube in a Drainage Easement Gateway to the Park Subdivision, Block 1, Lot 22, Grid 5E1005, 1835 Mount Yukla Circle, Eagle River The Right of Way Division has reviewed a request for a letter of non -objection to an existing septic leach field and monitoring tube, which encroaches approximately 3' into the drainage easement. On the Wastewater Disposal System Detail survey dated 10/25/13, submitted with the request, the petitioner has shown the septic leach field and monitoring tube in the drainage easement. This letter of non -objection is issued with stipulations, and by using it the petitioner is agreeing to the following: 1. Municipality of Anchorage (MOA) will be held harmless, now and forever, for any damages or injury to any person as a result of the encroachments. 2. All applicable codes and regulations will be observed and maintained within the easement. 3. This letter of non -objection will in no way preclude MOA from full use and enjoyment of its rights within any portion of the easement. 4. Additional and extraordinary costs incurred during any future required construction, repair or reconstruction of MOA improvements to accommodate any or all of the encroachments shall be paid by the property owner. 5. Maintain letters of non -objection from the following utilities: ❑ Anchorage Water & Wastewater Utility ❑ Chugach Electric Association, Inc. ❑ Matanuska Electric Association, Inc. ❑ Municipal Light & Power ❑ Eyecom (Girdwood Cable TV) ❑ Alaska Communications Systems ❑ Matanuska Telephone Association ❑ Enstar Natural Gas Company ❑ GCI Cable of Alaska ® No letters required All letters of non -objection should be retained in your permanent files. If you have any questions, please call me at 343-8240. Sincerely, ik L. Frost, Jr. l7 Right of Way Supervisor Concur Mailing Address: P.O. Box 196650 • Anchorage, Alaska 99519-6650 • http:/twww.muni.org WASTEWATER DISPOSAL SYSTEM DETAILS GATEWAY TO THE PARK S/D B1 L22 APPROX. LOC. SEPTIC DECOMMISSION INSTALL 1000 POST TANK 5'+ FROM FOU & EXIST /0/2365" -/y tic ren,Fre, : w 0 XISTI GAL. S. . 0s4,4 MAIN ATION/SON G %EPTIC FI 0.6 5-6 FIREWOOD LEANTO ryR' 3356 6 ^M 780 F hO % rye. SF 9S, o AY 78o M N 4 COVERED ENTRY r A VEL /W S1 Cn s o. 0 S.T. W/ AIN TUBES D Co NOTE: DESIGN BASED ON ELECTRONIC 4 SCHULLER AS -BUILT FCO o. CANT NEW TANK 0 10' DRAIN. 588'07'09"E APPROX. LOC. WE LOT 23 FLAG ALL WELL RADII, EASEMENTS & LOT LINES PRIOR TO CONSTRUCTION Scale: 1'= 30' PAGE 2 OF 2 PREPARED FOR: ETHAN BENSON TRUST 1835 MOUNT YUKLA CIR EAGLE RIVER, AK 99577 FIELD BOOKS CdFUim 80INDAR" BOUNDARY ORA • BMW srAmHa STAKING at -an KMD AMU! JLS DAIt 10/16/13 DW& FILE: GED: SE1005 ACRD Fie FILE lye x9.: 13-215 et'1t�S�N ULTING. 6' R AK 99517'-3 POST IN A CONSPICUOUS PLACE ALL WORK MUST BE INSPECTED Field Inspection Request required 2 working days in advance of starting work and 2 working days in advance for final inspection. Call (907) 343-8206 (voice recorder) for scheduling. Permit is not valid without the call-in and also must include the one -call ticket (utility locate) number. MUNICIPALITY OF ANCHORAGE RIGHT OF WAY DIVISION PHONE (907) 343-8 RIGHT OF W Type: Construction S Permi Contact P Sit Lega Fi Fe Per R132527 05 =:,.te .:;d: 11/14/2013 Last U. ., to 3. PWDEW Last Upda `_, : `' °.14/2013 iption: GATEWAY TO THE PAR I Work ription: L nObjeciion . See reverse for requirements/remarks. I have read and understand both sides of this permit. I agree to the terms and conditions; and I certify that all work will comply with federal, state, and munici..I codes and regulations and the provisions of this permit. Signature: Date: 1/ —11-13 / 3 �� MUNICIPALITY OF ANCHORAGE • 1 f, 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/412 b-roi J f PHONE �!.• 2.// Y`✓_ - ArNEW El UPGRADE MAILING ADDRESS/2v C /` /C 10 ) E ^ /]�� 77 �NIJ /� 7 LEGAL DESCRIPTION G 2 Z /� / 0-47,4'G4Jtry /-t 7--6f4.7 /,)4 LOCATION S ? 7 /3/t NO. OF BED MS Uy DISTANCE TO: Well // Absorpti�ar�a S Dwelling? PERMIT NQ._/ e 6 7 Y� /r/_iJ�t 1— Z W Manufacturrp� _,% , i + .`-.L -j-T / _ MC is / No. of compartments H co Liq. capgcit gallons e C.7CJ IF HOMEMADE: Inside length Width Liquid depth a y J0Z DISTANCE TO: Well welling PERMIT NO. F Manufacturer /2 ! Material Liquid capacity in gallons DISTANCE TO: Well /2 3 r Foundatipz 3 Nearest lot lino (11._ PERV fyLk S„[ 9 6 0 FILE ENC No. of lines Length Sei line Total lelerf Ijnes �jjj Trench y�i h // /Q inches Distance beettweeeJn lines Top of tile to finish grade 4 f Material beneath tile/� inches Total effe veAbso rp area Id Length Width Depth _ PERMIT NO. EPAC PIT Type of crib Crib diameter Ai /C{.depth Total effective absorption area DISTANCE TO: Well // Building foundation Nearest lot line W c�. L �C / S7/NG Depth �i✓Ct Driller Distance to lot line PERMIT NO. DISTANCE TO: Buil ng foundation Sewer line Septic tank Absorption areals) OTHER 0 L �/ we r PIPE MATERIALS LC SOIL TEST RATING /2 / e INSTALL to i..) /Verc/4LF — p�5 n REMARKS _. OFhi ,„ ,y6, woo sco . 'r • . !Os 'Wieriit v, rf• of"• iffin>c- ,..-.....,...... •r:_ •a i Robert A. Shafer • �, No. 1497-! yi T ••. :` ' .. c. •••• ••..•..•,,P.>•� t,tq W 4 PRC�:c.S'1''•t ` . pf2� Ra w -lo /- a $ r Elat W.:N r M APPROVED 196X e.v.., DATEILEGAL (,/ ,�� 0/' dr i.b RIVER,H.13 ALASKA / . — /n ----if 4 T T ��,! F-4 1--7%� DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STREET, ANCHORAGE, AK 99501 264-4720 P3RMlT NO: 840B6S DATE ISSUED: 10/11/74 APP! I[ANT: RnN METCAFE ADDRESS: % S&S ENGINEERINP EASLE RVIER, AK 99577 CONTACT PHONE: 694-2979 LEGAL DESCRIP: GATEWAY TO THE PARK LOT: 22 SECTIOM: 9 TOWNSHIP: 13N RANGE: 1E LCT SIZE: 71444 (SO.FT. OR ACRES) MAX BEOROOMS: 3 BLOCK: 1 below are the options available Lo you in designing septic Choosc the option that best your site. DEPTH TO PIPE BCTTON GRAVEL DEPTH (FT.) TOTAL DEPTH (FT.) GRAVEL WIDTH (ET_) GRAVEL LENGTH (FM) GRAVEL VOLUME TANK SIZE (GALS) SOIL RATING (SO.FT. 4.0 5.0 9.0 ** TANK MUST PAVE AT LEAST TWO COMPARTMENTS ______________________ _ T • s ,.5 4'='; 17.0 21.5 4.� �.5 5.0 41�� I certify that: I. I am familiar with the requirements for on-sitesawers and wells as set forth by the Municipality of Anchorage (MOA) and the State of Alaska. 2. I will install the system i: accordance with all MOA codes and regulations, and in compliance with tha design criteria of this permit. 1 will adhere to all MCA and State of Alaska requirementa. for the set back distamces from any existing well, wastewater disposal system or public sewe~a�e system on this or any adjacent or nearby lot. 4. I understand that this peraiL is valid for a aaximum of 3 bedrooms and any enlargemert permit. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES, THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST TE OETAINED; (2) A5-��lLTS ',,JILL NOT DE APPRCVED WITHOUT AN ELECTRICAL INSPECTION PEPORT; AND (3) THE ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN. APPLICANT: PON ME DATE: ISSUED D'T DATE 1/, ___ lF1 XSOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG — PERCOLATION TEST PERFORMED FOR: ✓0 gr:- /- 7` /9`._ LEGAL DESCRIPTION: DATE PERFORMED: ❑ PERCOLATION TEST /a//o/9� 2 2 2 ei f////1izic /I-) SLOPE ( ti SITE PLAN G'rel c (9-/lc---7/s/L7 10 11 12 13 c 1, r -to <<i 14 Cjr 40: 15 A••it h d 16 i•:�%J�L�%.�(�,..:.� e '•P 17 ,/� { �bart A. Shafer •z.s• No. 1457.E ,r 18 . oa'• •o >i APO Ar 19 ‘10•N.a->dvak-411". 20 COMMENTS WAS GROUND WATER {1 �;1 S ENCOUNTERED? ��/ V L 0 P E IF YES, AT WHAT DEPTH? K 1n 2 1 2 Reading Date Gross Time Net Time Depth to Water Net Drop PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND FT 0 —. tn..X PERFORMED BY:r �t ,t c;: CERTIFIED 6 DATE:/6 /j- MUNICIPALITY OF ANCHORAGE Development Services Department ''=' "°' ,` Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 06761106 1. GENERAL INFORMATION Expiration Date: 0-2-1:40( Complete legal description GATEWAY TO THE PARK BLK 1 LT 22 Location (site address) 1835 Mount Yukla Cir Current property owner(s) Benson Day phone 862-8015 Mailing address Real estate agent Same Day phone 862-8015 78970 2. TYPE OF DWELLING: u >> ti 0 Single Family (w/wo ADU) ❑ Duplex °� AUG 14 2019 a ❑ Multiple Dwellings (Single Family and/or Duplex) ti � w 3. NUMBER OF BEDROOMS: 3 `! 01 6 8 G 9 5� 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well 0 Private Septic E Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 6-5K) Date of Payment 3Ltq /I I p Receipt Number O oLt p COSA# (��SCIR C �� Waiver Fee $ Date of Payment Receipt Number Waiver # 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, 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-site 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. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm NorthRim Eng. Phone 694-7028 Address PO Box 770724, Eagle River Engineer's Printed Name Steve Eng Date 8/15/19 6. DSD SIGNATURE System #1 Approved for Z, — bedrooms System #2 Approved for bedrooms Disapproved Conditional approval for bedrooms, N =Y ° e ^ r Sr2ven iii125/ . 4'r.. ` H0FES with the following stipulations` %_V oPa-,TY OF, r, r_ ,")))4) 1 w W I� By: Original Certificate Date: 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 State 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 Checklist blue sheet Legal Description: GATEWAY TO THE PARK BLK 1 LT 22 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled unk Total depth 123+ ft Cased to 40+ ft ❑ Sanitary seal is functioning correctly Al Wires are properly protected Casing height, (above ground) 40 in. Date of flow test for COSA 8/15/19 Static water level at beginning of test 98.5 ft. Comments B. TANK DATA Age of tank(s) 1218113 years Tank type/material Steel Measured operating fluid level in septic tank 47 Al Standpipes/foundation cleanout per record drawing Date of pumping. 8/12/19 D. ABSORPTION FIELD DATA 10/16/84 Which system tested (date installed) 10/16/84 ❑ ALL standpipes present per record drawing Total measured depth from grade 8.5 ft (max) Measured depth to pipe invert from grade 3 ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Code, -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Comments/Deficiencies: COSA Checklist yellow sheet Parcel ID: 06761106 Structure served by this system Well production at time of test 3+ gpm Water storage tank volume 0 gallons Well disinfected for coliform test? ❑ Yes ❑ Nc ❑ Coliform bacteria is Negative Nitrate 1.6 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ' ❑ Arsenic less than MRL (ND) Collected by NRimEng Date of Sample 8/2/19 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 8/15/19 Results ❑✓ Pass For 3 bedrooms Fluid depth prior to test 5 in Water added 450 gal New depth 15 in Elapsed time 30 min Final fluid depth 7 in Absorption rate 450 gpd Any rejuvenation treatment (past 12 months) If yes, enter date no E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' ✓❑ Yes Community Sewer Manhole/Cleanout > 100' ❑✓ Yes if No ft M Yes if No Neighboring Tank > 100' ❑✓ Yes if No ft Private Sewer/Septic Line > 25' ❑✓ Yes if No Absorption Field on Lot > 100' ❑✓ Yes if No ft Holding Tank > 100' ❑✓ Yes if No Neighboring Absorption Fields > 100' Yes if No Animal Containment > 50' ❑✓ Yes if No ❑✓ Yes if No ft if No ft F. ENGINEER'S COMMENTS Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' P-1 Yes if No ft ❑✓ Yes if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑✓ Yes if No ft Surface Water > 100' ft ft ft ft ft ❑✓ Yes if No ft Property Line > 5' ✓❑ Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' 0 Yes if No ft Private Wells > 100' ✓v Yes if No_ Water Main > 10' ❑✓ Yes if No ft Community Wells > 200' dQ Yes if No _ Water Service Line > 10' r✓ Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ❑✓ Yes if No ft If absorption field is under driveway comment below Property Line > 10' ❑ Yes if No 7* ft Wells on Adjacent Lots: Water Main > 10' ✓❑ Yes if No ft Private Wells > 100' Yes if No Water Service Line > 10' ❑✓ Yes if No ft Community Wells > 200' ❑✓ Yes if No Surface Water > 100'✓❑ Yes if No ft F. ENGINEER'S COMMENTS * Waiver G. ENGINEER'S CERTIFICATION 1 certify that 1 have determined through field inspections and review , of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. s . COSA Checklist yellow sheet ft ft ft ft SECTION LINE— — 83"27 tN76. 5ti r i C , Z 0 CV CA j ri W L O G to C 4 v lb n m j z� LOT 22 BLOCK 1 a_ ts.a' FIREWOOD LEANTO 7� 4, ELL Os n� JJS' reo• eki 12.o' 2'a yON�N� a ao h $f n"•90• � 93• o o CANT T m 0 GRAVEL �^ D/R' CO E opy 10' DRAINAGE EASEMENT ED SEPTICe �NTR, S88'07'09"E 171.39' VENT (771,24' R) CS 01 LOT 23 r f ! ANCHORAGE RECORDING DISTRICT, ALASKA ASBUILT OF; O = FND 518" REBAR. GATE NVAY TO THE PARK SUBDIVISION FND MONU?,IHN'I- LOT 22 BLOCK 1 PLAT 82-251 ISURVI:YCL'RTIFICATG:I,.1ohnL.Schuller, ilaveeonductcda ® OFA tip �L N4D physieal stirt,ey of this property as shomn on this droving and that the �d �� . •' Q� 4 51 pr �� improvemants situated hereon are within the properly lutes : nd now 0 G enchroachmeots exist other Than noted. Under oo circumstmtcc should 0� 49 1 .! �� any iiilium:nion on this drawing he used rommslruction or rcnecs. _iruelores, improvements. or for establishing boundary lines•I„` i3XCLl l510 J NO'rES: It is the owners responsibilily to determine A�' � ' OHN L. S�CHU /LhER; 0 0/ ^ C the cxistcna orrst: any cnrents, cat..cmm�s, or resh'iclianJ s which ,p.. .. �Al N LS -10408 do nal ;Ippear on the recorded subdivision pial. f r ® »+ .. � 31 WORK ORDER. NUMBER: DoT[: SGAE E-uut: �1P& ''..' 5JO® 16.11 Talkeetna Street ' DEC 3, 2013 1"=50' p>�op �•3'"" �6 Anchorage, Alaska 99506 13-042-2 �� OY: 6EbED OY Q9 HU BER: BOCK PnGE d® ofessional4 (907} 227-1455 office JLS SE1005 730216 1+\\®�.�o (907) 274-4997, fax L2• Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 067-611-06 cOSA# Oa X55 Expiration Date (O £ 0 1. GENERAL INFORMATION Complete legal description Gateway to the Park S/D, Block 1, Lot 22 Location (site address) 1835 Mount Yukla Loop Eagle River, Alaska 99577 Current Property owner(s) Marge Brehm Day phone (866)915-9023 Mailing address Lending agency Day phone Mailing address Real Estate Agent ReMax of Eagle River/Audrey Mason Day phone 622-3344 Mailing Address 1660 Centerfield Drive Ste 201, Eagle River, Alaska 99577 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System 3 TYPE OF WASTEWATER DISPOSAL: Individual On-site (] ❑ Individual Holding Tank 0 ❑ Community On-site 0 ❑ Public Sewer 0 The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. 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, 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-site 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. Name of Firm Douglas T. Kenley, P.E. Address 9806 Northstar Circle, Palmer, Alaska 99645 Phone 907446.1073 Engineer's Printed Name Date 1 ''S ' °") F i‘, AN., • A I • r.49 rH. " *F: ` • t 5. DSD SIGNATURE . D3U31YJ37 KfiLEY. _� Approved for 3 bedrooms. vii CE B176..,.•.;;;„ Disapproved. ' •i �Vr^�a?��'• Conditional approval for bedrooms, with the following stipuratidtt'" Af•,./56,0% • • ON SITE WATER AND ;m= . WASTEWATER PROGRAM• • c moo. •� �. Attachments: COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other By: v /42 /70—et—Original Original Certificate Date: 3 -.5"--0 9 (Rev 11/05) Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: Gateway to the Park SID, Block 1, Lot 22 Parcel ID: 067-611.06 A. WELL DATA Well type Private If A, B, or C provide PWSID # _ Well Log (YIN) Date completed unknown Sanitary seal (Y/N) v Wires properly protected (Y/N) V Total depth 123+• ft.Cased to 40'' ft. Casing height (above ground) 35 in. FROM WELL LOG AT INSPECTION Date of test _ 02/14/09 Static water level ft. 96.4 ft. Well production g.p.m. 3 0 g.p.m. WATER SAMPLE RESULTS: Coliform etas colonies/100 mL Nitrate '• 2`'mg/L Other bacteria colonies/100 mL Arsenic: 1)0 mgllDate of sample: 02/03/09 Collected by: F. Kenley B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septc/Steel Date installed 10/16/84 Tank size 1000' gal. Number of Compartments 2' Cieanouts(Y/N) Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (WN) N/A Date of pumping 8/12/08 Pumper JRs Pumpers C. ABSORPTION FIELD DATA Date installed 10/16/84 Soil rating (g.p.d./ft2 or ft2/bdrm) 125' System type Trench l Length 38' ft. Width 4' ft. Gravel below pipe 5' ft. I, Total depth 8.5 ft. Eff. absorption area 380 ft2 Monitoring tube Y Depression over field N - Date of adequacy test 02/14/09 Results (Pass/Fail) Pass For 3 bedrooms Fluid depth in absorption field before test 8-3/4' in. Water added 480 gal. New depth 76 In. Elapsed Time: 101 min. Final fluid depth 11-1/4 in. Absorption rate >= 450 g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes. give date D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at _ in. "Pump off' level at • wa er alarm level at Datum ---'—" Cycles tested Meets alarm 8 circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100+ ft. On adjacent lots 100+ ft. in. Absorption field on lot 100+ ft. On adjacent lots 100+ rt. Public sewer main N/A Public sewer manhole/cleanout N/A Sewer /septic service line 25+ ft' Holding tank N/A Animal containment areas _ 50+ ft. Manure/animal excrete storage areas 100+ rt. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5+ ft. Property line 5+ ft. Absorption field 5+ ft. Water main N/A Water service tine 25+ ft. Surface water 100+ rt. Wells on adjacent lots 100+ ft SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ? 2•• Building foundation 10+ ft. Water main N/A Water Service line 25+ ft. Surface water 100+ ft. Driveway, parking/vehicle storage 5+ ft. Curtain drain NwNso••.r Wells on adjacent lots 100+ ft. F. COMMENTS: • From MOA records. ••Waiver on file G. ENGINEER'S file k 1•4,16iso .�:4�rN. 1 certify that 1 have determined through held inspections and ' �' ' • • •�0. review of Municipal records that the above systems are in +� • � conformance with MOA COSH guidelines in effect on this date. • a g Si T•jy. Engineer's Printed Name Douglas T. Kenley ��! ;., 8 T6 ,: SAE'`•^! .• o , W ff Date 1l• 3. OBJ •'.•• a ti r..Y440,* COSA Fee $ T 9 Q Date of Payment 3 — 3 - 0 5 Waiver Fee $ Date of Payment Receipt Number O,7 Pe ' Receipt Number (Rev 11/05) Municipality of Anchorage Development Services bepal•tment Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw S1 P.O. Box 196650 Anchorage, Ak 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL Parcel I.D. 06 7 -611-06 FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal descriptjop Tin t 99 • Rlnrtr 1 • Cn tot ay to the Park Sip HAA# Expiration Date: - 9 - d 0— Location Location (siteaddresslordirections) 1835 Mt. Yukla Cir -Current Property owner(s) Ge rome Montague Day phone 552-2769 • Mailing address. 1A35 Mt Ynkla Cir Pap1e River, AK 99577 Lending agency Day phone Mailing address • Real Estate Agent Day phone Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System 0 0 0 3 7a/z 4C.-_ 5—(t-R/ot TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding tank Community On-site Public Sewer 0 The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given In paragraph 5 by an Independent professional civil engineer registered In the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water supply system. DSD also Issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage Is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION 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 Health Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal s$teni is(are) safe, functional and adequate for the number of bedrooms and type of structure Indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my Investigation and Inspection, the on-site water supply and/or wastewater disposal system (s(are) In compliance With all applicable Municipal and State codes, ordinances, and regulations In effect at the time of installation. Name of Firm S & S Engineering Phone 694-2979 Address 1703h M Eagle. Pivot Loop Eaglc River, AK 99577 Engineer's Printed Name qr r rncrnn P E Date 51//0 z 5. DSD SIGNATURE Approved for 3 bedrooms. Disapproved. Conditional approval for By: '(G OF A!> GINEER$ y—' '• ��+Ir ROBERT C. COWAN / V 1 eC. CE -8801 ; f 'sI off``. , - .• ;($' bedrooms, with the following stipulations: Additional Comments 1/41/44 cc( Or itiv„„rerte_ • 2 ' ON-SITE WATER AND : m V'JASTEWATFR • :. PROGRAM ... .c. ALF •. JJJ�`gyp miSc s,\ -//6li») ))))))» Attachments: HAA Checklist X Maintenance Agreements Septic System Advisory Supplemental Engineer's Report Well Flow Advisory Other R� (Peg umn) Original Certificate Date: S- 2 `7 - E7 Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.d.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: torn 'aoct. 1;Thr✓A^t 771 J7ter A. WELL DMA Well type P Date completed IA,* Total depth 7/i 5 ft. >�/c-- If A, B, or C provide PWSID # = Well Log (YM) 9 Sanitary seal (Y/N)i Wires properly protected (Y/N) —� Cased to 4D ft Casing height (above ground) /Z in. Parcel ID: t%7 -6„/p06, FROM WELL LOG AT INSPECTION Date of test g1z/v-r) Static water level ft. 9 3 r ft. Well production g.p.m. 3. D g.p.m. WATER SAMPLE RESULTS: �AJ Conform (% colonies/100 ml. Nitrate 44/Mg.A. Other bacteria 0 colonies/100 mi. Date of sample: 5) I O 1 Pit— Collected by: s i s t1 G IIJeeti kt, (— B. SEPTIC/HOLDING TANK DMA Tank Type/Material 10.71C., / / S Date installed AY/ / 84 Tarrk size (000 gaL . Number of Compartments L Cleanouts (Y/N) Y ;Foundation cleanout (YM) Y Depression over tank (Y/N) High water alarm (Y/N) AJ Data of pumping Sid 9 r o t Pumper 7 Q S C. ABSORPTION FIELD DATA Date installed L / Length ft. Total depth 9.6. Date of adequacy test Soil rating (g.p.d./ft2 or ) / ZS Width 4 ft. Eff. absorption area 3B? ft2 Monitoring tube oz) Results (Pass/Fail) AI 5 System type iee'Ve H Gravel below pipe C ft. 7 Depression over field ^l Fluid depth in absorption field before test t% in. Water addeda5;a1. Elapsed Time: bo min. Final fluid depth Q in. Absorption rate >= For 3 bedrooms New depth r / in. 45t g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) ^ If yes, give date D. UFT STATION / Date installed y'a Size in gallons Manhole/Access (Y/N) `Pump on' level at _ in. 'Pump oft' level at _ in. High water alarm level at Datum Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot /00 /a- On adjacent lots / CO Absorption field on lot in. /0 0 ra- On adjacent lots (00 + Public sewer main ^/! 4 WC/septic service line b rt Public sewer manhole/cleanout N/4 Holding tank N / SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5 ÷ Property line S f Absorption field / Water main ^t/ 4 Water service line / 0 'r Surface water /0 O r - Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line - ~` t- Water main /D r'"- - - -- Building foundation / t� Water Service line /0 /'t- Surface water /00 it Driveway, parking/vehicle storage Curtain drain ha& £i/ifWvells on adjacent lots APO f4- 514 - F. COMMENTS * w2 Qba2n G. ENGINEER'S CERTIFICATION 1 certify that 1 have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA MAA guidelines in effect on this date. Engineer's Printed Name Po ' /C- (Q w4 Date r// a/ / 2- ,¢i c \ R*$ ..MROWJIN 4.: \ CE - 8801 `'v HAA Fee $ 3 ! S. , 4 Date of Payment 3-731/4.2. Receipt Number O a D 0 if 9 (Rev. 12/00) Waiver Fee $ Date of Payment Receipt Number MAY- 9-91 THU 12:24 FNBA FAX 907-265-3094 FAX NO. 9072653094 6 • 0 6 •� OIiiM /' i4'.9ir+9edr eel A -m7, e 4,619"art-ap- 'rear i AS9UILT-No CORNERS SET THIS DATE. I HEREBY CERTIFY THAT I NAVE SURVEYED THE FOLLOWING DESCRIBED PROPERTY' Gateway To The Park Subd.,Lot 22,Blk. 1. AND THAT NO ENCROACHMENTS EXIST EXCEPT AS INDICATED, It 1$ THE RESPONSIBILITY OF THE OWNER TO DETERMINE THE EXISTENCE OF ANY EASEMENTS, COVENANTS, OR RESTRICTIONS WHICH DO NOT APPEAR ON THE RECORDED SUBDI- VISION PLAT. UNDER No CIRCUMSTANCES SHOULD ANY DATA BE USED FOR CONSTRUCTION OF PENCE LIENEES, OR FOR ESTABLISHING BOUND- ARY LINES. P, 01 , SEWARD & ASSOCIATES LAND -SURVEYING 688-4566 SCALD 1"50' DATE' 4-22-91 GRID: SE 1005 FS! 19-79 DRAWN' DNS .., .pF. A. 4'3'44 of er- O FA...Dime Mark Sewad • t ,.._ LS•6918 M 1' yo•t/sskkal4 s• �a% *NS.' dr 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 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I D # 067-611-06 HAA# VAMr-L7-)a-A 1. GENERAL INFORMATION Complete legal description Gateway to the Park Lot 22, Block 1 Location (site address or directions) Mt. Yukla Circle, Eagle River Property owner Thomas Jennings Day phone 696-0963 Mailing address Hr 8'1 PDX 749E FFgle River. AK 99577 Lending agency Norwest Mortgage Day phone 272-6594 Mailing address P.O. Box 142347, Anchorage, AK 99514 Agent Pe/MaX of Eagle Riveric Olmstead Day phone 694-4200 Address 16635 Ccntcrficld Drive, Eagle River, Ak 99577 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water 3 x NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer X NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 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 Phone 694-5195 Address P_O Box 771294 glP River, TK 91577 Engineer's signature - 6. DHHS SIGNATURE Approved for 3 bedrooms. Disapproved. Date 7— - `'( 1 t C I 1ir 5 ' 1.::, i < '', ' sei V:i Conditional approval for bedrooms, with the following stipulations: Additional Comments ByC1iv„.vly Date 84 -76. 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 (Rea. 1/91) Back MOA e21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES RECEIVE Environmental Services Division 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744 ENVIRONMENTAL SERVICES DIVISION JUL 3 01996 Health Authority Approval Checklist Legal Description: 6.4-7" WAY TO %HE ?ARk Parcel I.D.: D&%- 6//-,067 / A. WELL DATA Well type ?R/V//7- If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) IVO Total depth t 422 Date completed Cased to VNI IOWA) /W1 Casing height (above ground) q8 Sanitary seal (Y/N) Yes Wires properly protected (Y/N) Yz FROM WELL LO AT INSPECTION Date of test Static water level Well production g.p.m. WATER SAMPLE RESUL S: Coliform Nitrate Date of sample: G"1/Zv/(A/ O 2/? -0/9(v �7L / *;$- • g.p.m. /,C5 me/z_ Other bacteria Collected by: C /et- S B. SEPTIC/ice TANK DATA 7 Date installed /O/ 4' Tank size 00 Number of Compartments ` Cleanouts (Y/N) Y6--5Foundation cleanout (Y/N) YES Depression (Y/N) 1Y17 High water alarm (Y/N) N/A Date of Pumping 617/Z51/94/Pumper C. ABSORPTION FIELD DATA Date installed /O/Yy N772 's Soil rating (g:p7&ft2-orft2/bdrm) / 2 5 System type 2e CN Length 3 S' Width Gravel thickness below pipe 5/ Total depth 7. 5 Effective absorption area G Monitoring Tube present (Y/N)Y63 Depression over field (Y/N) _N/7 Date of adequacy test ,09/Zt-P/9" Results (Pass/Fail) PASS For -4 bedrooms Fluid depth in absorption field before test (in.); 00 Immediately after Ccc gal. water added (in.): Fluid depth (ins) Minutes later: , - Absorption rate = Peroxide treatment (past 12 months) (Y/N) 72-026 (Rev. 3/96)* N/ tc� g.p.d. If yes, give date D. LIFT STATION JV/4 Date installed Size in Manhole/Access (Y/N) High water alarm leve Cyc = : - sted E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: /a 'mon" level at* *Datum Septic/i•roiding tank on lot Absorption field on lot Public sewer main -Sewer /septic service line /3 N/A SLS On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station N/A "Pump off" level at* SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: N/4 Foundation /0 Absorption field i Water main/service line t �s Surface water/drainage t/OO Wells on adjacent lots /CV Property line 20 SEPARATION DISTANQE FROM ABSORPTION FIELD ON LOTTO: �/;P �NANse) / Property line / Building foundation Z� Water 1:F1844/service line 74/1' - Surface water '/"/DD Driveway, parking/vehicle storage area /0 Curtain drain A/DNE APPARCA✓T Wells on adjacent lots f /00 F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal records Oat the abpve,systgbis are in conformance with MOA HAA guidelines in effect on this date. Signature Engineer's Name Laws sev7--E,e4, RE. Date 7--1 6 HAA Fee $ 307) • Ua Date of Payment 730/?,C, Receipt Number 0Zn7? (/ LS7 > 72-026 (Rev. 3/96)* Waiver Fee $ E l u A ,u°era • q;e0 gr • I.' 'of CL 7 Z -ap 8"3(zS /) Date of Payment 7 /O bc, Receipt Number Ab �� 6 `4 Rick Mystrom, Mayor Municipality of Anchorage August 7, 1996 Department of Health and Human Services 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 Lou Butera, P.E. Eagle River Engineering Services PO Box 773294 Eagle River, Alaska 99577 Subject: Waiver Request for Lot 22 Block 1 Gateway to the Park Subdivision Waiver Request #WR960037, PID #067-611-06, HA960322 Dear Mr. Butera: Your request for a waiver of the required 10 foot separation between an on-site wastewater disposal system and a lot line has been approved. The waived distance is 7 feet from the absorption area to the property line. This approval applies to the existing septic system lot line separation only. Any future upgrade to the on-site wastewater disposal system will require all separations be met or another approval from this department. If there are any further questions or concerns regarding this waiver, please call our office at 343-4744. Sincerely, Daniel J Roth Civil Engineer On-site Services DJR/ljm:Jennings .MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-site Services Section Waiver Review Worksheet WR# WR960037 PID# 067-611-06 HA# HA960322 Permit # Date Received: July 30, 1996 Legal Description: Lot 22 Block 1 Gateway to the Park Engineer: Lou Butera, P.E., Eagle River Engineering Services PO Box 773294, Eagle River, Alaska 99577 Applicant: Thomas Jennings Waiver Requested: Lot line waiver of 7 feet from the absorption area 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: X Waiver is NOT Granted: List Conditions or Reasons for above: SEE ElVG/l'kER'f A7f)C11ED Leatie of Ju s if Fick Tr0AV Date: 8_6 ` /lo By: 9/9,/ Rec #: #0280/0281 Name of Reviewer Amount: $ 115.00 Date Paid: 7-30-96 Eagle River Engineering Services Louis Butera, P.E. P.O. Box 773294 (907) 694-5195 tel Eagle River, AK 99577-3294 (907) 694-3297 fax July 30, 1996 Jim Cross, P.E. Manager, On -Site Services Municipality of Anchorage P.O. Box 196650 Anchorage, AK 99519 Re: Gateway to the Park Lot 22, Block 1 Lot Line Waiver Application Dear Mr. Cross: The proposed lot line waiver from 10 feet to seven feet distance will have very limited impact on the adjacent property for the following reasons: 1. Immediate neighboring septic systems are approximately 50 feet distant. 2. The surrounding lots are large, allowing sufficient room for septic sites. 3. The system has been in place since 1984 and is functioning adequately. The lot line distance was entered incorrectly on the septic inspection report and subsequent Health Authority Approvals. We do not see any adverse impacts to allowing this leachfield to remain in the present position on the lot. If you have any questions please call our office at 694-5195. Sincerely, Louis Butera, P.E. \1996\96-068A-LTR.00c 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 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I D # 7 ---//--- 1. / 1. GENERAL INFORMATION Com plSeutedIQ aI fion;escription �JT 4c HAA# !Y/7 9lZ17 Lot 22; Mock 1; Gateway To The. Path. Location (site address or directions) NHN Mt. Yulart Caste Property owner Chnietophen Bennett Day phone Mailing address Lending agency Day phone Mailing address AgentAudney Mahon RE/MAX OF EAGLE RIVER Day phone 694-4200 Address 16600 CvntPn6iePd D'ivv. #201 EagPe Riven. Afz. 99577 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water 3 Xx NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer Xx NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 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. c Name of Firm Phone - ` 9 t 2?7 7 Address 12566 elsely !IIaIfie j f'OL'°N peps doo1 Jeela el6e3 KOLL ONla3atalON3 S a S ' / Engineer's signature Date 467/7 REPLACEMENT OF H.A.A. APPROVED 6/13/91. ORIGINAL LOST IN DELIVERY. aar7 R AQzka. rt f r 6. DHHS SIGNATURE Approved forAe bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: By: Additional Comments Date CAUTION 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. 1/91) Back MOA 921 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 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I D # (o l \ - 0( n 1. GENERAL INFORMATION HAA# A Complete legal description Lot 22; Back 1; Gateway To The Patk Subdivision Location (site address or directions) NHN Mt. yuhi'a CincCe. Property owner Chn is tophen. Bennett Day phone Mailing address Lending agency Day phone Mailing address Agent Audney Ma3on RE/MAX OF EAGLE RIVER Day phone 694-4200 Address 16600 Centegieed D'.-Lve #201 Eag.2e Rivet, Afa. 99577 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water 3N Xx NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer XX NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA x21 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 Address T-a➢GI:ZEER1ttG 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 Engineer's signature Date Phone 6. DHHS SIGNATURE Approved for ____ _ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: 61' '277 Additional Comments By WS,/ Date 4/t5A CAUTION 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. 1/91) Beck MOA k21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lnf 7Z glec_I(1.) t Ate.wALI Parcel I D Io The PAP tC S.�. A. WELL DATA !'JN 10 1991 RECEIVED Well typeSi&s a t=nn41'It1 If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) (J Total depth 1 Z 9 Sanitary se& (Y/N) Date of test Static water level Well flow Pump level Date completed U1( Driller t ) Cased to FROM WELL LOG f 2 Casing height Wires properly protected (Y/N) gpm AT INSPECTION s-•3-11 1 z.0 gpm SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot / DO /1 ; On adjacent lots Absorption field on lot / On t ; On adjacent lots 00 t 100t Public sewer main r J/IA Public sewer manhole/cleanout 1 00 Public sewer service line Nfa Petroleum tank S 0 ,t (A.Looe 1100.0a) WATER SAMPLE RESULTS: Coliform CAC I -GV' Nitrate+tis-iFlctorN (ei el-) Other bacteria Date of sample: `-1 - zero Collected by. `I S E"..13 ((^1 Cerl B. SEPTIC/HOLDING TANK DATA Date installed / O - I b - e'r% Tank size 1 0010 514 I Compartments 2 Cleanouts (Y/N) J Foundation cleanout (Y/N) Depression (Y/N) 0.) High water alarm (Y/N) 14A Alarm tested (Y/N) AiIW Date of pumping S - I S -q SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot 1 0O t" On adjacent lots 1 00 t Foundation To property line / D t Absorption field 5 Water main/service line 1 0 Surface water/drainage / 00 f t 72-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) "Pump on" I: el "Pump off" level at High water alarm level Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA Date installed j 0 - 1 D - 8q On adjacent lots Length Width Surface water Soil rating 1 z,5/61? Total absorption area 3go Depression over field (Y/N) IJ Results (pass/fail) P.4 S S Gravel thickness System type .Ee JcJi1 Total depth Cleanouts present (Y/N) Peroxide treatment (past 12 months) (Y/N) kVA l ' Date of adequacy test S - P1 - 1 for 3 bedrooms If yes, give date n3/44 SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot oo r t On adjacent lots Property line 1 0 ,f To building foundation 20 To existing or abandoned system on lot AJ/W On adjacent lots 3o F Cutbank 5O t Water main/service line 1 t7 t / Surface water 1 00 fi Driveway, parking/vehicle storage area 1 0 -I- Curtain Curtain drain /Vi Sysfet+n Pre 4+0.41<ed priof` to 1ZS-1-; E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. S 8. S i_Zif INEER!M1!G Signature 1703,i River Loop Road No. 204 Eagle River, Alaska 99577 Engineer's Name Date d/7/`l/ f to ; ib • -e 0 J HAA. Fee $ X70 Waiver Fee' $ Date of Payment 6 -(Q 1 / Date of Payment Receipt Number 9j w / 7 ) Receipt Number MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL -1�( - Q OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date November 20. 19R6 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 22; Block 1; Gateway to the Park Location (address or directions) (b) Applicant Name Alan Larson Telephone: Home 694-9238 Business Applicant Address P.O. Box 230875. Eagle River, Alaska 99577 (c) Applicant is (check one): Lending Institution 0 ; Owner/builder ® ; Buyer 0 ; Other 0 (explain). (d) Lending Institution Bank of the North Telephone Address (e) Real Estate Company and Agent Address Telephone (1) 191'3i1the HAA to the following address: S & S ENGINEERING SRB 196X Eagle River Road Eagle River, Alaska 99577 2. TYPE OF RESIDENCE Single -Family ® Multi -Family 0 Other Number of Bedrooms 3. WATER SUPPLY Individual Well Community 0 Public 0 Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite g Public 0 Community 0 Holding Tank 0 Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (11 84) 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 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 Address Date 5 & 5 ENGINEERING Telephone 2_Q79 B 196x EAGLE RIVER, AK 99577 6. DHEP APPROVAL Approved for I l//.s—/86 bedrooms by R/ fe" "` Date /2 -2-86 Approved / Disapproved Conditional Terms of Conditional Approval 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 lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 A. WELL DATA Well Classification Well Log Present (Y0 Total Depth /2-5 I Cased to Static Water Level l Z ' DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION 61986 RECEIVED Legal Description L97 - T1 -6.; 9 T1-6. 1).tR rc._ If A, B, C, D.E.C. Approved (Y/N) ?fl Date Completed Yield C9• S be.>rK /Z-5 Depth of Grouting Casing Height Above Ground Electrical Wiring in Conduit/N) Depression Around Wellhead (Y,(9) Separation Distances from Well: To Septic/Holding Tank on Lot /oo(4 ; On Adjoining Lots 3, Pump Set At /20' Sanitary Seal on Casing (ON) To Nearest Edge of Absorption Field on Lot fix) /f' • On Adjoining Lots To Nearest Public Sewer Line N/A To Nearest Public Sewer /o tP/-,L / c./0 Cleanout/Manhole - To Nearest Sewer Service Line on Lot z5 -i- Water Sample Collected by S d S c Nv.wrc` v , I.4 ; Date Water Sample Test Results 5!�1 rS?*'E-C-tca - // -a/ -e3C= Comments Vier -r-- 713s7 &, ON /1- - (56, % . 9.✓,o fixc d' B. SEPTIC/HOLDING TANK DATA Date Installed /O - / 67- S Standpipes &A) /!� .t.>•� . vF D. /O 3r 7/o.++ f .0,'_ Size /vC'Q Air -tight Caps 6'J) No. of Compartments e_ FoundationCleanout/N) Depression over Tank (Y64? Date Last Pumped Pumping/Maintenance Contract on File (Y/N) 1`1/� Aff-44.1 for Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply Well /co.) ' To Building Foundation To Property Line /C, r To Disposal Field To Water Main/Service Line Course (0 IC' O / 4- S To Stream, Pond, Lake, or Major Drainage Comments 'K'(-{ sc.; t.d4./3c�aJ LAtc- 51 u c4.; -!«.. seg I I -$ Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata /ZS 11'4r - Date Installed / G -/1 - PS 4 Width of Field Type of System Design /g1=-Ni4-1 Length of Field 3.c Depth of Field F i Gravel Bed Thickness Square Feet of Absorption Area 3 Sd Standpipes Present ,6'N) Depression over Field (Y/a Date of Last Adequacy Test Results of Last Adequacy Test Separation Distance from Absorption Field: To Water -Supply Well /vv 64 To Property Line /� To Building Foundation Z v To Existing or Abandoned System on Lot /`i//4 ; On Adjoining Lots TC -3i To Water Main/Service Line / 0 r4 To Cutbank (if present) N/A To Stream/Pond/Lake/or Major Drainage Course /(DD /-/- To Driveway, Parking Area, or Vehicle Storage Area /v / f Comments Hvuscs 146•5 jiYlci r srtvcc.; Mows w,t» aur�T D. LIFT STATION Date Installed Dimensions Size in Gallons ,)` , Manhole/Access (Y/N) "Pump On" Level at D 1 "Pump Off" Level at High Water Alarm Level at Vent (Y/N) Tested for Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments " Check Permitted Bedroom Rating Against HAA Request "" I certify that I have checked, verified, or conformed to all MOAan HAA guidelines in effect on the date of this inspection. p 2sp6 Signed t &S ENGINEERING Date Compar$R B 196X MOA No. _ 6 6n) 3 Receipt trittljni5149,77 Date of Payment //72•0,6 Amount: $ l0�• v l/ Page 2 of 2 72-026 (11/84) • Rabe, A. flr.kr • s • �.Y Ho. 1467-E �yCe ��Q ••+wN•,44->o• � t4