HomeMy WebLinkAboutSOUTHFORK NORTH LT 4AOnsite File
Southfork
North
Lot 4A
#078-021-24
Was Southfork North Block 4 Lot 4
Municipality of Anchorage
On -Site Water and Wastewater Program • (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP181134 PID Number: 078-021-13
Dwelling:❑ Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑Q New ❑ Upgrade
Name:
Donald & Kelly Johnson
ABSORPTION FIELD
❑ Deep Trench .❑ Shallow Trench F-1 Bed E] Mound
Address
CMR 415 Box 6170, APO, AE 09114
❑ Other
Phone
Number of Bedrooms
Soil Rating
depth from original grade
4
JTotal
2.0 GPD/SF
+1.0 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
+1.5 Ft.0.5
Gravel depth beneath pipe
Ft.
Subdivision Block Lot
Southfork North 4 4
Fill added above original grade
7.7 Ft.
JGravel length
60 Ft.
Township Range Section
Gravel width
5.0 Ft.
Beds: Number of Lines
Distance between lines
Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
300 Ftz
1
Ft.
Well
>50'
>50'
N/A
N/A
>25'
TANK ❑ Septic ❑ S.T.E.P. ❑ Holding 9 Other
Manufacturer
Orenco/FAP
Capacity
1500 Gal.
Surface Water
>50'
>50'
N/A
N/A
Material
Number of compartments
Lot Line
>5'
>10'
N/A
N/A
Fiberglass
2
NA
Foundation
>10'
>10'
N/A
N/A
LIFT STATION
Manufacturer
Capacity
Curtain Drain
>50'
>50'
N/A
N/AJ
Orenco/Anchorage Tank
100 Gal.
Remarks No insulation was used.
Pump on level at
13 in.
Pump off level at
25 in.
High water alarm at
11 in.
Pump make and model
PF2005
Electrical Inspections performed by
Powertec Elec
PIPE MATERIAL House to tank D3034 Tank to
drainfield F810
Installer
Northern Excavation
Drainfield D1785 CO/MTD 3034
Inspector J. Millette / J. Williams
BENCH MARK (Assumed elevation) 100 ft
Inspdectes: 151 tion10/24/18 11/7/18
Location and description
2nd
3`d 41h
Bottom of siding on west wall.
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
Engineer's Stamp
Conditional Approval: Date
��t�„., • • `' ,cS'5�.
49
'. BenjaaVchiller
�'�•. CE 12592
Approved Date /�J q��9QPROFESSI4�A��U
Inspection Keport_9-1-12.doc
���yN|T�(���1A11��
. `_. `=. . ., OSP181134
" . . �_,
ALTERNATE SITE S
oABSORPTION TRENCHES (zV'.z5'.&3O'LONG)
u'vV|DExO.5'EFFECT|VEDEPTH, 8oLrTOTAL
—�`
NORTHRIM TESTHOLE
DEPTH ABSORPTION TRENCH
P BASIN
OUTFALL FLOWS THROIJAH NATURAL
CHANNELS AWAY FROM SEPTIC TANK
�
�J|[l�fO��A—O�1-1q
' '`^ `'°'" ""-' '^'
LE
/
/ —
DITCH ALONG SOUTH RIVER CIRCLE
50'WELL RADIUS
EXISTING WELL
LOT 3
4 BEDROOM HOME
FC URTAIN DRAIN
1500 -GAL ADVANTEX
100'GEPTICSETBACK ` / } // ' � \ / / ` \�\\�\` ` ---~—~-
1rCROSSCOUNTRY 8mAND
� / ��
EQUESTRIAN TRAIL EASEMENT \ / / / / \LOT 425'CREEK MAINTENANCE EASEMENT co
`
/
MH1
22.5
37.6
MI -12
30.5
43.1
MI -13
25.1
47.6
MT1 21.0
23.0
MT2 42.9 43.3
Lu
tR
TRACT D
CO
) \ \
cc
'�
---�----T—\
A 8 C D
FCO 17.9 34.5
MH1
22.5
37.6
MI -12
30.5
43.1
MI -13
25.1
47.6
MT1 21.0
23.0
MT2 42.9 43.3
LEGEND
CO'CLEANOUT
2CO'DOUBLE CLEANOUT
FCO - FOUNDATION CLEANOUT
FS'FLOW SPLITTER VALVE
MH'MANHOLE
MT'MONITORING TUBE
SV SEPTIC VENT
TH'TEST HOLE |
SOLITHFORK NORTH, BLOCK 4 LOT 4
PERMIT# OSP1 81134 PID # 078-021-13
S6A\,IVEER 'CIRC
ALTERNATE SITE
3 x 20' LONG x 5' WIDE x 0.5' EFFECTIVE
DEPTH ABSORPTION TRENCHES
60' LONG x 5' WIDE x 0.5' EFFECTIVE
DEPTH ABSORPTION TRENCH
x/
LOT 5
(UNDEVELOPED)
100' SEPTIC SETBACK
;
15' CROSS COUNTRY SKI AND
EQUESTRIAN TRAIL EASEMENT
(U N D LOP/ED)
25' CREEK MAINTENANCE EASEMENT
TRACT D
TYPE 11 (�
TOPSOIL AND SEED
4" DIRECT -BURY INSULATON
2' HIGH RETAINING WALL
CONC BLOCK OR EQUIVALENT
(WHERE REQUIRED DUE TO PROXIMITY TO DRIVEWAY)
4' WIDE x 4' DEEP TRENCH
FILL W/ CLEAN DRAINAGE ROCK
INSULATE EDGE OF TRENCH WHERE
IMMEDIATELY ADJACENT TO DRIVEWAY
4" PERFORATED CPEP
W/ HEAT TRACE WIRE
WRAP IN GEOTEXTILE FABRIC
CURTAIN DRAIN
SEE DETAIL
MAINTAIN 10'
SEPARATION FROM
EXISTING WELL
LOT 3
(UNDEVELOPED)
4 BEDROOM HOME
OUTFALL
w
CURTAIN DRAIN - NTS
3ANK
SOUTHFORK NORTH B4 L4
PERMIT # OSP181134 PID # 078-021-13
ENGiN EFRING
c� DRAINFIELD ROCK
G
85.3 GROUNDWATER 11/16/18
83.8
(NO SCALE)
JU. i
91.8 ORIGINAL GRADE
N
Ti
. .. .......
Benja in Schiller
CE 12592
.scv 30,2019.•�•'o
DEPTH
(feet)
1-
2-
3-
4-
5-
6-
7-
8-
9-
10-
11-
12-
13-
14-
15-
16-
17-
18-
19-
20 -
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT
4700 ELMORE ROAD ANCHORAGE, AK 99519-6650
SOILS LOG AND PERCOLATION TEST
LEGAL DESCRIPTION: SOUTHFORK NORTH B4 L4
PERFORMED FOR: TROY DAVIS
DATE: 11/7/18 PROJECT No.:
PARCELID#: 078-021-13 TECHNICIAN: J. MILLETTE
COMMENTS:
TEST HOLE B
COBBLY CLAY
� SILTY SAND W/ GRAVEL (SM)
SITE PLAN
SEE SITE PLAN
WAS GROUND WATER ENCOUNTERED?
YES
GROSS TIME
(MINUTES)
IF YES a WHAT DEPTH?
8'
NET DROP
(INCHES)
DEPTH OF WATER AFTER MONITORING:
6.5'
LS
LS
DATE OF MONITORING:
11/16/18
P
E
DATE
READING
GROSS TIME
(MINUTES)
NET TIME
(MINUTES)
DEPTH To
WATER
(INCHES)
NET DROP
(INCHES)
TEST HOLE PRESOAKED PRIOR TO TESTING:
PERCOLATION RATE: (MIN/INCH) PERC. HOLE DIA. (INCHES)
TEST RUN BETWEEN: FT. and FT.
DEPTH
(feet)
1--
2
3
4
5
6
7
8
9
10-
11-
12-
13-
14-
15-
16-
17-
18-
19-
20 -
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT
4700 ELMORE ROAD ANCHORAGE, AK 99519-6650
SOILS LOG AND PERCOLATION TEST
LEGAL DESCRIPTION: SOUTHFORK NORTH B4 L4
PERFORMED FOR: TROY DAVIS
DATE: 10/19/18 PROJECT No.:
PARCEL ID#: 078-021-13 TECHNICIAN:
TEST HOLE A C
1.5' OB
V7 i/nknown
a
COBBLY CLAY
SILTY GRAVEL
J. MILLETTE
ri noc:
51 I L FLAN
SEE SITE PLAN
WAS GROUNDWATER ENCOUNTERED?
YES
IF YES @ WHAT DEPTH?
1.5 L
DEPTH To
WATER
(INCHES)
DEPTH OF WATER AFTER MONITORING:
1.5 0
TEST HOLE PRESOAKED PRIOR TO TESTING:
DATE OF MONITORING:
10/28/18 P
DATE
READING
GROSS TIME
(MINUTES)
NET TIME
(MINUTES)
DEPTH To
WATER
(INCHES)
NET DROP
(INCHES)
TEST HOLE PRESOAKED PRIOR TO TESTING:
PERCOLATION RATE: (MIN/INCH) PERC. HOLE DIA. (INCHES)
TEST RUN BETWEEN: FT. and FT.
COMMENTS: SOILS WERE SATURATED, GROUND WATER ASSUMED TO BE BELOW
THE ORGANIC LAYER.
Wheaton Water Well, Inc.
1190 N. Wasilla-Fishhook Road
Wasilla, AK 99654
(907)376-2041
Name:
Troy Davis Homes Inc.
Address:
1689 Knik Goose Bay Road, Suite 400
City:
Wasilla State:
AK
Zip Code: 99654
Well Site:
Southfork North
Lot/Block: 4/4
Additional:
2004 South River Cir.
Well Depth:
80 ft.
From:
To:
Formation:
0
7
stickup, fill
Below Ground: 78 ft.
7
14
silt, brown gravel
Above Ground: 2 ft.
14
27
wet clay, cobble
Gal/Min:
5
27
31
boulder
31
32
silt, dry gravel
Static Level:
50 ft.
32
34
boulder
34
52
silt, dry gravel
Casing:
80ft. of 6 in. x .25 in. steel
52
63
boulders, gravel
63
74
silt, gravel
Liner Pipe:
N/A
74
80
gravel, water
Screened:
N/A
Perforated:
N/A
Grouted:
bentonite
Depth:
20 ft.+
Develop. Method:
Air
Use of Well:
Residential
Drilling Method: Rotary
Misc:
C.A.S. Shoe, commercial cap
Other:
well disinfected with chlorine 50 ppm
WATER QUALITY TESTING
Collform COV100ML
Nitrates o`( (o M91L
ArWNC I ug/L
The well was pumped 5' off the bottom with 100% draw down for 2 hours and recovered at 5 glom.
Date Drilled:
8/27/2018
Driller:
Ben Mattson
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program n� G `'<4
4700 Elmore Road
P.O. Box 196650
Mark Begich Anchorage, AK 99507 s a F e r Y
Mayor www.muni.org/onsite
(907)343-7904
Pump Installation Log
Well Drilling Permit Number: SW OSP Date of Issue:
Parcel Identification Number:
Legal Description Property Owner Name & Address:
Southfork North 1_04!1304 Troy Davis Homes, Inc.
1689 Knik Goose Bay Road #400
Wasilla, AK 99654
Pump Installation Date: 9/11/2019
Pump Intake Depth Below Top of Well Casing: 61
Pump Manufacturer's Name: MEYERS
' Pump Model: 3NFLS2-8-P401
Pump Size 1/2 hp
Pitless Adapter Burial Depth: 13 feet
Pitless Adapter Manufacturer's Name: Campbell
Pitless Adapter Installer: unknown
Well Disinfected upon Completion? ✓❑ Yes ❑ No
Method of Disinfection: Sterilene
Comments: Artesian plug- intermitten flow overtop
Pump Installer Name: Wheaton Water Well, Inc.
1190 N. Wasilla-Fishhook Road
Wasilla, AK 99654
feet
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
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\ 1.9'x4.9' CANT
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\ PIPES
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50 PROTECTIVE N
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w/ WALKOUT BSMT.
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/ o PLOT PLAN AS BUILT x SCALE 1" = 50' -RID SW 1059 Protect No 18-190/BS
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w11500 Daryl Avenue, Anchorage, Alaska 99515-3049
Lang & Associates, inc. (907) 522-6476 Phone Q0000
(907) 522-4625 Fax
/ m Professional Land Surveyors ken®langsurvey.com o C)F ALq�o
Jonathan®longsurvey.com '�_"''• ••• s4a
w 1 hereby certify that I have surveyed the following described property: ....�OP
LOT 4, BLOCK 4, SOUTHFORK NORTH SUBD. (Plat No. 86-205) o c) 49TH
/\ Anchorage Recording District, Alaska, and that the Improvements situated thereon are 0."'
within the property lines and do not encroach onto the property adjacent thereto, that Q---�!�,�/�
no Improvements on the property lying adjacent thereto encroach on the survoyed Q. ..�" ETH ..............�
premises and that there are no roadways, transmission lines or other visible Q mm KENN Gp. LA e: G
easements on sold property except as Indicated hereon. QQ�P•. '(L ••'o��
tsSg Dated this the 1 Day of 0—'oft r_ i�1LBi 01 Anchorage, Alaska Q�Fop'.LS-$202.•'oyo
'OS 4B It Is the responsibility of the owner to determine the existence of any easements, �40 ONAL
covenants, or restrictions which do not appear on the recorded subdivision plot. AECC963
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14
20' DRMNA.GE
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o�5ry�0�'
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ERANOS �
(APPROXIMATE) I
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100' SEPTIC-" I
�
to
V
SETBACK
\
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LOT 4•
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"C EOUESTRIAN TRAIL EASEMENT
25' CREEK
,p
MAINTENANCE EASEMEI
TRACT D\
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ry oy �s c� rr �[a.yo
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/ o PLOT PLAN AS BUILT x SCALE 1" = 50' -RID SW 1059 Protect No 18-190/BS
N
w11500 Daryl Avenue, Anchorage, Alaska 99515-3049
Lang & Associates, inc. (907) 522-6476 Phone Q0000
(907) 522-4625 Fax
/ m Professional Land Surveyors ken®langsurvey.com o C)F ALq�o
Jonathan®longsurvey.com '�_"''• ••• s4a
w 1 hereby certify that I have surveyed the following described property: ....�OP
LOT 4, BLOCK 4, SOUTHFORK NORTH SUBD. (Plat No. 86-205) o c) 49TH
/\ Anchorage Recording District, Alaska, and that the Improvements situated thereon are 0."'
within the property lines and do not encroach onto the property adjacent thereto, that Q---�!�,�/�
no Improvements on the property lying adjacent thereto encroach on the survoyed Q. ..�" ETH ..............�
premises and that there are no roadways, transmission lines or other visible Q mm KENN Gp. LA e: G
easements on sold property except as Indicated hereon. QQ�P•. '(L ••'o��
tsSg Dated this the 1 Day of 0—'oft r_ i�1LBi 01 Anchorage, Alaska Q�Fop'.LS-$202.•'oyo
'OS 4B It Is the responsibility of the owner to determine the existence of any easements, �40 ONAL
covenants, or restrictions which do not appear on the recorded subdivision plot. AECC963
� tncnt f
Mun
�ci ality of Anchorage
z..1 rM
P.O. Box 196650 ® 4700 Elmore -Road
Anchorage, Alaska 99519-6650 e (907) 343-7904 ® Fax (907) 343-7997
http://www.muni.org/Onsite
Development Services Division
On -Site Water and Wastewater Program
* * * * VARIANCE/WAIVER REVIEW * * * *
Waiver#: OSV191068 COSA#: Permit#:OSP181134
PID#: 078-021-13
Legal Description: Southfork North Blk4 Lt 4
Engineer: Forge engineerinq
Your request for a waiver of the required 10 feet horizontal separation from the absorption field to
the property line has been approved. The approved separation distance is 3.0 feet for the alternate
fields and 9.0 feet for the primary. In addition, the curtain drain may be 10' from the well. See the
attached design and justification.
This waiver approval applies to the existing absorption field only. Any fixture upgrade to the on-
site wastewater disposal system will require all separation distances be met or another approval
from this department.
............................................... ■ ............................. ■ 1
Waiver is Granted: X Waiver is not Granted:
Date: T�g Approved by:
Name of Revigher
■..........................■.............................■ 71M...................r
**** VARIANCEMAIVER REVIEW ****
September 11, 2019
Municipality of Anchorage
Development Services Dept- On -Site Water & Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
Subject: Southfork North Block 4 Lot 4 — 2004 South River Circle
Lot line waiver
Dear On -Site Services Engineer:
This system was designed using test hole information from the subdivision. However, during
construction, we did not find soils similar to the historical test hole. We were able to find perkable
soils up by the driveway of the house. However, it turned out to be impossible to fit both the
primary and alternate trenches in the tight space next to the driveway. The primary trench ended
up encroaching to 9' from the property line. In addition, the alternate site only fit if some of the
trenches were extended to 3' from the property line.
We request that a variance be issued to allow for a trench within 3' of the property line. There is
no threat to the neighboring property in allowing this waiver.
Sincerely,
Benjamin Schiller, PE
lkll
TH
. � ......
Benjan'rochdler
9/11/192 G�
PROFES5Op
August 30, 2019
PO BOX 240773
ANCHORAGE, AK 99524
522-7773
677-7766 (FAX)
FORGECIVIL.COM
MOA Development Services, On -Site Water & Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
Subject: Southfork North 134 L4 — 2004 South River Drive
Waiver for curtain drain to well
Dear On -Site Services Engineer:
f
'49 Tia
- .
Eenjerr> r Schiller :1
GE 12592 `4
8/30/19
PROFESSO
After construction of the home at this property, the surface water from uphill started to cause a
significant glaciation problem during winter months. In order to address this safety issue, it was
necessary to install a curtain drain to channel surface water away from the driveway and down to
the back of the house. However, the drain passes within 25' of the existing well location.
The reason for this separation is to prevent surface water from being directed toward the well,
possibly contaminating it. In this case, however, the purpose of the drain is to pick up surface water
that is currently flowing toward the well and drain it away. It will not direct water toward the well.
In addition, the upper layers of the soil in the area are very silty, with high amounts of fines and
clay. They do not allow water to soak through them very quickly. The water that runs through the
curtain drain, therefore, will not soak through the soil and contaminate the well.
The well is new construction, built to current code and grouted. Allowing the curtain drain in this
location will not pose a health threat to this or neighboring properties. We request a waiver to
allow a 10' separation from this curtain drain to the well.
Sincerely,
Benjamin Schiller, PE
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
POBox 19665 40OElmore Road
Anchorage, Alaska uys1e5s5oPhone: -rno4Fax: (SQr)343'799r
Permit Number: O3P181134
Work Type: VVeUSopbo|niUo|
Tax Code Number: 07802113000
Site Legal Address: SOUTHFORK NORTH BLK 4LT 4 B1059
Site Mailing Address: 2004 SOUTH R|VERC|R. Eagle River
Owner: JOHNSON DONALD RIII & KELLY A
Design Engineer: FORGE ENGINEERING
This permit is for the construction of:
WTARFUSTAXOTM
Lot Size in Sq Ft:
Total Bedrooms:
6/14/2018
6/14/2019
131048
2Disposal Field 2 Septic Tank ElHolding Tank E71 Privy PPrivate Well r_1 Water Storage
All construction shall beinaccordance 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 (18AAC8O)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.85.Provide notification bycalling (gO7)343-78U4(24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall baeither:
a. Opened and Closed onthe same day, ur
b. Covered, sealed, and heated to prevent freezing
El
Special Provisions: Atest hole is to be completed prior to construction of the septic field, in location shown on
approved site plan, to confirm separations to ground water and impermeables, as well as confirm percolation
rate.. Construction may proceed at your own risk prior to the 7 -day ground water reading. }fthe results require a
design change, construction of the system shall stop pending On-site review and approval of a change order,
Please submit stamped and signed results with the inspection report.
\
» "
Received By: Date:
Issued By: Date: its
PLOAS
MUHjuF A Lry OF ANCHORAGE
Community Development Department Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
On -Site Water & Wastewater Program
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 078-021-13
Property owner(s) Donald & Kelly Johnson Day phone
Mailing address CMR 415 Box 6170, APO, AE 09114 (Armed Forces Europe)
aooLi
Site address South River Circle
Legal description (Sub'd., Block & Lot) Southfork North Block 4 Lot 4
Legal description (Township, Range & Section)
Lot Size 131,048 Sq. Ft. Number of Bedrooms 4
APPLICATION IS FOR: APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field 0 Initial 0
Single Family (SF)
ADU)
Septic Tank 0 Upgrade El(w/wo
(D) El
Holding Tank ❑ RenewalDuplex
❑
Multiple Dwellings ❑
Privy ❑
(SF and/or D)
Private Well 0
Water Storage ❑
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that
this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: (d 4 Waiver Fees:
Date of Payment: (42 /1-2 Date of Payment:
Receipt Number: CjgC9(acft> Receipt Number:
Permit No. OS PI'Sl c/ Waiver No.
Permit
PO BOX 240773
ANCHORAGE, AK 99524
June 7, 2018
Municipality of Anchorage
Development Services Dept- On-Site Water & Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
Subject: Southfork North Block 4 Lot 4 – NHN South River Circle
Septic system design and permit application
Dear On-Site Services Engineer:
The owner of the above lot intends to build a 4-bedroom home on the property, so we are
submitting this permit application for the construction of a new well and septic system. The
attached site plan identifies the location of the home as well as the proposed well, septic location
and alternate site. No conflicts exist between this proposed system and any other well or septic
system, whether on this lot or adjacent lots.
The ground surface on the lot slopes toward the west at a moderate slope- between 15-20%. On
the lower portion of the property the ground flattens out to closer to 5%. The home will be located
up near the road, so the trench will be in this steeper area as well. There are no slopes greater than
25% within 50 feet downslope of either the primary or alternate site. Drainage arrows are shown
on the site plan showing the grade and direction of flow. Stormwater drainage will not impact this
septic system. The new trench will be constructed parallel to the slope.
The proposed well is shown, but both neighboring lots are undeveloped. The 100’ and 50’ well
radii are shown. We are proposing an advanced Category III system for this lot, so it will be a
minimum of 50’ from all wells and surface water. Additionally, the property has a platted 100’
septic setback from the east and south property lines, presumably to protect a drainage channel
along the property line. The system will be outside this 100’ setback.
In 2005, Northrim Engineering was hired to design a system for this lot, and they proposed a shared
system with Lot 5. The test hole log for Lot 5 is shown, indicating percolation rates at under 15
min/in and groundwater at 6’ in May. Neighboring lots show percolation rates closer to 30-60
min/in, and groundwater at 3 -4’. We have designed a system for percolation rates of 60 minutes/in,
and seasonal high groundwater at 2’. We are requesting permission to dig a test hole and perform
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP181134, Rebecca Carroll, 06/14/18
a new perk test at the time of construction, with the understanding that if conditions are not met
we will need to submit a change order.
Please refer to the attached test hole logs, soils lab analysis, plan and profile pages for the septic
design. If this design is followed, there will be no adverse impacts to adjacent properties.
Sincerely,
Benjamin Schiller, PE
6/7/18
100' SEPTIC SETBACK ' -- ---~
15' CROSS COUNTRY SKI AND ` u
EQUESTRIAN TRAIL EASEMENT`
25CREEK MAINTENANCE EASEMENT
jL
i .
Y`Y
LIRA k' \
2
3 .3 rf ✓ yr c<,% t: „, .
um U,8DPXA0EU
s
NOTE: LEGEND
NO SURFACE WATER WITHIN 100' OF THE PROPOSED SEPTIC CO - CLEANOUT
a ' SYSTEM OR SLOPES >25% WITHIN 50'
. < a ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS 2C0 -DOUBLE CLEANOUT
'. PROPERTY ARE SHOWN. NO CONFLICTS WITH WELLS OR SEPTIC FCO -FOUNDATION CLEANOUT
Ag DMjFS - FLOW SPLITTER VALVE
s o ro.
p SYSTEMS. MH -MANHOLE
MT - MONITORING TUBE
sen `" Schiller 0 100 200 SV - SEPTIC VENT
�`' TH -TEST HOLE
`
�95q FEET
's�t 1"=100'
)f 1
DESIGN FACTORS: SYSTEM REQUIREMENTS:
600 GPD PEAK FLOW 5' WIDE SHALLOW TRENCH SYSTEM
PERK RATE: 30-60 MIN/IN 1500 -GAL ADVANTEX TANK
APPLICATION RATE: 2 GPD/SF
600 GPD / 2 GPD/SF / 5' WIDE * 1 REDUCTION = 60 LF TRENCH REQUIRED (60 LF SPECIFIED)
BOTTOM OF TRENCH: AT GRADE
FLOW LINE ELEVATION: 0.5' ABOVE GRADE
TOP OF TRENCH: 3' ABOVE GRADE
INSULATION
3:1 MAX SIDE SLOPES
2' 6..'
PIT RUN DOWN TO RECEIVING SOILS
NOTES:
1. GRADE AREA OVER TRENCH TO DRAIN AWAY
2. PROVIDE 3' OF COVER OVER TRENCHES AND 4' OVER SEPTIC TANK, OR 2'
WITH 2" OF INSULATION
3. CHECK GROUNDWATER AT TIME OF CONSTRUCTION. IF LEVEL IS HIGHER
THAN PREVIOUSLY OBSERVED, CALL ENGINEER IMMEDIATELY
M
PO BOX 240773
ANCHORAGE, AK 99524
October 29, 2018
Municipality of Anchorage
Development Services Dept- On -Site Water & Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
Subject: Southfork North Block 4 Lot 4 — 2004 South River Circle
Adjacent property test holes
Dear On -Site Services Engineer:
In preparation for the construction of the system on this lot, per the permit, we dug a new test hole.
The test hole showed perkable soils below a layer of clay. However., we were unable to perk the
soils because of the high groundwater.
We took a sample of the soils and they were graded as "'Silty gravel with sand (GM)". In addition,
we examined the test hole results for the subdivision. All of the test holes that were perked had
rates that were faster than 60 min/in. We request that these results be accepted in lieu of a perk
test.
Sincerely,
Benjamin Schiller, PE
A
.9 ih
anip, mirt, Scl mier
CS 12592
.10/29/18 2-
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT
4700 ELMORE ROAD ANCHORAGE, AK 99519-6650
SOILS LOG AND PERCOLATION TEST
LEGAL DESCRIPTION: SOUTHFORK NORTH BL, LL,
PERFORMED FOR: TROY DAVIS
DATE: 10/25/18 PROJECT No.:
PARCELID#- 078-021-13
TECHNICIAN:
DEPTH TEST HOLE A
(Ilect)
1
2
4
5
6
7
8
9
10
11
12
13
16
17
18
COMMENTS:
COBBLY CLAY
SILTY GRAVEL W/ SAND (GM)
B. SCHILLER
SLOPE
WAS GROUND WATER ENCOUNTERED? YES
SI I E PLAN
SEE SITE PLAN
IF YES,@� WHAT DEPTH') 3
SL
GROSS TIME
(MINUTES)
DEPTH OF WATER AFTER MONITORING: -
0
NET DROP
(INCHES)
DATE OF MONITORING:
P
E
DATE
READING
GROSS TIME
(MINUTES)
NET TIME
(MINUTES)
DEPTH TO
WATER
(INCHES)
NET DROP
(INCHES)
TEST HOLE PRESOAKED PRIOR TO TESTING:
PERCOLATION RATE.: (M INANCH) PERC. HOLE DIA. (INCHES)
TEST RUN BETWEEN: FT. and FT.
0
PROJECT CLIENT:
Forge Engineering
PROJECT NAME:
South Fork Not-th
PROJECT NO.:
4914-18
SAMPLE LOC.:
Lot 4
NUMBER/ DEPTH:
N/A
DESCRIPTION:
Silty gravel wl sand
DATE RECEIVED:
10/23/2018
TESTED BY:
CH
RE, VIEWED BY:
- IUPC
100
90
80
70
60
50
fn 40
30
20
30
0
145
1110
115
0 2 4 6 8 10 12 14 16
MOISTURE CONTENT (-/.)
w1f I
% GRAVEL 50.3
% SAND 27.7
% SIMCLAY 22.0
% MOIST. CONTENT 10.3
USCS Gm
USACCE FC N/A
% PASS. 0.02 turn N/A
% PASS. 0.002 Dun N/A
UNIFORMITY COEFFICIENT (Cu)
UNKNOWN
COEFFICIENT OF GRADATION (C,)
UNKNOWN
ASTM D 1557 (uncorrected)
N/A
ASTM D4718 (corrected)
N/A
OPTIMUM MOIST. CONTENT. (corrected) N/A
PARTICLE SIZE ANALYSIS ASTM D422/ C136
1.5 314 112318 91 010 020 190 .060 0100
100 10 1 0.1
GRAIN SIZE (In rt)
COBBLFS GRAVEL SAND
ICoarse I rine Coarse I Medium Pine
SIEVE ANALYSIS RE' SULT
SIEVE
SIZE (mm)
SIEVE
SIZE (U.S.)
TOTAL % SPECIFICATION
PASSING (°/ PASSING)
N/A
DL4 GRADATION
152.40
6"
PLASTICITY INDEX
76.20
3"
100
38.10
1.5.1
78
19.00 1
3/4"
69
22.70
1i2"
63
9.50
59
4.75
44
—310
50
2.00
44
0.85
1120
39
0.43
#40
36
0.25
#61
33
0.
0.075
#200
22.0
0.01 0.001
HYDROMETER RESULT
SILT or CLAY
1\401STURE-DENSITY RELATIONSHIP ASTM D 1557
120
(ASTM D2434)
N/A
DL4 GRADATION
(ATIVI T-313)
NIA
PLASTICITY INDEX
ASTM 4318
N/A
�W
mow
CSG ��C���
������
ELAPSED DIAMETER TOTAL %
TIME (MIN) (-M) PASSING
0
2
4
8
15
30
60
150
1440
IIYDRAULIC COND.
(ASTM D2434)
N/A
DL4 GRADATION
(ATIVI T-313)
NIA
PLASTICITY INDEX
ASTM 4318
N/A
The testing services reported herein have been performed to recognized industry standards, unless otherwise noted. No other warranty is made. Should engineering
interpretation or opinion be required, NGE-TFT will provide upon written request.
11301 Olive Lane - Anchorage, Alaska 99515 - Phone: 907-344-5934 - Fax: 907-344-5993 - imvmnge-�flxom
1,II1i4ICIPALITY OF ANCHORAGE
ADVANCED WASTEWATER TREAT TIENT SYSTEM
MAINTENANCE ANIS REPAIR AGREEMENT
THIS MAINTENANCE AND REPAM AGREEMENT, herein the "AGREEMENT" made and
entered into as of this 1� Day of of 20 `S . by and between
TROY DAVIS HOMES , herein the "OVER," and the Mimicipality of
Anchorage, herein. the "l'v1tiNIC1PALITY", in accordance with Anchorage Municipal Code
(AMC) 15.65.365. In consideration of the mutual covenants contained herein, the parties to this
Agreement agree as follows:
1. Advanced Wastewater Treatment Systems The Municipality- grants permission to the
01inler to utilize and operate an Advanced Wastewater Treatment System (AW)AgS),
described as ADVANTEX SYSTEM
located at (legal description)
SOUTHFORK NORTH, BLOCK 4 LOT 4
2. Maintenance Repairs and Alterations.
(Owner is requited to read, understand and initial each section)
13 Throughout the term of this Agreement, the Owner shall enter into a service agreement
with an AWWTS seri-ice and maintenance provider approved by the Municipality or the
manufactureCs representative. The AWtiNITS shall be maintained in a satisfactory
condition capable of performing as designed and producing treated septic effluent in
accordance with the equipment's approval for operation in the Municipality.
It shall. be the responsibility of the Owner during the term of this.Agreement to pay for all
repair(s), maintenance, adjusttnent(s), replacement costs, and inspection costs. This
includes an annual maintenance fee (typically $400 to $600).
Owner agrees that only maintenance and repair personnel approved by the Municipality
or the manufacturer's representative will inspectand slake any necessary, maintenance,
repairs or permitted alterations to the system.
Owner acknowledges that regular maintenance of an AWiA7TS reduces the potential
failure of the system, which could include sewag;- backup and costly repairs or drainfeld
replacement.
(rev. 05/18/2018) Page 1, of 3
ID Owner ackDowledges that the Municipality may, request records of maintenance and
repairs from the manufacturer"s .representative or maintenance provider.
Owner acknowledges that the fine for failing to maintain and repair an A W"WTTS may be
assessed in accordance with .kMC 14.60.030.
Owner agrees to grant the Municipality reasonable access to test and inspect the
AWWTS. The Municipality will give at least 24-hour notice.
Owner agrees that any sale ar transfer of title of theproperty will not occur without a new
Certificate of On -Site 5ysteius Approval,
Owner agrees that the AWWTS installation and maintenance requirements as provided
by the AWWT5 vendor/installer and appro-ved by the Municipality are the governing
guidelines for the construction, maintenance and repair of the Owner's AWWTS.
. O-v%,ner agrees to maintain. remote monitoring of the AW-WTS as rewired by the
AL'L Vi -TS approval.
3. Term. The term of this Agreement shall begin on the date of approval by the
Municipality to operate the installed system, or upon transfer of title, and shall continue
while the AWVEr TS is operational or until title is transferred.
4. iLonwaiver. The failure of the Municipality at any time to enforce a provision of this
Agreement shall in no way constitute a waiver of the provisions, nor in any way affect
the validity of the Agreement or any part hereof, or the right of the iVlunie.ipaliiy
thereafter to enforce every provision. hereof
5. Amendment. This Agreernent shall only be amended by authorized representatives of
the 0, ner and Municipality. Any attempt to amend this agreement by either an
unauthorized representative or unauthorized means shall be void.
6. Jurisdiction; Chnive of I ,aw. Any civil action arising from this Agreement shall be
brought in the Superior Court for the Third Judicial :District of the State of Alaska at
Anchorage. The laws of the State of Alaska shall go-vern the rights and obligations of the
parties under this Agreement.
7. Scverabili6% Any provisions of this Agreement decreed invalid by a court of competent
jurisdiction shall not invalidate: the remaining provisions of the Agreement.
(rev. 05/18/2018) Page 2 of 3
()VNER:
By: Date:
_Cprini now",
STA F F OF A LAS` KA
TFHRID KEMAL DISTRICT AS,
TQMawlecind hetive ime dos 11111Y of
2( inti'
NOT'mjy
�R
txpi-t's:
MUNICIPAT 1TY:
By:
JA em, dl, -,17)
natne.)
Ti
?ie:
(rev. 0511 WO i 8) Page 3 of,3
Certificate of On -Site Systems Approval
Parcel I.D. 078-021-13
1. GENERAL INFORMATION
Expiration Date: �2, —1 — z I9 Z d
Complete legal description Southfork North, Block 4, Lot 4
Location (site address) 2004 South River Drive, Eagle River, AK
Current property owner(s) Troy Davis Homes Day phone 357-9394
Mailing address 1689 S. Knik Goose Bay Rd #400, Wasilla, AK 99654
Real estate agent Day phone
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: Four
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
E
Private Septic
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
COSA # 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. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm Forge Engineering Phone 907-522-7773
Address 1399 W. 34th Ave Suite 101, Anchorage AK 99503
Engineer's Printed Name Michael E. Anderson, P.E. Date 10/1/19
6. DSD SIGNATURE
System #1 Approved for _Y__ bedrooms
System #2 Approved for bedrooms
Disapproved
Conditional approval for bedrooms, with the following stipulations:
r i
Original Certificate Date:
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
Legal Description: Southfork North, Block 4, Lot 4
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled 8/27/18
Total depth 80 ft
Cased to 80 ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) 24 in.
Date of flow test for COSA 8/27/18
Static water level at beginning of test 50 ft.
Comments
B. TANK DATA
Age of tank(s) 19f2"�e years
Tank type/material Advantex/Fiberg lass
Measured operating fluid level in septic tank
Standpipes/foundation cleanout per record drawing
Date of pumping New Construction
D. ABSORPTION FIELD DATA 5' Wide Trench
Which system tested (date installed) 10/24/18
❑ ALL standpipes present per record drawing
Total measured depth from grade ft (max)
Measured depth to pipe invert from grade 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: New Construction
COSA Checklist yellow sheet
Parcel ID: 078-021-13
Structure served by this system
Well production at time of test 5 gpm
Water storage tank volume gallons
Well disinfected for coliform test? ❑ Yes ❑ N
ON Coliform bacteria is Negative
Nitrate •046 mg/L ❑ Nitrate less than MRL (ND)
Arsenic •31 ug/L ❑ Arsenic less than MRL (ND)
Collected by Wheaton Water Wells
Date of Sample 9/11/19
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date New Construction
Results Q✓ Pass For bedrooms
Fluid depth prior to test in
Water added gal
New depth in
Elapsed time min
Final fluid depth in
Absorption rate gpd
Any rejuvenation treatment (past 12 months)
If yes, enter date
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
0 Yes
if No
Community Sewer Manhole/Cleanout > 100'
Q Yes
if No
ft
M Yes
if No
Neighboring Tank > 100' ❑✓ Yes
if No
ft
Private Sewer/Septic Line > 25' Q✓ Yes
if No
Absorption Field on Lot > 100' M✓ Yes
if No
ft
Holding Tank > 100'✓Q Yes
if No
Neighboring Absorption Fields > 100'
Yes
if No
Animal Containment > 50' Q Yes
if No
❑✓ Yes
if No
ft
if No
ft
F. ENGINEER'S COMMENTS
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' M✓ Yes
if No
ft
M Yes
if No
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' Fv� Yes if No ft Surface Water > 100'
ft
ft
ft
ft
ft
®✓ Yes if No ft
Property Line > 5'
0 Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
F/71 Yes
if No
ft
Private Wells > 100' F✓ Yes if No.
Water Main > 10'
P/ Yes
if No
ft
Community Wells > 200' Q✓ Yes if No
Water Service Line > 10'
Q✓ 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'
❑✓
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'✓�
*'
Yes
if No
ft
Private Wells > 100' ®✓ Yes if No
Water Service Line > 10'
❑✓
Yes
if No
ft
Community Wells > 200' Q Yes if No
Surface Water > 100'✓1
Yes
if No
ft
F. ENGINEER'S COMMENTS
Well and Septic System recently constructed.
G. ENGINEER'S CERTIFICATION
I certify that 1 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.
'off
4 "asset saes setssau. " Sstcst�
OPt°t�OdlYiftYaA4lagRntitkiirY [etxfttaaM.
N41CHAEL E. ANDERSON
*'
COSA Checklist yellow sheet
10/1/19 .•"' 'cam
c`, "•.,°#.a
ft
ft
ft
ft
NIVNICIPALITV OFA!NCIHORA(;E
ADVANCE'D �YSTTKNT
7 , - P MR AGREEMENT
NI A I N CE AND REP,
JU'-'PAIR AOREEAMENIT, herein the -ACRE-I"NIEN"I"' In"Ide 'alld
C
t o, o j' it I i is av of r -c- Of 1 ULL� !)N and bet wot�n
D,
-Chl flm"OWNF he 1
and t unicill;.Inti' of
N
in accordilice with Ancho!'<,`-�'.0 lunicipal Co&
aillc6he"t;II, One to !!I;,,
do t�tk�tcizt'tttitll: of the ML111"It Covenant Cola,
(A \4 C) 1 6 65,
Agrec-1i10111 as fQIIQWS:
van cod N,V as telva el�- re, Svstem-, The Mullicipaht5,gan
<_-'rants permi.s.,iol the
1
uCSc�.I3eCd fr.;
..
Advante, Waste Water Treatment Systern--_.._......
tc-�Calcd at Oq-'al description)
Southfork North, Block 4, Lot 4
sand Alterations.
re-.'(!, undcrtand and initial eLIJI
liev'sh-01 c'mer into a 'servlcc a� lc��Inej.t
`rltrou-phout tile term of this A'ortement. the (,)%v
,,vith an ASV' VTS Service and, 1-nai"11C)IMICC P!'Ovkler "Ipprovt�d by the IvIumicit Itilv 01" ill,'
representative, Tin e.N�IKVVTS shill I)C nlainlailwd 111 a
Capabile as desjj�'J!Cd MI LI
J-MA"'I'llice with 1;IC equipmem s upprov')I for operalio'l in tlw ll OpH'\
'IQ of this Aul-OCIIIC111 to P"'.'�' i'br all
it
Costs. alld hIsqvC'fikw tit sl
Ijv$4001o�000).
mainte-nance fee
re�,-s lh,-ii on1v nl�linienwweilvd ropnir petsonwel approv'Od ity
C- nwr :w I I
'v
ve Nvill irn-oejke ani
c� and I,
i'Q W permitted altev10011' w title Sysmil.
maintemmcc ofm A\VVVTSI zhc
.wlu ivtv�ri. orJ1
N�. ol
J-2
t
_, d. ivner :icknClwledgetsthat the Municipality nlay request rceordS of t�i:llxlt+=;! «il4t tt11
repairs Froin the manu I'acturer`s representative «t' rllaintcnalICC P�Ovidcl
0%viler <ack nowlediges that the file for failing to maintain and repair :in A A}Tl+'TL il'iay ill;'
aysassed in accordance, with AN -IC 14160-030,
l 0%vner ngrccs to wru the NWniviptiq, lvastlnable sleets t0 test and inst1ut IS
i
AW \t"! S". The vftillicipalit- will € iive at least 24-hour nollicc,
FIX`-'` t_)',\ w r agrees th a any `alt', l€:' lrlla'SS.fel- of title Of We Pwpe'rty 1`,•ill not (1ti;C lr 1 into) ! llc\'
( ei d ictate of On -Sits:. Syste,,ms Appro-val.
{-)tl'11tir Gat Be ANWS it15i111:ltS n Alii Il aintt'alilili requir:`m nts as t'w'Tde J
by the 0NAN'-I's venclodiilstal:k and rtplymed by to lE.ticY°ai Y me Be 9MM;F
uiidelil 's for the Construction, inainitnanct: id itlpjj1 " ()f to 0\vile i`sAW`4 1 S.
glees to maintain rei oie Inonito itl:_'; of the, rNV W I" , t-, i' tiiiiq d hY t11L
AW"NTS approval.
Tema. The tl: ni of this .1 Lwnetlt Mwil bogin on the &,te of appro-val by me
°1Lit1 U't)Lllitt' tt1 tlpsme the MUM sr`steni; £1r Uponi.stc r t i tine. an.dshall i ti)31tii"itl
"?a'ilile then ,'�, iV%V'f S is 0il�ratib)rltal. or tilltli t1 IC is t.3'ali: {i't'i"':it.
o(€lili'211' ur. The falhwe or me '1'tUl'!ICltlalit.' at any Illi e to t'ni'orce it p t i isi n tz' Elim:
- ' E' a lis,€VU of me p "'self "; no", in any tl "'} 1i't��t
E'Cei3i3?':tlt :`•lIG}le«C? illi way C(131atic�Et i° .
tl1 lxilidity of the %Lw'1'€ C"slltlat t_rr,111)i part heretlt, l i°flli €is ill. l 411e N`li'iiis ljl ii1'
tti i'e?G1i'` P to enforce 4` ,c_ 'provisio'n, hereof,
�xEnt'SI€1C11t d. This k2rcement shall only he: amended by althorized'T'Pr�se"U,1ti` 4- of.
the ".11d N'JuniCipali"t`.'. Ali,,' attempt til a111end this <I xE` ille»'It EtX ittS j «i?a
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itl"i5tl14tEi)1l. . t10tce of L,i1�'. Any vil i .C-tii7n is >i,°l<s ;6 311 11,, -4?1 ;t4"ii ?Slat i`w
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ONVNER,
Y:
SIATE OF ATASKA
TJ TIR D St. IDI CLAL DlV-FRI CT
The Nregoina insvWment
2 "iiiiii!4;
Al in,
N0TA;0(TU,'BLTC FOR -
My Conumission e\Pires,';
Daic:
1
ed before Ilie 01i ll ay 01'
A NICIPAUTY,
L"', 2*, -,0`"`,7!,s, '00
kly:I �L,�w
714- _;-,
0 (print nalmr)
Tide'.
(rev. 0511 U701 R) Fago 3 X1''3