HomeMy WebLinkAboutROCKHILL BLK 3 LT 1Onsite File #015-362-18 Municipality of Anchorage On-Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP191455 PID Number: 015-362-18 Dwelling: FEI Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New R Upgrade Name JOHN HIGGINS ABSORPTION FIELD ❑ .Deep Trench ❑Wide Trench ❑Bedound Site Address 6200 BARRY AVENUE, ANCHORAGE, AK 99507 ❑ Other Phone Number of Bedrooms Soil Rating Total depth original grade - 4 GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot ROCKHILL; BLOCK 3, LOT 1 Fill added above original gr Ft. Gravel length Ft. Township Range Section - Gravel width Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total orption area Number of trenches Dist. between trenches From Tank Field Tank Line Ft? Ft. Well 1001+ TANK X Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer GREER TANK Capacity 1250 Gal. Surface Water 100'+ Material HDPE Number of compartments 2 Lot Line 5'+ NA Foundation LIFT STATION Manufacturer Capacity Gal. 110'+ Remarks OLD TANK DECOMMISSIONED PER UPC PER CONTRACTOR Alarm location Electrical installed by PIPE MATERIAL House to tank EXISTI Tank to EXIST6 6 drainfield Installer A+ HOME SERVICES Drainfield DawaiExisnNG CO/MTD3034 Inspector TIM ECKLUND AND DAVID GARNESS BENCH MARK (Assumed elevation) 97:26 ft Inspection15` 10/11/2019 - Location and description TOP OF MH 3b - 4"' _ ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's St p oQQ600p �4 Conditional Approval: Date o ..... 9 . ..:��QO D D Septic S stem ss;' p E—A79�'r Approved 1 tom. Date %©'{ C 3 Note: this approval does not include well permit requirements. p0 �0fess'°Q\ #AECC884 �000�o (Rev 05/02/18) PERMIT NUMBER: OSP191455 RECORD DRAWING BARRY AVENUE \ / NEW 1250 GALLON HDPE GREER TANK RATED FOR 10' BURIAL - Y DRIVEWAY 1 +. 1&2 &4 EXISTING TRENCH; NEW C/O INSTALLED ON NORTHEAST END OF TRENCH CSEPTIC AR!n PARCEL ID NUMBER: 015-362-18 GARNESS ENGINEERING GROUP, Ltd - --- -- ENGINEERING'S SALES o CONSULTING ------------ - 3701 E. TUDOR ROAD, SUITE 101 *ANCHORAGE, AK 99507 • PHONE (907) 337-6179 • FAX (907) 33&3246 • WEBSITE: w gamessengineenng.com PREPARED FOR: PHONE NUMBER: PAGE NUMBER: JOHN HIGGINS - 2 OF 3 LEGAL DESCRIPTION: DRAWN BY: ROCKHILL; BLOCK 3, LOT 1 D.J.G. TYPE OF WORK: DATE: SEPTIC TANK RECORD DRAWINGS 10/14/2019 W 1"=40' OF ,.....::.................. ... ..::.....; r s r...... .... • ................. ......0 ♦♦ ��: J r A. Games s :'�= ♦♦% G C -7953 Ar LICENSEeO4';:a;SS\Ok •• #AECC884 / PERMIT NUMBER: RECORD D RAW I N G PARCEL ID NUMBER: OSP 1'9 1455 015-362-18 TOP OF MH = 97.26 FINAL GRADE = 95.74-96.73 MH ST2 TOP OF TANK AT INTLET = 90.40 TOP OF TANK AT OUTLET = 90.40 NEW 1250 GALLON INVERT OF BUNG AT INLET = 89.84 H. D. P. E. G REER INVERT OF BUNG AT OUTLET = 89.56 SEPTIC TANK RATED FOR 10' BURIAL i\AV GARNESS ENGINEERING 49 *•'• G NG GROUP, Ltd ................................; �- --- _ = ENGINEERING G SALES o CONSULTING 0 3701 E. TUDOR ROAD, SUITE 101 ' ANCHORAGE, AK 99507' PHONE (907) 3376179' FAX (907) 338-3246' WEBSITE: x gamessengineenng.00m . ,,,, ,,,„., , PREPARED FOR: PHONE NUMBER: PAGE NUMBER: JOHN HIGGINS - 3 OF 3 �j �'• reyA.•••arnes. :�-Q= LEGAL DESCRIPTION: DRAWN BY. / C -795 �= 1p 4W ROCKHILL; BLOCK 3, LOT 1 D.J.G. I . E OF WORK: DATE: LICENSE Q �O PROFESS\������ SEPTIC TANK PROFILE 10/14/2019 #AECC88a ,��►������ MUNICIPALITY OF ANCHORAGE 61*_j Community Development Department Phone: 907-343-7904 Development Services Fax: 907- 343-7997 On -Site Water & Wastewater Program Mayor Dan Sullivan On -Site Sewer/Well Permit Application For A Single Family Dwelling Parcel I.D. 015-362-18 Property owner(s) JOHN HIGGINS Day phone Mailing address 6200 BARRY AVENUE *ANCHORAGE, AK 99507 Site address 6200 BARRY AVENUE `ANCHORAGE, AK 99507 Legal description (Sub'd, Block & Lot) ROCKHILL; BLOCK 3, LOT 1 Legal description (Township, Section & Range) Lot Size Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DEWELLING: (Mall that apply) Initial ❑ Single Family (SF) Absorption Field ❑ Upgrade (w/wo ADU) Septic Tank ® Duplex (D) ❑ Renewal EJ Holding Tank ❑ Multiple Dwellings ❑ Privy ❑ .(SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE/ WAIVER REQUEST FOR: N/A Distance: - I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal codes. GARNESS ENGINEERING GROUP, Ltd. (Signature of property owner or authorized agent) Permit/Rush Fees:d1 ai 5� Waiver Fees: Date of Payment:y Q 6 i Date of Payment: Receipt Number: 2a3 ( C-1 Receipt Number: Permit No. QS Plq `y5_T Waiver No. ®I (j 01 P m (Rev. 01/11) y,"PA"rr MUNICIPALITY OF ANCHORAGE \, On-Site Water & Wastewater Program .?; PO Box 196650 4700 Elmore Road �"°"� c Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 i http://www.muni.org/onsite v I)epartineiit On-Site Wastewater Disposal System Permit Permit Number: OSP191455 Effective Date: 10/10/2019 Work Type: SepticTank Upgrade Expiration Date: 10/9/2020 Tax Code Number: 01536218000 Site Legal Address: ROCK M I LL SLK 3 LT j Site Mailing Address: (0a00 gc,-;rrcl �V�.rl fie, chplr e� (�I�� TV` >Oi Owner: HIGGINS JOHN M & DEBORAH A Lot Size in Sq Ft: Design Engineer: GARNESS ENGINEERING GROUP LTD Total Bedrooms: 4 This permit is for the construction of: ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ 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 BN Issued By: Date: (V111 �q Date: GARNES.S ENGINEERING GROUP, ENGINEERING -SALES -CONSULTING October 10th, 2019 Municipality of Anchorage Development Service Department On -Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 Ref: Proposed Septic Tank Upgrade for Rockhill; Block 3, Lot 1 To whom it may concern: The subject lot is served by a private well and septic system. Per MOA records, the existing septic tank is approximately 36 years old. Per MOA memorandum, a septic tank of this age must be physically inspected and/or replaced prior to COSA approval. Based upon this fact, we are proposing to replace the septic tank. We are proposing to decommission the existing septic tank per UPC and install a new 1250 -gallon HDPE Greer tank rated for 10' burial. See attached design drawings for tank location and other MOA requirements. We are unaware of any adverse impacts this installation would have on adjacent wells or septic systems. If you have any questions, please contact us at 337-6179. Thank you for your assistance. .S. 3701 East Tudor Road, Suite 101 * Anchorage, Alaska 99507-1259 Phone: (907) 337-6179 * Fax: (907) 338-3246 * Website: www.garnessengineering.com ■ 1 o SEPTIC ARE _ i / CREIWOD; LOT 1 ❑ I zk'�p2 Ste/ ROCKHLIL; BLOCK 1, LOT 9 I \ - � - ----------------BARRY AVEN U CRESTWOOD; OT 24 / w I SEPTIC I / AR�n \ -I I ❑ CRESTWOOD; LOT 23 QSEPTIC ARE�D ROCKHLIL; BLOCK 1, LOT O (-SEPTIC ARE 'Oo o,G I s �! \V ROCKHLIL; BLOCK 3 OT 2 \ / V (:'SEPTIC ARE SEPTIC ARHj _ ` ROCKHLIL; BLOCK 3, LOT 3 / ASSUMED LOCATION FIELD VERIFY / PRIOR TO CONSTRUCTION I 100' WELL RADIUS 1 I GARNESS ENGINEERING GROUP, Ltd ENGINEERING oSALES %CONSULTING 3701 E. TUDOR ROAD, SUITE 101 ' ANCHORAGE, AK 99507' PH@g4E (907) 337-6179 • FAX (907) 338-3246 • WEBSITE: www. gamessengineedng.com PREPARED FOR: PHONE NUMBER: PAGE NUMBER: JOHN HIGGINS - 1 OF 2 PROJECT/LEGAL DESCRIPTION: DRAWN BY: ROCKHILL; BLOCK 3, LOT 1 D.J.G. TYPE OF WORK: DATE: �,_ SEPTIC SYSTEM DESIGN UPGRADE 10/8/2019 GEG, Ltd. HAS AN 8 PAGE SPECIFICATION LETTER THAT PERTAINS TO THIS DESIGN. BY PROCEEDING FORWARD WITH THIS INSTALLATION, THE ENGINEER, WELL DRILLER, CONTRACTOR AND PROPERTY OWNER AGREE THAT THEY HAVE READ THESE SPECIFICATIONS AND AGREE TO ACCEPT THE TERMS AND CONDITIONS OUTLINED. 70, I I I I BARRY AVENUE 4' / \ EXISTING 4 \ BEDROOM • HOUSEci w \ 1 Jw ca I � I O I I / I \ I I PROPOSED 1250 GALLON HDPE GREER TANK \ RATED FOR 10' BURIAL; INSTALL DOUBLE I O CLEANOUTS BEFORE AND AFTER I ° I I I I APPROXIMATE LOCATION OF EXISTING 1250 GALLON STEEP SEPTIC TANK TO BE _ DECOMMISSIONED PER UPC 10' TELE g ELEC. EASMT — — — — — — WELL FOR ROCKHILL; BLOCK 3, LOT 3 TO — BE LOCATED PRIOR TO CONSTRUCTION CSEPTIC GARNESS ENGINEERING GROUP, Ltd =---- ---—, ENGINEERING o SALES o CONSULTING —_— — 3701 E. TUDOR ROAD, SUITE 101 • ANCHORAGE, AK 99507' PHONE (907) 337-6179' FAX (907) 338-3246 • WEBSITE: w .gamessengineenng.com PREPARED FOR: PHONE NUMBER: PAGE NUMBER: -T JOHN HIGGINS I - 2 OF 2 PROJECT/LEGAL DESCRIPTION: ROCKHILL; BLOCK 3, LOT1 TYPE OF WORK: DESIGN OF SEPTIC TANK UPGRADE DRAWN BY: D.J.G. DATE: 10/8/2019 I N SCALE: 1"=40' tilt ��••� OF,'4, Ar i * 4 • * •�0 .....:....................................0 0 o �....... ........................... 0 :, Je . Gar ss c Q i 0��%'. CE -795 ?i AV 17. LICENSE 1oFESS1 #AECC884 �""' / MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 1*0 ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE NEW -Q ❑UPGRADE MAILING ADDRES 9y� S tl <i 'S LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS U Y DISTANCE TO: Well r Absorption area s Dwelling —,S-/ PERMIT NO. a : E' EPAF:TP`IEP,IT OF HEALTH TF:EET: PEF:P"I i l 1',I!=!.:Q14__':7 APPLI!-:Ai'•!T PHYLLIS Artl':I+_!P 'SIC -P•4 L01 -- :AT 10 P. -I LEGAL I_1E=F:!=i!: l'%'Fj I L.I._ -u c a 1.' -1: u= "u' _ u a "_u=� AP•!G' EP!' i F:i !Pdl IEP,iTt IL F'F:!-!TE!=:T 10 N AI',I!_Hi RFi! E : Ak%'_ j•1 2G 4— 4 1' ;2;i_i E-_ �-=-7 I)= F° E=" FE � " 11-4 1 -T_ _ F i FTIX 4—'4:---' 9'95!•:! _ LOT SIZE 999999 TYPE !::!F __lI I L FiE,Si IRPT I t_ N E'•r'E.TEI'I I _ : 1'Ih is; 1_' 1' ►C'1 Pdi_IP'1E EF: ± !F E.EG�F:!=!� IIS - 4= FI I L F:AT I I'•!! SC-'! FT/BR' = = 5 THE RE! -!I I I F:EC SIZE OF THE SOIL AE. _i-_ !F'PT I !_!P,l E.'• STEll I E : � 1C- �_tt E-9 = _ B P-„ P:-3 1- 9-0 = -4 � 3 I--„ F=flLLE= r)_ ID REE_" _T_ ('17-0 s - q -,a/� -?a THE LEI' -4G T H D I NDIS I OP•! IS THE LEP-:I!3TH -:' I N. FEET) OF THE TF:EP•,IE:I-1 � iF: GRA I Y IF i ELD.Rnq,� THE C EF'TH i !F A Tr==:EI' I! I -I OF. F' I T IS THE f_:- I C. T(=►I' IC:E BET14EEP•`I THE '�I_IF:FA!_ E OF THE GF:!=!111',ID AiNDI THE BOTTOM OF THE E -;i :A'.,'ATI0N -% IP•! FEET). THERE I,=" P,IO SET IAI I LATH FOR TREI'•!!=:HE ^. THE I__jF:A%'EL DEPTH I S THE l'l I l',I I I`il_1M DEPTH i �F !__3iF:A%'EL E,ETI.-.IEEN THE OUTFALL PIPE AP -1D THE BOTTOM OF THE EX!_i=►VAT I OP•! :'P-4 FEET T C—_ -i a=a g" -A fF =_ I =E_=-- a. = = J_ :2 !f _- H-!! Q a=a L L_11- I -4A PERI"el I T ADPL I C :AI',IT !-IAS, THE TO I hIFORM TH I E, DEPAF:TME1'•4T DDR I kli-A THE INSTALLATION 11'•!SPE!_T i i !i',I,� DF ANY WELLS AC: JA!_ENT TO THIS PRF_IPERTY AkID THE 1',1Li1''1E,EF: i �F RES! :E ~ THAT THE kIELL Ij.I I LL SERME. ;I _d LL _ ,_ _ z 9-4 �_-" � ate_ -a- ,>_ �_o '-d e a�j F° 1= �° a_II I DACE -.::F i LL I P•!!3 OF AP•!'.' E'r` -TEP ! 1.-.1 I THi !I -IT FII -,..IAL I NSPE!_T I i !P•! AP,ID APPROVAL E:',' THIS C:-EPAFM IEi%IT WILL BE =,►—IE, ,IE!_T TE! PR !=,E!_ -IT I i iP,l. � •! ON-SITE !EI''Ii!,1II' Yl DIST=,I�::E BETkIEEII A I!ELL ANE, AIr_EWAGE GI_PEHL -'r'' TEP'I IS D,DiD FEET FOR FI PR i', ATE WELL OF, 150 Ti ! 201_D FEET FROM A PLIE.L I !_ I.,.IELL DEPEI'ID I P -M UP OP•! THE TYPE i !F F'I_IF;LI!_ kIELL.. I'l i I',I 11,11 IP'1 C:- I _,TAP,K:E FROP 1 A PRIVATE I..!ELL T� � A PRI %,,ATE SEI.%IEF: LINE I FEET A!'•!G, TO A !_OI%V111P,I I TY EEI.dER i_ I I',IE IS 5 FEET. !=!THEE: RD -!I I I REI'lEP,ITS IlA',' APPLY. +PEi : I F I i :ATI !=!P•! _ AhID !_i !P•!= TF:I I!_T I &I DIAGRAMS AF:E A!jAILAE,LE Ti! INSURE PROPER INSTALLATION. F=" II-_ ° [F-11 L 9 F—` I CERTIFY THAT 1: I All FAMILIAR kI I TH THE RE! -!I I I REP'1EP,IT_. FOR OP -1 -SITE -EI.4EF:S AND l. -JELLS AS 'SET FORTH BY THE I* II Ii',! I i=: I PAL I T'i-` OF I=!I' III-IORAGE. �iFI WILL INSTALL THE -r-TEPIN h_P.I I T! -I THE !_E!DE=,. T THE !=!P•!-•-E� I TE SEI.-.IEF: E.'T` = TEf 1, FLAY RE! -!I I I F:E EI',ILAF:!_3EP'1E1'•!T I F THE i U1',1L EF:r TAP!C:� THA ` F-HAI,C.)ED.-IC:E I = Cr,_G1rF,I �I E:EDF:Oi !I''1=. S I G!'•! APDL/'I'1!:AP,I T 1 _,= I -IEC:' E--'r'__-----C.q F'!-I`�'LLI' AAP•!!=!P! F - IN - r f i r _ ff T SOILS LOG f, \ MUNICIPALITY OF ANCHORAGE / DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION El PERCOLATION TEST \\ 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG — PERCOLATION TEST PERFORMED FOR: P'K ;5 ASI an . n h DATE PERFORMED: LEGAL DESCRIPTION: :Rod. �G J(-.) Y tyiS! UV-) Loi ��< 33 PtNK3w `i 5r S O? SLOPE SITE PLAN ) Ot or�ani't Sa;l t I 2 ) (#•1 L) -)-run sit t s i 5- 6- 7 67 i 8 r � 9 10- 13- 14- 15- OF 013- 14-15 clean well gr dad J14ae I no S; l �r Layers o�=n�atl-Si�c q.-,tee\ -F.r--i-;�;c€ �•tt� 14yer5 fpbb\eS I b at a e� } ail CtCar cr M0.1t $P. ai'+'i$ O'Y GtUn, r�rxv Ct, f WAS GROUND WATER ,., S ENCOUNTERED?., t� o L O IF YES, AT WHAT E y++l� -EtrrSt�t Sa•� y .. DEPTH? jw •+ 0 • foe .*ia N• • pHi• ` w mY C Reid, Jr, �� d'1� ' • Ato. ?23 t •!: - 20 ®O .,., PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND FT � 1 COMMENTS Sc>;� -rurn �( c�r\!y rs rdy s ,u11�, 85 C1`/ �d•m, . PERFORMED BY: 5eve.n� _CERTIFIED BY: DATE: 72-008 (5/79) Gross Net Depth to Net Reading Date Time Time Water Drop aaee � 8 20 ®O .,., PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND FT � 1 COMMENTS Sc>;� -rurn �( c�r\!y rs rdy s ,u11�, 85 C1`/ �d•m, . PERFORMED BY: 5eve.n� _CERTIFIED BY: DATE: 72-008 (5/79) .. 'A=T19t11 T;t: Dlvlstom � iMlogl aphyslgal Sssrwys c�ti ari TargtrAus{sz 2"-66151 ' 3fAT�'�. OVA{tTtli{R ®/ SOOT perewtee Anchora". Mashe I WA`TEIt WILL Rttsgii . gr{Illnq Coayaaq Maar Vein $ �It 1 p� g�Nc .o..�.� " Y.S.Q.t. LN+B1 Via. Milling peomlt ft.. T100 OF WILL please ea,plete either la. 111. or 16. A So+pUP Ssirivlslr Lot /10" Ib. Fraction Section No. 441" TwnshIp Adage J1l atawcm and o l rw t low from Rod Intersect) ). &An of %W" r ' ti 4-`'-: P}" 1' Sub 5 W� n�T �,(!/ dcc, /�, Ai1r...t k.'.C� ZJ•� NsB-1 9 5 8 7.1941, R 3-661 6 goc�� G: Street Address and Area of Well Location . WELL. LOG Feat Below 4. WELL DEPTH: (cowls 34irface ilwrtisn , Surface 101 j Material Type Top Bottom ft. ' ravel;[rave O 15 5. pCable tool 39Rotary pDrlrea ltillpJotted p Auger per. p rn s t e sand rave W s 6. USE:X�Domestic pp"lic Supply ©{ i ou ers jq pIrrigation 13Rechargey Ity rave = pTest Well C] Other: ou eff rn s sand7. CASING: p Threaded 14ed �. rave 6_1n. to 10 1 ft. Depth w140K In. to ft. Depth AM e. FINISH OF WELL: Typo: �nTA2e n Slot/Mash/Size: Leyth: y' Sat between ft. aM ' Fittings: ' 4G 9. STATIC WATER LEVEL: ft.' OF AN & 1 by OF H EGT10 r pAtwva 0aelw laved s OMM ;i«\1 Type of Measurement: 10. PUMPING LEV[l below Aland surface ft. after hrs. pglglag g'� 9 C. ft. after _ Ara. �{zBlgl ii ""': 11. YELL MEAD COMPLLT IOU t isl flgws-my p pItI*sf Adapter 1sa11Re aj�jjt 12. GROVIMGz weII Gsstab"s (ry3 Too ` Ms tar i a 1 t ❑ Iluli CatlMt I.J :' *'F I3 PW: (if eve118614 Larytle of &,no flawg ftp. Water.4zst ,ptis,�." IS. WATER WELL CONTRACTOR'S CERTIFICATION: L� ��4���p `• s �'� This well •.as drilled underurisdiction and this •thet my J sport I s trw Z1 freak ��, Alaska Now-Well-Vern' s Drilling & Ent A1��g2� ` ' `° `M1 Aegistar siness tmMe r{k Address: qqr SI fined:law , J: Form 02- 11�S ✓ 7� Coot 01stributlon: WHITE -"State DGGS, PINK - Miller, CAMAY - Customer - H Ll 1 DEPART -NT OF HEALTH AND ENV I RONM( `AL PROTECTION _ 'L' STREET: ANCHORAGE, hn. 99501 264-4720 PERMIT NO. ( 830=:00 APPLICANT N'1AR V I N AAMONS hl SRA BOX 4242 ANCHORAGE RAGE 9954= 2 349-2812 LOCATION LEGAL L183 ROCKH I LL -/ D LOT SIZE _?999__ 9 SQUARE FE MINIMUM DISTAN CE BETWEEN H WELL AND AN',PT ON—SITE SEWAGE DISPOSAL _,Y _,TEM I i4_ O FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DI -TAN CE FROM A PRIVATE WELL TO A PRIVATE _,EWER LINE I 25 FEET AND TO i A COMMUNITY _EWER LINE I 75 FEET. WELL LOG_ ARE REQUIRED AN'dG' MUST BE RETURNED TO THE DEPARTMENT WITHIN _ 0 D1=1Y OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE Ti � INSURE PROPER INSTALLATION. F" E_ F' 9-•1 1 T F::- a E" -il_ 1 =: E_ E o E= C1 E_ tl EA E_ FR -T-1 = AL c3 ED I CERTIFY THAT :1.: I AN FAMILIAR WITH THE REQUIREMENTS FOR ON—SITE -ITE _EWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY CSF ANCHORAGE. RAGE. : I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. 113NED : _—------------ APPLICANT ----------- APPLIGAN•dT MARV I N AAMONd _C iN.d --- 4___ _--- � ----DATE----y 4za 0 MUNICIPALITY OF ANCHORAGE 0 Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 0l0'- :7007 - JF 1. GENERAL INFORMATION Complete legal description UGIC� i Location (site address) Current property owner(s) / vl ✓1 'u," Mailing address / i Real estate agent Expiration Date: I — 122C72 0 'L 3 LoI- ?'nu-6 I�I�,1 ✓1S Day phone go' 0 - gs q 2. TYPE OF DWELLING: �9Single Family (w/wo ADU) Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well 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 $ X60. 60 Date of Payment 90 AI Im Receipt Number (, +163 COSA # ®Sct9 Nq I - Waiver Fee $ Date of Payment Receipt Number 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 ��� Phone 3�S Address %60 Engineer's Printed Name h:� ,����.� � � ®pip• Y -N pdW '•@ '@J Yl Q' A='�Lcr- ppC>b D D 6. DSD SIGNATURE -P� L t, 1. Pf�•: , -. n r. � uY. \.7Ct:�2d�a1 FF! � System #1 Approved for bedrooms System #2 Approved for bedrooms Disapproved Conditional approval for bedrooms, with the following stipulations: WATE'R A N U m tt, 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 )C� �cJ zOSA Checklist Legal Description: c �ILtu`� )3)of , ZoL Parcel ID: ��� �3�0� �i✓ty If more than 1 septic system on lot: COSA Checklist # of Structure served by this system A. WELL DATA [Well log is filed with Onsite (or attached) Date drilled sJa1183 Total depth —L(—D1 ft Cased to _I QLft Sanitary seal is functioning correctly 0 Wires are properly protected Casing height (above ground) J7 in. Date of flow test for COSA'9 Zb Static water level at beginning of test 6&2sft. Comments Well production at time of test 02 � gpm Water storage tank volume gallons Welpdisinfected for coliform test? ❑ Yes *0 Coliform bacteria is Negative Nitrate �'� mg/L itrate less than MRL (ND) WIn Arsenic 'uQ�/L48rsenic less than MRL (ND) Collected by add 1f�Q%U v - Date of Sample l wl l q B. TANK DATA Age of tank(s) L years - O RE Tank type/material �ov< - I�Sv (a10 Mea ured operating fluid level in septic tank 4A,(►W) Standpipes/foundation cleanout per record drawing Date of pumping D. ABSORPTION FIELD DATA Which system tested (date installed) *LL standpipes present per record drawing Total measured depth from grade 1a+3 ft (max) Measured depth to pipe invert from grade') 161 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 C. LIFT STATION ❑ Required maintenance Age of lift station Lift station mater' Comments! Adequacy test date ZYJ( I Results Pass For bedrooms Fluid depth prior to test in JD4 1 Water added 6,,3?9al New depth in D f&� Elapsed time R 1- min Final fluid depth in D(? -y Absorption rate 4,00 gpd Any rejuvenation treatment (past 12 months) If yes, enter date Jv 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 >_ 10p' Community Sewer Manhole/Cle/t>l(,es if No ft Neighboring Tank > 100' N4es if No ft Private Sewer/Septic Line > 25' n,-,J*,yes i Absorption Field on Lot > 100' NKes if No ft Holding Tank > 100' [jk<es i Neighboring Absorption Fields >X Animal Containment > 50' Yes i Yes if No ft Manure/Animal Excreta Storage > 1 Pd Community Sewer Main > 75' ❑ Yes if No ft 211yes i From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' NI Yes if No ft Surface Water > 100' n/Yes if No Property Line > 5' []'Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' Lryes if No ft Private Wells > 100' b4s if No Water Main > 10' 0/yes if No ft Community Wells > 200' P/Yes if No _ Water Service Line > 10' U 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' LrYes if No 0' If absorption field is under driveway comment below Property Line > 10' [�Yes if No f No ft Wells on Adjacent Lots: Y f No ft Water Main > 10' E s if No f No ft Private Wells > 100' 'esif No Water Service Line > 10' �s if No f No ft Community Wells > 200;res�if No Surface Water > 100' des if No ft f No ft Building Foundations > 10' NI Yes if No ft Surface Water > 100' n/Yes if No Property Line > 5' []'Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' Lryes if No ft Private Wells > 100' b4s if No Water Main > 10' 0/yes if No ft Community Wells > 200' P/Yes if No _ Water Service Line > 10' U 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' LrYes if No ft If absorption field is under driveway comment below Property Line > 10' [�Yes if No ft Wells on Adjacent Lots: Y Water Main > 10' E s if No ft Private Wells > 100' 'esif No Water Service Line > 10' �s if No ft Community Wells > 200;res�if No Surface Water > 100' des if No ft F. ENGINEER'S COMMENTS � Q1O -kld/ iy`gia,l Zd= 10 - lI,-l"1. 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 1k • ��j'I!41�i: S ' Evan J. Griffith lilt �•• CE 10003 ft ft ft ft ft SGS Ref.# 1195494001 Client Name Residential Testing - Cash Account Project Name/# Chad Weiler Client Sample ID 6200 Berry St. Matrix Drinking Water Printed Date/Time 10/04/2019 16:36 Collected Date/Time 09/20/2019 12:15 Received Date/Time 09/20/2019 12:30 Technical Director Stephen C. Ede Sample Remarks: Allowable Analysis Parameter Results Limits Units Container ID Method Date Metals by ICP/MS Arsenic ND Waters Department Total Nitrate/Nitrite-N 8.64 Microbiology Laboratory E. Coli Negative Total Coliform Negative (<10) ug/L B EP200.8 10/03/19 (<10) mg/L C SM214500NO3-F 09/25/19 100mL A SM219223B 09/20/19 100mL A SM219223B 09/20/19 2 CT r • O *----- qsJ 9; 49 LH 0��x,20 04 LS -6914 500 P •. SAT C DISH ------------------ AS BUIL NO CORNERS SET THIS DATE `sT�'EET " = 30' �p4a ....... �a o I HEREBY CERTIFY THAT -I HAVE PERFORMED A SURVEY �Ofessional�o OF THE FOLLOWING DESCRIBED PROPERTY O�DODDo�� LOT 1, BLOCK$ ROCK1-JILL 5UB. THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SHOW ANY 'ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE CONFLICTS BETWEEN EXISTING STRUCTURES AND PLATTED LOT LINES AND/OR EASEMENTS; AND IS VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN NOT TO BE USED FOR POSITIONING ADDITIONAL STRUCTURES, IMPROVEMENTS, OR FENCELiNES. THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS EASEMENTS OF RECORD, OTHER THAN THOSE APPEARING ON THE RECORD PLAT , ARE NOT SHOWN EXIST OTHER THAN NOTED. HEREON ( UNLESS INDICATED) DATED AT ANCHORAGE,ALASKA THIS 12 TH DAY OF. NOTE: FEN ELI NES THAT MAY APPEAR ON THIS DRAWING ARE NOT TO BE USED TO DETERMNE OCTOBER , 2019 PROPERTY LINES OR POSITION ADDITIONAL IMPROVEMENTS. ANY PAVING SHOWN HEREON MAY BE APPROXIMATE DUE TO EXCESSIVE SNOW AND/OR ICE. HOLT LAND SURVEYING 9309 GROVER _DRIVE ANCHORAGE,AK 99507 345-5513 14408, FB 200-10,199-72 BARRY �- N 89 5744 E 100.02 L = 66.21 R = 265.6 71 a m D OM'fLL a SHED ?� 2c Z, SHED ti(D O 4V' p W qy i 4i DECK CT r • O *----- qsJ 9; 49 LH 0��x,20 04 LS -6914 500 P •. SAT C DISH ------------------ AS BUIL NO CORNERS SET THIS DATE `sT�'EET " = 30' �p4a ....... �a o I HEREBY CERTIFY THAT -I HAVE PERFORMED A SURVEY �Ofessional�o OF THE FOLLOWING DESCRIBED PROPERTY O�DODDo�� LOT 1, BLOCK$ ROCK1-JILL 5UB. THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SHOW ANY 'ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE CONFLICTS BETWEEN EXISTING STRUCTURES AND PLATTED LOT LINES AND/OR EASEMENTS; AND IS VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN NOT TO BE USED FOR POSITIONING ADDITIONAL STRUCTURES, IMPROVEMENTS, OR FENCELiNES. THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS EASEMENTS OF RECORD, OTHER THAN THOSE APPEARING ON THE RECORD PLAT , ARE NOT SHOWN EXIST OTHER THAN NOTED. HEREON ( UNLESS INDICATED) DATED AT ANCHORAGE,ALASKA THIS 12 TH DAY OF. NOTE: FEN ELI NES THAT MAY APPEAR ON THIS DRAWING ARE NOT TO BE USED TO DETERMNE OCTOBER , 2019 PROPERTY LINES OR POSITION ADDITIONAL IMPROVEMENTS. ANY PAVING SHOWN HEREON MAY BE APPROXIMATE DUE TO EXCESSIVE SNOW AND/OR ICE. HOLT LAND SURVEYING 9309 GROVER _DRIVE ANCHORAGE,AK 99507 345-5513 14408, FB 200-10,199-72 a DEVELOPMENT SERVICES DEPARTMENT It j On -Site water and wastewater Section l www.muni.org/onsite \� Nitrate Advisory Certificate of On -Site Systems Approval # osc191492 Subdivision: Rockhill, Block: 3, Lot: 1A water sample revealed a nitrate concentration of 8.64 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. �8t tCt arel4, 0"W0E) ���$ 11C K3 8 OWN%21 0 ',,990 90" CiiUX1I OC a From Northern Testing Laboratories, Inc. Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells. SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners, food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil. TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization. TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home water treatment systems such as softening or iron filtration does not readily remove nitrate. The best method for limiting nitrate in well water is source control. This can include avoiding overdosing of fertilizer near the well and maintaining good separation distances between septic tank leach fields and the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate. TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect the activity of nitrate in water. This laboratory uses several different wet chemical methods approved under the public water supply laboratory certification program. They also have test kits available, which the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can monitor the change in nitrate levels from their well. They recommend comparing the test kit results against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples. Mailing address ; f p`� U " "'� itxc�r� o v yc 7�✓'! A Lending agency Day phone Mailing address - - - ': v aUF ti Ax f, i k# gentDay phone ¥ xJ, Unless` otherwise requested, HAA willbe held for pickup 2 rr,t* NUMBER OF BEDROOMS:`� � -- u r 3 'TYPE OF WATER SUPPLY Individual well__.....'.. *fr3 Y3 i 4 Community wesnll Public water..", NOTE: if community well system, provide written confirmation from State ADEE`attest-'. h ing to the legality and status of system. c C.: ' 1 4 .-'TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 APprovedTfor bedrooms., ry , Disapproved i _m , r u bedrooms, with the following astipu By: CAUTION ons: Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-M (Rev.1/91) Back MOA #21 O MUNICIPALITY OF ANCHORAGE ® DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. #Z— /8 HAA # 1. GENERAL INFORMATION Complete legal description Loi Location (site address or directions) G/c.ti /"'ciliac/fo/. Property owner a 6e Lc c Day phone _2 77",2S// Mailing address Lending agency v Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. MUNICIPALITY OF ANCHOkt GE 2. NUMBER OF BEDROOMS: ENVIRONMENTAL SERVICES DIVISION 3. TYPE OF WATER SUPPLY: ! '' t3 'IQ b Individual well E%C E I V E Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site_ Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm KIND Engineering Phone ZL. Address Eacgie FI;vor, AK 99577-8736 Engineer's signature 6. DHHS SIGNATURE 0 Approved for bedrooms. X Disapproved. �X Conditional approval for `f' bedrooms, with the following stipulations: SFE E,V61-1gPA.5 /97TACHEp L ETTER PUC14)Tj/n16 T1 -1E U, 0R t FO BE i�fCO�rPLlSH�EI' 70 FuLLF/LL TI -IS '&A"'01 1—__A'9 PRROVAL ' 'M' SHALL Of FtCROU EV TO COMPLETE w01PK '9AV-L-0911- LOT 6g kELS 6D 4PPROy144 15 Additional Comments G1vfv Y 7_1-0.s OFFICE CO'yDlTica,' sY,911- 0',E RE7PA4PR'542pr No L 1�7-?-�R T'1lRAl T t A,,F- l5 /�fyd NL1TIC Date 2 — 22 —1Z The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72.025 (Rev. 1/91) Back MOA #21 Municipality of Anchorage MUNICIPALi7 "uF AI,,CHuk,AGC_ DEPARTMENT OF HEALTH & HUMAN S"&fflt.SERVICES DIVISION Environmental Services Division 825"L" Street, Room 502 • Anchorage, Alaska 99501 • (907) 314-31474'41 M6 ry I ' /'Health Authority Approval Checklist Legal Description: Le� Q/aLK �CK�/i6� Parcel I.D.: O/S — 36 2 — A8 A. WELL DATA Well type /RJD If A, B. or C, attach ADEC letter. ADEC water system number Log present (Y/N) Y Date completed 5 f 21 L 3 Total depth /U/ Cased to /U/ Casing height (above ground) 33' Sanitary seal (Y/N) Wires properly protected (YIN) FROM WELL LOG AT INSPECTION Date of test S�vP3_/g 3 Static water level Well production 3U 9.13.111. 7 . /R.D.M. WATER SAMPLE RESULTS Coliform Q Nitrate 3, Y /)V// Other bacteria Q Date of sample: /�07�/9� Collected by: /1// B. SEPTIC/HOLDING TANK DATA Date installed 63 Tank size /Z `J 0 Number of Compartments p >i Cleanouts (Y/N) Foundation cleanout (Y/N) �_ Depression (YIN) /A/ High water alarm (Y/N) A1,4 Date of Pumping 112'511f6 Pumper A/D/ �J Cl`I C� / e YE 4as onl j oh.'c CO. 4L05 e"Vo Co . ar, 7;V e. C. ABSORPTION FIELD DATA Date installed S 3 A9 3 Soil rating (g.p.d./ft' or ft'/bdrm) g5 System type iDE6P %2ENCf1 Length _�16_ Width Gravel thickness below pipe 5 Total depth /Z S/ Effective absorption area 350 Monitoring Tube present(Y/l)—L— Depression /over field (Y/N) /V Date of adequacy test / Results (Pass/Fail) A1SS For 7 bedrooms Fluid depth in absorption field before test (in.); 112 Z Immediately after gal. water added (in.): Fluid depth 37 (ins.) Minutes later: /o2oo Absorption rate = 706 fi g.p.d. Peroxide treatment (past 12 months) (Y/N) /V If yes, give date AIA D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested E. SEPARATION DISTANCES Size in gallons "Pump ori" level at* *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: "Pump off' level at* Septic/holding tank on lot /oo ,.7 : On adjacent lots /00 1 + Absorption field on lot /oo ; On adjacent lots loo Public sewer main/✓f /� Public sewer manhole/cleanout Sewer /septic service line S 1 -f Lift station /V SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation lP 0 f Property line /0 1 + Absorption field lv Water main/service line /D Surface water/drainage /60 + Wells on adjacent lots /60 f SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation 76 + Water main/service line ZS 1 4 - Surface water /00 + Driveway, parking/vehicle storage area Curtain drain 160 -�Wells on adjacent lots F. ENGINEER'S CERTIFICATION -f- Property line /D '4 I certify that I have determined thru field inspections and review ofNlunicipal records x tl@Fhgqq%QhVFs are in con armance with AvIOA H.1.41 uidelines in effect on this date. J g ff � .* �o�'"'°'aa `'r= ., s, Fater SignatureCV J'3 s �� ®ca6�e"socca:.aee�:oa „s Engineer's Name ��'�*G� Date Z- 19Z c+F;�-..;:f:�i.i•�,A�',`,';,> � HAA Fee S • 41t) Date of Payment Receipt Number Rev. 8/95 OSS: haa.wk.doc Waiver Fee $ Date of Payment Receipt Number