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Home My WebLink AboutSILVERWOOD HILL ESTATE #2 LT 1DB Onsite File Silverwood Hill Estate # 2 Lot lbB #050 - 762 - 24 uu lg- Lbdu U U G_d� Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP191209 PID Number: 050-762-24 Dwelling: M Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑® New ❑ Upgrade Name James Weatherby ABSORPTION FIELD El Deep Trench M Wide Trench ❑ Bed El Mound Address ddress 1te Silverwood Hill Drive ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 4 6.0 GPD/SF 1.0 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 0.5 Fl. Gravel depth beneath pipe 0.5 Ft. Subdivision Block Lot Silverwood HMIs Est #2 1 DB Fill added above original grade —2.6 Ft. Gravel length 20 Ft. Township Range Section Gravel width 5.0 Ft Beds: Number of Lines n/a Distance between lines n/a Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line 100 Ft'- 1 n/a Ft. Well 50'+ 50'+ I 251+ TANK ❑ Septic ❑ S.T.E.P. ❑ Holding (] Other Manufacturer Orenco Capacity 1500 Gal. Surface Water 50'+ 50'+ Material Number of compartments Lot Line 5'+ 5'+ I NA Fiberglass 2 Foundation 10'+ 101+ LIFT STATION Manufacturer Capacity Remarks Gal. Alarm location Electrical installed by PIPE MATERIAL House to tank 3034 Tank 0k to 3034 Installer Groundbreakers Drainfield 3034 co/MT3034 Inspector Pannone Engineering BENCH MARK (Assumed elevation) 1455 fi Inspection 1s 9/9/19 9/9/19 Location and description 2nd 3`d 9/9/19 4`h 6/4/20 concete slab @ SW corner of house ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional Approval: Date �E0. AL4k�� P Steven Septic System Approved R. Pannone 8149 Date Note: this approval does not include well permit requirements. �1\CV VJ/VL/ 10) M 0 rN.. F -X D (7 TAW D (/) m� �� C y C Z7 � Kr- -9 c) m -0 -1 m RECORD DRAWING v_(DO0r—XXm)< NN) n-z-�0Z20-'D SILVERWOOD HILLS EST #2 LIDB.. . JAMES WEATHERBY 19062 SILVERWOOD HILL DRIVE EAGLE RIVER, AK- r�_0� O –1 rn O omOZ .700 D coo I I m m Z in n O AD Z O z :Emm x. m (>J m D r I+ c0 -� 22 4- n cm O N (_4 -I N C � U) 'D (n -0 -1 Z - Oorn Z(AmO'�zOX� 0 rN.. F -X D (7 TAW D (/) m� �� C _ �X �p 0 DODI DN IVB RECORD DRAWING N NN) O 0 O m SILVERWOOD HILLS EST #2 LIDB.. . JAMES WEATHERBY 19062 SILVERWOOD HILL DRIVE EAGLE RIVER, AK- o(" om0P',00 c -)D m N o �m p F-� �U) K '^U) -0 .700 D (n (n -a 41 -P, P (>J .7u c0 U) 4- (A N (_4 N D —. N CP \1 O -• O •P p CA C4 .P P ( r -1 (b N O v CP c() Cp N 0) 00 (r O -I N C � U) 'D (n -0 -1 Z - Oorn Z(AmO'�zOX� 0 rN.. F -X D (7 TAW D (/) m� �� C _ �X �p 0 DODI DN IVB RECORD DRAWING D� S m p Z rn o m O( z O 0 O m SILVERWOOD HILLS EST #2 LIDB.. . JAMES WEATHERBY 19062 SILVERWOOD HILL DRIVE EAGLE RIVER, AK- o(" om0P',00 c -)D m o �m p F-� �U) K '^U) -0 .700 D 0 4 x m -0 - -0 0 SITE PLAN Z p D M FTI p Z a O FTI .7u Un X U) fl O 7. `0.D / m— i Z —I K: D – S < O / r'l r m / / r p -T1 / N, ;u cri � OOZOz- R,oc(nXD _/��D r _TIZI �OZO0 XD' >��n 1 _ I rn \- I/D m p / N x _ I m I I ITI X r p / n D m x Z = D ^ / r tl \I m Z O Z / - I 7 O / Dom_ m Z C+ p� c i O Z O r P p Z p p 0 / ' 0 U) -P, O \- / Ln / R -a \ .. — _ -jU. rr l - z fn m �- 0 Do mn� mr0 LA \m� mm§ o a NO WELL/ SEPTIC m (f)m WITHIN 200' -moirg. NOTES: PANNONE ENG SVC LLC (C.I. 1088) P.O. BOX 1807 PZIER, AK 9645 PHONE (907) 745-8200 FAX (907) 745-8201 ""` „ 6 OF qC _ q , = ��? •S�'4 ... =" " � 1............: Stevon R. Ponnone ,, %,�o .. CE -x149 �'''� �'• - REVISIONS DATE 2/25/21 RECORD DRAWING SCALE 1" 50' SILVERWOOD HILLS EST #2 LIDB.. . JAMES WEATHERBY 19062 SILVERWOOD HILL DRIVE EAGLE RIVER, AK- P.I.D. NO 050-762-24 DRAWN ACP SITE PLAN PERMIT NO. OSP191209 SHEET 2 OF 3 Iv IN 1 f I i 0 O Z_ � A N N ' j i i I n 0 m j m n o O � N t>' 0 0 m 't Zr n n z -i �m j c S Z ( 0 .Zi G D Z V ' v a I1 I � i v j < y D A i A i ~ O n y I O y 1 9 O \ U K: i O O O o� NOTES: PANNONE EMG SVC LLC (C.I. 1088) P.O. BOX 1807 PAL. SER, AK 99645 PHONE (907) 745-8200 PAX (907) 745-8201 ."""", A '�6 0F... Gq'' , - �? ' Sb ''. REVISIONS DATE 2/25/21 RECORD DRAWING_ SCALE SILVERWOOD HILLS EST #2 L1 DB JAMES WEATHERBY 19062 SILVERWOOD HILL DRIVE - l�,". - 4 h /N " "� %- `"" '"" = "•" Steven R. Ponnone " .• ce-8149 = NTS P.LD. NO 050-762-24 DRAWN ACP NO.PERMIT OSP191209 SITE PLAN EAGLE RIVER AK 'ess,a' .-` SHEET 3 OF 3 d OWNER OF LAND: James & Denise Weatherby ADDRESS: 19062 Silverwood Hill Dr. Eagle River Bore Hole Data Depth From To LEGAL DESCRIPTION Silverwood Hill Estate #2 Lot 1DB DATE: 6-26-19 0 2 PERMIT NUMBER: OSP191209 DATE OF ISSUE: 6-13-19 TAX IDENTIFICATION NUMBER 05076224000 Is well located at approved permit location: ®Yes [—]No Method of Drilling: ®air rotary cable tool Depth of Well: 400' Casing Type: Steel Wall thickness .250 inches Diameter: 6 inches, depth 44 feet Liner type 2 4 4 6 6 18 18 121 121 140 140 209 Static Water Level: 20 feet Recovery Rate .5 ® gpm F-1 gph Method of Testing Air Well Intake Opening Type: Flopen end ®open hole RScreened Start feet Stopped Perforations Start feet Stopped Grout Type: Bentonite Volume: 400lbs Depth: from 2 feet, to 42 feet 209 279 279 400 Well Disinfected Upon Completion: ®yes Ono Method of Disinfection: Chlorine 50 PPM Comments: Shallow bedrock surface seal installed .5 GPM after hydrofrack ArseNc -�_ 9 15 ao :2O i Casing Stickup Overburden Hardpan Broken Bedrock Bedrock Gray Bedrock Gray w/ Quartz Bedrock Gray Bedrock Green Hard Bedrock Gray Drillers Name: Cole Sullivan ATTENTION: It is the responsibility of the property owner to submit a copy of the well log to the proper authority. Municipality of Anchorage: Department of Health & Human Services and/or Department of Environmental Conservation. Matsu Borough: Department of Environmental Conservation. 1 Big :11111111111111IM11111111111 �VIVIXJ Well Drilling Permit Number: SW Parcel Identification Number: www.sullivanwaterwells.com Pump Installation Log OSP191209 Date of Issue 6-13-19 05076224000 Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation. SGS Ref.# Printed Date/Time 10/20/2020 12:44 Collected Date/Time 09/15/2020 11:20 Received Date/Time 09/15/2020 12:40 Teclinical Director Stephen C. Ede 1204983001 Client Name Residential Testing - Cash Account Project Name/# Jim Weatherby Client Sample ID HoseBibb Well Entranceto House Matrix Drinking Water Sample Remarks: Allowable !'rep Analysis Parameter Results LOQ Units Method Container II? Limits Date Date but Total Dissolved Solids 240 Metals by ICP/MS Hardness as CaC,03 192 Waters Department Total Nitrate/Nitrite-N Microbiology Laboratory E. Coli Negative Total Coliform Negative Private Individual Analysis Chloride 1.77 Conductivity 394 Fluoride ND Sulfate 60.6 Alkalinity 141 Aluminum 28.9 Antimony 3.64 Arsenic Nn Barium 34.9 Cadmium ND Calcium 62500 Chromium ND CO3 Alkalinity ND 10.0 5.00 0.200 mg/L SM21 2540C A (<500) mg/L SM21 2340B C mg/L SM21450ONO3-F D (<10) 09/18/20 S.S 09/22/20 09/24/20 DMM 09/21/20 EWW 100mL SM21 9223B B 09/16/20 A.L I00ml, SM21 9223B B 09/16/20 A.L 0.200 mg/L EPA 300.0 A (<250) 09/25/20 09/26/20 A.A 5.00 umhos/cm SM21 2510B A 09/17/20 EWW 0.200 mg/L EPA 300.0 A (<2) 09/25/20 09/26/20 A.A. 1.00 mg/I. EPA 300.0 A (<250) 09/25/20 09/26/20 A.A 10.0 mg/L SM21 2320B A 09/17/20 EWW 20.0 ug/L EP200.8 C 09/22/20 09/24/20 DMM 1.00 u0/I, EP200.8 C (<6) 09/22/20 09/24/20 DMM 5.00 ug/L EP200.8 C (<10) 09/22/20 09/24/20 DMM 3.00 ug/L EP200.8 C (<2000) 09/22/20 09/24/20 DMM 0.500 ug/L EP200.8 C (<5) 09/22/20 09/24/20 DMM 500 ug/1- EP200.8 C 09/22/20 09/24/20 DMM 2.00 ug/1, EP200.8 C (<100) 09/22/20 09/24/20 DMM 10.0 mg/I., SM21 2320B A 09/17/20 EWW 5G' B�/LD/NETBACK �[NFR�TOR --~- C0WCRET[ PAD ' ROOF DpA|N UUTFALL ~ (\ � nOUSEE \ C4mTILEvER \\ ROOF DRAIN OUTFALL UPPER DECK LOWER CONCRETE - LEGEND 8UiU}iNG Wx 5R R SIR� SR 9� 50' BUILDING SETBACK ENLARGEMENT �\�T�|| `-'`._,...`,u./�_/` / �/�_/'`/�_ CONCRETE ---- -- -- ---- ADJACENT PROPERTY UN[ --- --- --- --' BU|G}!wC OVERHANG -- -- -- -- -- -- -- EASEMENT LINE PROPERTY LINE � ------ -- ------ RIGHT-OF-WAY CENTERLINE CLEANOUT CO "RD ROOF DRAIN om� SEWER MANHOLE [}sn SEWER RISER WELL Wx 5R R SIR� SR 9� 50' BUILDING SETBACK ENLARGEMENT �\�T�|| `-'`._,...`,u./�_/` / �/�_/'`/�_ } UNDERGROUND UTILITIES HAVE NOT BEEN LOCATED OR SURVEYED. UTILITY LOCATIONS TO BE FIELD VERIFIED, 2m0 CORNERS SET THIS SURVEY 3, SURVEY DATE: 8/20/20 SURVEY CERTIFICATION: RODNEY P. KINNEY ASSOCIATES, INC. HAS CONDUCTED A PHYSICAL SURVEY OF THIS PROPERTY AS SHOWN ON THIS DRAWING AND THAT THE IMPROVEMENTS SITUATED THEREON ARE WITHIN THE PROPERTY LINES AND NO ENCROACHMENTS EXIST OTHER THAN NOTED. EXCLUSION NOTES: IT IS THE OWNERS 0vSoB0Ty TO DETERMINE THE EXISTENCE OF ANY EASEMENTS, COVENANTS, OR RESTRICTIONS WHICH DO NOT APPEAR ON THE RECORDED SUBDIVISION PLAT. LOT I DB SILVERWOOD HILL ESTATE SUBDIVISION Rodney F. KluflevAwfaje� 10C, ADD. NO. 2 (PLAT 2009-1112, ANCIHORAGE RECORDING, DISTRICT) GRAPHIC SC0 100 20 INT FEET AClark E. K' 141 LS— 11760 LE AS—BUILT 02/04/2-11 FIGURE l| Uj � / c/ / } UNDERGROUND UTILITIES HAVE NOT BEEN LOCATED OR SURVEYED. UTILITY LOCATIONS TO BE FIELD VERIFIED, 2m0 CORNERS SET THIS SURVEY 3, SURVEY DATE: 8/20/20 SURVEY CERTIFICATION: RODNEY P. KINNEY ASSOCIATES, INC. HAS CONDUCTED A PHYSICAL SURVEY OF THIS PROPERTY AS SHOWN ON THIS DRAWING AND THAT THE IMPROVEMENTS SITUATED THEREON ARE WITHIN THE PROPERTY LINES AND NO ENCROACHMENTS EXIST OTHER THAN NOTED. EXCLUSION NOTES: IT IS THE OWNERS 0vSoB0Ty TO DETERMINE THE EXISTENCE OF ANY EASEMENTS, COVENANTS, OR RESTRICTIONS WHICH DO NOT APPEAR ON THE RECORDED SUBDIVISION PLAT. LOT I DB SILVERWOOD HILL ESTATE SUBDIVISION Rodney F. KluflevAwfaje� 10C, ADD. NO. 2 (PLAT 2009-1112, ANCIHORAGE RECORDING, DISTRICT) GRAPHIC SC0 100 20 INT FEET AClark E. K' 141 LS— 11760 LE AS—BUILT 02/04/2-11 FIGURE l| 20 - - - \ LO7 /D� �� ``'"� PRIVATE"' "E -ES EA�E�ENT--'~ � - V\ '' �y «} ( '~ DRAIN'AGE E"SE=E.`. C-E."/Encu ON PxurER// umI: cc: `D . _ L� `+ _~ � <c6 m ~z �� Lu m � LL_ 0� � 0 Ff) r) 0c {� ~ zo ,� � 0 o } UNDERGROUND UTILITIES HAVE NOT BEEN LOCATED OR SURVEYED. UTILITY LOCATIONS TO BE FIELD VERIFIED, 2m0 CORNERS SET THIS SURVEY 3, SURVEY DATE: 8/20/20 SURVEY CERTIFICATION: RODNEY P. KINNEY ASSOCIATES, INC. HAS CONDUCTED A PHYSICAL SURVEY OF THIS PROPERTY AS SHOWN ON THIS DRAWING AND THAT THE IMPROVEMENTS SITUATED THEREON ARE WITHIN THE PROPERTY LINES AND NO ENCROACHMENTS EXIST OTHER THAN NOTED. EXCLUSION NOTES: IT IS THE OWNERS 0vSoB0Ty TO DETERMINE THE EXISTENCE OF ANY EASEMENTS, COVENANTS, OR RESTRICTIONS WHICH DO NOT APPEAR ON THE RECORDED SUBDIVISION PLAT. LOT I DB SILVERWOOD HILL ESTATE SUBDIVISION Rodney F. KluflevAwfaje� 10C, ADD. NO. 2 (PLAT 2009-1112, ANCIHORAGE RECORDING, DISTRICT) GRAPHIC SC0 100 20 INT FEET AClark E. K' 141 LS— 11760 LE AS—BUILT 02/04/2-11 FIGURE l| ,„/.0.,. .(...,).1:.:. \ MUNICIPALITY OF ANCHORAGE �..__ On-Site Water& Wastewater Program scA .S'f • PO Box 196650 4700 Elmore Road• �• 1; Anchorage,Alaska 99519-6650 Phone:(907)343.7904 Fax:(907)343-7997 ,�,fti �; d�' hitp:Ilwww.rnuni.org/onsite "coot t)C i).1I'l'111eIt[ On-Site Water & Wastewater System Permit Permit Number: OSP191209 Effective Date: 6/13/2019 Work Type: WellSeptic Initial Expiration Date: 6/12/2020 Tax Code Number: 05076224000 Site Legal Address: SILVERWOOD HILL ESTATE#2 LT 1DB G:0354 Site Mailing Address: 19062 SILVERWOOD HILL DR, Eagle River Owner: WEATHERBY JAMES L Lot Size in Sq Ft: 272473 Design Engineer: PANNONE ENGINEERING SERVICES Total Bedrooms: 4 This permit is for the construction of: El Disposal Field 0 Septic Tank ❑ Holding Tank D Privy 0 Private Well ❑ Water Storage All construction shall be in accordance with: • 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations(18AAC72)and Drinking Water Regulations(18AAC80) 3. The wastewater code requires inspections during the installation.The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907)343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day,or b. Covered, sealed, and heated to prevent freezing Received By: 4// C" / f , Date: Issued By: Q.(‘' )0,-rDate: 7 9 Efl1/INS MUNICIPALITY OF ANCHORAGE tlj • .CommunitY Development Department r ' 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. 050-762-24 Property owner(s) James & Denise Weatherby Day phone Mailing address P.O. Box 92001, Anchorage, AK, 99509 Site address NSN Silverwood Hill Drive Legal description (Sub'd., Block & Lot) Silverwood Hill Estate #2, Lot 1DB Legal description (Township, Range & Section) Lot Size 727,473 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (®all that apply) Absorption Field ❑X Initial 0 Single Family (SF) IXC (w/wo ADU) Septic Tank Upgrade ❑ Duplex (D) ❑ Holding Tank ❑ Renewal ❑ Multiple Dwellings Privy ❑ (SF and/or D) Private Well ❑X Water Storage U 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: 8O Waiver Fees: Date of Payment: 6t3//9 Date of Payment: Receipt Number: 6211 7 Receipt Number: Permit No. 05P/q/.69 Waiver No. Permit App_:-: :;..,:t Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191209, Deb Wockenfuss, 06/13/19 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191209, Deb Wockenfuss, 06/13/19 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191209, Deb Wockenfuss, 06/13/19 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191209, Deb Wockenfuss, 06/13/19 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191209, Deb Wockenfuss, 06/13/19 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191209, Deb Wockenfuss, 06/13/19 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191209, Deb Wockenfuss, 06/13/19 N. • MUNICIPALITY OF ANCHORAGE ADVANCED WASTEWATER TREATMENT SYSTEM MAINTENANCE AND REPAIR AGREEMENT THIS MAINTENANCE AND REPAIR AGREEMENT,herein the"AGREEMENT"made and entered into as of this () Day of—..b.c4:.,. of 20/ % ,by and between //),;1...-4. /.')d-/4 pi;5 dti;,-- ,herein the"OWNER,"and the Municipality of Anchorage,herein the" ICIPALITY",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 Owner to utilize and operate an Advanced Wastewater Treatment System(AWWTS), described as f � �nv'a9.iJ/3Jh located at(legal description) ` • 2. Maintenance,Repairs and Alterations. (Owner is required to read,understand and initial each section) Throughout the term of this Agreement,the Owner shall enter into a service agreement with an AWWTS service and maintenance provider approved by the Municipality or the manufacturer's representative. The AWWTS 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,adjustment(s),replacement costs,and inspection costs. This includes an annual maintenance fee(typically$400 to$600). 'J 7V ) Owner agrees that only maintenance and repair personnel approved by the Municipality or the manufacturer's representative will inspect and make any necessary maintenance, repairs or permitted alterations to the system. 4: ,_.I Owner acknowledges that regular maintenance of an AWWTS reduces the potential failure of the system,which could include sewage backup and costly repairs or drainfield replacement. (rev. 05/18/2018) Page 1 of 3 Owner acknowledges that the Municipality may request records of maintenance and repairs from the manufacturer's representative or maintenance provider. `SAA.J Owner acknowledges that the fine for failing to maintain and repair an AWWTS may be assessed in accordance with AMC 14.60.030. \Tw% 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 or transfer of title of the property will not occur without a new Certificate of On-Site Systems Approval. \•.:17-ti Owner agrees that the AWWTS installation and maintenance requirements as provided by the AWWTS vendor/installer and approved by the Municipality are the governing guidelines for the construction,maintenance and repair of the Owner's AWWTS. Lft! Owner agrees to maintain remote monitoring of the AWWTS as required by the AWWTS 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 AWWTS is operational or until title is transferred. 4. Nonwaiver. 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 Municipality thereafter to enforce every provision hereof. 5. Amendment. This Agreement shall only be amended by authorized representatives of the Owner and Municipality. Any attempt to amend this agreement by either an unauthorized representative or unauthorized means shall be void. 6. Jurisdiction: Choice of Law. 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 govern the rights and obligations of the parties under this Agreement. 7. Severability. 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 OWNER: By: `�,/!--Z•( ...._....`,'._._.- ' (signature) Date: (St/Z:0 i ‘17:/-G.ti(--.c /1.)e' :. IL; 1.,Pe.-/ (print name) h&)s : -A,t STATE OF *S ) .n,'1")'G i1/5 (tA c('I-t )ss. - !A! ,'l b I• . ..C—T- ) a( r^ �, The foregoin�jnstrument was c iowledged before me this `•day of �L/lc/ s 20 111 ,by ')71/N-,,j C_ r!`I/1y 1\10, RY PUBLICFORFOR?d. .SIS Ji%°S W WYATT PRESTON My Commission expires: (.2.1,-/=-/'2 2? Notary Public-State of Kansa tU(yAppt,ExpireOP MUNICIPALITY:� AL�� By: '�" C(2 / (signature) Date: 640cr (print name) Title: (rev. 05/18/2018) Page 3 of 3