HomeMy WebLinkAboutEAGLE CREST #1 TR A LT 9agl
Ceest
Te A
Lot 9
050- 303
-02
t CUs?.
Municipality of Anchorage
On -Site Water and Wastewater Program • (907) 343-7904 OCT 1 ® Page �r� 3
ON-SITE WASTEWATER INSPECTION REPORT �pjII
Permit Number: OSP111242 PID Number: 050-303-02
Dwelling: ❑E Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑ New Upgrade
Name:
Kenneth & Vicki Helm
ABSORPTION FIELD
t❑ Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound
❑ Other
Soil Rating Total depth from original grade
1.2 GPD/SF 14.1 Ft.
Address
19232 Citation Road Eagle River, AK 99577
Phone Number of Bedrooms
Five (5)
LEGAL DESCRIPTION
Depth to pipe invert from original grade
6.1 Ft.
Gravel depth beneath pipe
Ft.
Subdivision Block Lot
Eagle Crest #1 TR A g
Fill added above original grade
0 Ft.
Gravel length
9 Ft.
Township Range Section
Gravel width
3 Ft.
Total absorption area
144 FtZ
Beds: Number of Lines
Number of trenches
1
Distance between lines
Ft.
Dist. between trenches
Ft.
SEPARATION
To
From
DISTANCES
Septic Absorption Holding Sewer
Tank Field Lift Station Tank Line
Well
>100'
>100'
N/A
N/A
>25'
TANK 9 Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
Anchorage Tank
Capacity
1,500 Gal.
Surface Water
>100'
>100'
N/A
N/A
Material
Number of compartments
Lot Line
>5'
>10'
N/A
N/A
NA
Steel
Two
LIFT STATION
Foundation
>10'
>10'
N/A
N/A
Manufacturer
Capacity
Curtain Drain
None
Noted
Gal.
RemarksExisting septic tank decommissioned
Pump on level at
in.
Pump off level at
in.
High water alarm at
in.
per MOA Code. Additional 9' of trench added
to accomodate 5 bedroom design.
Pump make and model
Electrical Inspections performed by
Installer
Stuart Gilbert
Tankto
PIPE MATERIAL House to tank D3034 dra nfield D3034
Drainfield D3034 CO/MT
Inspector AH
BENCHMARK (Assumed elevation) 100 ft
Inspdat ectioes: 1st 9/9/11 2nd 9/10/11
3rd 4'h
Location and description
Door Jamb.
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
Engineer's Stamp
Conditional Approval: Date
At
r%Q'� • •:qs,���}
49 TH
.......... ......:..�
'• Michael E. Anderson /
�� �F� • 4381-E • ����
pp � Ez�lt�y_ A roved Date
nsoection RPnnrt A-1-19 rine
Municipality of Anchorage
DEVEOPMENT SERVICES DEPARTMENT
4700 Bragaw Street Anchorage, AK 99519-6655 - 343-7904
Permit No.: OSP111242 On -Site Wastewater Disposal System or Well Inspection Report
migm
Sl - Septic Vent
C4 - Cleon Out
Ml - Monitor Tube
TH - Test Hole
FS - Flow Splitter
CITATION ROAD
89'59*00'E 132.00'
(D
Existing
Well
LOT 9
18,066 S.F.
Five Bedroom Home
PAM
-,-WOODEN FENCE
Garden $2 e THI
2C4 CID
FS CO Shed
----- ------- ----
04
OP OF SLOPE — — — — — — —
Page 2 of 3
PID No. 050-303-02
\�WOODEN FENCE
LOT 11A
Existing septic tank decommissioned
in accordance with MOA Code.
49th
MICHAEL E.
% No. CE -4381
N
..............
10* UnLffY EASEXENT
A 1 8
S1 11.0,
—
11.7'
S2 20.5'
21.5*
C4 29.1'
33.9'
. 41- 49.4
Go
Municipality of Anchorage
DEVEOPMENT SERVICES DEPARTMENT
4700 South Bragaw Street Anchorage, AK 99519-6655 - 343-7904
On -Site Wastewater Disposal System or Well Inspection Report
Permit Number: ®SP111242
Final Grade
99.4
0
C04
Page 3 of 3
N • t • $M
LO
9' (Trench Length)
Test Hole completed for percolation test only. Groundwater study
completed to verify lack of groundwater. Existing Septic Tank
decommissioned in accordance with MOA Code.
92.7
. Z ................ oo
'V C�' ,
AV
W
EAGLE CREST NO. I
0 " 49th W
TRACT A, tOT 9 .0 ....... .... I ...... .... .......... * ...
..............................................
MICHAEL E. ANDERSON
4-,
PROFILE AS -BUILT 0, No. CE -4381 I
No Scale Ak
44h.- FESSIt
Un -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: OSP111242
Tax Code Number: 05030302000
Work Type: Septic Upgrade
Permit Effective Dates: September 07, 2011 to September 06, 2012
Design Engineer: ANDERSON ENGINEERING
Subdivision: EAGLE CREST #1
Site Legal Address: EAGLE CREST #1 TR A LT 9 G:0055
Owner/Address: HELM KENNETH R & VICKIE D
19232 CITATION RD EAGLE RIVER AK 995778416
Site Mailing Address: 19232 CITATION RD, Eagle River
Lot Size in Sq Ft:
Total Bedrooms:
�l�lcnt
1.)("partment
I- q— I/ C
.5w_lr
2-1
18066
-A- 5
This permit is for the construction of:
Y X 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.
q�lR%ll C01 Chan9� to S b��reo,�s anol ex�and,'ny �,�ldl.
Received By:
0 Z)
Community Development Department
Development Services Division
On-Site Water & Wastewater Program
-"~ MUNICIPALITY OF ANCHORAGE
~ Phone: 907-343-7904
Fax: 907-343-7997
Mayor Dan Sullivan
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 0~'0-_~..~0._~-_0___;~,_
Property owner(s)
Mailing address i9~. ~Z.
Day phone
Site address
Legal description (Sub'd., Block & Lot)
Legal description (Township, Range & Section)
Lot Size ! ~, O~,~,Sq. Ft. Number of Bedrooms
~ CO~I
THIS APPLICATION IS FOR:
([~ all that apply)
Absorption Field
Septic Tank
Holding Tank
Privy
Private Well
Water Storage
THIS APPLICATION IS AN:
Initial []
Upgrade ~'
Renewal []
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
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.
(Signature of property owner or authorized agent)
~ush Fees: ~ - -C~< ¢.e4~'~aiver Fees:
Date of Payment: d~l (¢ i \\ Date of Payment:
Receipt Number: ¢~to'-! ~ id Receipt Number:
Permit No. ~-~,.~*~ , \'~ ~ i~. Waiver No.
G:\Building\On Site\Forms\Client Forms\Permit App_010411 .doc (Rev. 1/11 )
Co x l
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
522-7773 522-6779 (FAX)
September 16, 2011
Municipality of Anchorage
Development Services Department
On-Site Water and Wastewater Program
4700 South Bragaw Street
Anchorage, AK 99519-6650
Subject:
Lot 9, Block A, Eagle Crest Subdivision No. 1
Septic System Design and Permit Application
Impacts to Adjacent Properties
Dear Onsite Services Engineer:
The septic tank on Lot 9, Block 2, Eagle Crest Subdivision No. 1 is near failure and
must be replaced. We are proposing to replace the tank with a new 1,500-gallon steel
septic tank to serve the four-bedroom home on the lot which may be expanded to five
bedrooms in the future. In addition the existing absorption trench must be expanded a
minimum of 9' to meet the requirements for a five bedroom home. We are therefore
requesting a permit be issued for the construction of a new septic tank and expansion
of the absorption trench to serve the home. The attached Site Plan and backup
documentation identify the location and configuration of the existing septic system and
the location of the new tank. Also identified on the plans is the existing well on the lot.
The existing tank on the lot will be properly disposed in accordance with Municipal
Code. The drainage patterns on the property will be maintained after construction.
The ground surface on the lot slopes to the southeast at a 3% grade in the area of the
new tank and absorption trench extension. The tank will be placed in the same location
as the existing tank at nearly the same elevation. The trench extension will be
constructed from 12' to 20' below the surface and entirely in the soils identified suitable
for the percolation zone. The ground slope will have no bearing on the orientation of
the absorption trench.
The existing absorption trench has been in service since 1978 and is in good condition
with no evidence of groundwater intrusion. Test holes placed on all lots adjacent to this
lot show no evidence of groundwater at any time of the year. We are confident
groundwater does no encroach within 4' of the bottom of the trench. In addition the well
log on this lot and the neighboring lot show no evidence of bedrock or any impermeable
Lot 9, Block 2, Eagle Crest No. 1
September 16, 2011
Page 2 of 2
C O, l
soil lense. All lenses have been identified as either gravel or sand. Additional test
holes to prove the absence of groundwater and bedrock are unnecessary as sufficient
verification currently exists.
If the tank and trench extension are constructed in accordance with our design the
following statements apply:
The system, if constructed as designed, will have no adverse impact on the wells
in the area or those to be constructed in the future.
The system, if constructed as designed, will have no adverse impact on existing
septic systems in the area or those to be constructed in the future.
The system, if constructed as designed, will have no adverse impact on reserve
space, either surface or subsurface, on any lots located in the area.
The system, if constructed as designed, will have no adverse impact on drainage
patterns in the area. The current drainage pattern will be maintained.
Sincerely,
Michael E. Anderson, P.E.
Attachments
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
522-7773 522-6779 (FAX)
September 19, 2011
Municipality of Anchorage
Development Services Department
On-Site Water and Wastewater Program
4700 South Bragaw Street
Anchorage, AK 99519-6650
Subject:
Lot 9, Tract A, Eagle Crest Subdivision No. 1
Septic System Design and Permit Application
Groundwater Absence
Dear Onsite Services Engineer:
The attached drawing provides detailed topographic information of the area surrounding
Lot 9, Tract A, Eagle Crest Subdivision No. 1. The drawing shows the elevation of the
surface at the absorption trench on Lot 9 at 712'. The bottom of the trench is 20' below
the surface at this point or elevation 692'. Subsurface soils at this location are coarse
sand and gravel and no groundwater was found in the test hole placed on the lot.
The lot immediately to the west, Lot 10, has two test holes with the locations shown on
the drawing. Test Hole No. 1 is at surface elevation 706' and Test Hole No. 2 is at
elevation 692'. Both holes were completed to depths of 16' and indicated well graded
sand and gravel with some silt. No groundwater was found in either hole at any time.
The ground elevations at the bottom of the test holes was calculated at 690' and 676'
respectively.
A test hole was placed on Lot 11A at the location shown on the drawing. The ground
elevation at the location is 672' with the bottom of the test hole at 658'. Soils
encountered were coarse gravel with varying amounts of silt. Again, no groundwater
was found at any time of the year.
Soils in the area are consistently sand and gravel with small amounts of silt. No silt
lenses or impermeable layers are mentioned in any of the test hole documentation.
Similarly, no groundwater is noted. Typically groundwater is found at the interface of
clean soil lenses and tighter siltier lenses. It is apparent based on test holes placed in
the area that groundwater is not found above elevation 688' which is the elevation at 4'
below the bottom of the absorption trench on Lot 9. In our opinion a test hole to verify
Lot 9, Block 2, Eagle Crest No. 1
September 19, 2011
Page 2 of 2
the absence of groundwater at 4' below the bottom of the absorption trench on Lot 9 is
unnecessary. We therefore request the requirement for the test hole be waived.
Sincerely,
Michael E. Anderson, P.E.
Attachments
'-CITATION ROAD
AREA
MAP
SCALE 1" = 50'
o ~-_~
'-FO
o_. "' 0 <
S O0'08'O0'E 136.81'
~ //
/
/
~ /
o~ - /
/
?
/
?
/
?
0
S 00'08'00'£ 136.91'
m
3,0.00'
EAGLE CREST SUBDIVISION NO. 1
TRACT A, LOT 9
Co~l
DESIGN FACTORS: SYSTEM REQUIREMENTS:
Five Bedroom Home Deep Absorption Trench
Perc. Rate: 1 to 5 Min./Inch 1,500 Gallon Septic Tank
Application Rate: 1.2 GPD/SF 8' Drainfield Rock
Existing Trench: Satisfactory for Four Bedrooms (38' x 16 SF/LF = 608 SF)
1 Bedroom X 150 GPD/1.2 GPD/SF (Application Rate) = 125 SF Absorption Area
125 SF/16 SF/LF = 7.81 LF Trench Length
THEREFORE: Construct a 9' Long x 3' Wide x 8' Effective Depth Absorption Trench at the End of
the Existing Absorption Trench. Flow Line Elevation in Trench to Match Existing Flow Line.
Total Depth to be nearly 20' Below Existing Ground. Provide 4' Cover Over Septic Tank
and 3' of Cover Over Absorption Trench. Maintain 100' Separation from Wells in the Area.
11'6"
Natural
Backfill
Geotextile
Fabric
4" Perforated
PVC (Holes Down)
Drainfield Rock
TYPICAL DEEP TRENCH SECTION
........
(NO SCALE
) .
NOTE: Grade Area Over Trench to Drain Away. ,~'
M n m m ' ' ~
u 6 Separation From Bedrock. ~.....~., ........................... :,.....~
Minimum 4' Separation From Groundwater. ~ ~~~]'~'~
. ~ . ~.~,,..I .............
Minimum 100 Separation From Wells in the Area ~: MICHAEL E ~'"'?'~'~
M~n~mum 100' Separation From Sugace Water or Streams. ~.~ ,o. c~-~
~700
DEPTH
(~et)
1
2
3
4
5
6
7
8
9
11
20¸-
MUNICIPALITY OF' ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT
BRAGAW STREET ANCHORAGE, AK 99519-6650
SOILS LOG - PERCOLATION TEST
LEGAL DESCRIPTION: LOT 9, TRACT A, EAGLE CREST SUB. NO.
PERFORMED FOR: KENNETH HELM
DATE: 9/IA?2011 PROJECT No.:
PARCEL ID#: TECHNICIAN: S. g ILBERT
TEST HOLE 1
OB/OG SLOPE
SILTY GRAVEL
SAND
GM/SH
FILL TO 8'
FILL MATERIAL IDENTICAL
TO IN SITU SOIL
Professional Enginee~ Stamp:
SITE PLAN
SEE SITE PLAN
WAS GROUND WATER ENCOUNTERED? NO
IFYES~WHATDEPTH? ~ ] ~
DEPTH OF WATER AFTER MONITORING: NON~ 0 2 %
DATE OF MONITORING: p
E '-
DEPTH TO
DATE READING GROSS TIME NET TIME WATER NET DROP
(MINUTES) (MINUTES) (INCHES) (INCHES)
TEST HOLE PRESOAKED PRIOR TO TESTING:
9/14 1 9:28/9:38 l0 12"/16" 4.00"
2 9:39/9:49 10 12"/16" 4.00"
3 9:50/10:00 10 12"/16" 4.00"
4 10:01/10:11 10 12"/16" 4.00"
5 10:12/10:22 10 12"/16" 4.00"
6 10:23/10:33 10 12"/16" 4.00"
BOH @ 15'
PERCOLATION RATE: 2.5 (MIN/INCH) PERC. HOLE DIA. 6" .(INCHES)
TEST RUN BETWEEN: 12 FT. and 13 FT.
COMMENTS: TEST HOLE PRE SOAKED PRIOR TO TEST.
TEST PERFORMED BY ANDERSON ENGINEERING. I, MICHAEL E. ANDERSON CERTIFY THAT
THIS WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPLE GUIDELINES IN EFFECT ON THIS
DATE: 6/10/2010
r(-~---~UNICIPALITY 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
Steve Leinber~er
PHONE
J337-6223
NAME
MAILING ADDRESS
3350 Boniface
Anchorage, AK
LEGAL DESCRIPTION
Lot 9 Block A Eagle Crest Subdivision
LOCATION
NO. OF BEDROOMS
4
IAbsorpuon area PERMIT NO.
We, 105' . ' 780345
8.5'I 7'9"
I Steel
DISTANCE TO:
No. of lines
1
Greet
IF HOMEMADE: I Inside length J Width
Well Dwelling
we, 11R'
Length of each ne
Top of llte to finish rade
16'?"
Total length of lines
52r
Depth
Length
Material2 5 !
96
inches
inches
Width
Liquid depth
PERMIT NO.
Liquid capacity in gallons
PERMIT NO.
78036,5
Distance betv~en lines
Total effective absorption area
832 S.F.
PERMIT NO.
Type of crib Crib diameler Crib depth Total effective absorption area
Well Building foundation Nearest lot line
DISTANCE TO:
.~lass Depth Driller Distance to lot line PERMIT NO.
DISTANCE TO: Building foundation Sewer line Septic tank Absorpt on area(s)
OTHER
PiPE MATERIALS
Castiron & plastic perforated
SOIL TEST RATING
150 S.F./SR.
INSTALLER
Curt Abbas
REMARKS
·
72.013 (Rev. 3/78)
OWNER OF LAND
ADDRESS
A & L DRILLING COMPANY
BOX 97, EAGLE RIVER, ALASKA 99577 · TELEPHONE 694.2588 ~
,..
/ti/~ t~ i~ ~' DEPTil OF WELL
LEGAL DESCRIPTION ff. ~'/ 7'~,,~cT /q
DATE-Started .C//; ¢~7 r Ended
PE~M~NUMBER 7f~f
STATIC LEVEL OF WATER FT.
GALS. PER tlR '~ O D
KIND OF CASING 6 ~--L"'O O
KIND OF FORMATION:
From O FI. lo c~ Ft.
From ~L FI. to ~/ Ft.
From ~ ~ FI. lo '~ ~" Ft.
From ~ ~ FI. to ~._~__Ft.
From ~3'"'Ft. to 7.3 Ft.
From 73 FI. to ~"~" FI.
From ,~" FI. to Io ~ Ft.
From /OI Ft. to/?O Ft.
From !70 Ft. toc~l
From ~10 FI. to
From c~7~Ft, to ~'} Ft.
From O~ I Ft. to "~/~-' Ft.
From '~/~"Ft. to ,~c,t,~ Ft.
From Ft. to Ft.
From Ft. to__Ft.
From Ft. to____Ft.
From Ft. to Ft,
From--
F~o,.
~¢~From~
From~
F~om
From__
From__
From
From
From
From
From
.Ft. to Ft.
FI. to Ft.
.Ft. to Ft.
.Ft. to.__Ft,
Ft. lo FI
.Ft. to.__Ft.
.Ft. to Ft.
.Ft. to.__Ft.
.FI. to Ft.
.Ft. to.__.Ft.
Ft. to Ft,
Ft. to__Ft,
FI. to Ft.
Ft. to Ft.
Ft. to Ft.
__Ft. to Ft.
Ft. to__.Ft
MISCL. INFORMATION:
DRILLER'S NAME Z~.,,~ ~--~'"
· '- DEPRRTMENT ALTH RND EHVIRONMENTRL
825 'L' STREET, RNCHORRGE, AK. 99501'
· ~' ' R64-47~0
P~RMIT NO. ( VOO~45 )
fiPPLICRNT
LOCRTION
LEGRL
STEVE LEINOERG~R
4TH
L 9 B R ERGLE CREST SUB
~50 DONIFfiCE
LOT SIZE
17952 SQURRE FEET
TYPE OF SOIL RBSORDTION SYSTEM ID: TRENCII
M~IMUM NUMOER or BEDROOMS = 4
SOIL RATING (SO FT/DR)=
TIlE REQUIRED SIZE OF THE SOIL RBSORPTION SYSTEM IS:
Dr"- PTI -I~= '1--'~-' Lr"I'~II~TI-I= ~:~ ~F(Ft%/EL DEPTI-I= ~
TH." LENGTII DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIELD.
TIlE DEPTH OF fi TREHCH OR PIT IS THE DISTRNCE BETWEEN THE 5URFRCE OF THE
GROUND RND THE BOTTOM OF THE EXCflVflTION fin FEET).
TII~RE I5 NO SET WIDTII FOR TRENCtlES.
TII~ CRRVEL DEPTH IS TH~ MINIMUM DEPTtl OF GRRVEL BETWEEN TIlE OUTFRLL PIPE
fiND TII~ DOTT~ OF THE D~CflVRTION (IN FEET).
~EI;iU I EEl) ~:EPT I C: TRNI( $ I ZE= '1250 I~iRLLO~'{5
PERMIT RPPLICRNT HRS THE RESPONSIDILIT',' TO INFORM TIII5 DEPI~,'~TMENT DURING TIlE
INST~LLflTION INSPECTION5 or fiN',' WELLS flDJflCENT TO TIII5 PROPERT',' fiND TII~
------ T~O (2-) -" ,"-'$PECT I OtIS RRE I~E~U I
B~CI(FILLINO OF fiN',' S','STEM WITHOUT F~Nf]~. INSPECTION fiND fi,'sPRO'~'AL D',' TIII5
DFPi~RTMEHT WILL DE SUBJECT TO PP~OSECUTION.
MINIMUM DISTnNCE BETWEEN ~ I~LL RND 13N%' ON-SITE 5EWnGE DISPOSI'IL SYSTEM I5
IO0 FEET FOR ~ PRIVATE t~r'LL; CR
:tS0 TO P_00 FEET FROM R PUBLIC t~rLL DEPENDING UPON TIlE TYPE OF PUBLIC W~LL.
WELL L. OC5 fiRE REQUIRED fIND MUST BE RETURNED TO THE DEPRRTMENT WITHIN 30 DFIVS
OF TIlE t~ELL COMPLETION.
OTII~'R REQUIREMENTS MPIY fiPPL','. SPECIFICflTION5 fIND CONSTRUCTION DIfiGRRMS lIRE
flVP, ILROLE TO INSURE PROPER INSTftLLftTION.
I CERT I F',' TI
.~.~' I AM FAMILIAR WITII TIlE R."QUIREMEHTS FOR ON-SITE SEWERS fiND WELLS fi.f, SET
FORTII B',' Tilt' MUNICIPRLITY OF RNCHORAOE.
2: I WILL IN~TI~LL THE SYSTEM IN RCCORDRNCE WITH THE CODES.
~: I UNDER5TRND THRT THE OH-SI~TE SEWER SYSTEM MRY REQUIRE ENLRRGEMEHT IF THE
RESI~ELE~ ~E2E ~tlR" 4 DED~O0"S'
5 ......
Performed For
Lena1 nescrtntton:
This rorm Renorts Soils
2204 Cleveland AnChorage, Alaska 99503
Curt Abbas O~te Performed
Lot 9 BIOCk, A Subdivision Eagle Crest
LOft Ye~
5-q-7R
Subdivision
Percolation Test
Oevth
Feet Sot1 Characteristics
Slightly Silty Sandy Gravel
4-- (with occasional cobbles &
boulders)
B--
10--
12--
14--
16-- Bottom of Test Hole
20--
Was Ground Vater Encountered? No
If Yes, At what De.th?
Readtnq Date Gross Time Net Time De.th to H20 Net Dron
Percolation Rate fltnute
Prnposed lflsta-l'l~-f~: 'Seenaae Pit Drain Field
Deoth of Inlet Depth To Bottom Of Pit Or Trench
Cn~EgT$: I~Q Se. Ft. drainage are~ r~,,~r~a.p,~ ~
Test Performed Data Certified BY: CTt
~vtd Paul Date~ 5-9-78
.~ ~, "~.~,~.-.il [~*~\.~ ~,
~:. ~, ,.
't, 'P~rce ID.~:
:;Comp ere lega des~r pt
Location (site address
.1,:, ~.~, ,,. T ,',~',~'~'~
.~e n~,~e'~ *'.' *
~at based on the Informat on obta ned from
, the on-s te water
~ .... ?:'"~"' P one
is-not [ '~" .'1 ~
'"~ Municipality. of An,cho.rage
Depa~ment of.Health and Human Services
HEALTH A UTHQR .1~.., .,~ .Q,V,~.~ C ,H .ECKLIST
Legal Description: Z~,~. ~' .'7"~,,~ ~,,~ ~",,~z.~ d~'~Jl~Tcel I.D.
A. Well Data
Well type
Leg present (Y/N)
Total depth ../-~-- /
Sanitary seal (Y/N)
Date of test
Static water level
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed ~'~/-~Y'./~, /~'X~' Driller ,.dz,
.Cased to
.~-. ,' ~:',~. Casing height .~'~. ,,xJ.
Wires propedy protected (Y/N) ~
AT INSPECTION
FROM WELL LOG
Well flow
Pump level1 ..fz~ ~' ·
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot / ~-.~"'~'~
Absorption field on lot
Public sewer main
Sewer service line
g.p.m.
: On adjacent lots / ~ ~ '"'~"r~
; On adjacent lots
Public sewer manhole/cleanout
.Petroleum lank /"J,/~,~
WATER SAMPLE RESULTS:
Coliform ~" Nitrate
Date of sample: ,,~,~. ,,~.
B. SEPTIC/HOLDING TANK DATA
Other bacteria
Collected by:
Cleanouts (Y/N) /
High water alarm (Y/N)~ ,
Date of pu~ping' '.~-~,..~1/ J
Datelnstalled ../uz.y ,~..z/ ,q~ Tanksize /~.,5'"~ ~,,,~z.., Compartments
Foundation cleanout (Y/N) ~- , Depr.ession (Y/N) .
SEPARATION DISTANCES FROM 8EPTIO/HOLDING TANK TI~: - · ,. , ,,
Well(s) on lot -/o r ~'/':
To property line ..~'~ '~'-~
Surtace water/drainage
72-02~ (3~3)' Froot
On adjacent lots / ~ "~"-'" .Foundation
Absorption field. / ~ ,~'~z. Water main/service line
CONTINUED ON BACK PAGE
C. UFT STATION
Date Installed
Size in gallons
Vent (Y/N)
'Pump on' level at
High water alarm level
Meets MOA electrical codes (Y/N) / ./~r
SE TION TO:
W~on lot On adjacent lots '
.Manufacturer
Manhole/Access (Y/N)
Sudace water.
D. ABSORPTION FIELD DATA
Length ~ n~
'D~to of a~ te~
Watar ~ In ~n f~ ~fom test
pemx~e ~at~m (~ 12 ~) ~)
.
Soil rating (GPD/FF) '
~ ~/x..~ . Gravel thickness ~'
~'.,"~- .~',/~ .Cleanout~)resent (Y/N)
'~'-//'~' ~ ~' Results (pass/fa~)
/..~.--,, ~j
System type '~'""~,~".~.-~ z ,~
Total depth
rv DePression over field (Y/N)
~',~.r~ .for ~ Bedrooms
Ntertest .~ o ~ ,.~J. '
.If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot / / ,~ .,~',,z On adjacent lots /~z)""'z"~ Property line
To building foundation .~'.5"~-/-. To existing or abandoned system On lot
On adjacent lots /~ ~ '"' ,~"/' Cutbank ,~,,~z Water main/service line
Surface water A J/-'4
Cuilain drain
D~eway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I cern'fy that I have checked, vedfied, or conformed to alIMOA and HAA guidelines in effec~n3h'e'.dat~.~ this inspec~on.
.~'~.' /~
I I
(~, ~ ~.. ·... · ..,:.;~_'~_'~ V
HAA Fee $ ~ ,' ~ ' ' '
Date of Payment ~//~c/~q~...-
/?!
Waiver Fee $ II
Date Of Payment
Receil:X Number
Municipality of Anchorage
Department of Health and Human Services
825 "L" Street
Rick Mystrorn, P.O. BOX 196650 Anchorage, Alaska 99519-6650
Mayor
August 31, 1995
Doug Kenley, P.E.
HC 01 Box 6034
Palmer, Alaska 99645
Subject: Waiver Request for Lot 9 Tract A Eagle Crest Subdivision
Waiver Request #WR950042, PID %050-303-02, HA950358
Dear Mr. Kenley:
Your request for a waiver of the required 10 foot separation
between a septic system and a lot line has been approved. The
waived distance is 5 feet from the absorption field to the property
line.
This approval applies to the existing septic system lot line
separation only. Any future upgrade to the septic system will
require all separations be met or another approval from this
department.
~ Sincerelw~ ,I ~ ! .
\ / J.ame__s P. Williams
~/ Civil Engineer
On-site Services
ljm
MUNICIPALITY OF ANCHORA~,
Department of Health and Human Services
WR# %,%0c~.a~Vqq~PID# 050-303-02
Date Received: August 30r 1995
On-site Services Section
Waiver Review Worksheet
HA# HA950358
Permit #
Legal Description: Lot 9 Tract A Eagle Crest Subdivision
Engineer: Doug Kenley, P.E.
HC 01 Box 6034, Palmer, Alaska 99645
Applicant: Curtis Abbas
Waiver Requested: Lot line waiver of 5 feet from the lot line to
the absorption field
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:
List Conditions or
Reasons
Waiver
for above:
is NOT Granted:
Date:
By:
Name of Reviewer
Rec #: #01256/2680 Amount: $ 115.00 Date Paid: 8-30-95
HUSTON.XLS
Douglas T. Kenley
Civil Engineer
State of Alaska C.E. 8176
SEPTIC SYSTEM ADEQUACYTEST
Legal Description
Applicant
Date of Test
SYSTEM DATA
Tank Volume
Number of Bedrooms
Absorption system
Number of Bedrooms
Absorption required (1.5 daily flow)
TEST DATA
rIME FLOW VOL. TANK LEVEL~¢~*/ TUBE LEVEL COMMENTS
(gpm) (gals)
System Passed
Sysytem Failed
Page
HUSTON.XLS
Douglas T. Kenley
Civil Engineer
State of Alaska C.E. 8t76
SEPTIC SYSTEM ADEQUACYTEST
Legal Description
Applicant
Date of Test
SYSTEM DATA
Tank Volume
Number of Bedrooms
Absorption system
Number of Bedmoms
Absorption required (1.5 daily flow)
TEST DATA
TIME FLOW VOL. TANK LEVEL ~./ TUBE LEVEL COMMENTS
(gpm) (gals)
System Passed ~ Sysytem Faile~
Page I ~'~
· ~"' '"':' ' ' ' ' : ~,.~.~ I
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,./.. ,~,,-.~, .... ~.,,>-,,,~.../ .. .,,,~;.,t../~,/. ,.. ; . , '., . .
/'.w! ~ ' ~ J' "' .... ' ' '
~ ~ /. " ' 't~ ' . · ~ . ' ' · .- ....
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'.' ~,, ~t . " .' . '' . . '£' ' ' · ' , .... ' " ' "9 't .
· .. ,,!; ... .. ]./ . . .. . . .
~',.i '. ./ '":".' ~ ..'.. '.',.' -,, · - "'
....,, ~; : ' , .... .;,~' . . .... · ~, . · .
~ ..... , .' .... · , · ~,f,t , ..
. . ,. .'h~. . · · .. ,',,~, · '. /,~ ~ "·
' .,'>'..."'~ . ". ,.a~r'. . · .' ,. . '17.¢ :
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· ..'. .:..-,. ;.,.- '.....' . · '.'. '. . t~2.,o.o '. . , ~. ^.~.BU~LT.. · ·
.-~ '.' · .' ; · . ' .' ' · ' I hereby ce~tL~v that l have survey, ed the followS desc=
'.,..": '" . : .. · · ' ' ' : . 'oroc~ertv:J-';~)'/" ~"', "r'~- ... . .
;.;.. ' .... .' .... . ... ". ' . · -:,,~-/.~ (~.,~- ,~
"" '"' '' : N ,<...,~..~,,,.,. vt
· . · . · : .:. · ' Anchorage Rec6rding r~¢inct, Al~skl, i~c[ th.~t the.
, ;.,.......' .... :' .,,:....... .. , · . · . mcnLs situated thereon 3re within the property IL, aes and
... _._.._=~. ~ . /.,- · .ovedapocenczoJ¢ho~theprol~e~y, lym~adjKemtheteto.
· .; . , no improvements on propett7 lying ~djacemt theret~ en¢~
· : · ,,, - · O~ the premises in question and thU theTe are no to,Iv
r ...... .'. tr3nsmis$ion lines or other visible easements on said prOl
· . .. ·. . . · except as mcl~ated hereon.
J .,t -. · ~; · . ,'. <, · DatedaJEageRvet, Alask~ , , '
"-I .~'~':..'.",' '. ". ':" '~.. . ...," i' , ' RO~EgTC. IOHNSON ~ fi: ~-
"I .~-.:..~,. ': , - .~o~e(~6~2~
?)J .~. .. ,, .', · . , ..................
., ........ MUNICIPALI FANCHORAGE : *- *~- ..... '-"~. ~ .......
~ :. . i. DEPARTMENT 0F HEALTH & HUMAN SERVICES ..... : ...................
" ": ' ' ' Division of Environmental Services ' ": ~ .... ' '";" ;:''
........~-...---'-- ".:' '-~= ......... '" -"-=--::-::-On-Site Services Section :'.: -~-~;=:- -- ' ' ---;"::'-"~....- .........
GENERAL INFORMATION
.Complete legal description
. .... ' .... . ~ ,P.O. Box 196650 Anchorage;Alaska 99519-6650 ' : ..... "' ' ·
,,.- .... ..,.. ' .::~..,',,~.",'-~' ,, !:::.~!'~343-,4744 ...... ,:.',:. ;:~.. ~ '~' · . ~.~ ,:~'..
'" '" ' ' CER'I:iFiCATE el~'HEALTH AUTHORITY" ' · APPROVAL FOR A SINGLE FAMILY DWELLING ....
Parcel I.D. # (~J~('~- 9.,¢%_~.~,~). HAA# J~:2L/~¢::).~:~..~ '
Location (s'ite ~ddr~s~ (~; directions)
19250 C~,~c~o~ Ro~E
............ Property owner ' .,Cu.,t..C~ 1). Abb~ Day phone 694-$175
Mailing address *'~lg~$o'.c,L,tzz,f~on Road E~t,~.¢ I~ue,~r ~ 99577 - .:
......... - ~V ~o~gage
. Lend,.~ ~.~ - Day ph6ne
· Agent~
' ~' Day phone ',-"
Unless otherwise requested, HAA will be held for p~ckup. . '..; ,.%'~,.,. ..... '* . '
2. NUMBER OF BEDROOMS: 4~ 'N ; t~?,.'
3. TYPE OFWATER SUPPLY: '- r'' ' :
· Individual well ....... *. '.~-. · : /
Community well . F~, ,.,'~,
Public water
· . NOTE: If community well syst. em, provide.written confirmation from State ADEC attest-
lng. to the legality and status of system, v* '.'
4. TYPE OFWASTEWATER DjSP0~AL:* · '
· ~ ............. Ind v dua on-s te ..**--.= =*,:. ..... ..... = ~_,;~ ~ ........... , ..... .,.-, -*
Unl ·
· ........ , ...... - .-~ iComm ty.onTsite ;~,~ ~...,.,
......... , ........... Pub csewer ............... ~- .................. ~: .... .:, ~-:-:.. *= - -
~'*,.. (~ *~/-' .-NOTE: If commumt~ was~ewa~er system, provide wri~en confirmafion from State AD~C
STATEMENT-OF INSPECTION BY ENGINEER
As certified by; .my. seal affixed he. [~t0 and a~ of the Validation date shown below, I verify that my
lnvestigatiori 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 file. s and from my Investigation and inspection, the on-site water
supply ~nd/or wastewate~;.disp~.s.al system is in c/3.mpliance With ali.Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name Of Firm' ' ~ & 5 ENGiNEE~<iNG Phone
Address 17034 Eagle River Loop Road No. 204
Eagle River~ Alaaka ~95~7
Engineer's signature :' Date
_ ! .... -".'" .. ·'. . SHAFER
'" C(~h~litional approval for "~' -"; : "'bedrooms, with the following stipulations:
'".'Additional Comments
By:. .... Date
The Municipality of Anchorage Department of Health and Human Servicas (DHHS) Issues Health Authority
;~ .'_ ~ 2': Approval Certificates based only upon the representations given In parsgraph' 5 abo~ve by an Independent
? :-' ~ ~ ~ professional engineer registered in the State ~f Alaska. The DHHS does this as a courtesy to purchasers of homes
............'- ' and their lenc~ing institutions In order to satisfy Certain federal and state requirai~t~2 Employees of DHHS do not
~!'i i~;:, conduct InsPeCtions o/: ana yze data before a certificate is Issu~L.Tho Munlclpality'iof Anchorage is not
Municipality of Anchorage ~i~'
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
"J:~,' ~,,~t.~- ParcelI.D.
Legal Description:
A. WELL DATA
Well type '~1'~' If A, B, or C, attach ADEC letter. ADEC water system number
Datecompleted ~'--'~t.-~6 Driller,, ~,
Cased to '~ 7-.-'t t Casing height
Wires properly protected {~N)
Log present ~YN) ~
Total depth 'z,>'Z--~ ~
Sanitary seal ~N)
Date of test
Static water level
Well flow
Pump level- '
FROM WELL LOG
' '
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot t C'~' [
Absorption field on lot ~ ~'~
g.p.m.
; On adjacent lots
AT INSPECTION
; On adjacent lots
Public sewer main
Sewer serVice line
WATER SAMPLE RESULTS:
Date of sample:
Public sewer manhole/cleanout
Petroleum tank
SEPTIC/HOLDING TANK DATA
Date installed ~ ... '7.-~, ."]~
Collected by:
Other bacteria
S & S ENGINEERING
E~le River, Aliska ~577
Tank size ~ ?.-5' Z) Compartments
Cleanouts {~TN)
High water alarm
Date of pumping
Foundation cleanout (Y/I~;J) ~ Depression (Y~]) /'-J
~,larm tested (Y/N) '~-
Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) onlot J o~t On adjacent lots ~cx:> I,~
To propertyline ~t;' t~- ll~ ,~ ~
Surface water/drainage
Absorption field
Foundation
Water main/serviceline-
72-026 (Rev. 7/91) Fm~t CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent(Y/N)
Manufacturer
Manh01~/Access (Y/N)'
High water alarm level
Meets MO.A ~lectri~
SE ANCE F.OM UH' T^T 0N 70:
W'E~on lot "' ' On adjacent 10ts
D. ABSORPTION FIELD DATA '
Date Ins'tailed '7 o Z.'~ -*~ ~
Cycles tested
Length *~'"2'*'~'' * Width
Total absorption area
Depression over field (Y~:I~
Pe~o}dde treatment Ipast 'l~, months)
Surface water ,'
Soil rating ~ ~'°~'/(5~' . System type
Gravel thickness ~ ~ I' '
Cleanouts present
Date of adequacy test
for
~,~-E.. l~oCJ , Ifyes, givedate
Cutbank ' ~'/L Water main/service line
Driveway, parking/vehicle storage ,area .
SEPARATION DISTANCE FROM ABSORPTION FIELD TO: ;
Well on lot [.ti~ t On adiacent I~ts ~oo ~ ~' P~perty line
building foundation ~, ¢,. '7- To e×isfing or abandoned ays!em on lot
To
On adjacent lots. "'~,c=, ~ ~''
Surface water
Curtain drain
E. ENGINEER'S CERTIFICATION
Total depth
Y
bedrooms
~- el~ 4/.
Waiver Fee: $ .
Date of Payment
Receipt Number
HAA Fee $ ~'~
Date of Payment
Receipt Number
~2~ (R~. ~1) ~k MOA
· . "~ $&SENGINEERING _ ' .... ':
Signature 170~4 Eaqle River Loop Road Ne. 204
· Eagle River, Alaska 99577
Engineer's Na,me
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
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
(a) Legal,Description (include lot, block, subdivision, section, to..~,wnship, range~
Location (address or directions)
Applicant Name/'''q~'~[~''' _/~'~'~ .. Telephone: Home /~ ~/'-..~,J ~g Business ~",~/- Z//,-,,~,~,5''''
(b)
Applicant AddreSs / ~-~ ('?~'~ ,'~' ~"~,,,,, ,~,,~'~-'"~""
(c) Applicant is (check one): Lending Institution []; Owner/builder,~; Buyer I-I ;. Other I-I (explain);
(e) Real Estate Company and Agent ? ~"'~/~,' ~ /~
Address
Telephone
(f) .Maff'the HAA to the following address:
TYPE OF RESIDENCE
Single-Family,~ Multi-Family []
Number of Bedrooms '~
Other
3. WATER SUPPLY '
Individual Well ~' Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality a.nd status.
4. SEWAGE DISPOSAL
Onsite~(~ Public[] CommunityD Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environ mental Conservation
attesting to the legality and status.
Page 1 of 2 12-025 (11/84)
, 5.
ENGINEERING FIRM PROVIDI'~'%INSPECTIONS, TESTS, FILE SEARCH, D'""~ 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
Telephone
the date of this inspection.
Name of Firm .c ~ S-ENGINEERING
Address _~.D. ~ _~ 96X
Date EAGLERll/ER,_AK 99577
JUN I 0 1986
Approved for ,'~,~-'-~/'z///)bedrooms by te
Approved ~/~ Disapproved Conditional _
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues H~alth 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
72-025 (11/84)
MUNICIPALITY OF ANCHORAGE (MO~,J ' ~,LTH &
HEALTH AUTHORITY APPROVAL (HAA) F"NVIRO'~:NTAL F~OT£CTIoN
CHECKLIST- FEBRUARY 1984 JUN 1 0 1~
2644720
Legal Description: ct ~' t~'
- ' . '~ ---'"~I.¥LL,/
WELL DATA
Well Classification '~,, I~. If A, B, C, D.E.C. Approved (Y/N)
Well Log Present~'/N) Date Completed ~"- '~ - ~, ~ Yield
Total Depth :~Z.~ f %ased '~'Z.-~ ' -----"'-
to Depth of Grouting
Static Water Level .Z.e~~ t Pump Set At ~/~-
Casing Height Above Ground '"~:>~' Sanitary Seal on Casing~/N)
Electrical Wiring in Conduit~N) Depression Around Wellhead (Y,~
Separation Distances from Well:
To Septic,qde~ Tank on Lot ! ~ ~ ~'~" ; On Adjoining Lots
To Nearest Edge of Absorption Field on, Lot ~ t ~ On Adjoining Lots
To Nearest Public Sewer Line , /i~. To Nearest Public Sewer
CleanouVManhole R/~- To Nearest Sewer Service Line on Lot
Water Sample Collected by ~ ~ ~ ~ ! ~;:~1,~ ; Date ~ '~'~ -
Water Sample Test ~Results ~ ~'~
comments ~' ~,*/~t..4~ ~/t~=~:> -.'t'~.~.-"l" '~-~.t~,-~=~> ~ ,.
B. SEPTIC/H~I~TANK _D.ATA
Date Installed "J -Z~.- ~ ~ Size ~,.'~.~"Z~ No. of Compartments
Standpipes~N) Air-tight Capa~N) Foundation Cleanout (Y~.
Depression over Tank ('~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/t-~Tank:
To Water-Supply Well J
To Property Line J ¢::' ~"'~
To Water Main/Service Line t c> I.,,~.
Course
Date Last Pumped
;for
Temporary Holding Tank Permit (Y/N)
To Building Foundation ,71~ t~'
To Disposal Field ~ · ~
To Stream, Pond, Lake, or Major Drainage
Comments
Page I of 2
72-O26( 11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~ -'Z--(~ -'~ B
Width of Field [,=~:) rt
Square Feet of Absorption Area ~::~ ~'~--
Depression over Field (Y~
Results of Last Adequacy Test
Separation Distance from Absorption Field;
To Water-Supply Well
TO Building Foundation \1.~ ',z....
Lot
To Water Main/Service Line t c> f4-
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
Type of System Design
Length of Field ~...
Depth of Field
Gravel Bed Thickness '~'
Standpipes Present~)N)
Date of Last Adequacy Test
To Property Line 'Z.~;
To Existing or Abandoned System on
; On Adjoining Lots
t,.~.utbank (if present)
D. LIFT STATION
Date Installed
Size in Gallons /~/
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions '
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
Check Permitted Bedroom Rating Against HAA Request **
I certify that [h av.e.checJ(ed verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
~ & ~ ENGINEJF.~ING - -
Signed ~ 'J~'6X ua[e
compan MOA No ,,~ .~,,~,,~,,~,,~,,~,,~ ~ ~
Receipt No. ..~ (:~0 ~ '~ ~"~ '
Date of Payment
Amount: $ ~ ...,~-- ,~)~5
Page 2 of 2