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EAGLE CREST #1 TR A LT 19
Onsite File Municipality of Anchorage Community Development Department Page 1 of 3 On -Site Water & Wastewater Program 4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 • http://Www.QT r�g/onsite (907)343-7904 ON-SITE WASTEWATER INSPECTION R Q:uu (�u��` Permit Number. OSP191333 PID Number. 050-303-12 p, Ne(Cv Upgrade Name: BRIAN GORNICK ABSORPTION FIELD ❑ Deep Trench ❑ Shallow Trench ❑ Bed ound Address: 19515 THIRD STREET, EAGEL RIVER, AK 99577 ❑ Other Phone: No. of Bedrooms: Soil Rating: Total Depth from origin de: 862-6812 3 GPD/Sq. Ft FL LEGAL DESCRIPTION Depth to pipe Invert from original g a de: Grave epth beneath pipe: Fj, FL Subdivision: Block: Lot: Fill added above original grade: Gravel length: EAGLE CREST #1 TRACT A 19 `01 Ft Ft. Township: - Range: _ Section: - Gravel width: *\ Ft Beds Number of lines: Distance between lines: Ft SEPARATION DISTANCES Total absorp' area: Number of trenches: Dist between trenches: To Septic Absorption Lift Holding Public/PrivaIs From Tank Field Station Tank Sewer Lines So. FL Ft Well 100'+ 25'+ TANK ■ Septic ❑ S.T.E.P. ❑Holding ❑ Other Manufacturer. GREEK TANK Capacity. 1000 Gal. Surface Water 100'+- z Lot Line 5'+ N/A Material: Number of compartments: IX POLYETHYLENE 2 LIFT STATION Foundation 10'+ Curtain Drain NONE KNOWN Manufacturer. o Gal. Remarks: "Pump on' level at "Pump off" level at High water alarm at Pump Make &Moder Electrical Inspections performed by. PIPE MATERIAL House to tank D3034 (FOR NEW) Tank to D3034 dralnfield Installer ARM SEPTIC SERVICES, LLC Drainfield EXISTING CO/MT D3034 (FOR NEW) Inspector GEG, Ltd. BENCH MARK (Assumed elevation) 100.00 Ft Inspection Location and Desc ptlon: Dates: 1 St 8/29/2019 2nd - 3rd - 4th - BACK DOOR THRESHOLD ENGINEEFFS SEAL Community Development Department Approval Conditional approval: Date: `��'�� OFjIV N A * ' ' * •� ....... ......... ............. / / .. .... ....... ............... 0 �^ J ey A. Garness = i�7 i C -79 3 ' _� Approved: �L� 't E'� Date:I 1 I �414 • "ROFESS��es•♦ ICEN � e l e 11%k1%L # 4 Inspection Report_1-1-12.doc ) I -kd Cu) ,_ bu,� I I S (,k� Lk;be C j') V I d J rL,D t., PERMIT NUMBER: PARCEL ID NUMBER: OSP191333 RECORD DRAWING 050-303-12 NOTE: THE OLD SEPTIC TANK WAS DECOMMISSIONED PER UPC PER THE CONTRACTOR. 5 0 / a EAGLE CREST #1; OTRACT A, LOT 2 i X / IL / IL / —--moi I —NEW 1000 GALLON GREER POLYETHYLENE SEPTIC TANK D8L1 &DBL2 SHED _ _ _ EAGLE CREST #1; TRACT A, LOT 1 �- - AWWU WATER — — — EXISTING \ I \ \ I co Z / \ \ \\ I I \ I A B / FCO \ \ FCO 8.6 1 45.9 EAGLE CREST 91; \ MH 48.4 32.4 EAGLE CREST #1; TRACT A, LOT 18 STI 52.4 30.8 \ DBL1 53.4 29.3 / EAGLE CREST#1; DBL2 53.2 28.3 TRACT A, LOT 3 C01 53.9 20.4 SUMP 85.2 33.1 — — — AWWU WATER — — — — — — — - — — — NOTE: THE OLD SEPTIC TANK WAS DECOMMISSIONED PER UPC PER THE CONTRACTOR. 5 0 / a EAGLE CREST #1; OTRACT A, LOT 2 i X / IL / IL / —--moi I —NEW 1000 GALLON GREER POLYETHYLENE SEPTIC TANK D8L1 &DBL2 SHED _ _ _ EAGLE CREST #1; TRACT A, LOT 1 �- - AWWU WATER — — — EXISTING F r / \ DRAINFIELD co Z / \ \ / FCO \ \ / EXISTING EAGLE CREST 91; \ 3 BEDROOM / EAGLE CREST #1; TRACT A, LOT 18 \ ur HOUSE TRACT A, LOT 20 / \ I RADIUS\ / 1 0' LL RADI S -- - - \ - -- / A THIRD STREET j \ SCALE: / - — — — — — — — — i — — EAGLE CREST TRACT -- / / AR22 100' VVEL.L RADIUS Ad c�a A *. . *••� GARNESS ENGINEERING GROUP, Ltd ;................... .......I.....; _ -- — --- --- — ENGINEERING c, SALES o CONSULTING _--- ---- ----- 0 10 3701E. TUDOR ROAD, SUITE 101ANCHORAGE, AK 99507' PHONE (907) 337-6179' FAX (907) 338-3246' WEBSITE: www.gamessengineering.mm •••• • .•..••••..•..........x.}..•10 PREPARED FOR: PHONE NUMBER: PAGE NUMBER: J Gar ess : BRIAN GORNICK 862-6812 2 OF 3 ���i C -79 3 PROJECT/LEGAL DESCRIPTION: DRAWN BY: ♦� f EAGLE CREST #1; TRACT A, LOT 19 J.L.M. �1c�Q • •� . •(•���, TYPE OF WORK: DATE: ��kill ES S LICEN RECORD DRAWING OF SEPTIC TANK UPGRADE 9/9/2019 # ICEN8E PERMIT NUMBER: PARCEL ID NUMBER: OSP191333 RECORD DRAWING 050-303-12 AW GARNESS ENGINEERING GROUP, Ltd ;.� 49 • -- --- - ENGINEERING o SALES o CONSULTING ---- -- — — — 3701E.TUDOR ROAD, SUITE 101 -ANCHORAGE, AK99507' PHONE (907)337-6179•FAX (907)338-3246'WEBSITE:www.gamessengineering.com •••••••• • ••••••••• •� PREPARED FOR: PHONE NUMBER: PAGE NUMBER: % •@ y . Gar ess •••••• •_e W ■ BRIAN GORNICK 862-6812 3 OF 3 �j J,%•• CEf 95 �� PROJECT/LEGAL DESCRIPTION: DRAWN BY: �♦ ..... •`�/�•����� EAGLE CREST #1; TRACT A, LOT 19 J.L.M. ���� pRpFESS1�NP�•• TYPE OF WORK: DATE: LICENSE,1" �� RECORD DRAWING OF SEPTIC TANK UPGRADE 9/6/2019 #AECCa84 ������ MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP191333 Work Type: SepticTank Upgrade Tax Code Number: 05030312000 Site Legal Address: EAGLE CREST #1 TR A LT 19' G:0055 Site Mailing Address: 19515 THIRD ST, Eagle River Owner: NESHEIM WILLIAM H & SUE A Design Engineer: GARNESS ENGINEERING GROUP LTD This permit is for the construction of: ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy Effective Date Expiration Date Lot Size in Sq Ft Total Bedrooms: ,�t�tetlt r� 13epartmeat g1Zgl q 8/8/2019 8/7/2020 18159 ❑ Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received B Issued By: y Date. Gf/ Date: i 3 Municipality of Anchorage ne,atment P.O. Box 196650 ® 4700 Elmore Road Anchorage, Alaska 99519-6650 ® (907) 343-7904 ® Fax (907) 343-7997 http://www.muni.org/Onsite Development Services Division On -Site Water and Wastewater Program x x x x VARIANCE/WAIVER REVIEW x x x X Waiver#: OSV191064 COSA#: Permit#:OSP191333 PID#: 050-303-12 Legal Description: Eagle Crest #1 Tr A Lt 19 Engineer: Garness Engineering Group Your request for a waiver of the required 10 feet horizontal separation from the absorption field to the property line has been approved. The approved separation distance is 5.0 feet. This waiver approval applies to the existing absorption field only. Any future upgrade to the on- site wastewater disposal system will require all separation distances be met or another approval from this department. ■.............................................................. ■ .............. I Waiver is Granted: X Waiver is not Granted: Date: C/ l% Approved by: 4� Name of Re ' wer ........................ ■ ............................. ■ ..................... **** VARIAN C E/WAIVER REVIEW **** MUNICIPALITY OF Community Development Department Development Services On -Site Water & Wastewater Program ANCHO Mayor Dan Sullivan On -Site Sewer/Well Permit Application For A Single Family Dwelling Parcel I. D. 050-303-12 Property owner(s) Brian Gronick Mailing address 19515 Third Street *Anchorage, AK 99577 Site address 19515 Third Street 'Anchorage, AK 99577 Legal description (Sub'd, Block & Lot ) Eagle Crest #1; Tract A, Lot 19 4809W-'343-7 10 aWL967= _W979 \CV Day phone 862-6812 Legal description (Township, Section & Range) Lot Size Sq.Ft. Number of Bedrooms 3 APPLICATION IS FOR: Duplex (D) APPLICATION IS AN: ( ® all that apply) ❑ Initial ❑ Absorption Field ❑ Upgrade Septic Tank Renewal ❑ ❑ Holding Tank Privy ❑ Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE/ WAIVER REQUEST FOR: TYPE OF DEWELLING: Single Family (SF) (w/wo ADU) Duplex (D) ❑ Multiple Dwellings ❑ (SF and/or D) D Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal codes. GARNESS ENGINEERING GROUP, Ltd. (Signature of property owner or authorized agent) Permit/Rush Fees: /�� Waiver Fees: 9;) Date of Payment: gG f 1 �'7 Date of Payment: 2Zt 119 Receipt Number: 05P1010' t Receipt Number: 6j—p� Permit No.y 5P`01 `3' Waiver No. (35V-1 DiO (Rev. 01/11) GARNESS ENGINEERING GROUP9 Ltd ENGINEERING= SALES =CONSULTING June 19, 2019 Municipality of Anchorage Development Service Department On -Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 Ref: Proposed Septic Tank Upgrade for Eagle Crest #1; Tract A, Lot 19 To whom it may concern: AdlanCed iMaO'nenf Sy�[em D - - The existing 3 -bedroom house is served by a private well and private septic system. The septic tank is 41 years old and the owner is wanting to have the tank upgraded. We are proposing to install a new 1,060 Infiltrator septic tank (2 -compartment) and decommission the existing 1,000 - gallon FRP tank per UPC standards. During the design, we also became aware that the existing drainfield is encroaching on the west property line. We are requesting a five (5) foot waiver be granted for this encroachment. Justifications for this waiver are as follows; The encroachment has existed for over 41 years The drainfield on the neighboring property to the west (Lot 18) is approximately 9 feet from the shared property line. In short, there is at least a 14 foot separation between the two draifields which meets the required separation distance of the draifields. We are unaware of any adverse impacts this installation or waiver would have on adjacent wells or septic systems. If you have any questions, please contact us at 337-6179. Thank you for your E., M. S. 3701 East Tudor Road, Suite 101 * Anchorage, Alaska 99507-1259 Phone: (907) 337-6179 * Fax: (907) 338-3246 * Website: www.garnessengineering.com HERITAGE HERITAGE HERITAGE HERITAGE HERITAGE PARK;PK; PARK; PARK; PARK; BLOCK,, BLOCARK 2, BLOCK 2, BLOCK 2, BLOCK 2, LOT 27 LOT 26 LOT 25 LOT 24 LOT 23 CITATION VOAD j— APPROXIMATE U I (PER MOA ONSITE THIRD STREET 700' wF�C 100' WELL RADIUS LL RAD EAGLE EAGLE EAGLE EAGLE EAGLE CREST #1; CREST #1; EST #1; CREST#1; CREST#1; TRACT A, TRACT A, TACT A, TRACT A, TRACT A, LOT 5 LOT 4 L T 3 LOT 2 LOT 1 AWWU AWWU A AWWU WATER WATER WATER WATER TRACT A, CREST#1; LOT 23 EAGLE LOT 25 TRACT A, CREST #1; EAGL GLE ACT A, CR #1; CRE 1; E CSEPTIC L 20 CT A. TRACT #1; AREA AREA LOT 16 LOT T A, VACAN TRACT A, TRACT A, :CREST 8 EAGLE LOT 36 LOT 37 LO 38 CREST #1; EAGLE TRACT A, CREST #1; LOT 39 TRACT A, 100' WEL RA S RADIUS LOT 40 THIRD STREET GARNESS ENGINEERING GROUP, Ltd -T ENGINEERING SALES - CONSULTING -- - - 3701 E. TUDOR ROAD, SUITE 101 -ANCHORAGE, AK 99507 -PHONE (907) 337-6179 -FAX (907) 336.3246 - WEBSITE: www.gamessengineedng.com PREPARED FOR: PHONE NUMBER: PAGE NUMBER: BRIAN GORNICK 862-6812 1 OF 2 PROJECT/LEGAL DESCRIPTION: DRAWN BY: EAGLE CREST #1; TRACT A, LOT 19 PNB TYPE OF WORK: DATE: � SITE PLAN 1 7/17/19 W AA Z g ~N U7 W w U J SCALE: J �of ..P�� • OF �1ee •'� . ,e AV 19. .. �� ..................., / �ryAA.. Guamess ♦ s,•c -7953 ♦1e PROFESS\PNP �� LICENSE ,IOTAiO\\\•e #AECC884 / 700' wF�C EAGLE 10 ' W LL RAD 7(/S CREST41; TRACT A, E LOT 22 CREST # , EAGLE TRACT A, EAGLE CREST #1; T 21 CREST #1; EAGLE TRACT A, TRACT A, CREST#1; LOT 23 LOT 25 TRACT A, LOT 24 CSEPTIC EPTIC EAGLE EAGLE EAGLE AREA AREA CREST#1; CREST#1; CREST#1; TRACT A, TRACT A, TRACT , EAGLE LOT 36 LOT 37 LO 38 CREST #1; EAGLE TRACT A, CREST #1; LOT 39 TRACT A, LOT 40 100' WELL RADIUS GARNESS ENGINEERING GROUP, Ltd -T ENGINEERING SALES - CONSULTING -- - - 3701 E. TUDOR ROAD, SUITE 101 -ANCHORAGE, AK 99507 -PHONE (907) 337-6179 -FAX (907) 336.3246 - WEBSITE: www.gamessengineedng.com PREPARED FOR: PHONE NUMBER: PAGE NUMBER: BRIAN GORNICK 862-6812 1 OF 2 PROJECT/LEGAL DESCRIPTION: DRAWN BY: EAGLE CREST #1; TRACT A, LOT 19 PNB TYPE OF WORK: DATE: � SITE PLAN 1 7/17/19 W AA Z g ~N U7 W w U J SCALE: J �of ..P�� • OF �1ee •'� . ,e AV 19. .. �� ..................., / �ryAA.. Guamess ♦ s,•c -7953 ♦1e PROFESS\PNP �� LICENSE ,IOTAiO\\\•e #AECC884 / NOTE: CONTRACTOR MUST HAVE ALL 1 00'WELL RADII SHOWN FLAGGED BY A PROFESSIONAL LAND SURVEYOR PRIOR TO CONSTRUCTION AND ENGINEERS LAYOUT. \ EAGLE CREST#1; TRACT A, LOT 3 AWWU WATER EXISTING DRAINFIELD \ EAGLE CREST 91; \ TRACT A, LOT 18 \ \ I 100' LL RADIUS I \ I GEG, Ltd. HAS AN 8 PAGE SPECIFICATION LETTER / THAT PERTAINS TO THIS DESIGN. BY PROCEEDING / FORWARD WITH THIS INSTALLATION, THE ENGINEER, WELL DRILLER, CONTRACTOR AND / PROPERTY OWNER AGREE THAT THEY HAVE READ THESE SPECIFICATIONS AND AGREE TO / ACCEPT THE TERMS AND CONDITIONS OUTLINED. / / / i INSTALL rrtvr vo�� i,uou nvnu vyiv� DOUBLE CO'S SEPTIC TANK (TWO-COMPARTMENT) / EXISTING 1,000 GALLON / RFP TANK TO BE ° DECOMMISSIONED PER UPC / / / EXISTING 3 / BEDROOM HOUSE /�RFV�WP;Y I EAGLE CREST #1; j TRACT A, LOT 1 AWWU WATER \ EAGLE CREST#1; \ j TRACT A, LOT 20 \; VACANT 1 00'WELL RADIUS THIRD STREET / N SCALE: EAGLE CREST #1; TRACT \ / / I A, LOT 22 / 100' L RADIUS / OF i � ♦SCP : •••"•.. ! � GARNESS ENGINEERING GROUP, Ltd , ENGINEERING- SALES o CONSULTING, 3701 E TUDOR ROAD, SUITE 101 -ANCHORAGE, AK 99507 - PHONE (907)337-6179- FAX (907) 33&3246' WE 3SffE: a_ emg.com PREPARED FOR: PHONE NUMBER: PAGE NUMBER: BRIAN GORNICK 862-6812 2 OF 2 PROJECT/LEGAL DESCRIPTION: DRAWN BY: EAGLE CREST #1; TRACT A, LOT 19 PNB TYPE OF WORK: DATE: DESIGN OF SEPTIC TANK UPGRADE 7/19/19 .� �... .....arn ss: C -79153 Air AV /��JJ''pp11 LICEN�•,1 ,{ \SSO� •• #AECC884 I I Loft 3 in' 11TII ITY FASFMFNTS Lot 18 CHAIN-LINK FENCE 0 0 M I I Lot 2 i Lot 1 10.2' x 12.2' _r SHED — S 89'56'00"E 132.00' Lot 1 17,820 S.F. z ao SEPTIC--� PIPES . o . 36.4' RETAINING—� WALL � 1 CHAIN-LINK FENCE � 38.9' -' 1 STORY RESIDENCE I O Lot 20 ` W/ DAYLIGHT BSMT. 2a.o. :3'x2.3:.- o x C O .CANT• . p0 �G`J�c. ( a F DECK I �p Q dF• x I a. oo CV M WELL N] 89'56'00"Wx 132 \3rd - - 1 f i PLOT PLAN AS BUILT JL SCALE 1" = 40' GRID NW 0055 Project No. 19-345 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Long 515-3049 Long & Associates, .nc® (907) 522-6476 Phone (907) 522-4625 Fox Professional Land Surveyors ken0longsurvey.com F A jonothan0longsurvey.com I hereby certify that I have surveyed the following described property: LOT 19, TRACT A, EAGLE CREST #1 (PLAT No. 63-70) Anchorage Recording District, Alaska, and that the improvements situated thereon are within the property lines and do not encroach onto the property adjacent thereto, that no Improvements on the property lying adjacent thereto encroach on the surveyed premises and that there are no roadways, transmission lines or other visible easements on sold property except as indicated hereon. Day of 4 1, ` `t`z Doted this the �Da of at Anchorage, Alaska It is the responsibility of the owner to determine the existence of any easements, '* 49TH .................. KENN U�. LAN a p '' •.LS -5202.• ''SJ p� FbA 2:0 f ~MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAM PHON~.. [-] UPGRADE MAILING ADDRESS LEGAL DESCRiPTiON LOCATION NO. OF BEDROOMS DISTANCE TO; I I Llq. capeclty~t'n ga~Jons Inside length Width Liquid depth OO~ IF HOME'DE: ~O ~ Well OweJling PERMIT NO. DISTANCE TO: Z O Z ~ Manufacturer Material Liquid capacity in ~llons ~ Well Foundation Nearest Iol hne PE~MIT NO. No. of lin~ Length of each line Tolal length of lines Length ' ' Width ~pth ~ ~ Ty~ of crib Crib diamete~ C~ib depth Total elf~li~ abso~ptlon a~ea m Well Building foundation Nearest lot line ~ DISTANCE TO: ~ Class Depth Driller D~stance to lot line PERMIT NO. ~ : Building foundation Se~r line Septic tank Absorption area(sD ~ DISTANCE TO: OTHER PiPE MATERIALS SOIL JEST RATING REMARKS APPSOVED DATE LEGAL 724313 (Rev. 3/78) PER~'II T HO. APPLICANT D_,¢_R~.~ ~ t.lnt ~nD SR BO>,' 165 B :LOCRTION OFF 3RD ST. ERGLE R~R , LEGRL L~9 TRRCT 8 ERGLE CREST S/D LOT SIZE TYPE OF SOIL RE:SORBTIO~ SYSTE~,I IS: TRE~-~CH - ~RXI~IU~I [.~Ur,IBER OF BEDROOMS = 3 , SOIL 'RRTIHG THE REQUIRED SIZE OF THE SOIL RBSORPTION SYSTEfl DEPTH= 8 LE[-~GTH= 4~ : GRR~..'E~ DEPTH= 5 THE LE~GTH DIFENSIO~ IS THE LENGTH (Iii FEET> OF,THE TRENCH OR DRRIf'~FIELD. THE DEPTH OF R TRE['~CH OR PIT IS THE DISTRNCE B. ET~IEEN THE SURFRCE OF THE GROLIND AND THE BOTTOr'l OF THE EXCR'./RT.ION <If-4 FEET>. :' "' . THERE IS ~0 SET I,IIDTH FOR TRENCHES. ' ' THE GRRYEL DEPTH IS THE f'IINIMUf'I DEPTH OF GRRVEL E:ET~EEN THE OUTFRLL PIP~ , Rf4D THE BOTTO[d OF THE EXCRYRTIOF~ (I[-~ FEET>. REQi_IIRED SEPTIC -TRf4~( SIZE= 2_[4¢_4E~ 6RLLOf-.IS PER,lIT FCPLIC, RflT HRS THe RESPOf.~S~BILITY-TO ~fI~ORP~ THIS DEPRRTblEf.it DURI~IG ThE If.~STRLLRTIOH IN~PECTIO~-~ OF. R[-~ ~ELLS RBJRCENT TO THIS PROF'ERT? R~.~ THE r ~Uf,]BER OF F:E~IDENCE~ THRT .tHE I,ELL ~,IILL SERYE. , TW¢' ( 2 ) I f4SPECT I Of 4~ RRE REQIJ I RED, BRC~.~FILLIf4G OF ANY SYSTEI'I F]ITHOUT FIt'~RL INSPECTION Rr.~D RPPROYRL BY THIS ~DEPRRTPlENT I,IlLL BE SUBJECT TO PROSECUTION. - HIHIMU['I DISTRNCE BET~,IEEN R I,~ELL RND RNY Of'~-SITE SEI¢tGE DISPOSRL SYSTEM IS iCC FEET FOR'F1 PRIVRTE I,~ELb OR :i50 TO 200 FEET FRO['I R PUBLIC ~ELL DEPEHDIH~3 UPON THE TYPE OF PUBLIC ~IELL. ! I,IELL LOGS RRE REC!UIRED RND PlUST BE RETURNED TO THE DEPRRTf'IEHT ~IITHI/.~ ;O DRY~ OF THE ~IELL CO~'IF'LETIOf.~. OTHER REQUIREMENTS ~IRY RPPLY. SF'ECIFICRTIO['~S RND CONSTRUCTIOH DIRGRRf'IS 8RE 8VRILRBLE TO If4SURE PROPER I~'~STRLLRTION. , .. Pi~:t4 I t EXP' I I CERTIFY THRT ±: I PPI FR~IILIRR filtH THE REQUIRE£'ENTS FOR ON-S. ITE SE~.IERS RND ~IELLS RS SET FORTH BY THE MU~-IICIPRLITY OF RNCHORRGE. 2: I ~IILL INSTRLL THE S'./STEbl IN RCCORDRNCE 14ITH THE CODES. 3: I UNDERSTRND THRT THE ON-SITE SEI4ER SYSTE[,1 ~'IRY REQUIRE ENLRRGEF1ENT IF THE 'RESIDENCE IS RE~IODELED TO I~CLUDE ~IORE THR[.~ _~ BEDROO£dS. SIGNED: ................... ~ .................... GreATEr ANCHOrAgE AReA BOROUGH SEWAGE DISPOSAL SYSTEM m APPLICATION AND PERMIT t FINANCED THROUGH SOIL TEST RESULTS TO BE INSTALLED BY NOT~I THIS PERMIT IS NOT YAI-ID WITHOUT ~OIL TEST COMPLETION DATE ANTICIPATED FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEEPAGE AREA SIZE TYPE SEPTIC TANK TO NEAREST LOT LINE. WELL TO SEPTIC TANK DRAIN FIELD DRAIN FIELD · DRAIN FIELD SEEPAGE PiT ~ ALSO LO.SIDE. ^.E^ WELLS. SEEPAGE PIT WATER MAIN TO SEPTIC TANK DRAIN FIELD SE.~,c TANK. \ ~0 SEEPAGE P,T TO RIVER· LAKE. STREAM. CAST IRON INTO AND OUT OF' SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION S FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FI~ED WITH AIRTIGHT REMOVABLE CAPS. GRAVEl. RACKFIL~. CONFORM TO IqOROUGH REGULATIONS REGARDING INSTALLATION. DIAGRAM OF SYSTEM I i I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA E~OROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE / ' DATE APPL'CA"T'.,IGNATG. performed for: le desc. ~ M.D.G. ENGINEERINGt''''~ SOILS LOG ' PERC. TEST ~' softs log percolation test dine, 4-/.:~-2~ -~ 6 --8 I0- II -I .13. 14., 15. 16- 17- 18' 19 2O ground waler depth read,nodate lo.brae ~n.time d.fowoter net dron' perc. rote · between · . t ' -:"7.'""*:~'~'' performed by: /~1~(-i4~---, ~ ¢:.~4t,~; cerhfied by.,.'~.~'Z.~'c~-~;~.~;~date: .~-,.'5-'?~ •ax o,o�__. �..,� c�c>,�o lGi i i l t l l l l f 1 1 I I I I i I i i I I J i � 1-_ 000 JJJYJY YJ-��JtmPrx-_�„o�•o0 1 I I I I I I I t I I j I t I� I IT r+ C P Y P P n m N O tD m J m P A 'uo N '-' O @+ P �! P R C W 20 ✓ O C r -: G P n ii P 7 P R ptiP QQ R R C e� A S G +. N OGv J6tPPCON✓ 00 P J PP p4�FJHgrD O> --��I,i lil! lllf l illi l ll' i I lillilf l lillll hill t!IIIIII I r D cn n iNr�N nto D t" 'D0 0 Ir+i I I I I I I U) r � Glp Y[0 P.>`W Nom' I I o al ^ I •ax o,o�__. �..,� c�c>,�o lGi i i l t l l l l f 1 1 I I I I i I i i I I J i � 1-_ 000 JJJYJY YJ-��JtmPrx-_�„o�•o0 1 I I I I I I I t I I j I t I� I IT r+ C P Y P P n m N O tD m J m P A 'uo N '-' O @+ P �! 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F 4as Cts w k4 0 111111t -- - - - - - - - - - - -- - - - - - - - - - - - - - - - 0 - - 00' 41 o - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- kr * V (I V) -am > 0 M r— C3 r- 90 0 M M x 0 M L" z X - a) 0 > co CA Mz r> - ,,,J Z \ 7" 22 > `-A LN * V (I • _to_ Municipality of Anchorage On-Site Water and Wastewater Program (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 050-303-12 Expiration Date: ( -S / 1. GENERAL INFORMATION Complete legal description: Eagle Crest#1 Tract A Lot 19 Location (site address) 19515 Third St. Current Property owner(s) William H. Nesheim Day phone Mailing address Real Estate Agent Day phone 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) n Duplex Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 TYPE OF WASTEWATER DISPOSAL: 4. TYPE OF WATER SUPPLY: Individual Individual Well ® Holding Tank [l Individual Water Storage Community Community Class Well n Public Sewer Public Water System ( 1 Waiver/Variance request for: Distance: Received by: Date: COSA to be released to the engineer,unless otherwise requested by the engineer. COSA Fee $ 556 Waiver Fee $ Date of Payment 6-123119 _ Date of Payment Receipt Number Ce4- i4 alg Receipt Number COSA# _ 0C161 I ri- / 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. Name of Firm ARCTERRA CONSULTING, INC. Phone 696-6111 Address 20441 PTARMIGAN BLVD., EAGLE RIVER AK 99577 Engineer's Printed Name KENNETH M. DUFFUS Date Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future occupants or can ArcTerra guarantee that no unseen t' encroachments, deficiencies or discrepancies exist. �T�ti O'L�f\\, 10, 49TIl 6. DSD SIGNATURE System #1 Approved for bedrooms. `ENTNE ", 1E. ° j �. System #2 Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the followin�`�!04I f0frt, NAT P 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 blue sheet 10-10-12.doc COSA Checklist Legal Description: Eagle Crest #1 Tract A Lot 19 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA N Well log is filed with Onsite (or attached) Date drilled 9/20/78 Total depth 301 ft Cased to 40 ft Sanitary seal is functioning correctly Wires are properly protected A Casing height (above ground)/a in. Date of flow test for COSA 5/8/19 Static water level at beginning of test 278 ft. Comments ** Coliform retested 5/12/2019 B. TANK DATA Age of tank(s) 41 years Tank type/material Ss' i -Owl /� Measured operating fluid level in septic tank H hnp Ad.x/1 Standpipes/foundation cleanout per record drawing Date of pumping 5/7/19 D. ABSORPTION FIELD DATA Which system tested (date installed) 5/15/78 ALL standpipes present per record drawing Total measured depth from grade 8.2 ft (max) Measured depth to pipe invert from grade 4.0 ft (min) ❑ N/A - pressurized field N 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: 050-303-12 Structure served by this system 1 Well production at time of test 1.3 gpm Water storage tank volume gallons Well disinfected for coliform test? ❑ Yes Nc 0 Coliform bacteria is Negative Nitrate mg/L ® Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Arcterra Consulting Date of Sample 5/8/19 t 5 tts(lq C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 5/8/19 Results 21 Pass For 3 bedrooms Fluid depth prior to test 0 in Water added 450 gal New depth 2 in Elapsed time 337 min Final fluid depth 0 in Absorption rate 450 gpd Any rejuvenation treatment (past 12 months) If yes, enter date 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' Community Sewer Manhole/Cleanout> 100' ®Yes if No ft m Yes if No ft Neighboring Tank> 100' ®Yes if No ft Private Sewer/Septic Line>25'm Yes if No ft Absorption Field on Lot> 100' ®Yes if No ft Holding Tank > 100' ®Yes if No ft Neighboring Absorption Fields> 100' Animal Containment>50' ® Yes if No ft ®Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ®Yes if No ft ®Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations> 10' ®Yes if No ft Surface Water> 100' ®Yes if No ft Property Line >5' ® Yes if No ft Wells on Adjacent Lots: Absorption Field >5' ® Yes if No ft Private Wells > 100' ® Yes if No ft Water Main > 10' ® Yes if No ft Community Wells>200' ® Yes if No ft Water Service Line> 10' ®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 ft Wells on Adjacent Lots: Water Main > 10' ® Yes if No ft Private Wells > 100' LA Yes if No ft Water Service Line> 10' 0 Yes if No ft Community Wells>200' ® Yes if No ft Surface Water> 100' ® Yes if No ft F. ENGINEER'S COMMENTS lsooraiiii IN* G. ENGINEER'S CERTIFICATION .��,�` � �.. �. I certify that I have determined through field inspections and review f *N7 ••of Municipal records that the above systems are in conformance with a * 49Ittz Y #j MOA COSA guidelines in effect on this date. , ........ .... . ..... 41 0rn • is ENv m'TI 05 kki: 1�.' ik. CE 71 . ; . COSA Checklist yellow sheet �RtflJl ...qt..* : ..... .•• _3_ (' ( -2- ( r _1 _ - ;Z S89°6-Co /3 _O'�__-y:c p./32.0' _.__ __ ___ i.O' j_T_ /O' !?/i,/jy eySEMENT LOT /9 , TRAc 'sn " ✓ 4 G•L. PA,vc e -h, N -- TY1 o I Dob 2'uw J L I _/8- I ! N 7 kE Gr_NO Pi) ) :::-----1-(--- 4.1 • 1 • Mit, Ye REb1A - Ly/2/7, a • nOug�eF • az it____ • SEPTIC VE/rTS t . N 17674.12.0.1.2C .1 a RECORG DfilEMS/ON I. (t' P . + DATE 7f StRVEy 40-/. . 78 ^- 1 W i 4 � ' • ;\ NOTE: ALA. EI)SE/7ENT5 ? 8 BGoGor O of .4 :n ¢t7. w.ot.. , q \n- %'. S//iJwN hk•= TaH:.:FC', ON Li� I hippo AspNArw; ,` e- ►c Etc C.0 CEG P:./R1 NO. V P47/fl 1° yo' _ "A �- pa. %'r. I3�, (.3-70, L/-TE I, 9-/,2.-G._3, DELµ '3 E/ G .E CREST 5z/et. . • I d..tIN\ w �F� 0 t .c'-;--1 / N..(5EG°5co'E /3.Z..O1_3 11 /32.0' r ` - - t Nlit .1{ i 41 0 ` +j ,;(3 A M 3.�r STREr:- _ I _9______i_____ - .... --- - — - A.,: . .. :LI :-.2.7-,,s0. z1- 0 . ..Robert M. Schwe;fze e , � s sor i'•.• NO.2240-S A(r° •'.c.OQ �ec�r7/1 g5/14/1e7 41 dir \`‘�.....�.��`=P Ag viv ,-_ y a . P•s/ 90//z 9 r OWN: TigP ALASKA D LOPMLNT CONSULTANTS AS -,BU/4T EEL - p-) CKD: X,i/S CtViL ENO EER. LAN,SURVIIYORf PLANNtRs LOT /9, TRAC TC .D•*R" GRID: 4/14/!): Q DATE: (p-/5-78 OLD SEWARD HI4HWAY 4- 6/..L.- C R G.5T S U. PROD.NQr/ : (V`- ANC ORAO, i19502 ---• - 7" 30 ,c-n4, P/Iir v/ r: ‹Un -...- . , MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # ~(~)- ~('"'-~° l~ HAA# [:~. ~'~,°V'"'t~ ~L[lr, 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) LoY; 19; T/t~tc;t. "A"; E~g,~.e C~¢~ Su.§dJ.v~.6~on Location (address or direction?) 19515 TIz~.~d $~ec,~ (b) Property owner l~(lnn_~ I~Zce MailingAd_dress 19~I~ Tl~d St~tee,t (c) Lending Institution Telephone: (home) Ect_~e R~ue)~. A~ct6hz[ 99571 Telephone Business Mailing Address (d) RealEstate Company andAgent RE~ CAEPETIAECffOR REALTY ATTN=G~enn Hugh~o~ Address~6~ FZ~F.g.I~,--[.~~3~ A~z 99~0~ Telephone £77-6655 (e) Mail the HAA to Ihe following address: (or check here {~,'~f hold for pick up.) List contact person and day phone number below: S & S ENGINEERING 17034 Eagle River Loop Road No. 204 Eagle Rlver~ Alaska 9~577 2. TYPE OF RESIDENCE Single-Family.~r. Number of bedrooms 3. WATER SUPPLY Individual Well ~ Community i-I Public I-I Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. S'EWAGE DISPOSAL On-site ~ Public r'l Community I-I Holding Tank I-I Note: II community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. ;2.~s (..,,. 7/K) Page I of 2 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 Ihat 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 Telephone (~'~'/~Z/'''~ ~:?-~'~ ,~2'~.,~ Address Date S & S ENGINEERING 17034~ag1,~ River Loop Road No. 204 Eagle Rlver~ Alaaka 99577. 6. DHHSAPPROVAL Approved for , Approved. Terms of Conditional Approval bedrooms by O!/?~//Date Disapproved Conditional The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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 Ihe professional engineer's work. 72-025 (Rev. 7/~8) Beck Page 2 of 2 ~ MUNICIPALITY OF_ANCHORAGE (MOA) , ~ , (,*~,~UHtOP^tF~fl~_.Approval (HAA) ~t~ONM[~~VJ~RUARY 1984 ' ~43-4744 ~UG2 [ .~0 Legal Description: L~ -~ RECEIVED . .' '. Well Classification ~ ~ ~ ~ ~ ~ ~ /f A, B, C, D.E.C. Approved (Y/N) Total Depth~t Cased to , Depth of Grouting (, Static Water Level Casing Height Ab0ve Ground I Electrical Wirir~g In Conduit~)N) ' y Pump Set At ~j. {z,~ Sanitary Seal on Casing(~N); ~,~ Depression Around Wellhead (Y~) SEPARATION DISTANCES FROM WEI'L: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot ; On Adjoining Lots ~3G I .{-- ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole Water Sample Collected by ~ S ~k~,~,~-..~.~.~--.~..t~, ; Date Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Date installed ~"- t~' -"7~ Size t C>c~ o No. of Compartments '2.... Standpipes~.) y Air-tight Caps{~YN) ~'~ Foundation Cleanou~N) Depression over Tank (Y(~) ~./ Date Last Pumped Pumping/Maintenance Contact on Fi~le (Y/N) , ~/~'" ; for Holding Tank High-Water Alarm (Y/N) r41~' Temporary Holding Tank Permit (Y/N) ~.~..~__ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well I0'~ I ~,' To Property Line -- ~t4.', . To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course Comments To Building Foundation lOt ~ To Dis~0sal Field ~ t ~.o~(.~,.~,~e) F~ Page I of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata ype 0f System Design Date Installed ~'-" %~" "'~ Length of Field "'~ ~ WirJih Of Field Square Feet of Absortion Area Depression over Field (Y~) ,Result? of Last Adequacy Test ~,,!~ ~.. ~'~-'~"~'I SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well ~C~ To Building F~oundati~3'r{ : Lot ' ~J~' To Water Main/Se~vice Line . To Stream, Pond, Lake, or Major Drainage Course To DrivevTay, Parl~ing Area, or Vehicle Storage Area Comments. " Depth of Field ~.~' e Gravel Bed Thickness to i Statndpipes Present (~) Date of Last Adequacy Test To Property Lin~' t ~t4.- To Exist ng or Abandoned System on ; On Adjoining Lot~ ' ~ To C~tback (if present) D. LIFT STATION I~atelnstalled ' ' ' -' .... ~" Dimensioned', t . Size in Gallor~s-~~ ' ~ ' ' Manhole/Access (Y/N_.J~~--~ Tested for ~/ ~~ Cycles during Adequacy Test. Meets MOA Electrical Codes (~ Comments / ' **Check Permitted Bedroom Rating Against HAA Request** I ce~ify that I have checked, Verified, or conformed to all MOAand, H~~in effect on the date 0f this inspection. -. , ' Signed 17034 Eagle E,ver L~ -- ~/'~' ~~~~Engineer's Seal Date . ~.~tver. Alas~a995~ .~/~ MOANo. ~ ~' ~ /' J ~/~ ~ *Receipt No.* ~;~'*' ' Receipt No. Date of Payment Amount: $ ?; -2/- ?o Waiver Fee: $ Date of Payment Page 2 of 2 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION · ~25 L Street. An~, Al~sk~ ~9501 ENVIRONMENTAL ENGINEERING DIVISION Telephone 2644720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTION~: Co~ete ail peris o~ page 1. I~eoml~lete ~ will rim bi peeemlld. Ftleae allow ten (10) days for pro~l~ing. PROPERTY OWNER MA~L~NG ~RO~TY R~SlDE~T Hf d~fer~t fro~ e~) PHONE IPHONE PHONE MAILING ADDRESS ~. LENDING INSTITUTION I PHONE ADDRESS [] SINGLE FAMILY ~., Two/,~-~ [~ Five I'-I MULTIPLE FAMILY [~ Thrt~..~&~- Six 7. WATER SUPPLY " {:~"~NDIVIDUAL" * ATTACH WELL LOG. A well log is required for all wells drilled [] COMMUNITY since June 1975. For wells drilled prior to that date, give well [] PUBLIC UTI LITY depth (attach log if available.) 6, SEWAGE DISFO~AL SYSTEM ~ INDIVIDUAL/ON-SITE** **if ir~dividual/on-site, give installation date /~4v ,~2 . If system is over two (2) years old an edequ&cy (est is required [] PUBLIC UTILITY by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED 724)10(3/78) ~ .,'~; THIS SIDE FOR OFFICIAL USE ONLY jJ DATE RECEIVEO INSPECTION APPOINTMENTS TIME TIME TiME DATE DATE DATE I NSPE'..;¥'.J~ INSPECTOR I NSPEDTOR DIRECTIONS: 1. TYPE OF RESIDENCE NUMaER OF BEDROOM~ E:] SINGLE FAMILY [] ONE [] THREE [] FIVE r'-I OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY r-I INI~IVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER : [] INDIVIDUAL/ON -SITE DATE INSTALLED Connect;on Verified INSTALLER r"lSeptic Tenk or [] Holding Tank If Tank is homemade ' SOILS RATING give dimensions: ! TYPE OF TANK MANUFACTURER 4. DISTANCES WELL TO: S~otic/Holding Tank JAbsorption Area ISlet Line J N~rest Lm Line [~[]'"~APPROVED FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [~""DISAPPROV ED LEGAL DESCRIPTION 72-010 (Rev. 3/78)