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Home My WebLink AboutT15N R1W SEC 8 LT 125T15N R1W Sec. 8 Lot 125 #051-154-06 Aug 01 11 11:47a Sultivan Water Wells 907 688 2759 p.2 184 Borehole Data: Soil Type, Thkkr~ss & Water Strata - Casing Stickup Overburden Silt Sand Gr~vel Silt Sa~d Gravel WJClay Silt Sa~c~ Gravel Silt Sand G~ W/C~ SiR Saad G~ Dele Silt Saad G~ Well Log Date of Issue ?t2uam Parcel identification Number: Permit Number: OSP Date Started: ?129120~¶ Date Comptcted: 712~/2011 [$ well located at approved permit location? Property Det, cdption TI 5N R1W SEC 8 Lot 12S Block NONE Section: T~vn: Property Owner Name & Address: ROBERI AIKEN 2113~ JAYttAWK DRIVE CHUGU~, AK 99SS7 ..... r}epth Method of OrilUng [~, air rotary From To Casing 0 2 Wall thickness 0.2s inches Diameter 6 inches Total: 120 feet 2 4 ! .inet type: 4 Diameter inches Depth: feet a 22 Casing sticE~U¢[bove ground: "' -~' feet 22 74 Static Water Level(from top of casing) 89 feet 74 80 Pumping Level: feet after ...... 80 t03 ..... ~ hours pumping gpm Recovery Rate so gph 103 110 Method af Testing: 110 t20 Well Intake Opening Type [ "ope. E.a t ' I.' Screened Start feet Stopped I~-, Perforations Start ss feet Stopped Grout Type: Be~.t0.nlte d~.gra~ular ..... Volume: too Depth 44 Start o leer Stopped 44 Pump Intake Depth: Pump size: HP brand name Well disinfected upon Completion.* Method of di~infe~tioa CHLORINE Commeets: Water Sample Results: Ameaic: uSA Well Driller: .... Cole Sullivaa Nitrates mg/I S utliva a W at~ Wsi~ Total Coliform Bacteria colonies/100mL P.o. mx .... Chuglak, AK Other bacteria: col/lOOmb (907) 688-27S~ Attention: Thc proper[7 owner shall provide this tog to DSD (onsit¢) and DNR within 30 da~s of completion. 05115406000 ',x-"y~s Range: feet ss feet Pounds feet Aug 01 11 11:48a Sullivan Water Wells 907 688 2759 p.3 Pump Installation Log w., ~... ~_,,._....¢¢~ ~). ~.,.o,~.~ .7-.~¢-~~t Aug 01 11 11:48a Sullivan Water Wells 907 688 2759 p.4 ' " f Anchora~ ......... Municipality o e Community Development Depar~nent O~-Site Water and Wastewater Program 4700 Elmore Rd. - P.O. Box 196650 A~chorage, AK 99519-~650 · ht~p:/lwww, muni.org/onsite · (907) 343-7904 Well Oecommissior ing Log L~-~al Address: S ubd iv is ion B lock Lot T15N R1W Section8 Lot125 , .7 COLE SULLIVAN C~mpany: SULLIVAN WATER WF! LS M~tlhed<)fdecu,,.,~issio. ing: AJ~C 15.55.060L1 a, [] b, [] c. ~ Location: Use the s~ec~ belo~ to provide a dra~ing of the prope~y st~owing the f~llowi~g ilems; · Nort~ arrow · Dec~missionect well, · Qther water wells o~ ~ property, , Two separate swing-tie distalices fol' e. acfl well sllmm on l~e drawing, Ne~e: The s~ing-tle distances shat be measmed from ei~ler pesmanent s~tctums or the property corners. ---., . .....' . . .... .....- .. · . . ~.~.,¢". . . . ....... - ~., ~o.,~-,~=~dlna S=~Y~C)n E a Water and IN'astewa~Fom~stCli~nt FonmsXWeli Dec~,.,~onincj form.doc G:lCommunity Develaixnent~Develo~, Permit Number: Tax Code Number: Work Type: Permit Effective Dates: Design Engineer: Subdivision: Site Legal Address: Owner/Address: Site Mailing Address: On-Site Water System Permit OSPl11182 05115406000 Well July 28,2011 MUNICIPALITY OF ANCHORAGE Development Services Department On-Site Water & Wastewater Program 4700 Elmore Road, PO Box 196650 Anchorage, AK 99519-6650 Telephone: (907) 343-7904 Upgrade to July 27, 2012 PANNONE ENGINEERING SERVICE T15N RIWSEC 8 T15N RlWSEC 8 LT 125 G:1257 AIKEN ROBERT M & KELLEY-AIKEN PAULA S PO BOX 672061 CHUGIAK AK 995672061 21136 JAYHAWK DR, Chugiak Lot Size in Sq Ft: Total Bedrooms: 108900 5 This permit is for the construction of: N Disposal Field N Septic Tank N Holding Tank N Privy Y Private Well N Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80). 3. The wastewater code requires inspections during the installation. The engineer must notify the Development Services Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either: A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: ~,,~ Issued By: ~/I~F~ Date: Date: 7//~%// MUNICIPALITY OF ANCHORAGE Community Development Department Development Services Division On-Site Water & Wastewater Program Mayor Dan Sullivan Phone: 907-343-7904 Fax: 907-343~7997 ON-SITE SEWER/WELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. ~' Property owner(s) ¢--o~1' ~)K~______~/ Mailing address ~, Site address ¢_J Legal description (Sub'd., Block & Lot) Legal description (Township, Range & Section). Lot Size Sq. Ft. Number of Bedrooms Day phone THIS APPLICATION IS FOR: ([~ all that apply) Absorption Field Septic Tank Holding Tank Privy Private Well Water Storage THIS APPLICATION IS AN: Initial [] Upgrade ~L Renewal [] THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: I certify that the above information is correct. I further certify that this application is being made for a S, iqgle, Family Dwelling and is in accordance with applicable Municipal Codes. (Signature of proPerty owner or authorized agent) Permit/Rush Fees: Date of Payment: _. Receipt Number: Permit No., Waiver Fees: Date of Payment: Receipt Number: Waiver No. G:\Building\On Site\Forms\Client Forms\Permit App_010411 .doc (Rev. 1/11 ) Pannone Engineering Services LLC Steven R. Pannone, Principal Registered Professional Engineer E-mail: steve@panengak.com July 28, 2011 Municipality of Anchorage Development Services Department On-Site Water & Wastewater Program 4700 S. Bragaw Street Anchorage, Alaska 99519 Subject: Southpark S/D, Block 3, Lot 9 Emergency Well Replacement Permit Request Ladies and Gentlemen: I am writing to request that a permit to install a new well be issued for this lot. The proposed systems will serve an existing four-bedroom house. Currently the lot is developed. The existing well serves a five- bedroom house. The existing well has perforations and a broken casing at 24 feet below ground level and at 38 feet below ground level. The existing well will be abandoned per code. The clean out at the end of the existing drain field is separated and will be repaired. The surrounding lots are served by private wells and septics, and there are no septics within 100 feet of the proposed well. 1. Upgrade Well Design. a. Sec Sheet 1 of 1 of thc plan set b. The proposed installation will not affect the future development of the surrounding or existing lots. There arc no septic systems within 100 feet of the proposed well location. If you have any questions or concerns, please contact me at 272-8218. Sincerely, I.....~~ ....... ~.....~ . ........... Steven R. P~one, P.E. O~effCivil Engineer Maiiing: ?,O, Box l[002:i.?~ Anchora6% AK PSysicak 61.5 t::.as~. 82~x~ Ave, Cuite B6~ fx~cl'~orage~ Ai( 99505 Teielshone: (907) 272~8218 I:AX: (907) 272~,821f,.~, ' ! tf~. , ~. ~59 2 t . .~, ~ ~[ ~'' ~ ~,~ ABANDON PER COb~ ~ i~ ,~ ' NOTES: P~O~ ~G ~C, L~ ~: OF A/?~J Date EBER~ENCY ~LL REPLACEMENTP.O. BOX 1002~7 ANCHORASE, AK 995~0 ~ ...... ~jj 7/28/~ PHON~ (~oz) ~2-s2~8 tAX (~OZ)2Z~-8~ ~.." ~~,, so~,~ ~... ~ m ~ ...~ 1":so' z~N, ~w, s~c a, LOZ ~ i_.~..~N..... ~ ~.,.~. ~o ROBERT AIKEN & PAULA KELLEY AIKEN ~ ~'. CE 8149 .'~ PERMIT NO. P.O. BOX 672061 ~:. .~ xxxxxxxxx PLAN CHUGIAK, AK 99567 ~i{?~z. ..... ,~ Sheet ~ ~:~O~SS~A%~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONIv]ENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL [NSPECTI()N REPORT PHONE I E~NEW ~PGRADE__ LOCATION DISTANCE TO'. IF HOMEMADE: Inside length.__~.~. DISTANCE TO: Well DISTANCE TO: Length of each No, o[ lines line Top of tile to finish grade Material INn, OF BEDROOMS PER IT N . I U~', 0f coq,~tments/ -- ngth of lines beneath time Liquid depth PERMIT NO. Liquid capacity in gallons Nearest lot line PERMIT NO. Trench width Distance between lines inches Length ~'/ ~., ~ Width /~_~ ! ~ /'~'i~ ~' Type of crib Crib diameter Crib depth Nearest lot line DISTANCE TO: Total effective absorption area ]nce to lot line PERMIT NO. DISTANCE TO: Building foundation tic tank Absorption area(s) OTHER PIPE MATERIALS REMARKS DATE LEGAl_ DIi[F'rqF~'.THE:I',I'I" DF:' I'tI.'~(:~L.'FI.I ~:~I',ID 1E:I"I~]:I::~[)I",II"IIEN'I'('~L.. I:::')~l:rll"'l I T I',10 ~ r'~l I L .[ [.,(~111 . ~.)I)l I ........... [.:'(] N 'T'F~ ITl" -)~"1~' (:IIxAVI.L I-,.l:::lq(:.~ll"'l :> '7',5 I:::"1",. I~E.I,,IJ],I I., I ILJLI .I.I I..t- I::d. JIqS; (Iq[IT LX(.,L.I..,I.).LI,I... '7~,:5 I:::"1'~ I!!:('~CH) · )i'¢~ 'T'~NK IqlJEB'I" ]-IF,~VE~ ~'1" I..I![()[~T 'I"WC) C[)I~IF'(~F?Tlqli~NTE~ ]: (:: ~a r' i:, J. F y 'L h ,'=a t. :: :1, ,, :r, [~kl'II (' ,v:wi) J. ]. :i, ~1.1" ~tJ J- '[. h ~, [1 e:) I" E? (::ILl :i. P C{ffllC)II '~', ici '~' C) I" CJl-)'"'!]i J 'L (Z) !~i(Y)CU('.:~ F' ~; ;::~11 c:l t.'4(~ ], ]. !B ~VB !~![~::? {'. ~;?.,,:[ v, lJ,].]. J.l"~i'l:.al:L '[:.htze ~s~y!~ss't'.c;~rl~ :i.n ac:c::c]r'd~:ar'v:::(z.~ ~,~J,'t.l"i ~A].:I. Iq[JR (:::~::icl(.~)!~i al'~l::l ar'id J. rl c:c:)ml::~].J. Lu"lc::~i~ v,~J.i:.h 'Lh~:~ d(a!.~$:i, gli c:l'J.'Ll:~,r,:La~ [][' i:,l'lJ.t~i l::)c.H',m:i.l'.. :5. :1: c,~:i.I]. ~cll'n~.H'c:, i',.o ~:t],l Iq[)(~ amd [3t. ai:.e cH' (4],~:'~il<a i,eclLt:i.r,~'unc~rvL~i fcm i:,he !~i(::.~'('.. I::$ ~F.w::: I< !E~ (.])~l E:') P ~k) g (~) ![~ y !~ ~. ('3) ()) C)FI ~, m') :i. ![~] c) i', ?~:t F) ~ ~:~ (::J j ~:t c: (gJ'J '(',, c) p i') G)b~ I', m:) y ], c),L. LEGAL [DESCRIPTION: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONIVIENTAL PROTEC'rlON 82S L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG -- PERCOLATION TEST 4- 5- 6 7 8 [] SOILS LOG [] PEFICO LATION TEST DATE PERFORMED: SLOPE SITE PLAN 10 11 12 13 14 15 16 17 18 19- 20- O P ! E IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time 'Fime Wate~ Drop PERCOLATION RATE ~//~/h (minutes/inch) TEST RUN BETWEEN , FT AND FT CERTiFiEDB~~~ ~~~~'( DATE: Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program~ / 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www. muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. o5~-~54-o6 GENERAL INFORMATION Complete legal description T~sN RIW Sec 8, Lot ~.25 Location (site address) 2~36 Jayhawk Drive Expiration Date: 2, ¸. Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing Address Robert Aiken & Paula Kelley-Aiken P.O. Box 672o6:~, Chugiak 99567 Raney Hardman ! ReMAX Day phone Day phone Ur~less o?he.m(.ise requested, COSA will be held by DSD for pickup. Well Day phone 694-42oo TYPE OF WASTEWATER DISPOSAL: . NUMBER OF,BEDROOMS: TYPE OFWATER SUPPLY: ,Individual Well Individual Water Storage Community Class Public Water System [] Individual On-site [] Individual Holding Tank [] Community On-site [~] [] Public Sewer E~ The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Pannone Engineering Services, LLC Phone 272-8218 Address P.O. Box 100217, Anchorage, AK 99510 Engineer's Printed Name Steven R. Pannone, P.E. Date 7/22/2011 Engineers Comments: In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MOA DSD Guidelines & Regulations. The reported results describe 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 soil condition, ground water 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 this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. PES can therefore not provide any warranty for future performance nor give any estimate of how long the system will continue to meet the operational requirements of the 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. DSD SIGNATURE ~,,~/ Approved for .L)-'" bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory X Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: M icipality of Anchorage Development Services Department ' Building Safety Division On-Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 ~Nw.muni,org/onsite (907) 343-7904 CERTIFICATE OF ON- SITE SYSTEMS APPROVAL CHECKLIST Legal Description: T=.sN !RaW Section 8 Lot a25 A. WELL DATA Parcel ID: Well type P If A, B, or C provide PWSID # ~ Well Log (Y/N)Y Date completed ?lanl~,oaa Total depth ~.2o ft. Sanitary seal (Y/N) Y Cased to ~.20 ff. FROM WELL LOG Date of test 71a91~o~. Static water level 89 ft. Well production 0.5 g.p.m. WATER SAMPLE RESULTS: Wires properly protected (Y/N) Y Casing height (above ground) AT INSPECTION g.p.m. in. Coliform Neg coloniesll00mL Nitrate ND mg/L Arsenic: 64.9 ug/I B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic Steel Date of sample: ?lanlaoa', Collected by: Laura Pannone Date installed 1111q/lqS& Tank size a.5oo gal. Foundation cleanout (Y/N) Y Date of pumping ~.o/4J~o~.o C. ABSORPTION FIELD DATA Number of Compartments Depression over tank (Y/N) N Pumper JR's Pumping Cleanouts (Y/N) Y High water alarm (Y/N) N Date installed Length .4:~ ' ft. Width =.8 Total depth _6 ft. !Eft. absorption area 7~6 ft2 Date of adequacy test 7/2112011 Results (Pass/Fail) __ Fluid depth in absorption field before test o in. Elapsed Time: o min, Final fluid depth o in. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N Soil rating (g.p.d./ft= or ~/bdrm) =.oo ft. Monitoring tube _Y. Pass System type Deep Trench Gravel below pipe 0.5 Depression over field hi For 5 bedrooms Water added75o gal. Absorption rate >= 750+ If yes, give date New depth9 in. g.p.d. UFT STATION Date installed "Pump on" level at Datum SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO:~ Septic tank/lift station on lot .~oo+ Absorption field on lot =.oo+ Public sewer main 75+ Sewer/septic service line =5+ Animal containment areas Size in gallons , I _ Manhole/Access (Y/N) "Pump off' level at _~t ~i:~igh ~t~ alarm level at Cycles tested I ~ Meets alarm & circuit requirements? On adJacent lots =oo+ On adJacent lots =.oo+ Public sewer manhole/cleanout. 3.oo+ Holding tank =.oo+ Manure/animal excrete storage areas in. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: ~oo+ Building foundation S+ Water main =.o+ Wells on adjacent lots =.0o+ Property line. ~.o+ Water service line. SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line .,o+ Building foundation =o+ Water Service line 3.o+ Surface water =.oo+ Curtain drain So+ Wells on adjacent lots =oo F. COMMENTS Absorption field Surface water Water main 75+ Driveway, parking/vehicle storage =o+ I certify that I have determined through field ~nspections and · rewew of Municipal records that the above systems are in _ co. orma.ce o ect o, this date. ngineer, Printed Name StevenP.. Pannorm. P E E oSteven COSA Fee $ Date of Payment Receipt Number (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number Municipality of Anchorage Community Development Department Development Services Division On-Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 Arsenic Advisory Certificate of On-Site Systems Approval # 111267 A Certificate of On-Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block , Lot 125 of T15N R1W Section 8 Subdivision. This inspection revealed an arsenic concentration of 64.9 micrograms per liter (ug/L) for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 ug/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. Information on arsenic is available from the On-Site Water and Wastewater Program website (www.muni.org/onsite) or at 343-7904. This advisory must be attached to all copies of the subject Certificate of On- Site Systems Approval. SGS SGS Reft# I 113483001 Client Name Pannone Eng. Srv. Printed Date/Time 08/01/2011 8:25 Project Name/# 21136 Jayhawk Dr, Chugiak Collected Date/Time 07/29/2011 14:15 Client Sample ID 21136 Jayhawk Dr, Chugiak Received Date/Time 07/29/2011 15:40 Matrix Drinking Water Technical Director Stephen C. Ede Sample Remarks: Allowable Prep Analysis Parameter Results LOQ Units Method Container ID Limits Date Date Init Metals by ICP/MS Arsenic 64.9 * 5.00 ug/L EP200.8 C (<10) 07/29/11 07/31/11 NRB Waters Department Total Nitrate/Nitrite-N ND 0.100 mg/L SM20 4500NO3-F B (<10) 07/29/I1 AYC Microbiology Laboratory E. Coli Negative I 100mL SM20 9223B A 07/29/11 SDP Total Coliform Negative 1 100mL SM20 9223B A 07/29/I1 SDP hereby cer[ify that I have surveyed t~e following ~~e ~in~ ~, ~ ~ ~t ~e ~~ ~a~ t~n ~ ~in ~ prop~ ~ ~d do n~ o~ or ~ ~ ~e ~on ~ ~at ~ ~ ~ ~~ ~ or o~ ~b~ ~~ on ~d ~ ~t~ h~ ,IRs Pumping POBox773415 EagleRiver, AK99577 (907)694.6~54 IBillin,q Information .Paula & Robert Aiken 21136 Jawhawk Drive Chuglak, AK 99567-5909 (907) 686-2623 [Job site Informatio .n ,, Robert 21 I36 Jawhawk Drive Chuglak, AK 99567 (907) 688-2623. Job Desoriplion: P.O. Number:. Terms: Salesrep: MaP Book: Cross Streets: Job Comments: 2000g Net'30 Dawn-Dawn Jawhawk Ddve Last Service Service Agreement Number: 032172 Order Date: 28-Sop-2010 Service Date: 04-Oct-2010 12:00 Technician: -Mike & Dan Tax%: 0 Job Type: Repeat Map Grid: 34 - - -*07/27/2009* 2000g Additional Location Comments Diagram: Wooden Home has House #'s @ start of DW Gray & white House Septic ~ front of home cio is Inside of home so.ice Type Septic Se~ 2K S:'¢Dlaa rems~,22311 .bm~ Qty Price Each Tax? I $280.00 ' No Gallons Planned: 2000 Gal,.Actual; Hose Length: Double Tank: r-I Pump system: [] Baffles Inlet: [] .,_... Baffles Outlet: [] Extension Actual $28o.oo NonTaxable Total EsUmated Charges: $280,00 _ Aclual Charges: f~'~ ~ Customer agrees to the terms and conditions shown' THIS I$ A BINDING AGREEMENT. Taxable Total Tax Total Grand Total $0.00 $0.00 $280.00 . 61g .... t ......... ,.,,,, ., .~ed by JRs Pumping ....... ' Date Acoepted _ . / _ / ' ~/~-or your arided convenle .nee we accept; Amerf~n Express, Dlcover, Visa and Master Card payments over the pho . ARer 30 Days ac~0unt VAil be turned over to COLLECTIONS. $30.00 For NSF Che¢ke Returned.