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TONJESS ESTATES BLK 3 LT 23
Ton jess Estates Block 3 Lot 23 #051 - 532-09 Municipality of Anchorage Page 1 of 4 Department of Health and Human Services Division of Environmental Services On-Site Services Section 825 "L" Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6650 www.cLanchorage.ak.us (907) 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number: SWO100m �;Z S; PID Number: 051-532-09 Name: MM&M Contracting Wastewater System: New Address: P.O. Box 670495 Chu iak AK 99567 ABSORPTION FIELD Phone: Number of Bedrooms: 688-1236 Three 3 Deep Trench LEGAL DESCRIPTION Soil Rating: Total Depth from original grade: .45 GPD/Ft' 7 Ft. Block: Lot: Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe: 3 23 Ton'ess Estates 1 6 Ft. Ft. Township: Range: Section: Fill added above original grade: Gravel Length: 2-5 Ft. 112 Ft. Well: New Gravel width: Number of lines: Distance between lines: 3 Ft. 2 1 >12 Ft. Classification (Private, A, B. C): Total Depth: Cased to: Total absorption area: Pipe Material: Private 200 Ft. 23.3 Ft. 1,344 Flt ASTM D3034 PVC Driller. Dale Drilled: Static Water Level: Installer. Date Installed: Sullivan Water Wells 8/13/2001 37 Fl. MM&M Contracting 8/11-15/01 Yield: Pump Set at: Casing F eight Above Ground: TANK 1.3 GPM Ft. >2 Fl. SEPARATION DISTANCES ® Septic ❑ Holding ❑ S.T.E.P. ❑ Other: To Septic Absorption Lift Holding ublic/Pdvate anu ac urer. apace y in ons: From Tank Field Station Tank Sewer Line Anchorage Tank 1,250 well >100' >100' N/A N/A >25' Material: Steel Number of Compartments: Two (2) SudaceWater >100' >100' N/A N/A I LIFT STATION — NONE ON LOT Lox Une >5' >10, N/A N/A V :51, anu ac urer: Gal. Foundation >51 >10 N/A N/A 'Pump on' level at: in. "Pump off level at: in. High water alarm at: in. Cudain Drain None Noted Pump Make 8 Model Electrical Inspections performed by: Remarks: BENCH MARK Insulation over Septic I ank. Location and Description: Northeast 'Corner of Deck Front of House. Assumed Elevation: 100.0 Ft. E.pipess'�kStamp OF•'�� V� °•SIS r?, 457 ;5, 41C�TIf e °oa._.�a• O /7 h /Ahoe°a wer—w .� 1st Inspections performed by: in CH Dates: I 0/ rL/ V1 •eaeet ee° ooe✓ f� 2nd 8/15/01` ee0 e• e • e.,oe o qa JCHA.=L E. P.TSDERSOi4° Department of Health and Human Services approval PP < '^ ° �' -�$��t °° ��— Reviewed by: /owl �- -� �r.. '� ° b y;A♦°°0 C-°[.�� G w` and approved i Date: (Rev. 10/99) jf� P�pt SS�0 s ; Municipality of Anchorage Page 2 of 4 DEVELOPMENT SERVICES DEPARTMENT 4700 South Bragaw Street Anchorage, AK 99519-6650 - 343-7904 On -Site Wastewater Disposal System or Well Inspection Report Permit Number SW010284 PID No. 051-532-09 LEGEND: S - Septic Vent C - Cleanout M — Monitor Tube SV — Flow Splitter Valve TH — Test Hole Location PLAN AS-B'U"ILT SCALE17' ' = 50' OF +®WP�E q ® A B C S1 55.4 52.9 S2 58.9- 46.2 C2 15.1 43.1 M1 15.0 46.0 C6 65.3 41.3 C7 36.4 56.1 LEGEND: S - Septic Vent C - Cleanout M — Monitor Tube SV — Flow Splitter Valve TH — Test Hole Location PLAN AS-B'U"ILT SCALE17' ' = 50' OF +®WP�E q ® 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: SWO10284 i.3 Page 3 of 4 PID No.: 051-532-09 gle—l" t"migi�C PROFILE AS -BUILT Scale: t" = 10' 0 ® ; ® 49th _ vii` 1 MICHAEL E. ANDERSON ;: ;j) No. CE -4381 %��® 1 • �� ®� �®�pROFESSMO_t_ ®® Municipality of Anchorage Page 4 of 4 DEVEOPMENT SERVICES DEPARTMENT 4700 South Bragaw Street Anchorage, AK. 99519-6655 - 343-7904 On -Site Wastewater Disposal System or Well Inspection Report Permit Number: SWO10284 PID No.: 051-532-09 -,O = Nn U �- Ax U ft S PROFILE AS -BUILT Scole: t" = 10' v-q1n_1Ax m" r , Municipality of Anchorage x a r -: Development Services Department/On-Site Water &Wastewater Program Lr � { J 4700 S. Bragaw, Anchorage, AK 99502-0650 ': tn,9 cl- y, t SOILS LOG - PERCOLATION TEST !• °� w 'ocFS'1�t Performed For: MM&M Contracting_ Date Performed: 8/11/01° Legal Description: Lot 23 Block 3 Tonjess Estates SLOPE SITE PLAN ii ., tsielco l TESTHOLE NO, 4 4 GP/GM 5 Silty Gravel 6 to Poorly Graded 7 Gravel 8 9 10 11 12 13 14 15 Bottom of 16 Test Hole 17 18 21 North South Was Groundwater Encountered? No If Yes, What Depth? Depth to Water After Monitoring None Date: 8/20/01 S L O P E See Site Plan Perc. Rate: 48 Min./Inch Perc. Hole Diameter: 6" Test Run Between 5 Ft. and 6 Ft. Comments: Perc. Cavity Presoaked Prior to Test. Performed By: Tim Kimbrough. I, Michael E. Anderson Certify That This Test Was Performed In Accordance With All State and Municipal Guidelines In Effect On This Date: 1/24/02 ROM COUNTRY REALTY -PHONE NO. 9076881238 Dec. 28 2001 10:32RM P1 l; :• _ t te .. - •-n•.-9�1 Vit..• ;.�.�'�' „�`xtii•�' .•Ji.a: r;;.\61... ,ni•:::: 7.M +`;r:^:i:'::i'-i'':.:•: _ ;r.:Xl `� :Y._ ..r. >'.b'.x!`Yz1�w_a• _ _ _;.}.k..•t���._.•, :n.: `': •"'•' ,.f ,. .7. 17 '. ,l'"'•s::i:'cni;':i�:a- r PO: BOX670272`CHUGIAK :'ALA5Kh.99567 TELEPHONE -688=2750 .. ,,�9 ;.Y., .. OWNER OF LAND: / �` ;� ; : `x;'4 BORE HOLE DATA �:•: _ ,_DEPTH ADDRESS: ro LEGAL. DESCRIPTION: ''�1J e%J d DATE PERMIT NUMBER:"a /•0 'bate.:._ flssue TAX IDENTIFICATION'NUMBER: Is well located at approved permit_locafion?,:�es , : Na Method of Drilling::`_., rotary ,'rte cable tool.:' t O'�J G'� ' •�i�'� ',.J Depth. of Welf: �O •� t4474 .S �i4v�1 S Ltd, a Casing Type' •• , LWall-Thickness' ', ® inches - l �C.<i�caC./G ��e ,• - .. Diameter - inches: depiti' 4• ' '"-i` feet:. /3c� ��'�; LinerTypeaiJ'�l^enj[' Casing Stickup Above Ground: :'; -;'feet Static Water Lever • :.. feet Recover ' Rate: ., '® �" _ 9nnPm •• • ' Method Well Intake Op o- a ^'eri' . eOing Type: Ct •p•ri `d: n hole. -_- a 71 Screened; ' `Sta � f -ef -,&6 eG - PP �•feec ' :U Perforations'=;. -'''Start fee- -topped — :,rte A. �: �:'r'a•, • ! :ya•; �: Grout .T e: '� •.;.,, th: >t :: De "Well 'Disinfected- Upon Comp Method of Disinfection: ° C i ^ �d 4 e,. nts;Y ��4 i0�:iyr. �i8 •. ' �„ _ •;,�:� , �:., .:tin -'•"-_,. art. y - ':Y+ •.,tif.y:lL'.' A-f!'C•-: •.'-sI.ri=:%^,•Y. ' V1.Y;� - ATTENTIOm t is'the res onsibi( ~'vo¢ p ty ..� , tfie.•properijr owner". 'i, of Ariciiorage: Department af•Healiti'&'Human Services nepartrrient of.Envi,- • ' �.::.,: _:;.,.•.. Received TimeeDec.28a,10:12AM:':r erJs Name_: �� copy'o' welt logto the proper authority; Municipality artmenti of Erivi�orimeiital Conservation;,-MatSu Borough: '' i . Nr.., erJs Name_: �� copy'o' welt logto the proper authority; Municipality artmenti of Erivi�orimeiital Conservation;,-MatSu Borough: '' i . —//- 0I n MUNICIPALITY OF ANCHORAGE Development Services Department r On -Site Water & Wastewater Program 2 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 ����"Ci (907) 343-7904 .J� _ D ON-SITE WASTEWATER DISPOSAL SYSTEM / WATER SUPPLY PERMIT Initial Permit Number: SWO10284 Legal Description: TONJESS ESTATES BLK 3 LT 23 Design Engineer: 0014 Anderson Engineering Owner Name: MM & M Owner Address: PO Box 670495 Chugiak , AK 99567-0000 Date Issued: Aug 01, 2001 Expiration Date: Aug 01, 2002 Parcel ID: 051-532-09 Site Address: Lot Size: 87536 SQ. FT. Total Bedrooms: 4 Permit Bedrooms: 4 This permit is for the construction of: Z Disposal Field 0 Septic Tank Holding Tank [–] Privy Private Well Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ). 3. The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. 5. The following special provisions. TOTAL DEPTH OF THE ABSORPTION FIELD SHALL BE MAXIMUM OF 7 FEET FROM GROUND SURFACE. 1-L Movl-S }�S 7-F_/+� ; 40 " ro TkE NA/E. L.vp o,' S YSTF_M LWLL OF- w1T1KIM 30 �aF %F57 1I0LE � 3, ENlr. pip 5701L5 Tr_pST P F N C. R, 47 -.r- wJ+.F' r�-et_ s qAtE. Received By: Issued By: Date: J o d Date — � — O� DATE: August 12, 2001 TO: Dan Roth FROM: Mike Anderson, P.E. , SUBJECT: Lot 23, Block 3, Tonjess Subdivision Septic System Construction Permit No. SW010042 The owner of Lot 23, Block 3, Tonjess Estates Subdivision has changed the orientation of the house on the lot and wants to relocate the septic system as shown on the attached drawing. We have completed a test hole and percolation test which indicates the soils in this area are similar to those in Test Hole Nos. 1 through 3. We therefore request the permit be amended to allow the location of the septic system to that shown on the attached plan. Thank you for your time with this modification and please call if you have any questions. l Municipality of Anchorage, f d p Development Services Department/On-Site Water & Wastewater Program 4700 S. Bragaw, Anchorage, AK 99502-0650 SOILS LOG -PERCOLATION TEST H Performed For: MM&M Contractina Date Performed: 8/11%I> Legal Description: Lot 23. Block 3 Tonjess Estates SLOPE SITE PLAN 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 OG/OL TESTHOLE NO. 4 GP/GM Silty Gravel to Poorly Graded Gravel Bottom of Test Hole North South Was Groundwater Encountered? No S If Yes, What Depth? L Depth to Water O After Monitoring None P Date: 8/20/01 E See Site Plan Perc. Rate: 48 Min./Inch Perc. Hole Diameter: 6" 21 Test Run Between 5 Ft. and 6 Ft. Comments: Perc. Cavity Presoaked Prior to Test. Performed By: Tim Kimbrough. 1, Michael E. Anderson Certify That This Test Was Performed In Accordance With All State and Municipal Guidelines In Effect On This Date: 1/24/02 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. 051-532.09 Permit Number SWO/02.84 Property owner(s) MM&M Contracting Day phone 688.1236 Mailing address (1) P.O. Box 670495 Chugiak, AK 99567 Mailing address Zip Code Legal description (Lot, Block & Sub'd.) Lot 23, Block 3, Tonjess Estates Subdivision Legal description (Section, Township & Range) Lot Size 87,536 SF Acres/Sq.Ft. THIS APPLICATION IS FOR: Number of Bedrooms Four 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. E (Signature of property owner or authorized agent) Permit Fees: Waiver Fees: Date of Payment: T oobaC31 Date of Payment: Receipt Number:5 Receipt Number: (Rev. 12/00) July 20, 2001 Municipality of Anchorage Development Services Department On -Site Water and Wastewater Program 4700 South Bragaw Street Anchorage, AK 99519-6650 Subject: Lot 23, Block 3, Tonjess Estates Subdivision Septic System Design and Permit Application Impacts to Adjacent Properties Dear Onsite Services Engineer: The owner of Lot 23, Block 3, Tonjess Estates Subdivision intends to construct a four- bedroom home on the lot. We are therefore applying for a permit to construct a new well and septic system on the lot to serve the new home. The attached Site Plan and backup documentation identify the location and configuration of the new septic system and the parameters used in the design. Also identified on the plans is the location of the new well and alternate site along with the test holes. Existing drainage patterns are shown and will not be altered by the development of the lot. Test holes were placed near the location of the new absorption trenches and alternate site. These holes indicated silty gravel and sand with some cobbles. Percolation tests in the material resulted in a rates between 47 and 48 minutes per inch. Groundwater was found during placement of the test holes at nearly 13' and was noted at 12' during the monitoring period. We are therefore proposing to place a deep absorption trench with 6' of gravel beneath the distribution pipe. The total depth of the trench will be approximately 8'. The distribution pipe will be placed at 2' below the ground surface. A Zabel Flow Splitter Valve will be placed to evenly distribute effluent flow to each trench. The ground surface on the lot slopes as shown on the attached Site Plan with varying grades from east to west. The new absorption trenches will be constructed on a fairly flat surface in conformance with Municipal requirements and parallel to ground contours where possible. If the system is 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. 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. Lot 23, Block 3, Tonjess Estates July 20, 2001 Page Two 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. 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 Q� OF °ACS''': j 4' � V7 �57 4 g TIS . ° IUICHA.EL E. AINDERSCN CE - 4381 m , F� °PRO F E SS\)\�P ©' S - Septic Vent C - Cleanout M — Monitor Tube SV - Flow Splitter Valve TH — Test Hole Location SCALE 1" = 50' y('NO. LCE -^387,V1® LOT 23, BLOCK 3, TONJESS ESTATES SUBDIVISION DESIGN FACTORS: SYSTEM REQUIREMENTS: Four Bedroom Home Deep Trench System Perc. Rate: 48 Min./Inch 1,250 Gallon Septic Tank Avg. Application Rate: .45 GPD/SF 6' Drain Field Rock 4 Bedrooms X 150 GPD /.45 GPD/SF = 1,333 SF of Absorption Area 1,333 SF/12 SF/LF = 111.1 LF Trench Length Therefore: Construct Two Absorption Trenches Each 56' in Length by 3' Wide With 6' of Drainfield Rock Beneath the Distribution Lateral. Trenches Must be a Minimum of 12' From Edge to Edge. Distribution Lateral to Be Placed 2' Below Existing Ground. Total Depth of Trench to Be 8' from Existing Surface. A Zabel Flow Splitter Valve is Required to Evenly Distribute Effluent Flow to Each Trench. Mound Over Trenches if Necessary to Provide Minimum Cover of 3'. TYPICAL DEEP TRENCH SECTION (NO SCALE) NOTE: Grade Area Over Trench to Drain Away. Minimum 6' Separation From Bedrock. Minimum 10' Separation From Lot Line. Minimum 4' Separation From Groundwater. Minimum 100' Separation From Well. c. O 40-1 MICHAEL E. ANDERSGN CE - 4381 7 Natural Backfill. 1 .. 6.1 Geotextie .. Fabric 6... C '4* Perforated . ' PVC (Slots .Down) Drainfield. TYPICAL DEEP TRENCH SECTION (NO SCALE) NOTE: Grade Area Over Trench to Drain Away. Minimum 6' Separation From Bedrock. Minimum 10' Separation From Lot Line. Minimum 4' Separation From Groundwater. Minimum 100' Separation From Well. c. O 40-1 MICHAEL E. ANDERSGN CE - 4381 7 o 2 o f 3 4-/, l a 4g a GM 6 > °o O. 8-- 9 9 /f 10- 121 0 12 13 14- 15- 16- 17 4 151617 18- 19- Q11 8 19 Q11 COMMENTS / "' S/ 14 WAS GROUND WATER Gross Net Time Time ENCOUNTERED? G=(�NGIAIEEAS'SEAL) " S E °c aoa° j`c 1� � DEPTH? O �I/ P /Y' 'L F� O Z�� �.q ✓G¢ �t ® Municipality of Anchorage, Monitoring)�!`/ G 1 � DEPARTMENT OF HEALTH & HUMAN SERVICES s '' 71 �' oc�eoa 825 "L" Street, Anchorage, Alaska 99502-0650 ,�,,?�e� ^ c a°c��°0000caocc 6 SOILS LOG — PERCOLATION TEST y!1 peu! �'' �O cr, Cc°rd°Ua no 0000 no noo o°uL• t!hici,cel E. Anderson 4- uR ri.'e` � A 81 E ° e Ufa\o�� PERFORMED FOR: DATE PERFORNVEDt,"-� "Z7=" LEGAL DESCRIPTION: b7 10L'/fri�j� Township, Range, Section: TH, SLOPE SITE PLAN 1 o 2 o f 3 4-/, l a 4g a GM 6 > °o O. 8-- 9 9 /f 10- 121 0 12 13 14- 15- 16- 17 4 151617 18- 19- Q11 8 19 Q11 COMMENTS / "' S/ 14 WAS GROUND WATER Gross Net Time Time ENCOUNTERED? Net Drop S IF YES, AT WHAT L 3/7 / DEPTH? O �I/ P E Depth to Water Atter) �S Monitoring)�!`/ Date: Reading Date Gross Net Time Time Depth to Water Net Drop 4P21— 3 Z/29 2!3S 3e 6 07, � : c. • 31 y PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER --4)— TEST RUN BETWEEN r FT AND FT l .-r, /,r'L� K, /.E/ �� �' � L / 2A PERFORMED BY: / '/ I -7�" ftCL� C?[ (� ��GiL��e^�L Y THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) (ENG4NEER'S'SEAL) ® Municipality of Anchorage) ° DEPARTMENT OF HEALTH & HUMAN SERVICES P0,aonopc /f °yam 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST ��;m�',t"i`I'G�3�i f;Eders°�, J. (fid, � PERFORMED FOR: DATE PERFORMED��".:'-: "7~ LEGAL DESCRIPTION: L W4� 4�5�1 �V/ 10 17- 18- f I/yv� 19 -TI I/ 20 Township, Range, Section: SLOPE WAS GROUND WATER 1/ ENCOUNTERED? S IF YES, AT WHAT L DEPTH? / 7 p E Depth to Water After Monitoring? /3 Dale: SITE PLAN Reading Date Gross Net Time Time Depth to Water Net Drop l Z /L:/;7/ 12 0 / b ZLIS/-D 13 /p l� e/n.' r 7 3 /711,11ice" I g-45 �. i TTA 3 14 o•,, o 15 ° 16 17- 18- f I/yv� 19 -TI I/ 20 Township, Range, Section: SLOPE WAS GROUND WATER 1/ ENCOUNTERED? S IF YES, AT WHAT L DEPTH? / 7 p E Depth to Water After Monitoring? /3 Dale: SITE PLAN Reading Date Gross Net Time Time Depth to Water Net Drop l Z /L:/;7/ 8, io 3 ZLIS/-D v f2,e-,;' .(03 3 /711,11ice" I g-45 �. TTA 3 •1 . PERCOLATION RATE C� �- (minutes/inch) PERC HOLE DIAMETER TEST f,RUN /BETWEEN 1E 1FT/AND 2 FT COMMENTS lc51 k/� q L%��Q /��! / ",),L- Me, i Mei —L sLyvte. Soi� .ir rs� t6le— PERFORMED BY: IL^ "�`���CERTIFY THAT THIS 7ST pWAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: - `'A `�Y 10 11 12 13 14 15 16 17 18 19 20 TEST RUN BETWEEN FT AND FT COMMENTS So/ L'S A1%E TF>� SASE QS T'Nn S E orG (XUN-rsp ED irJ Te -S -r hbi s Ala, L . PERFORMED BY;�� I CLcLLgU- �-eL�^ CERTIFY THAT THIS /TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: =.�,� v(ENGINEER'S'SEAL) ® Municipality of Anchorage I-V 1Z 7& ° 4 DEPARTMENT OF HEALTH & HUMAN SERVICES "L" r?����?^�°f� E? �°��� F� 825 Street, Anchorage, Alaska 99502-0650 r'n �Ii^ SOILS LOG — PERCOLATION TEST, Cne°;ceG°O�oo oc oco oo na•>cae'r ca f,+ tnichaCI E. ::nderson ^ �`n�, a3a1 PERFORMED FOR: DATE PERFORMED:.= L..aI '> e� LEGAL DESCRIPTION: I,Z3� Township, Range Section: DE TH jar SLOPF SITE PLAN 10 11 12 13 14 15 16 17 18 19 20 TEST RUN BETWEEN FT AND FT COMMENTS So/ L'S A1%E TF>� SASE QS T'Nn S E orG (XUN-rsp ED irJ Te -S -r hbi s Ala, L . PERFORMED BY;�� I CLcLLgU- �-eL�^ CERTIFY THAT THIS /TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW940206 DESIGN ENGINEER:ANDERSON ENGINEERING OWNER NAME:WHITTERS JAMES D OWNER ADDRESS:13945 KNOB HILL DR. EAGLE RIVER, AK 99577 PARCEL ID:05153209 LEGAL DESCRIPTION: TONJESS ESTATES BLK 3 LT 23 LOT SIZE: 87536 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: PAGE 1 OF 1 DATE ISSUED: 6/27/94 EXPIRATION -DATE: 6/27/95 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 (24 HOURS) . 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED BY: ISSUED BY: y DATE: DATE: 6 Z 7 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Parcel I.D. 051-532-09 Certificate of On -Site Systems Approval Expiration Date:q— I - 7 1. GENERAL INFORMATION Complete legal description TONJESS ESTATES BLK 3 LT 23 Location (site address) Current property owner(s) Mailing address Real estate agent 2. TYPE OF DWELLING: 25261 Homestead Rd THORALL Noelle Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone 376-7653 Day phone 376-7653 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well 0 Private Septic 0 Water Storage ❑ Holding Tank i ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 5W / LjI 2.5b Date of Payment�_/VL6 Receipt Number 6��%J�� COSA # Q S(2 0- - Waiver Fee $ Date of Payment Receipt Number Waiver # COV I D-19 25% DISCOUNT APPLIED Distance: 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm NorthRim Eng. phone 694-7028 Address PO Box 770724, Eagle River Engineer's Printed Name Steve Eng Date g�P�E OF A9 ELL 6. DSD SIGNATURE �, �.:,�• • s 4 � '• 5bw Ehy. s System #1 Approved for 3 bedrooms ``4 '•, c�625e��.•�•�� System #2 Approved for bedrooms Disapproved Conditional approval for bedrooms, with the following stipulations: WTY oF(4o��� By: Original Certificate Date: '" Z62c) The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: �� COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet WA Tj� J f��R PRO— QGA By: Original Certificate Date: '" Z62c) The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: �� COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet Legal Description: TONJESS ESTATES BLK 3 LT 23 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 8113/01 Total depth 200 ft Cased to 23 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 24+ in. Date of flow test for COSA 5/12/20 Static water level at beginning of test 33.6 ft Comments B. TANK DATA Age of tank(s) s"5'01 years Tank type/material steel Measured operating fluid level in septic tank 50 ❑ Standpipes/foundation cleanout per record drawing Date of pumping 5/18/20 D. ABSORPTION FIELD DATA 8/15/01 Which system tested (date installed) same ❑ ALL standpipes present per record drawing Total measured depth from grade 11 ft (max) Measured depth to pipe invert from grade 5 ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Comments/Deficiencies: COSA Checklist yellow sheet Parcel ID: 051-532-09 Structure served by this system Well production at time of test 2+ gpm Water storage tank volume 0 gallons Well disinfected for coliform test? ❑ Yes ❑ Nc ❑ Coliform bacteria is Negative Nitrate 5.8 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by NRimEng Date of Sample 5/19/20 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 5112/20 Results F, -/]Pass For 3 bedrooms Fluid depth prior to test 8 in Water added 450 gal New depth 16 in Elapsed time 60 min Final fluid depth 8 in Absorption rate 450 gpd Any rejuvenation treatment (past 12 months) If yes, enter date MEG 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' M Yes Community Sewer Manhole/Cleanout > 100' 0 Yes if No ft Q Yes if No ft Neighboring Tank > 100' M Yes if No ft Private Sewer/Septic Line > 25' Yes if No ft Absorption Field on Lot > 100' Q Yes if No ft Holding Tank > 100' Yes if No ft Neighboring Absorption Fields > 100' Yes if No ft Water Main > 10' Animal Containment > 50' 0 Yes if No ft E] Yes if No ft nv Yes if No ft Water Service Line > 10' Yes if No Manure/Animal Excreta Storage > 100' If septic tank is under driveway Community Sewer Main > 75' 0 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' M Yes if No ft Surface Water > 100' 0 Yes if No ft Property Line > 5 M Yes if No ft Wells on Adjacent Lots: 0 Absorption Field > 5' M Yes if No ft Private Wells > 100' Yes if No ft Water Main > 10' n/ Yes if No ftCommunity Wells > 200' nv 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' 0 Yes if No ft If absorption field is under driveway comment below Property Line > 10' Q Yes if No ftWells on Adjacent Lots: Water Main > 10' 0 Yes if No -ft Private Wells > 100* Yes if No ft Water Service Line > 10' 0 Yes if No ftCommunity Wells > 200' Yes if No ft Surface Water > 100' 0 Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. COSA Checklist yellow sheet 4L. Ai�PT' OF �I-14 Nk stwm Eng CE—em cr www.muni.org/onsite Nitrate Advisory Certificate of On -Site Systems Approval # OSC201202 Subdivision: Tonjess Estates, Block:3 , Lot: 23 A water sample revealed a nitrate concentration of 5.8 milligrams per liter (mg/Q. The Environmental . Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. sw Mailing Address P ;O Box 196650 *Anchorage, Alaska 99519 6650 *www muni org Municipality of Anchorage /-2/f3jcC( GE B ® Development Services Department PST: tt" 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 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. ('".' HAA # 0 V 0 C Expiration Date: . 3 —1 3 _ 6- 1. GENERAL INFORMATION Complete legal description 7—UdTc--ss 5 l jlrc—:is 94 o0 3 , 4(3T n?, 3 Location (site address or directions) Current Property owners) % //UKSTd A/ °` %C -SG t i'A6j/_dCA6ay phone Mailing address Lending agency Mailing address Real Estate Agent Mailing Address 1. CH(JCf4fe Day phone 5TL-'�i� J! JSA(1� 1-sk t Day phone 0064 — QF42 r 4,4AI-0 /2G-JLT/� ,e, '-/6;f Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System 1 TYPE OF WASTEWATER DISPOSAL: �1 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 sample results. (Certificates may reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and -'as of the validation date shown below, I verify that my investigation, based on procedures outlined in the 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. 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 Anderson Engineering Phone 522-7773 Address P.O. Box 240773 Anchorage, AK 99524 Engineer's Printed Name Michael E. Anderson, P.E. Date 1/24102 5. DSD SIGNATURE V Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: tc((lff��rrrr l lam`: ON-SITE �a= Additional Comments WATER AND e t �WASTMAiAYFR ° ° PROGRAM Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory �JF�••• °.°off_`; Maintenance Agreements Supplemental Engineer's Report Other By: Original Certificate Date: (Rev. 12/00) Municipality of Anchorage GE PM U ' Development Services Department r Building Safety Division- _- On -Site Water & Wastewater Program 5 "FET .Y, 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: QN/ ZCff EcST%f %EJ' R 3 Z67_�3 Parcel ID: (1 % - _ 3 _2, _ A. WELL DATA Well type 72 Date completed V /.3/6 t Total depth 000 ft. If A, B, or C provide PWSID # Sanitary seal (Y/N) Cased to 02-3 ft. FROM WELL LOG Date of test 3 a( Static water level -37 ft. Well production A 3 g.p.m. WATER SAMPLE RESULTS: Coliform 6 colonies/100 ml. Arsenic: — mg./I. B. SEPTIC/HOLDING TANK DATA C, 2 /.7(or Nitrate Z2;( mg./I. Date of sample: / !o Tank Type/Material &AI�!�ti%C Tank size 125a gal. Number of Compartments 2 Well Log (Y/N) Wires properly protected (Y/N) Casing height (above ground) min. AT INSPECTION -a3 L6 q G - ft. 1.5 g.p.m. Other bacteria C5 —colonies/100m]. Collected by: Date installed Cleanouts (Y/N) X Foundation cleanout (Y/N) c./ Depression over tank (Y/N) A/' High water alarm (Y/N) A,114 Date of pumping ,//z. ! Q S4 Pumper C. ABSORPTION FIELD DATA Date installed elIS101 Soil rating (g.p.d./ft2 or ft2/bdrm)0. (S System type % 2�C�/l Length /12 ft. Width 3 ft. Gravel below pipe 46, ft. Total depth _//_ ft. Eff. absorption area /-'#q ft2 Monitoring tube 4— Depression over field Date of adequacy test l 3 Results (Pass/Fail) PWS For .3 bedrooms Fluid depth in absorption field before test z�_ in. Water addedd gal.fi New depths in. Elapsed Time: by min. Final fluid depth 4/' in. Absorption rate >= 41-S-0 g.p.d.t Any rejuvenation treatment (past 12 mo.) (Y/N & type) J,1A1 C If yes, give date D. LIFT STATION Date installed _ "Pump on" level at Datum Size in gallons in. "Pump off' level at in. Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Manhole/Access (Y/N) High water alarm level at in. Meets alarm & circuit requirements? Septic tank/lift station on lot >100' On adjacent lots >100' Absorption field on lot >100' On adjacent lots >100' Public sewer main NIA Public sewer manhole/cleanout NIA Sewer /septic service line >25' Holding tank NIA SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation >5' Property line >5' Absorption field >5' Water main NIA Water service line >10' Surface water >100' Wells on adjacent lots >100' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line >10' Building foundation >10' Water main >10' Water Service line >10' Surface water >100' Driveway, parking/vehicle storage >25' Curtain drain None Noted Wells on adjacent lots >100' F. COMMENTS G. ENGINEER'S CERTIFICATION 1 certify that I have determined through field inspections and:_ _, tt review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date.I f 5>, Engineer's Printed Name Michael E. Anderson, P.E. Cr. -4':81 W Date 112412002 ° X21 HAA Fee $� Waiver Fee $ Date of Payment 6DO 7>c� Date of Payment Receipt Number/'j Piga Receipt Number (Rev. 12/00) a ,ip' 690800/19®06f}NO� 9.9 "n e�•h V° . SS_ Y a .Robert C. J `?n;on N No. S aq a . 8uU {t,riCMx c�� C�3 �� °tea °. w oocg° �3`-•-,�3`•` h✓' I hereby certify that I have surveyed the following described property: L G % 3� t3 �v c 2 , --b z- >TI 5"it1 , R I w, Anchorage Recording Precinct, Alaska, and that the improve- ments situated thereon are within the property lines and do not overlap or encroach on the property lying adjacent thereto, that no improvements on property lying adjacent thereto encroach on the premises in question and that there are 'no roadways,, transmission lines or other visible easements on said property except as indicated hereon. Dated at Eagle River, Alaska this. ZO Fd day of N `t`vy 200 I ROBERT C. JOHNSON SCALE: Registered Land Surveyor No. 880 -LS Box 77-0456, Eagle River, Alaska 99577 Phone (907) 699-2543 Municipality of Anchorage Development Services Department �A°t Building Safety Division 4 On -Site Water and Wastewater Program 5 A e E T Y 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. 051-832-94 HAA #� Expiration Date: 0 Z- 1. GENERAL INFORMATION Complete legal description Lot 23, Block 3, Tonjess Estates Subdivision Location (site address or directions) Current Property owner(s) MM&M Construction Mailing -address Lending agency Mailing address Real Estate Agent Mailing Address P.O. Box 670495 Chugiak, AK 99567 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System Four 4 Day phone 688-1236 Day phone Day phone 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 5 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on- site water supply and/or wastewater disposal 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 FirmkD� 9722(im rktr Phone Address/ 7-237. /P•'g� Clre�4 Engineer's Printed Name i, Date: 5. DSD SIGNATURE Approved for :3 bedrooms. Disapproved 9 [; Steven W. En ��% t�!'�••o PE 6256 .• C• nlA. it Y�''�y.1 ��� P.Y'�7' Conditional approval for bedrooms, with the following stipulations: Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory WASTEWATER MrnN AKA Maintenance Agreements Supplemental Engineer's Report Other gy:4114e� Original Certificate Date: (Rev. 07102) 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 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lot 23, Block 3, Toniess Estates Subdivision Parcel ID: 051-532-09 A. WELL DATA Well type Private If A, B, or C provide PWSID # Date completed 811312001 Sanitary seal (Y/N) Y Total depth 200 ft. Cased to 23.3 ft. FROM WELL LOG Date of test 811312001 Static water level 37 ft. Well production 1.3 g.p.m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 ml. Nitrate 1.07 mg./I. Date of sample: 12128/2001 Collected by: Tim Kimbro B. SEP T ICiHOLDING TANK DAT A Tank Type/Material Septic/Steel Tank size 1,250 gal. Number of Compartments 2 Foundation cleanout (Y/N) Y Depression over tank (Y/N) N Date of pumping Pumper C. ABSORPTION FIELD DATA Well Log (Y/N) Y Wires properly protected (Y/N) Y Casing height (above ground) >24 in. AT INSPECTION 12/2812001 36 ft. 1 9 - p.m - Other bacteria 0 colonies/100 ml. Date installed 811112001 Cleanouts (Y/N) Y High water alarm (Y/N) N Date installed 811512001 Soil rating (g.p.d./ft2 or ft2/bdrm) .45 GPD/SF System type Deep Trench Length 112 ft. Width 3 ft. Gravel below pipe 6 ft. Total depth 9-12 ft. Eff. absorption area 1,344 ft2 Monitoring tube Y Depression over field N Date of adequacy test Results (Pass/Fail) For bedrooms Fluid depth in absorption field before test in. Water added gal. New depth in. Elapsed Time: min. Final fluid depth in Any rejuvenation treatment (past 12 mo.) (Y/N & type) N Absorption rate >= g.p.d. If yes, give date D. LIFT STATION Date installed Size in gallonsnhole/Access (Y/N) "Pump on" level at i "Pump off' level at in. High water alarm level at in. Datum Cycles tested Meets alarm &circuit req rements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot /64 fl - Absorption field on lot /0617- Public 6Qi7- Public sewer main i(/Af Sewer /septic service line On adjacent lots On adjacent lots /CJ Qffi Public sewer manhole/cleanout Holding tank /V SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation /6 (� Property line �4 �� Absorption field s '- Water main 'g Water service line /0 rt Surface water Wells on adjacent lots /06 1,4 lQ D �r SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line /,/), ((— Building foundation /�J Water main A/ 1,4 Water Service line /& (t Surface water /D4 rr Driveway, parking/vehicle storage ZO I'Y_ Curtain drain Wells on adjacent lots le)t F. COMMENTS i G. ENGINEER'S CERTIFICATION G'��:• "�T�' �'�+.¢; 1 certifythat I have de =� � ��` �� �� determined through field inspections and .-' �t ice• .x .4*** *Bob •.•• �- • a review of Municipal records that the above systems are in+ conformance with MOA HAA guidelines in effect on this date. •.r� ....n r, -pt� Steven ng.. Engineer's Printed Name %��� div G �d s.0 PE 6256 0 4 J Date /��30/a y Qo �.'F�P ...,..••-';�,� `�'��' HAA Fee $ 11 TO • X70 Waiver Fee $ Date of Payment f Z/7 /c'/ Date of Payment Receipt Number 4 -I n(�?r Receipt Number (Rev. 12/01)