HomeMy WebLinkAboutDELUCIA LT 17 & T15N R1W SEC 9 LT 162
Municipality of Anchorage Page I of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: ~b~=[ ~Ot-/(=, PID Number: 051 ..'- i ~'J ~"~ ~
N~: ~~ ~U~C~ ~ Wastewater System: ~ New ~ Upgrade
Address: ~ ~
~z~¢o ~~ ~ c~u~,~, &~ ABSORPTION FIELD
Phone: &6~ --772~ J No. of Bedrooms:~
~ ~ Deep Trench ~ Shallow Trench ~ Bed ~ Moun er
LE GAL D ESCR I PTI O N Sol, Rating: Total Depth~~l
grade:
GPD/Sq. Ft.
Lot: Block: Subdiv~ion: Depth to pipe bosom from original grade: Gray--th beneath pipe
Township: I Range: I Sectiom Fill added above original grade: f Gravel length:
~ ~ ~ / Ft. Ft.
Gravel width: ~ Number of lines: ~9is~n~ ~n lin~:
WELL: Ex~T,~ New ~ Upgrade ~~ Ft.I Ft.
OIsssification (Private, A,B,C): Total ~ ~d To: Total abso~rea: Pipe material:
¢~¢ ~ .t. ~t.¢ so..t.
Driller: / Date Drilled: Static Water Levek Instal~ Date installed:
Yield: ~ I Pump Set at: I Casing Height Above Ground: TANK
~ GPM Ft. Ft.
SEPARATION DISTANCES ~ ~ Ho~Ui,g ~ S.T.E.P.
TO ~ptic Absorption Lift Holding ~ublic/Private Manufacturer: Capacity in gallons:
From Tank Field Station Tank ~wer Lin~ ~C ~O~ ~< JOO ~
Matedah Number of Compa~ments:
We~ Ioo~ Io~~ ~ ~ ~¢~+ %~L
Sudace
Water /OCt~ ~OO -- ~ -- LIFT STATION
Foundation ~t~ ~ '~ -- -- -- "Pump on', level at:
Cu~ain - ~ o~ ~ ¢~ ~ P~l~tri~l Ins~ions pedorm~ by:
Drain
Remarks: ~t& CA& ~ ~~ BENCH MARK
Location and Description:
I..
Inspections pe~ormed by: ~sr~r~ &~oc~r~ Dates: 1st ~.~...~.~..~
Depadment of Health and Human Se~ices approval - ~,, ::..,,,, .......
Reviewed and approved by: /~~ ~ ~ Date:/2-~- ~E
72-013 (Rev. 9/91) MOA 25
PERMIT NUMBER:AS BUILT D~WINGPARCEL ID NUMBER:
SW9801 76 ' 051-1 41 -;31
EXISTING TRENCH DBL2--~ ~--DBL1
x ~ NEEDLES LOOP
FIlL O~DE
95.69+ ~
~ I
90.27~ ~90.29
LECAL DE~CRIP~ON'.
~PE OF WORK:
AS-BUILT OF NEW SEPTIC TANK ............... ;...,~
CHURCHHILL 688-7720
Alaska Water & Wastewater
7320 East Chester Heights Circle - Anchorage ~ Alaska 99504
Phone (907) 337-6179 ~ Fax (907) 338-3246
July 28, 1998
Municipality of Anchorage,
Department of Health & Human Services
P.O. Box 196650
Anchorage, AK 99519-6650
Attn: Laura Montgomery
REFERENCE: Lot 17; Delucia Subdivision
Status of septic system documentation
RECEIVED
JUL 30 1998
Municipality of Anchorag~
Dept. Health & Human Service8
A permit (SW980176) was issued to install the referenced septic system 6/16/98. This
property is undeveloped and a new home is being built. The septic system has been
installed, however there are no points of reference to swing-tie the new septic system on
the property. After the house is complete, final grading is done and an as-built survey is
done, I will complete the documentation and as-built of the septic system which will be
submitted to your department (DHHS) for review and approval. If you have any
questions, please contact me at 337-6179 or 244-9612.
Thank you for your assistance.
Prin
JAG/gk
MUNICIPALITY OF is~NCHOP~AGE
DEPARTMENT OF HEi~.LTH AiN-D ~ SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
PAGE
1 OF lO
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT ~ER:SW980176
DESIGN ENGINEER:~A~ ~~ ~ ~;~$T~ ~ ~
OWNER NAME:CHURCHILL GRACE
OWNER i~DDRESS:22980 NEEDELS LOOP
CHUGIA/<,ALASKA 99567
DATE ISSUED: 6/16/98
EXPIRATION DATE: 6/16/99
PARCEL ID:05114131
LEGAL DESCRIPTION:
DELUCIA LT 17
LOT SIZE: 33976 (SQ. FT.)
~ER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONSTRUCTION OF:
SEPTIC TAigK SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 ~ 15.65 ~ THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE ENGINEER MIJST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEMUNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAMIE DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY:
DATE:
ISSUED BY: ~~~
Alaska Water & Wastewater
7320 East Chester Heights Circle N Anchorage - Alaska 99504
(907) 337-6179 - Fax (907) 338-3246
Consulting Engineers
May 29, 1998
Municipality of Anchorage
Department of Health & Human Services
Division of Environmental Services
On-Site Services Section
P.O. Box 196650
Anchorage, Alaska 99519-6650
Reft Septic Tank Upgrade for Lot 17, Delucia Subdivision.
To whom it may concern:
The referenced property has a existing well and septic system that was serving a trailer which has
been removed from this property. The septic system was documented with your department on
August 18, 1979 and the well was documented on November 9, 1971. A proposed 3 bedroom
house is to be built on the referenced property.
The existing septic tank is less than 100 feet from the well. The nitrate levels in the well have
been monitored and found to be at 1 t .8 mg/L on 4/18/97 and at 4.75 mg/L on 5/5/97. Due to the
high nitrate levels, a waiver of the separation distance from the septic tank to the well is not
justified. Consequently, we are proposing to install a new 1000 gallon septic tank outside of the
well radius.
I am unaware of any adverse impacts this installation would have on adjacent wells or septic
systems. If you have any questions, please contact me at 337-6179, or 244-9612. Thank you
for your assistance.
Sincerely,
Principal
.~ ,"" HUNTERS
,~ LoT ~ DELUCIA S/D ~
WELL
.~ INSTALL DBL CO~ ~
EXI~ING TRENCH~ / ~
~ /.-/ ~ ~ ..... < ~ -
~ 1~4' I I~1 ., t'-~ o
TO BE COMPL~ELY ~NDONE~~~ . ~ ~ °
/ ~' :' ~ ~ '.
NEEDLES LOOP
,~. ...
LOT 18, DELUCIA S/D
NO ~LL OR SE~IC W~IN 100 FE~
OF EXI~ING ~LL ~D SE~C ON LOT 17.
LOT 1fl, DELUCIA
PREPPED ~:
WA R WAS WA R
LEaL D~CRI~ON:
PR~AR~ FOR: PHONE NUMBER:
KEVIN WILLIAMS 688-7720
J.L.M. 1 = 100' 1 OF 1
MUNICIPALITY OF ANCHORAGE
~' ~l"J ~\ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ,
ENVIRONMENTAL ENGINEERING DIVISION
~'~~~~ ~~, 825 L Street- Anchorage, Alaska 99501 Telephone264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
~ ]PHONE
MAILtNGADDRESS
LEGAL DESCRIPTION
TNO. OF BEDROOMS
LOCATION ~~ ~--~--~
DISTANCE TO: ~ ~p ~n D~ellin~ ~
~ ~ Mate~al No. of compartments
p ~ U~nu~ac~u~.~ ~A~ ~~
iL q. L qu d
~ IF HOMEMADE:
Well Dwelling PERMIT NO.
6 ~ DISTANCE TO:
O ~ ~ Manufacturer ~aterial Liquid capacity in gallons
~ Well ~ Found~o~ ~ Nearest lot line ~ PERMIT NO.
~ DISTANCE TO: ~ I~W
~ Z N°' of ~ ' inches
~ ~ ~ ~op of tile to finish grade Material beneath tile Total effective absorption area
Length Width Depth PERMIT NO.
~ i
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
Class Depth Driller Distance to lot line PERMIT NO.
~ Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
ATERIALS SOl L TEST RATING ~ ; ~i /I
REMARKS ~/
APPROVED DATE LEGAL
72-013 (Rev. 3/78)
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THE: !._ENC~iTH D I I"IENS ]: O1",I I S 'THE/ LENCi'I'H ,:; [ I",1 F:'EtET ) OF THE: TF:E;NCt.-!
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O & E ENG,,~IEERING & DEVELOF ,,/lENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
Russell Oyster
694-2774
Performed for:
Legal Description:
Earl Ellis
SOIL LOG 688-2280
Name: ~.~./~Z,%';'-~ ~-~,,~ K/'~-~~¢ TeI. N0 ~-Z~
MailingAddress:~. ~ ~c~ ~~ ~< ~¢~--X'7
Depth (feet)
Soil Characteristics
1
2__
3__
6__
8__
z t97
PLOT PLAN
11__
12__
13__
PERC. TEST
14__
15__
16__
Ground Water Encountered: Yes
Proposed Installation: Seepage Pit
No /"/' If yes, what depth
Drain Field ~'~
Comments:
Performed by: '~ ~ $-~
Date:
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
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
051-141'-31 HAA# L'I
GENERAL INFORMATION
Complete legal description
Lot 17; Delucia Subdivision
Location (site address or directions)
22980 Needels Loop
Chugiak, AK
Property owner Kevin Williams Day phone
Mailing address P.O. Box 672363 Chuglak, AK 99567
Lending agency Day phone
Mailing address
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
XX
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
Name of Firm ~,u~w
Address AgO I j~C=.g
Engineer's signature /
~f this inspection.
_ ~ .,-./~/,, ~. X/,- '.~ .... "Phone
~ ~ Date /z.-/£,,/~,~
AT CLOSING FOR '~:"
bedr~,,,~. :,
ALASKA WATER & WASTEWATER CONSULTANTS,
IS TO BE PAID $1525.00
ENGINEERING SERVICES PERFORMED.
6. DHHS SIGNATURE
~ Approved for
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
By:
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91} Back MOA
RECEIVED
DEC 08 1998
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SER~^uT¥
Environmental Services Division ~NyIRON6~NT^LSERVICE$ DIVI$~
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Health Authority Approval Checklist
Legal Description:
A. WELL DATA p/~. o. /~.
Well type
~C~UlSo,~ 1 Zo? /7~ ParcelI.D.: 0~/ -//-//
If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N)
Total depth
Date completed
Cased to
Casing height (above ground)
Sanitary seal (Y/N)
Wires properly protected (Y/N)
Date of test
Static water level
Well production
FROM WELL LOG
AT INSPECTION
WATER SAMPLE RESULTS:
Coliform
Nitrate ~ Other bacteria
Date of sample:
B. ~~ TANK DATA
Date installed d~/7/'~ ~ Tank size
Foundation cleanout ~/1~) ~---~
Date of Pumping /Z/.~//~ ·
Collected by:
/ o ~ c~ Number of Compartments
Depression (t1~ /~J o High water alarm 0¢'/~
Pumper -~¢--, f)un~f~.~,,,J c.
C. ABSORPTION FIELD DATA
Date installed ~//~/$/-'f'~
!
Length ..~C) Width
Effective absorption area ~ tSO ~
Date of adequacy test
Fluid depth in absorption field before test (in.);
Fluid depth (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
Soil rating (~l~el~or ~ / ~
I
Gravel thickness below pipe
System type
Total depth
Monitoring Tube present (~). X'~ Depression over field (Y/~t
Results (Pass/Fail) (~,~.S For --~ bedrooms
Immediately after2 22~/gal. water added (in.):
I O~ Absorption rate z.~_~ +
= g.p.d.
N~ ~ /4',~o,~'~ If yes, give date
72-026 (Rev. 3/96)*
D=
/
LIFT STATION /'~//A
Date installed Size in gallons ~
M anhole/A~~)~~~. ~~''Pump Off'' level at*
Cy~ted ~
E. SEPARATION DISTANCES
Septic/holding tank on lot
Absorption field on lot
Public sewer main
SEPARATION DISTANCES FROM WELL ON LOT TO:
I
I
Sewer/septic service line
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM ~~ TANK ON LOT TO:
Foundation '7_8 I~.~. Property line ~11~ Absorption field
Water main/service line
I ol~' Surface wateddrainage /
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
- Water main/service line
Surface water
Curtain drain M ~ H e~ /Z,~ ' ,-J / Wells on adjacent lots .
oF
I certify that I r~ field inspections and review of Municipa~'t
in conforma~[ce ~<'~0/ ~ g~ ~elines in effect on this date.
Signature[
Engineer's Name
Date /
s are
HAA Fee $ ~d~, --'"" Waiver Fee $
Date of Payment ~<~"~ /~ //Y Date of Payment
Receipt Number ~ ~ Z/3 ~ Y/~ Receipt Number
72-026 (Rev. 3/96)*
GREATER ANCHORAGE AREA BOROUGH
DEPARTMENT OF ENVIRONMENTAL QUALITY
3500 TUDOR ROAD
ANCHORAGE, ALASKA 99507
279-8686
DATE RECEIVED:
INSPECT'._ Il- Y'- TI
TIME: ~ '-'
REQUEST FOR APPROVAL
INDIVIDUAL SEWER AND WATER
FOR
OF
FACILITIES
CA.i
APPROVAL REQUESTED
ADDRESS:
PHONE:
PROPERTY OWNER:
LEGAL DESCRIPTION'
TYPE FACILITY TO BE
NUMBER OF BEDROOMS'
u:~i ~-1 DLLU~rA
PHONE:
INSPECTED: ,?
STREET:
WELL DATA'
A. T Y P E
B. DEPTH
C. SIZE ~ ;'
D. CONSTRUCTION
·
E. BACTERIAL ANALYSIS /./~-'
SEWAGE DISPOSAL SYSTEM'
SEPTIC TANK (IF HOMEMADE, SHOW DIAGRAM
1 . S I Z E 'Ix.. ~L
2. AGE
3. MANUFACTURER
4. INSTALLER
ON BACK)
APPROVAL REQUEST FOR SEWER & WATER FACILITIES
PAGE TWO
B. SEEPAGE PIT
1 . SIZE ~
2. LINING L'?,!t L
'~x~ISPOSAL FIELD
· NUMBER OF LINES
2. TOTAL LENGTH
REQUIRED MEASUREMENTS
A. WELL TO SEPTIC TANK
B. WELL TO SEEPAGE PIT
C. WELL TO SEWER LINE
D. WELL TO PROPERTY LINE
E.
F.
G.
H.
./
WELL TO OTHER POSSIBLE CONTAMINATION
FOUNDATION TO SEPTIC TANK
FOUNDATION TO SEEPAGE PIT
SEEPAGE PIT TO PROPERTY LINE
COMMENTS:
APPROVAL'~ vALID FOR ONE YEAR FROM DATE SIGNED.
GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On-Site Services Program
825 L Street, Room 502
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-4744
ON-SITE WATER SUPPLY PERMIT
Initial
Date Issued: Dec 09, 1998
Expiration Date: Dec 09, 1999
Permit Number: SW980461
Legal Description: DELUClA LT 17
Design Engineer: 0041 AK Water & Wastewater Consutta
Owner Name: Grace Churchill
Owner Address: PO BOX 670257
CHUGIAK, AK 99567-0257
Parcel ID: 051-141-31
Site Address: 022980 NEEDELS LOOP
Lot Size: 33976 SQ. FT.
Total Bedrooms: 3 Permit Bedrooms: 3
This permit is for the construction of:
[] Disposal Field [] SepticTank [] Holding Tank [] Privy
[] Private Well [] Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ).
3. The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4, From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Date:
Date:/2 -
Alaska Water & Wastewater Consultants, Inc.
6901 Debarr Road, Suite 2B - Anchorage - Alaska 99504
(907) 337-6179 - Fax (907) 338-3246
Consulting Engineers
December 7, 1998
Municipality of Anchorage
Department of Health & Human Services
Division of Environmental Services
On-Site Services Section
P.O. Box 196650
Anchorage, Alaska 99519-6650
Ref: Potable Water Permit for Lot 17, Delueia Subdivision.
Mr. Roth,
As of this year, a new 3 bedroom house has been built on the referenced property. Prior to
construction of the new home, the property had a existing well and septic system that served a
trailer which has been removed. On June 6, 1998, apermit was obtained from your department to
upgrade the septic tank. The septic tank has been upgraded and all separation distances have been
met. The existing well has had several water samples taken for nitrate testing throughout the last
two years. The nitrate levels have ranged from 4.75 mg/L to 14.985 mg/L. A potable water
storage system has been installed in the crawlspace of the home. Attached is a water schematic
showing what has been installed. Our client would like to request that your department issue a
permit for the approval of this new potable water storage system in order to obtain a Health
Authority Approval. It is our understanding that our client has had several conversations with you
and that you have agreed to expedite the issuance of this permiL
I an~ unaware of any adverse impacts this installation would have on adjacent wells or septic
systems. If you have m V questions, please contact me at 337-6179, or 244-9612. Thank you
for your assistance. /~
Sin~cel~ely, ~///~//~/
SIGN ON OUTSIDE OF
V//x/~IOUSE FOR FILL PORT,
POTABLE
WATER
PVC (ASTM D-I765)
WELL-X-TROL
WX-205
PRESSURE SWITCH PRESSURE TANK PRESSURE GUAGE
TO ~OULD$
UNION
HOSE BIB
~CHECK VALVE
ALASKA WATER AND ~rASTE~'ATEI~ CONSULTANTS, INC.
69{31 DE'BARE ROAD SUITE 21::1. ANCHORAGE. AK 99504 ~¢,~. ~,~,C...?~ ?/~,
_EOAL OESCRIP~ON:
DELUCIA SUBDIVISION; LOT 17,
WATER SCHEMATIC AS-BUILT OF WATER STORAGE SYSTEM ..~.~,~.,~,--.v.- ........
360 E, Internatloaal Airport Rd., St* 9
Anchnrago, Alaska ~ I g
(907) 563-3770 Ph (907) 563-5502 Fax
DAm ~74+/C1~.,,
',PHONE/F~:
SENT BY:
MESSAGE:
URCH
~MANuFACTURING COMPANY, INC.
The Easy, Economical Way
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Model No.
Approximate Size
Approx.
Shipping Wt.
Gals. Liters Lbs, KG
FDA 50MT 40" x 50" x 12" (102em x 127em x 30em)
FDA 73MT ~0' x 73" x 16" [203cm x 185cm x 41cra)
73 276 11 5
275 I040 23 10.4
FDA 98MT
FDA 610MT
FDA 712MT
65" x 98" x 18" (165cm x 249cm x 46cm) 525 1987
6' x 10' x 2' (1.83m x 3.05m x .6lin) 800 B028
7'x 12' x2' (2.13m x 3.66m x .6lin} 1140 4315
33 15
42 19.1
58 26,3
FDA 714MT 7' x 14' x 2' (2.13m x 4.27m x .61m)
1340 5072 64 29
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Reg~flation, making it safe for drir~king water used toe hum. an eons~.tmptiol~.,
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Burch Manufacturtng has been making
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URCH
~~UFACTLrp, JNO COM~PANY. INC.
618 First Avenue North Box 876
For[ Dodge. Iowa 50501 Phone:(515) 573.4136
i~ 1-515-§73,41~8
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./