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HomeMy WebLinkAboutEAGLE RIVER VALLEY RANCHETTES LT 1BEngle River Valley Ranchettes Lot 1 B #050-221-35 Municipality of Anchorage Page 1 of 3 Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw Street P.O. Boz 196650 Anchorage. AK 995146650 www.a.anchorage.ak.us (907) 3417904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number: SW020079 PID Number: 050-221-35 Wastewater System: Upgrade Tank Only Mark Layman Aa"'31 10436 Crest View Lane Eagle River AK 99567 ABSORPTION FIELD ri'd'e: �w c'Be0O S' 696-1961 Three 3 Deep Trench LEGAL DESCRIPTION SW su". CPwe oW Depm ogm Wae: fl. SWk La: 5womron: cwpm to P" WIM On9"'•l @W awl "PE be Mt P": 16 Eagle River Valley Ranchettes Ft. FL Towuty: n•npe: SM4on: Maw Wore aq •W In: Ft. Ft. Well: City Water • N: fl. FL oav tan (Pn Me. A Q C): T" Depot: C."ad w: wp rea: I . FI. fl. FI' Peer: Dale pirea: $WPC Wier L•M: CCC Construction e 4/26-28/02 FI Ye : Puep Set W: Gaeta Aoor. r aen: TANK GM Ft. FI SEPARATION DISTANCES ® septic ❑ Holding Q S.T.E.P. D Other. To Fran Septic Tank Absorption Field tNt Station Holding Tank 'e Sewerllrw Ray's Services y :1,000 Wel N/A N/A N/A N/A N/A Tardw— Plastic ...... Two (2) Sut wales >100' >100' N/A LIFT STATION — NONE ON LOT Lair+ >5' >10' N/A �.. Faemwntt >5' >10' flNA N/A ti, GrUin Pa+t None Noted P y. Fta,WU BENCH MARK Tank Only Replaced Under This Permit. Top of Slab at Parking Area. Am•t m! ENvlcn: 100.0 FL Engineer Stamp �•.�� C)F - , ff f1 �•i /� 49th Inspections performed by: Stuart Gilbert Dates: 1" 4/26/02 �, '�{�)Aj�Y•�L�,.^-� 2nd 4/2t3/O2 ��'i WU4EL E. ANDERSS �- �'ps.�`� Department of Health and Human SSe�rvices approval No.CE-4381 fff • Reviewed and approved b : / — Date:G s.Z) PP Y SSI :' tale,oEel Municipality of Anchorage Page 2 of 3 DEVELOPMENT SERVICES DEPARTMENT 4700 South Bragaw Street Anchorage, AK 99519-6650 - 343-7904 Onsite Wastewater Disposal System or Well Inspection Report Permit Number SW020079 PID No. 050-22135 LOT 1B, EAGLE RIVER VALLEY RANCHETTES SUBDIVISION Three Bedroom Home Shed Retaining Wall \ \ S1 S2 \ \ 0 3 C I I -C4-. I I ITgxistinqq Absr tion area I�4 epe artd Coii$grata n nownp I I MAN O' WAR ROAD PLAN AS -BUILT SCALE 1" = 20' L9 r`,kL. 49th W `? MICHAEL E. ANDERSON No. CE -4381 f A B S1 36.75 15.0 S2 40.0 18.0 C2 44.6 22.6 C3 45.3 23.7 C4 61.75 43.1 Shed Retaining Wall \ \ S1 S2 \ \ 0 3 C I I -C4-. I I ITgxistinqq Absr tion area I�4 epe artd Coii$grata n nownp I I MAN O' WAR ROAD PLAN AS -BUILT SCALE 1" = 20' L9 r`,kL. 49th W `? MICHAEL E. ANDERSON No. CE -4381 f Municipality of Anchorage Page 3 of 3 DEVEOPMENT SERVICES DEPARTMENT 4700 South Bragaw Street Anchorage, AK. 99519-6655 - 343-7904 On -Site Wastewater Disposal System or Well Inspection Report Permit Number. SW020079 PID No.: 050-221-35 Absorption System (Type and Configuration Unknown) Tank Only Replaced Under This Permit 4TCNAEE E. ANDERSON ., No. CE -4381 y PROFILE AS -BUILT Scale: I' - 10' .1 JL' -.; c;471..° lCtl;.'(Hwn.d irvr. /•. 1?jJo• ..,•'`^_.ryCe;J9:: AS iAySeia• .vii(tr'••1.'li, ,...:,.r_�ti.%Y . t..i �: • } .. • ,.. • . •. .•••: .•.. • . ! . •y r,. .�•y tri. If jt • f::.4't. �.i i d ��•+yrL�� �Y•:•: • .. t � • `• .'� �. • r � :•�'rww.f s+i••1��') ^i� `.�,.(y�'�•'�'-'l:}�.,L{7• ' 1 ✓! ...'!.`L1ti Y ' Y` 1:a.: Ti-fi:M: '•f 7 • e \ Y • It''• r N•, \ '1� �,�.17 :'/� .:i:..:: \• )) q. iT••C 7xtt +a `i: C':vi�:a !:ter '�✓i• r.. r a3:i,;i1•v a:� •". :T:1 ��::f•a•i t Fy-r_.�a:'1 [i ;,..:,..-:..X�.T;c. L'.. .. �� ,Q ea.e � r•. Com., .. ^`�% •i�.l.�sli•. �� /,r.+Z�l•y `�a`i.: f>Y,•,::�1"3 Vs_L FOj%!;�.: ,'7.r: .tl � ! /� . i��ii'x�.• :Ie•if:N•r.'Z r Q� l'iray� fft �rr i� \. }.ir.,:pr'i'vw ..1. .. IUI ;. , •r:^L^+•r.fi, �: Wy,�': ...a Jvi. �Ia� �I IT' • � 4�• • �•.frl: v,..: aa.. �^y..r L::,�'•, •rte �.r.r.:r '.,���' • ' •:.. ' : • •' ,=.sem;:— "•�^ . • •.r .�'• :)�..:�_ r:.•, tit ' F., •1• .I. 1`•. .fes", Ti I.t11A•y: '.i .�i. } y +1•'i_'•.. }•• Y�•air f k•te�i,g�A3-BUILT -wt : ^ Received Tim ay. 4. 5:53AM I hereby certify that I have surveyed the. following described property / C —f3� E ��' �i•�K' 13 1 improvementtc sesituateed thereontrcere wsltlftnethhe propethat rty NInes and do not overlap or encroach on the ProPef%Y ine adjacent thereto, that no Improvamants on prop - arty lylne adjacent thereto encroach Ora the Prmnitea Ln questlon and that there an no roadways. transmaeeton liner or other visible easements on sold PropertY except as indicated hereon.. listed atm ti! River. -A,, rv: _: r•w} -. ' ' • IOLT. ti ROBERT c JOHNSON SCAM Registered I•and Surveyor No. es0-IS Z' a ZC I Box 456• Eaale River, Alaska Phone 694-2543 MUNICIPALITY OFANCHORAGE Development Services Department On-SdeWater& Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 Z11a 3P, ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: Apr 26, 2002 Expiration Date: Apr 26, 2003 Permit Number: SW020079 Parcel ID: 050-221-35 Legal Description: EAGLE RIVER VALLEY RANCHETTES LT 1B Design Engineer: 0014 Anderson Engineering Site Address: 010436 CREST VIEW LN Owner Name: Mark Layman Lot Size: 17955 SQ. FT. Owner Address: 10436 CREST VIEW LANE Total Bedrooms: 3 Permit Bedrooms: 3 EAGLE RIVER. AK 99577-8441 This permit is for the construction of: ❑ Disposal Field ❑✓ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified In Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72 ) and Drinking Water Regulations (18AAC80 ). 3, The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by catling (907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: Issued By: Date: Date: 7 26 02 Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 ON-SITE SEWER/WELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. 1550 – —a I Permit Number SW Oz 00 791 Property owner(s) Mark Layman Day phone 696.1961 Mailing address (1)10436 Crest Yew Lane Eagle River AK 99577 Mailing address (2) Zip Code Legal description (Lot, Block & Sub'd.) Lot 18 Eagle River Valley Ranchettes Subdivision Legal description (Section, Township & Range) Lot Size 1% 9S� Acres/Sq.Ft. THIS APPLICATION IS FOR: Number of Bedrooms Three (3) Sewer Only ❑ Well Only ❑ Sewer and Well ❑ Water Storage ❑ Sewer Upgrade THIS PROPERTY CONTAINS: Hot Tub ❑ Jacuzzi ❑ Swimming Pool ❑ Water Softening Unit ❑ Therapy Pool ❑ 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. atm (Signature of property owner or authorized agent) Permit Fees: Nab • oo Waiver Fees: Date of Payment: a 2 Date of Payment: Receipt Number: / g96Zs Receipt Number: (Rev. 12/00) ANDERSON ENGINEERING P.O. BOX 240773 ANCHORAGE, AK 99524 522-7773 522-6779 FAX April 26, 2002 Municipality of Anchorage Development Services Department On -Site Water and Wastewater Program 4700 South Bragaw Street Anchorage, AK 99519-6650 Subject: Lot 1B, Eagle River Valley Ranchettes Subdivision Septic System Design and Permit Application Impacts to Adjacent Properties Dear Onsite Services Engineer. The existing septic tank on Lot 1B, Eagle River Valley Ranchettes Subdivision has collapsed and must be replaced to prevent a possible health problem. The homeowners are unable to use the plumbing in the house until the septic tank is replaced. We are therefore requesting a permit be issued immediately for the construction of a new septic tank to serve the home. The attached Site Plan and backup documentation identify the location of the new tank. The new tank will be placed in the same location as the existing tank. The failed tank will be removed from the property and disposed in an acceptable manner. Existing drainage patterns are shown and will not be altered by the placement of the new tank. The subdivision is served by the Municipal water system and no conflicts exist between placement of the new tank and any wells or septic systems In the area. If the new tank is constructed In accordance with our design the following statements apply: I . 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 subdivision is currently served by a community water system. 2. 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. 3. 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. Lot'1B, Eagle River Valley Ranchettes Subdivision April 26, 2002 Page Two 4. 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 OF to 49th»» '�• �• �� 4�CNACL E. ANDERSON W � •�c�sr ND. CE -4381 t �- LOT 113, EAGLE RIVER VALLEY RANCHETTES SUBDIVISION MAN O' WAR ROAD �- 2% (2) Post Tan C leanou New 1,000 Gallon ' ' Septic Tank Three 1A iL SCOPE OF WORK: 1 C 1. Remove and Dispose Existing Septic Tank. 2. Place New 1,000 Galton Septic Tank. Place 2 Post Tank Cleanouts. 3. Regrade All Disturbed Areas. 3. Revegetate Area As Required. NOTE: NO CONFLICTS WITH WELLS OR SEPTIC SYSTEMS IN THE AREA. SITE PLAN SCALE 1" = 30' ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION AND MATERIAL SPECIFICATIONS SUBJECT: LOT 16, EAGLE RIVER VALLEY RANCHETTES SUBDIVISION GENERAL: 1. The scope of this project includes the removal and disposal of the existing failed septic tank and the procurement and placement of a new 1,000 gallon septic tank at the location shown on the Site Plan. The new septic tank must be constructed a minimum of 10' from the water service line serving the house. 2. Construction shall be in accordance with the approved site plan, design drawings, Municipal Permit with any special provisions or conditions, and all applicable State . and Municipal Wastewater Disposal Regulations. 3. The Contractor shall be responsible for obtaining all underground utility locates and for the layout of the septic system and verification of the location of all lot lines. 4. Unless specifically agreed otherwise, the contractor shall be responsible for final grading areas subsequently depressed from soil settling. Property owner shall be responsible for revegetation of affected areas unless specifically agreed otherwise. 5. Contractors installing wastewater disposal systems must be certified by the Municipal Department of Health and Human Services for system installations. Owners installing their own systems must receive prior approval from D.H.H.S. before beginning system installation. SEPTIC TANK INSTALLATION 1. A new 1,000 -gallon septic tank must be procured from an approved source and installed at the location shown. 2. A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. 3. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. 4. All standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 5. Tanks installed without 4' of cover shall have a minimum of 2" of direct burial insulation. 6. A foundation cleanout shall be installed one to four feet from the building foundation. Two cleanouts are required between the tank and the drainfield. 7. Final grading over the tank shall be such that a positive slope exists away from the septic tank. Lof 1 B, Eagle River Valley Ranchettes Villages April 26, 2002 Page 2 of 3 DRAINFIELD CONSTRUCTION: 1. The drainfield shall be constructed to the dimensions shown on the design. The bottom of the trench shall be within 2" of level. 2. Distribution piping must be placed level with perforations down atop a level bed of drainfield rock. Rock should then be placed over the pipe to provide a minimum of 2" of cover. 3. A silt barrier or geotextile fabric must be placed between the drainfield rock and the natural soil backfill. 4. Monitor tubes must be 4" in diameter and installed at the locations shown on the design. The portion below ground must be perforated. 5. Contractor shall verify the septic tank and drainfield are a minimum 100' away from any private water wells in the area, 150' from a Class "C" Well or 200' from any community well. 6. Direct bury insulation must be placed over the distribution system if less than 3' of backfill depth is available. Finish grade over the trench must be mounded to prevent settlement or depressions. 7. Grade area surrounding the absorption trench to drain away. 8. A minimum 2' of accepting soil is required below the drainfield rock for a 5' wide trench. Contractor shall verify this condition prior to placement of the rock. All pockets of unacceptable materials must be removed and replaced. MATERIAL SPECIFICATIONS: 1. Septic tanks must be constructed by a municipally approved septic tank manufacturer. 2. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Cast Iron (perforated and solid), ASTM D3034 or P.V.C. (perforated and solid), ASTM F810 or H.D.P.E. (perforated, but not solid) and ASTM D2662 or A.B.S. (perforated and solid). 3. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Co. Styrofoam HI or equal). 4. Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Femco, or equal). L.of 1B, Eagle River Valley Ranchettes Villages April 26, 2002 Page 3 of 3 5. A permeable geotextile fabric (Typar, Mirafi or equal) must be installed between the final drain rock layer and the native soil layer. 6. All drain rock shall be .5" to 2.5" in diameter with less than 3% passing the #200 sieve. INSPECTIONS: Municipal Ordinance requires a minimum of two inspections. These inspections must be conducted under the supervision of a professional engineer registered in the State of Alaska. The first inspection must be conducted after the excavation of trenches, beds or pits and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled. The second inspection must be conducted after the placement of the geotextile fabric, gravel, distribution piping, standpipes, cleanouts and insulation. No backfill should be in place at the time of inspection. Contractor shall provide a copy of all field survey layout and construction notes for use in preparing the certified as -built of the completed system. GRE�,ER ANCHORAGE AREA B0► UGH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON -SITED SEWAGE DISPOSAL SYSTEM NAMEJO n Q e MAILING DDRESS /'�% 6� /© EGCpp �9Q�bH0NE LOCATION LEGAL DESCRIPTION if7 �/� I%G/�Py /�UNC/J2PS SEPTIC TANK: u 1� Y_7 DISTANCE�.�j NUMBER OF FROM WELL MANUFACTURER -std ff'f~e 1 MATERIAL srlef COMPARTMENTS INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH I-IQUID CAPACITY/Z - GALLONS. SEEPAGE PIT: NUMBER %OgF/PITS DIAMETER OR WIDTH, LENGTH/- , DEPTH /4 LINW M/ATE�IAL _� Y� CRIB SIZE: DIAMETER_DEPTH_(�_ DISTANCE FROM: WELL �� ,Z& TOTAL EFFECTIVE �5& BUILDING FOUNDATIONZ4 , NEAREST LOT LINE ABSORPTION AREA (WALL AREA) SQ. FT. ADDITIONAL ABSORPTION WELL: Uan bell vt(fev 5 slh'm TYPE CONSTRUCTION DEPTH DISTANCE FROM: BUILDING NEAREST NEAREST SEPTIC SEEPAGE FOUNDATION LOT LINE , SEWER LINE , TANK SYSTEM CESSPOOL OTHER SOURCES APPROVED DISAPPROVED REMARKS DISTANCES: INSTALLED BY: 61h)OO PIPE MATERIAL: GY// cl LOT SLOPE: REMARKS: Cx r Pa �"PSfS Form No. EQ -031 DIAGRAM OF SYSTEM _ I ipld C), GREATER ANCHORAGE AREA BOROUGH �AA DEPARTMENT OF ENVIRONMENTAL QUALITY PERMIT NO. 3330 "C" STREET ANCHORAGE, ALASKA 99503 TELEPHONE 274-4561 SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT NAME OF APPLICANT �1 ` ` ,n MAILING ADDRESS ,L/.�.7�-��.y) " PHONE �r— INSTALLATION LOCATION'rjm'e-� Pw /� (� ��� ��� �'./ LEGAL DESCRIPTION INSTALLATION OF: SEPTIC TANK ��� SEEPAGE PIT TYPE AND SIZE OF FACILITY TO BE SERVED �iCn .el FINANCED THROUGH TO BE INSTALLED BY DRAIN FIELD OTHER , SOIL TEST RESULTS T/Ir //AJ NOTEI THIS PERMIT IS NOT VALID WITHOUT SOIL 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. SEPTIC TANK SIZE TYPE SEEPAGE AREA SIZE MINIMUM DISTANCES, REQUIREMENTS / FOUNDATION TO SEPTIC TANK L� FOUNDATION TO SEEPAGE PITL} DRAIN FIELD SEPTIC TANK TO SEEPAGE PIT WALL _.T T SEPTIC TANK SL�5' SEEPAGE PIT, DRAIN FIELD TO NEAREST LOT LINE. WELL TO SEPTIC TANK /(.�L SEEPAGE PIT DRAIN FIELD ALSO CONSIDER AREA WELLS. WATER MAIN TO SEPTIC TANK SEEPAGE PIT , DRAIN FIELD /yam SEPTIC TANK. 11-26 SEEPAGE PIT.�DRAIN FIELD , TO RIVER. LAKE, STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS. GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. a G.A A.B. OR LICENSED DESIGNER 1 CERTIFY THAT 1 AM FAMILIAR WITH THE REQUIREMENTS OF GREATER DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. 14 DATE r-5 APPLICANT'S SIGNATURE - !� FORM NO. E -016 TYPE DIAGRAM OF SYSTEM AGE AREA BOROUGH ORDINANCE NO. 28.68 AND THAT THE ABOVE r SUBJECT DATE i / //� �..y ♦ ♦ .Ii L I ♦ •000 ♦ I s 1 � 1PLEASE REPLY TOw--g*D- sioNED - v l DATE SIGNED Rodifprm 0 4S 464 SEND PARTS 1 AND 3 WITH CARBONS INTACT. Poly Pak 1330r 10469 PART WILL CE RETURNED WITH REPLY. r", Greater Anchorage Area Borough Department of Environmental Quality HOT LINE COMPLAINT AND ACTION FORM HOUSING AIR POLLUTION CASE NO. PUBLIC FACILITIES JUNK AUTOS DATE NOISE NUISANCE INVEST: SEWER & WATER SOTHER l COMPLAINTANT: e / c� iC�. (� �`a / //J, i 7 ADDRESS: NATURE OF COMPLAINT: LOCATION OF -COMPLAINT: RESPONSIBLE PARTY,, ADDRESS PHONE NUMBER RECORD OF CONTACTS AND CORRESPONDENCE Date Time Comments S Sic d � �s .� o f._• J?.,v s r��/ao . 9�3/J5d 16)5e-47 9 12 TIME & DATE COMPLAINTANT CALLED BACK EQ -045(9.74) Use Reverse Side of Form for Further Comments •t . Municipality of Anchorage J 1r�Jt"-. .� On-Site Water and Wastewater Programn (907) 343-7904 JAN' A 16 ti c- s. Certificate of On-Site Systems Approval `i oI 6 8 L a c) Parcel I.D. 050-221-35-000 Expiration Date: 7-1 0 1. GENERAL INFORMATION Complete legal description Eagle River Valley Ranchettes L/1 B Location (site address) 10436 Crestview Ln Eagle River, AK 99577 Current Property owner(s) Lynn Klippel Day phone 907-227-7394 Mailing address 10436 Crestview Ln Eagle River, AK 99577 Real Estate Agent Raney Hardman Day phone 907-440-7257 2. TYPE OF DWELLING: Ix I Single Family (w/wo ADU) n Duplex Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ❑ Individual 0 Individual Water Storage ❑ •Holding Tank ❑ Community Class Well n Community ❑ Public Water System x Public Sewer n WaiverNariance request for Distance: (..)Received by: 4 Date: /-aq-/B COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 5-P,Z, Waiver Fee $ Date of Payment //�P//1 Date of Payment Receipt Number a26a.(d) Receipt Number COSA# 65(/ (6 VO 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 Alaska Rim Engineering Phone 907-745-0222 Address 9131 E. Frontage Rd Palmer, AK 99645 Engineer's Printed Name Norman K. Gutcher Date 1/17/2018 .� OF AL 6. DSD SIGNATURE * (49 S- * Ag System #1 Approved for bedrooms °�;?. Nornin km tc er System #2 Approved for bedrooms • � /� CE 4919 .°C o` Disapproved �h�9FOp °°'yP Conditional approval for bedrooms, with the following stipulations: - - ' \1Y OF,qVy ON-SITE WATER AND 5":- `t�' WASTEWATER o t`t� PROGRAM „co: SERi1' C/6Original Certificate Date: 1 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_S c If more than 1 septic system is on the lot: COSA Checklist# of Structure served by this system Certificate of On-Site Systems Approval Checklist Legal Description: Eagle River Valley Ranchettes L/1 B Parcel ID: 050-221-35-000 A. WELL DATA Well type Public If A, B, or C provide PWSID# Well Log (Y/N) Date completed Sanitary seal (Y/N) Wires properly protected (Y/N) Total depth ft. Cased to ft. Casing height(above ground) in. FROM WELL LOG AT INSPECTION Date of test Static water level ft. ft. Well production g.p.m. g.p.m. WATER SAMPLE RESULTS: Coliform colonies/100 mL Nitrate mg/L Arsenic ug/L Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Tank Type/Material Plastic Date installed 4/28/2002 Tank size 1000gal. Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout(Y/N) Y Depression over tank(Y/N) N High water alarm (Y/N) N/A Date of pumping 7/10/2017 Pumper Sanitary Pumpers C. ABSORPTION FIELD DATA Date installed 9/3/1974 Soil rating (g.p.d./ft2 or ft2/bdrm) 85 System type Seepage Pit Length 19 ft. Width 19 ft. Gravel below pipe 5 ft. Total depth 11.63 ft. Eff. absorption area 456 ft2 Monitoring tube Y Depression over field N Date of adequacy test 1/15/2018 Results (Pass/Fail) Pass For 3 bedrooms Fluid depth in absorption field before test 34 in. Water added 479.3 gal. New depth 58.5 in. Elapsed Time: 1290 min. Final fluid depth 34 in. Absorption rate >= 479.3 g.p.d. None Known Any rejuvenation treatment(past 12 mo.) (Y/N & type) 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 in. High water alarm level at in. Datum Cycles tested Meets alarm &circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot On adjacent lots Absorption field on lot On adjacent lots Public sewer main Public sewer manhole/cleanout Sewer/septic service line Holding tank Animal containment areas Manure/animal excrete storage areas SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 101+ Absorption field 5'+ Water main 101+ Water service line 101+ Surface water 1001+ Wells on adjacent lots 200'+ ABSORPTION FIELD ON LOT TO: Property line 101+ Building foundation 10�+ Water main 101+ Water Service line 1CY+ Surface water 100 + Driveway, parking/vehicle storage 101+ Curtain drain None Known Wells on adjacent lots 200'+ F. COMMENTS G. ENGINEER'S CERTIFICATION 4...."19t °"' t OF 41°11%1 1 certify that I have determined through field inspections and .""t;. ‘'...... Gjj •`•°""" ••.. �s 11 review of Municipal records that the above systems are in o conformance with MOA COSA guidelines in effect on this date. " '. 4?;; Fs ,; t a�e Engineer's Printed Name Norman K. Gutcher e . .ertiet L:-.-77" "" .•i 1/17/2018 / • Norman K. Gutcher J c�AO Date ♦ �.'.� CE-4919 ,.•sc�,w� s 0. t�hep e�'••.�....•.•",�`"s ,t4 -RQFESSIOI"P� ` A.@'1►'g®w COSA canary sheet_2-6-15.doc 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.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 050-221-35 HAA# L' 1. GENERAL INFORMATION Expiration Date: 7- a g - o Ll Complete legal description EAGLE RIVER VALLEY RANCHETTES SUBDIVISION; LOT 1B, Location (site address or directions) 10436 CRESTVIEW LANE * EAGLE RIVER AK 99577 Current Property owner(s) Mailing address Lending agency Mailing address MARK & SOONHUE LAYMAN Day phone 10436 CREST VIEW LANE * EAGLE RIVER AK 99577 Day phone Real Estate Agent PORTIA w/ AMERICAN REALTY Day phone Mailing address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well ❑ Individual Water Storage ❑ Community Class Well ❑ Public Water System N 529-5778 TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding tank ❑ Community On-site ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 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 samples. (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. Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $ at, orprior to closing for the engineering services provided. 4. STATEMENT OF INSPECTION BY ENGINEER As cerfyrei�.by°• Yseal affixed hereto and as of the validation date shown below, 1. verify that my invtigation, based on procedures outlined in the Health Authority 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. l further verify that based on the' -''e 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 ALASKA WATER & WASTEWATER CONSULTANTS, INC. Phone 337-6179 Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date L63 Engineer's Comments: M conducting this evaluation, AKWWC, Mc. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. AKWWC, Inc. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DS,D SIGNATURE V Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the filowing stipulations: Attachments: HAA Checklist V� Manitenance Agreements Septic System Advisory Supplemental Engineer's Reort Well Flow Advisory Other YtOF qN'�' C'7o WATER AND ; m= PROGRAM Jai �ONTSE� Sl \ By: Original Certificate Date: 7' v2 8 " 03 (Rev. 17101) moz yXS <A, 0 A4m mm m C, 20 s o -Z KDKZ Z COOT >mK y x0m mom y Um,AD Mmz m OCti ycm A AyO Som m mcz 0cm O mmm 71 QIY)m Dom O Z: 0 v o ° moZ n Z2 Wm Pm SoI D ti D m > m -, mI K o z oym v 20 m y zm -mi 0 m IT O D 0 y� 0 mom Am O O Z DZ O yo O m S m S A v~C O➢ m D_I OZ 00 z OZ A O yy z v 0m O T o y> m A m m m CC N Z Mid m0 Oy O = °o O e oD z 0 3 A 00 M z0 mz A C Dy m Z py A m m ti y Z { m O mm m z V) D m m O N O°1 ❑ ❑° W 135.00 I L� �anda9 hyM3n�n� { 0 z Z p I N U R6 N P N _ 01,eO o ~ �OpiT,pM oNoa N ❑ o �R9Mf'yo M,zy ❑ � { SP ❑ < - m 16 1 52.2 D j in ENTRY 3 { z { z � N W _A ❑ m� 1N3 W35V3 Aijiur Cpl D t 5 0°10150°E 1 5.00' -1200 ov-> m0.m- �orK-D-I mom(z) -l"m A~m0 Z Amro ~xwj MM AA(jA Il�DI n O m W y< M y CA�ImA m mm➢K rz Zmmm 4)0mm CKO ZZ -x fmt�.'Imw( MI 0 1yAo A9z--rt uC 0pOp mAm< Z L) A ONm Z3z D 1y opD OZ4 ZS m z A 1 2 myti co n ma N y Zp Z 2 N IN o m AOS 0 0 m OO y D S ySS m O� y Im OmD �mz go ZD O zz- yD2 mmy x� y -1 Z -I 2 m O CLn G ci w 13 --- - — -- --—-—- —- — -— � M31A 1S3H3 AOIx Z3Nb DMInDI p yN O m W y< M y CA�ImA m D� m C tnmpy?m .. Zr m -r1 0 0 Z p 7Ap00x _. uC A m gpa00 m z A l 'I c tD A Zp Z y b ayN� Z S ��__ Rmm m -, pm Tl���e ��� Yo r. " .=- 0 = Z 0 9 A t 1. MUNICIPALITYOFANCHORAGE .'`;".:•:(C)2" 7V • '� DEPARTMENT OF HEALTH & HUMAN SERVICE$ . Division of Environmental Services `r', On -Site Services Sectibn P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 , CERTIFICATE OF HEALTH AUTHORITY '"'`' APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # o� - ?�Z.1 - 3S HAA # �i A 9 9-0 to e 1. GENERAL INFORMATION , Complete legal description �" B tz� $I,,vax Y4"yq Location (site address or directions) S WI g"V-,� .0� 040dVi' 0tQ4a .G =a't ct•� Property owner-'sL.aW Day phone Mailing address P, v. �os� 170306. C-AerIZ 12.rox /LA- 59J-77 Lending agency Day phone Mailing address AgentF_cr.&A•k VX_ X1,1+ - Dayphone Address _,rn 6w_afn- Am= Unless otherwise requested, NAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: ••••••..... 4. TYPE OF WASTEWATER DISPOSAL: ' •. Individual on-site Holding tank Community on-site Ir Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. . 72-0(=(Ray.1/91) Front MOA121 Individual well Community wellLSD Public water V,- = c= - NOTE: If community well system, provide written confirmation from State At'24C attest.-; = �t Ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: ' •. Individual on-site Holding tank Community on-site Ir Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. . 72-0(=(Ray.1/91) Front MOA121 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 furtherverify 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. �_ > _. • ' ' David R. Day�oti P.E. 6y'�O-o?f�i 7 Name of Firm 2021OLmnalar St. Phone Address Chugiak, Alaska "567 Engineers signature Dateyd �. r�.tit Ccvi.! fi. Dcy:cn r �e: d r+ 6. DHHS SIGNATURE Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: 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 engineers work r .. ?2-M (Ra.191) Back MOA t21 Additional Comments r� 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 engineers work r .. ?2-M (Ra.191) Back MOA t21 ® Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Zr /8 15&5-t& gi" Parcel I.D. -3 d A. Well Data Well type PDQ` `' It A, B, or C. attach ADEC letter. ADEC water system number a /0 Log present (Y/N) Total depth Sanitary seal (Y/N) Date of test Static water level Well flow Pump levell completed Driller to Casing height Wires properly protected (Y/N) FROM WEL"OG AT INSPECTION SEPARATION DISTANCES FROM WELL TO: g.p.m. Septic/holding tank on lot r- ; On adjacent lots Absorption field on lots'" ; On adjacent lots Public sewer main Public sewer manhole/cleanout Sewer service line Petroleum tank WATER SAMPLE RESULTS: Coliform Nitrate Date of sample: Collected by: g.p.m. Other bacteria B. SEPTICIHOLDING TANK DATA Date installed :�ZO —1 Tank size / Z Sn '� Compartments Z Cleanouts (YM) Y -Foundation cleanout (YM) Depression (Y/N) A/ High water alarm (Y/N) N//I Alarm tested (Y/N)' Date of pumping .11uA3X i Pumper 6e,' SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot A✓A On adjacent lots n4*. Foundation To property line /o e /, Absorption field Lo Water main/service line ZSf- Surface water/drainage 72-02sr+l•Front CONTINUED ON BACK PAGE Z m � 00 oT z C. UFT STATION Date installed//t Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) `Pump on" levet at "Pune off" Level at High water alarm level Cycles tested Meets MOA electrical codes (YIN) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed —Soil rating (GPD/Ft2) 8•�-5�6�= System typep�s. Length 19 efWidfth /5 r- Gravel thickness co r Total depth Total absorption area a%SL Cleanout present (Y/N) Y Depression over field (Y/N) /V Date of adequacy test V14, Results (pass/fail) toh55 for ¢ Bedrooms Water level In absorption field before test `/C Aftertest 46V4 Zv/,•s Peroxide treatment (past 12 months) (Y/N) A- It yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot On adjacent lots �'!/A Property line /p To building foundation Z o To existing or abandoned system on lot�� ✓ On adjacent lots 3© 0- Cutbank&,�/A Water maintservice line z50 - Surface water /00 Y- Driveway, parkingNehicle storage area 1:5- Curtain SCurtain drain Aloive f%&>C'JA ) E ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect onne date of this inspection. _ _ ypA . J - • r h C L• ., ( Y Y �y .. David IL Dayton P.E. Signature '202.10 Donalar 61 • •6 s .:> Chugiak, Alaska 99567• Engineer's Name Date 7/zyA� r r= vo. ^ t' r• HAA Fee $ 000 eco Date of Payment - a2l/—''� e Receipt Number 72.026 r=)- Bak Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL IMATTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date (a) Legal Description (include lot, block, subdivision, sec ion, towyAhip, nge) Location (address or directions) J c P1 ecu' e"t4l P G 01.1 v« y. Z-7' 'fio(b) Applicants NanC'���/ ' Telephone - o« 12WevI w�J -_5-74) Z 5-2o y Applicants Address (c) Applicant is (check one) Lending Institution Owner/builderE'!<J•; Buyer ; Other ] (explain); (d) Lending Institution Telephone Address (e) Real Estate Co. S Agent Address Telephone (f) Mail the HAA to the following address: 2. Type of Residence Single—Family'`El Multi—Family Other (describe) Number of Bedrooms 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 and status. 4. Sewage Disposal Onsite= Public Community Holding Tank Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. [Page 1 of 21 ' 5. Engineering Firm Providing Inspections, Testa, 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 regula- tions in effect on -the date of this inspection. Name of Firm Telephone Address $ C G•ia'n`..`n!"� (j Fi11EFL ALf:Sn.'1 4-�(i Date !w� prt. �� •0 6. DHEP Approval Approved for Wooms Approved Terms of Cond r •% (ENGINEER SEAL) 00;� 14 Disapproved Approval By Det:.. Conditional CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMEPTTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS 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 REQUIRE- MENTS. 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. RR4/ej/D18 (Page 2 of 21 7-19-84 A. WELL DATA /1MUNICIPALITY OF ANCHORAGE 1 DEPT. OF HEP.LTH & 11 ENVIRONMENTAL PROTECTION MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Legal Description: SEP 131284 RECEIVED Well Classification If A, B. or Co D.E.C. Approved(Y/N) Well Log Present (YM) Date Coupleted Yield Total Depth Cased to Depth of Grouting Static Water Level Pump Set At Casing Height Above Ground Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (YIN) Depression Around Wellhead (YIN) Separation Distances from Wall: To Septic/Holding Tank on Lot 000A ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot 200 A On Adjoining Lots To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole Tb Nearest Sewer Service Line on Lot Water Sample Collected By Date Water Sample Test Results ComTents B. SEPTIC/HOLDING TANK DATA Date Instal oe'Size .2.SC) No. of Ccnpartmentsft �^ Standpipes (Y Air -tight Caps (Y Foundation C:lleanout (i Depression over Tank (1!C ) Date Last Pumped 9 ���� T Pumping/Maintenance Contract on File (Y ; for l /J h Holding Tank High -Water Alarm Temporary Holding Tank Permit (Y/N)�'`� . Separation Distances from Septic/Maidtnig-Tank: To Water -Supply Wa11 0 C9 0 -A To Building Foundation !� To Property Line /0 A To Disposal Field Z % To Water Main/Service Line .30 4-, To Stream, Pond, Lake, or Major Drainage Course GJ I l� Comments Receipt # Date Paid: Amount: cpm--, 910 (Page 1 of 21 2-15-84 C. ABSORPTION FIELD DATA f Soils Rating in Absorption Strata Type of System Desig o r Date Installed 9 — 3 ?' Length of Field 19" Width of Field Depth of Field /3011 avel Bed Thickness Square Feet of Absorption Area Standpipes Presen (Y ) Depressior. over Field ( /N Date of Last Adequacy Test Results of Last Adequacy Tiest 1 q 7/ S FA •Tc�� y Separation Distance from Absorption Field: To Water -Supply 4b11 To Property Line ZC7 To Buildirg Foundation 2fl To Existing or Abandoned System cr: Lct J-5� /P- On Adjoining Lots a? O / To Water Main/Service Line 2-0 74 To Cutbark(if resent) To Stream/Pond/Lake% majorDrainage Course �Aa To Driveway, Parking Area, or Vehicle Storage Area ZOT Comments D. LIFT STATION Date Irstalled Dimensions Size in Gallons A Manhole/Access (Y/N) "Pump On" Level at I/VL"PLmp Off" Level at High Water Alarm Level at Vent (YEN) Tested for Pumping Cycles during Adequacy Test. Meets MOP, Electrical Codes(Y/N) Ccarmerts ** Check Permit Bedrocm Ratirg Against HAA Request ** I certify th I ve checked, verified, cr conformed to all MOA fiA limos in effect on the da cf ion. Sia C :• S1 ne Date 3 O f Company C� MOA No. ,sr sif 1% KB1/d5/s;,�'►��'Y+, k-`%_.r�•• �'� ins'" ::�`�* [Page 2 of 21'''•^ 2-15-84