HomeMy WebLinkAboutCHANDELLE ACRES LT 13L/I -01LC vvaLer ana/or nastewater System
Permit
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water & Wastewater Program
4700 Elmore Road, PO Box 196650
Anchorage, AK 99519-6650
Telephone: (907) 343-7904
Permit Number: OSP161342
Tax Code Number: 05182209000
Work Type: SepticTank Upgrade
Permit Effective Dates: December 07, 2016 to December 07, 2017
Design Engineer: NORTH RIM ENGINEERING
Subdivision: CHANDELLE ACRES
Site Legal Address: CHANDELLE ACRES LT 13 G:1560
Owner/Address: CUSHMAN DAVID W & PAMELA F
22006 CLOVERLEAF DRIVE CHUGIAKAK 995675560
Site Mailing Address: 22006 CLOVERLEAF RD, Chugiak Lot Size in Sq Ft:
Total Bedrooms:
This permit is for the construction of:
-c Z- 17
42950
3
N Disposal Field V Septic Tank N Holding Tank N Privy N Private Well N Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater
Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80).
3. The wastewater code requires inspections during the installation. The engineer must notify the Development Services
Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either:
A. Open and Close on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By:
Issued By:
ra-V16.4
Date:
2ZI—sh
�
Date: 12,107 ?-0
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
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
~ ¢:;3¢~- _1:~ ~. ~ i.-~! ~ ~--~ 0 ~ UPGRADE
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION NO. OF BEDROOMS
iWell / I Absorptio~area 2, i~j ~ PERMIT NO.
DISTANCE TO: /~ ~ + 7 ~
~ Z Manufacturer eri No. of compartments
Liq. capacity in gallons inside length Width Liquid depth
/ ~OO IF HOMEMADE:
~ DISTANCE TO: Well ~ Dwelling PERMIT NO.
~ -- ~ Manufacturer Material Liquid capacity in gallons
~ Well ,, ~n~a~h)e~' ~ Nearest lot line ~ PERMI~
~_ No. oflines I Length of ea~ ~tat e ~n Trenchwid~ inches Distance between lines ~
Total ~ffectiv~so rptio n area
~ Q ~ ~ Top of tile to finish grade 3 / Material beneath tile ~ inches
~ Length Width ~ ~ ] Depth PERMITNO.
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.
~ -- Cuitding foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
//
P¢o
INSTALLER
· I
(Rev. 3/78)
PERMIT NO.
DEPARTMENT OF HEALTH AND ENVIR. ONMENTAL PROTECTION
825 '"L'" STREET, ANCHORAGE., AK. 995E~&
264-472EI
~4ELL R~-~[:. Ci~-~.--~ I TE 5i~4i~: F'i~:l',l I T
8]:E~542 ::,
RF'F'L i CRNT
LOC:RT I C,N
LEGRL
C, ONRL[:, E SHEIK
E. F.:.
Ltl: CHRNDELLE RCRES
i2'_=,. MER[:,Okl CREEK E.R. ~577
LOT SIZE '_=,.D.D.'_=,,D:9 SQLIFIRE FEET
TYPE OF SOIL FIBSORPTICiN SYSTEM IS: TRENC:H
MFIXIMUM NUMBER OF BE[:,ROOMS = 3
SO I L F.:RT I NG ,:: S6! FT,.-'BR ) = ±'_-9.7
THE RE6.!UiRE[:, SIZE OF THE SOIL RBSORF'TION S'¢STEM IS:
[:,EF'TH= 9 L_ E i'-.i t3 T H = 5E~ ~_3 E: I'=1 "...' E L [:,EF'TH= 6
THE LENGTH DIMENSION IS THE LENGTH ,:;IN FEET::, OF THE TRENCH OR DRFtINFIEL[:,.
THE DEPTH OF FI TRENCH OF.: PIT IS THE DISTRNC:E BETWEEN THE SURFRC:E OF THE
GROUND ¢~N[., THE BOTTOM OF THE EXCR'¢FITION (IN FEET).
THERE iS NO SET i4iDTH FOR TRENCHES.
THE GRR',,,'EL DEPTH IS THE MINIMUM DEPTH OF GRR',,,'EL BETHEEN THE OUTFRLL PIPE
RND THE BOTTOM OF THE EXE:RVRTION (IN FEET;:,.
F-:E~;!Li ][ F-:E[:, '_=.EF'T I C: TRi'-.il<' '_=- I ZE= :1.~E~-="~£-~
PERMIT FIPPLICFINT HRS THE RESPONSIBILITY TO INFORM THIS [:,EPRRTMENT DURING THE
iNSTFILLRTION INSPEF:TIONS OF RN'¢ WELLS RDJFICENT TO THIS PROF'ERT'¢ FIN[:, THE
NLiI"iBER OF RESIDENCES THI=tT THE WELL WiLL SER',,,'E.
Tl--.l']~ .:: 2 ::, I i'-,.I'_-]F'EE:T 'Ii' C~l'-,,i:5 F--I I:~:E F4E~]:-!Li I I:~:E[:,
E',FIE:KF ILL i NG OF FIN¥ S"r'STEM H I THOLIT F I NFIL I NSF'ECT I ON RN[:, RF'PRO',,,'RL 8"? TH I S
[:,EPFIRTMENT WILL BE SUBJEE:T TO PROSECUTION.
MINIMUM [:,ISTFINCE BETWEEN FI WELL FIN[:, FIN¥ ON-SITE SEWRGE [:,ISPOSRL S'¢STEM IS
±~3E~ FEET FOR FI PRIVFITE WELL OF.: "lSEi TO 2EIE-1 FEET FROM FI PUBLIC WELL [:,EPEN[:,ING
UF'ON THE TYPE OF PUBLIC WELL.
MiNiMUM [:,ISTFINCE FF.:F~M t=t PF.:IVFITE WELL TO FI P~.:IVRTE SEWER. LINE IS c'.'5 FEET FIN[:,
TO R COMMUNIT'¢ SEWER LINE IS 75 FEET.
WELL LOGS FIRE REQUIRED FIND MUST BE RETURNED TO THE [:,EF'FIRTblENT WITHIN --.':E~
OF THE WELL COMF'LETiON.
OTHER REQL.t i REMENTS MFI'¢ FIPF'L¥. SPEC I F I C:FIT IONS FIND CONSTRUCT I ON [:,I FIGRFIMS FIRE
FIVFIILFIBLE TO iNSLiF.:E PROPER INSTFILLFITiON.
F'EF-:I-'-I :[ T E-'-=-,.; F' I F-:E$ [:,ECEI"'IE:EF-: -----::1__.
I E:ERTiF'¢ THFIT
±: i BM FRMILIFIR WITH THE RE6~UIREMENTS FOR ON-SITE SEWERS FIN[) WELLS FIS SET
FORTH B'¢ THE MLINICIF'RLIT'¢ OF FINCHORFIGE.
2: I WILL INSTRLL THE S'¢STEM IN RCCORDRNCE WITH THE E:O[:,ES.
].: i UNDERSTRND THFIT THE ON-SITE SEHER S'¢STEM MR'¢ RE64UIRE ENLFIRGEMENT IF THE
RESIDENCE IS REMO[:,ELE[:, TO INE:LU[:,E MORE THFIN --.': BE[:,ROOMS.
S I GNED:
'¢4.
1~ /l~.~OOhl CREEk' E R. 995??
LOT $IZI~ 999999 SQURRE FEi
TVPE OF 50IL RegORPrION 5'rSrEN I5: TREe, DH
H~X[MUi~ NUHBl~R OF 8EDROOH5 = Z SOIL Rt~T{NG (gQ FT?GR)= 15)7
THE_ REQu{RI~O SIZE OF THE ~O{L RGSORPTION ~'~sr~ ~:
£,EPTH= 9 L El%l~2i-rH= 50 ~]RFIYEL DEPTH~= 6
t'HE LCNGTH DIMENSION Jg THt~ LENGTM (IN FEEI'~ OF THE T~H
D~RE I5 HO ~r WIDTH FOR TR~C~.
THE GRRV~ O~rH ['~ ~ DIINIHUM DEPTH ~ P~~ ~r~ r~ ~rF~L PI~
~ r~ 8DITCH ~ ~E E~CRVRTION (~N
· RE~IJ I RED L~EPT · ~ TRNK S I ZE: '~J. 888 I]FtLLON_'J.
~ ~;FF~LL[~ OF RNV SYSTEM t4[T~DUT F[~ INSPECTION
O~RRT~IEt~F HILL ~ ~Ue4~Cr TO PROSECUTIO~
leON FH~ rv~ OF PU~[C &'tEL
TO A COHI'~N[TV ~ L[~ IS 75 FEE~.
t~L LOG'~
~ THE
OTHER ~DUIREP~TS H~'~
~VRI~E TO INSURE PR~ER INSFI~TION.
RES C~EC:ErNBER 31., 19Lq3
;~; [ HILL INSTRLL T~ ~VSFEH JN ~;CORO~ NITH T~ CODES.
RE'SIDEt-)~ IS ~HO~LEO TO Ir~lU~ MO~ ~N 3
~PPLICRNT ~N~ E '~[K
PERFORMED FOR:
LEGAL DESCRIPTION:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
~ ~[~---"~[~" DATE PERFORMED:
[] SOILS LOG
PERCOLATION
TEST
1
2
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
/
SLOPE SITE PLAN
J-'%' o.*'/ 1 FA '",,o"".~ ~'/'
~~ WAS GROUND WATER
ENCOUNTERED7
S
L
O
P
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
/ ~.'--/~-e.:~~,~.s'--o ~,,, ~ (,.. ~, '/ ._._---
~,,
~ Ig':ztr~ lc- I.~, /.3 ~
' I
PERCOLATION RATE (n~inutes/inch)
TEST RUN BETWEEN ~ , FT AND '~--~ FT
PERFORMED~ : : ~1~1~ t~ CERTIFIED _
72-008 (6/79)
DATE:
erlifieh rilling
by
Doc co. db~
SULLIVAN WATER WELLS
P.O. BOX 272, CHUGIAK ALASKA 99567 · TELEPHONE 688-2759
OWNER OF LAND
ADDRESS
LEGAL DESCRIPTION
DATE - Started
Ended
PERMIT NUMBER
DEPTH OF WELL
STATIC LEVEL OF WATER FT.
DRAW DOWN FT.
GALS. PER HR
KIND OF CASING '
KIND OF FORMATION:
From__Ft. to Ft.
From Ft. to ,, Ft.
From__Ft. to Ft.
From Ft. to Ft.
From__Ft. to__Ft
From__Ft. to.~.Ft.
From___Ft. to__ Ft.
From Ft. to ~ Ft.
From__Ft. to__Ft.
From Ft. to Ft.
From Ft. to__Ft.
From__Ft. to Ft.
From Ft. to__Ft.
From__Ft. to__Ft
From~Ft. to.~Ft.
From~Ft. to Ft.
From Ft. to Ft
From
From
From
From--
From
From
From
From
From
From
From__
From
From
From
From
From__
Ft. to
Ft. to
Ft. to
Ft. to
Ft. to
Ft. to
Ft. to
Ft. to
Ft. to
__.Ft. to
Ft. to.__
.Ft. to__
Ft. to
Ft. to
__Ft. to
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F t - -
--"'- ....
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Ft.
Ft.
_Ft.
MISCL. INFORMATION:
DRILLER'S NAME
Municipality of Anchorage •
On-Site Water and Wastewater Program
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
/Parcel I.D. 051-822-09 Expiration Date: ' 2-4�g
1. GENERAL INFORMATION
Complete legal description Chandelle Acres Lot 13
Location (site address) 22006 Cloverleaf Road
Current Property owner(s) Cushman Day phone 688-9845
Mailing address same
Real Estate Agent Owner Day phone 688-9845
2. TYPE OF DWELLING: u�6 ? 8 9 70 >>
® Single Family (w/wo ADU) .<
❑ 15.
DuplexEI,ry �� ���
❑ Multiple Dwellings (Single Family and/or Duplex) AUG 2 1013 3
c
3. NUMBER OF BEDROOMS: 3
<< n
6 8 L9
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ® Individual
Individual Water Storage ❑ Holding Tank ❑
Community Class C Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
Received by: - Date: 7 d
COSA to be released to the engineer,unless oth: ise requested by the engineer.
COSA Fee $ EEG- b() Date:
Date of Payment 6/24 1 $ Date of Payment
Receipt Number °97(d Receipt Number
COSA# Osc 19[ 4-2-2] 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.
Name of Firm NorthRim Engineering Phone 694-7028
Address PO Box 770724, Eagle River
Engineer's Printed Name Steve Eng Date 8/20/2018
•
•
in 9
6. DSD SIGNATURE r^ ^^41c` �` °,D, vw.•o
fo
System #1 Approved for bedrooms. ••••
65,
Leven \v. Eng o°• 6�
System #2 Approved for bedrooms. ;,5 •
,'.'c; � " ..ate,rt
Disapproved. '*� °°°0./u::'(\\ ``
Conditional approval for bedrooms, with the following stipulatiohls1.710
J
ON-SITE
WATER AND
:A WASTEWATER c`
PROGRAM
de Original Certificate Date: !
The Municipality of Anchorage Devlopment 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 blue sheet_9-1-12.doc
If more than 1 septic system is on the lot:
COSA Checklist# of
Structure served by this system
Certificate of On-Site Systems Approval Checklist
Legal Description:C/./A,/,o ELL 4C re.S L. 15 Parcel ID:os 8220
A. WELL DATA
Well type P If A, B, or C provide PWSID# Well Log (Y/N) �/
Date completed C/'7/P3 Sanitary seal (Y/N) 7' Wires properly protected (Y/N) (7'
Total depth 2Z I ft. Cased to 4/0 ft. f" Casing height(above ground) 24- in.
FROM WELL LOG AT INSPECTION
Date of testc A -� 7(1.3// .P
Static water level / ! ft. 3 S ft.
Well production Q g.p.m. .S'f" g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 mL Nitrate 2. 'smg/L
Arsenic /n+ ug/L Date of sample: 7//f/I J Collected by: /V gf4f
7"---47
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material S C.! �'Lf scr-r Date installed 102// 7
Tank size/000 gal. Number of Compartments Z Cleanouts (YIN) /
Foundation cleanout(Y/N) Depression over tank(YIN) N High water alarm (Y/N) ,An/
Date of pumping Pumper olt.\` 2../ U SI✓cL c 0� t Ow-lite
C. ABSORPTION FIELDDATA
Date installed Ofr #-3 Soil rating (g.p.d./ft2 or ft2/bdrm) /g7 System typeDeco 75..4e.4
Length 50 ft. Width 3 ft. Gravel below pipe 6" ft.
Total depth /0 ft. Eff. absorption area (OO ft2 Monitoring tube y Depression over field tet/
Date of adequacy test ',/ ?,8 Results (Pass/Fail) P For .3 bedrooms
Fluid depth in absorption field before test 3 in. Water added Z/50 gal. New depth /O in.
Elapsed Time: g() min. Final fluid depth 3 in. Absorption rate >= L/'J~a f g.p.d.
Any rejuvenation treatment(past 12 mo.) (Y/N &type) 1:1/1/fie— If yes, give date
D. LIFT STATION AM
Date installed Size in gallons Manhole/Access(Y/N)
"Pump on" level at in. "Pump off' level at in. High water alarm level at in.
Datum Cycles tested Meets alarm&circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot l(>O I'f' On adjacent lots OQ /1--
Absorption field on lot /064- On adjacent lots /00 r-F
Public sewer main /Oa' '-e. Public sewer manhole/cleanout /DO f
Sewer/septic service line ZS Holding tank 140 (4-
Animal
Animal containment areas 5.04 Manure/animal excrete storage areas /00 '#
SEPTIC/HOLDING TANK ON LOT TO:
7
Building foundation l 0 Property line /Q + Absorption field s f
Water main /O C'O. Water service line /O 'r Surface water (() O r1-
Wells on adjacent lots /661r
ABSORPTION FIELD ON LOT TO:
Property line /6 /1- -r foundation �a f Water main (Q (.4'
Water Service line �0 `+ Surface water /0 V /'- Driveway, parking/vehicle storage /0 'ft
Curtain drain Ci /K Wells on adjacent lots / 1i i4"
F. COMMENTS
G. ENGINEER'S CERTIFICATION '
•
I certify that 1 have determined through field inspections and ` r • `` '�
review of Municipal records that the above systems are in s••."e7
conformance with MOA COSA guidelines in effect on this date. <4' ° '.' ',
g � 7 J tEA) ' ,•.It -
Engineer's Printed Name ••.•••
�' z0(/�
Date '
COSA yellow sheet_2-6-15.doc
CHANDELLE DRIVE
q.1"7
7 ____
N
•
` �• o - - -
0'x15' UNDERGROUND
/ UTILITY EASEMENT
/
/ Lot 14 �o
/ l6Lot 13
/ ,y0i' 42,950 s.f.
/ N.‘� ,>. /
\ / ----- , I
/ \\ / �s
OJ
d'- SEPTIC '" n., PIPES oo, Ohi::
1l '
IWELL / ��F, o rnPI 71
75' COMMON < O *- N r-
USE EASEMENTS / �. �+ D
\ /
o -Ti
sem. 0
CAO 9�'0y9
(�
RETAINING WALL \
d O
Lot 12 66. A��•
<`i9,L
HOUSE DETAIL
Scale: 1" = 30' anti ?�
HANGAR
., ati 10' UNDERGROUND
•C)• ° UTILITY EASEMENT
�G,f- O�`',c 0
O 'o 13�:
0 q.•AA `gyp
2 STORY a� — — — — — I
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RESIDENCE ao 1 _ _ _ _ _ _
J
0 ,
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N
�out
< `- p _ r _
C
WOODEN_f\'1' gag PORCH IMMELMAN CIRCLE
FENCE
i
PLOT PLAN AS BUILT x SCALE 1" = 60' GRID NW 1560_ Project No. 18-337/A1 —
11500 Daryl Avenue, Anchorage, Alaska 99515-3049
Lan & Associates , inc . (907) 522-6476 Phone 00000Op��
g (907) 522-4625 Fax o OF g 4 opt
Professional Land Surveyors kenOlangsurvey.com Ov,GOz �C ,9sp40
jonathanOlangsurvey.com
I hereby certify that I have surveyed the following described property: VI-z):
61,_,. ..
• 49TH I' •-57 vA
LOT 13, CHANDELLE ACRES SUBDIVISION (PLAT No. 79-190) Q
Anchorage Recording District, Alaska, and that the improvements situated thereon are O A D
within the properly lines and do not encroach onto the property adjacent thereto, that a Q
no improvements on the property lying adjacent thereto encroach on the surveyed th73 KENNETH G. lAtltG . o
premises and that there are no roadways, transmission lines or other visible On . '11'2411 �Q
easements on said property except as Indicated hereon. •
44„,p, ••.4.5-5202.•• c,'
Dated this the Day of _ -- , , at Anchorage, Alaska ,oR "•-• ..10 <7'
�04� SSIONA�_.
It is the responsibility of the owner to determine the existence of any easements, O�pOoo��
covenants, or restrictions which do not appear on the recorded subdivision plat. AECC963
.Parcel I.D..O ,?-) - ~ 3-3. .--o ~
'1.
GENE'RAL INFORMATION
..~%:-~...' . .. ,... -. . ..... , : . , ,
Completelegaldes(~;il~'li6h Lot 13; Chandelle Acres Subdtv~.slon
L '
ocabon (site address 6r directions) 22006 ' Cl bverleaf Road
Municipality o1' Anchoral e
Devel°Pmen{ ServlC0 D j ;ittm-ent
Building Sate[y Divlslon · .
On-Sile Water and Waslewaler Program
' '4700 Soulh Br~gaw SI.
P.O. i3~x"196650 Anch6m~;'AK 99559-66§0'
CERTIFICATE OF HEALTH/ ,UTHORIfY APPROVAL
FOR A SINGLE FAMILY DWELLING
' ' ' ' Explrali6n Dale: ~ - 30 '- 'o ..Q_
Day phone _428-6324
Chugtakr AK 99567
Day phone.
Mailing address
Real Estate Agent
Mailing Address
Unless otherwise requested, HAA will be ~;eld by DSD for picl<up.
NUMBER OF BEDROOMS: 3
Day phone
TYPE OF WATER SUPPLY:
Individual Well
Individual Waler Storage
Community Class,
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
Individual On-site []
Individual Holding tank []
Community On-site
Public Sewer E]~
'l'he Municipality of Anchorage Development Services Deparbnenl (DSD) Issues Certificates of Health Authorily
Approval (tIAA) based only upon the represenlallons g van In paragraph 5 by an Inde endent
engineer registered In Ihe State o! Alaska Certificates of Heallh Authoriroval P professlonal civil
· ' · ' ty App are required for Ihe transtar of
lille (except belween spouses) for propedies served hy a single family on-Site wastewaler i
supply system. DSD also Issue . d sposal ahd/or waler
vel H rna- an ~ ........ so .HAAs ~pon requ..es~ lo homeowners. Cerhficales of Beallh Auth r' ,
........ u),.~ ,rom [ne cam or Issue ,or propemes served by a prlvale or Class C well and ma;~leY rAelPsPsr~eV~I
new Waler sample resul s ess than 30 days old. (Cedificales may be reissued for a period or up Io one year wilh
vapid waler samples.) Ced ~&les are valid roi' one year for properlies served by Class A or B we Is or a public
Waler syslem. The Mun c pality of Anchorage Is not responsible for errors or om~sslon
engineer's work. s In lhe professional
4e
.STATEMENT O~= iNSPECTION bY
· , . .
A~C~ '~y'my ea ~ffi edhe
rti~ed s I x reto and as vall~atio a~e sho~ below, I ven~ Ihat my Inves alloh,
based on procedures eutlined n Ihe Hea h
on-sile water Supply and/or waslewater dis~al~y~le~
..... ted h~6n.
bedrooms and type ~f structure I~d c~.
Munlcl alit :of ~chorage files aha ~r0m ~Y~
.';~e~]~g~ NJ .... ~ &g~m '1~
and regulations In effecl at Ihe time
NameofFirm S&S'~ng~neet~nR ..... ~ ........ :,"..-=.'- ~ ,'.' Phohe"694~979: ..... ·
Address [7036'~o~:h garde
En neer'sPrnte ameRobert C." P~'E';-, _1 ;28:2002~ ,' ....... ~.
gi . . . ,: .,..
, -..
DSD SIGNATURE ' ' -. ' '
Approved for ~ bedrooms,. ._..
. ,. ,~,,, . .,.-.. ~ ~ ~ · :: ·
Disapproved. ~ .,
~edrooms with Ihe following stiPUlations: ·
ConditionslepprovsIfor ~ . .. .. "..: . . . _ .-
Additional Comments
Attachments:
HAA Checklist
Septic SysJem .~dvisory
Well Flow Advisbry
X
Maintenance Agreements
suPp emental Engineer's Report
· Original Cedificale Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Sauth Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D.C.5'/ -~ :z~. -cc/'
GENERAL INFORMATION
HA # H.'q o o
Expiration Date: ~//- ~L_O - O J
C
Completelegaldescription L13: ~handel]e Acres S/P
Location (site address or direcfions) 22006 Cloverleaf Rd ChuRiak,
AK 99567
Current Property owner(s) Ron Gilson Dayphone 688-5120
Mailing address P.O,Box 672084 Chu~iak., AK 99567.-
Lending agency
Day phone
Mailing address
Real Estate Agent
Day phone
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class__
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site []
[] Individual Holding tank []
[] Community On-site []
[] Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single family on-site westewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with
valid water samples.) Certificates are valid for one year for propedies served by Class A or B wells or a public
water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional
engineer's work.
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 Health Authority 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
westewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm S&S Engineering
Address 17034 N. EaRle River Loop Eagle
Engineer's Printed Name Robert C. Co~,'~n P.E.
.7. bedrooms.,
DSD SIGNATURE
J..//" Approved for
Disapproved.
Conditional approval for
Phone 694-2979
River~ AK 99577
Date
,.-,- ~ .... ' .'..._'7,.~..
;;.'.;: .: .-.._
% ~ % ~os~ c cow*,
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: ~ ' ~ O - ~)/,
Municipality of Anchorage
Development Services Department
BulMtng Safety Division
On-Slte Water & Wastawater Program
4700 ,South Bragaw St.
P.O. Box 196650 Anchorage, AK 9951g-6650
www.cLm~c~orage.ak.us
¢~) a4a-~oa
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: /..O
A. WELL DATA
Well type ~,e/v~ rt
Date completed&/
Total depth ~ a~' fl.
Date of test
Static water level
Well production
IfA, B, or C providePWSIO#"
sandy sea
FROM WELL LOG
g.p.m.
WATER SAMPLE RESULTS:
Collfom~ O colonies/100 mi,
Date of sample:
B. SEe'ilC/HOLDING TANK DATA
Tank Typi~lamda1._._:
Nitrate J?/~ mg,/I.
Collected by:
Parcel ID: O .S' / '- P,,~ ,3 - ~,
Well Log(~)
Wires property protected {~N)
Casing height (above ground)
AT INSPECTION
aDD ft.
L/ g.p.m.
Other bacteria / ~ oolonies/100 mi.
S & $ ENGINE~'RINO
1703,: E~.,~. ~'
I.:,~ver Loop Road
Date installed, G/;L 3 / ~'-~'
Tanksize /Oo~ gal. Number of Compartments
Foundation cleanout~N),¥.~ Depression over tank (Y~ /'~ 0
Date of pumping 4~/,~/~p ! Pumper
C. ABSORPTION FIELD DATA
Datelnstai!.~l. ~'/,Z~/~'J Sctlrating (O.p.dJft~o~ It)'7
Length. ~'~ ft. Width :~c)" ,-fL-
Total depth./O ft.
Data of adequacy test
/
Fluid depth in abeorptlon field before test3 ,~' in. Water added,J-l/gal.
Elapsed Time: /;~3 min. Final fluid depth¥/*'}'~'i~. Absorption rate >=
Any rejuvenation treatment (past 12 mo.) (Y/N & type) ~'" ( ~/o ~,~ If yes, give date
Cleanouts(~/N) ¥ · J'
High water alarm (y~ x,J 0
System type T
Gravel below pipe
Eft. absorption area ~ ft= Monitoring tube
/
Depression over field ~ O
For ~ bedrooms
New depth/'/ Io in.
~'O .g.p.d.
D. UFT sTATIoN __ ~-"
Date installed __ Size in gallons _-..~leflfi'~e/Access (Y/N)
"Pump on' level at in~ High water alarm level at in.
Datum ~ .. Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DIb"FANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot )00 d-
Absorption field on lot
Public sewer main /d /~A
Sewer/septic sesvlce line ~L $' 4-
On adjacent lots ' /~ O ~
On adjacent lots ! O O -/-
Public sewer manhole/cieanaut
Holding tank a)/,6
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation ~' 4- Property line ~' '~'
Water main ~ / ~4 Water service line ! 0
Wells on adjacent lots I O 0 -4-
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ! O + Building foundation
Water Service line I O ~4,- Surface water. ) O 0 ~'
Curtain drain N,~,~4. ~a,.,~' Wellson adjacent lots )0
F. COMMENTS
Absorption field ' ~ ''/-
Surface water / 0 0
Water main ~ j'~
D~veway, pa~d~g/vehicle storage
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 HAA guidelines in effect on this date.
Engineer's Printed Name /~g 6~,eT C. ~"O/,/~
Date ~' /I 6/0 I
HAA Fee $
Date of Payment
Receipt Number
(Rev. 12/00)
e/i
Waiver Fee $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE TAL 'SERVICES DIVISION
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services 7 ~ 1,9,96
On-Site Services Section
P.O. Box196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
GENERAL INFORMATION
Complete legal description
Lot 13; Chandelle Acres
Location (site address or directions)
Property owner
Mailing address
Lending agency
Robert Sept
1347 E. 74th ~venue
22006 Cloverlea~
Ch~iak, AK
Day phone
Anchoraqe/ AK 99518
Day phone
344-5555
Mailing address
Agent
Address
Day phone
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
NOTE:
Individual well
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site
Holding tank
Community on-site
Public sewer
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 S & S ENGINEERING --- ,.... Phone ~/~/-/-- Z ~; ..~ 5:
I/U,$4 ~.agJe ~,iv~r Luop ~oau r~/o. ,~u,e
Address Eagle River,.A~k,a~957'/ ,/
Engineer's signature
DHHS SIGNATURE
~., Approved for
3
bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
By:
Date ~--/.3- - ~;~'~
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certific,~'~es 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-Q25 (Rev. 1/91) Back MOA #21
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825"L" Street, Room 502 · Anchorage, Alaska 99501· (907) 343-4744
Legal Description:
Health Authority Approval Checklist
(-~i>~c,~L ~X~'c~-4,-<~ Parcel I.D.:
A. WELL DATA
Well .type
If A, B, or C, attach ADEC letter. ADEC water system number
Log present ~I/N)
Total depth '7~Z4 '
Sanitary. seal
Date completed
Cased to 2. z_ t
Date of test
Static water level \ 'J ay '
Well production 7~o. O
FROM WELL LOG
Casing height (above ground)
Wires properly protected
AT INSPECTION
g.p.m. ~'E ~/ 4- g.p.m
Bo
WATER SAMPLE RESULTS:
Coliform O
Date of saxnple: 5- q- cio
SEPTIC/HOLDING TANK DATA
Nitrate
l,:~ O t/I ~ / C Other bacteria
/ S & S ENGINEERING
Collected by: 17034-:-.-...!v- ' ~'~ ~^
Eagle River, Alaska 99577
Date installed [-~'~"~ Tank size
Co
Foundation cleanout,l~N) ~ Depression (Y/~ ~ High water alarm (Y~
Date of Pumping ~//J/c}5"~ Pumper /~2~7/-~ /"49o ~7~
ABSORPTION FIELD DATA
Date installed [, ~% '5 Soil rating (g.p.d./ft2 or ft2flodrm) [~'/(~3t-~ System type
Number of Compartments '7~ Cleanoutsl~N) ~
Length ~"~ Width Z-,g' ' Gravel thickness below pipe La ~
Effective absorption area lo C> c>'~ Monitoring Tube present~)N) ¥
Date of adequacy test t4 -- t Cl 'q 4 Results4t~/Fail) PPis For
Fluid depth in absorption field before test (in.){. 5 b, ' t
Fluid depth ~ .(ins.) Minutes later:
Peroxide treatment (past 12 months) (Y~)
Total depth
. Depression over field (Y/~) ~
bedrooms
Immediately after ~ gal. water added (in.):
Absorption rate = t_/,?o.4- .g.p.d.
tt-,do,),,J If yes. give date ,,.t~
/ ,,~j t.~ ,¢- ~,) r ,-,4..'£,-
D. LIlT STATION
Date installed
Manhole/Access (Y/N)
Size in gallons
High water alarm level at* /
"Pump on" level at*
E. SEPARATION DISTANCES
*Datum
off' level at*
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
· On adjacent lots
· On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation ~5~ ~ Jr Property. line I~ ~ 4~ Absorption field
Water main/service line t O Surface water/drainage I O D Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation
Surface water
Curtain drain
\o x w Water main/service line
Driveway, parking/vehicle storage area ~
Wells on adjacent lots ~ o<~ x ''~ Property, line
ENGINEER'S CERTIFICATION
ce,'.Z h.t ,:th,',., ; ta
Signature
engineer s Nam~l
of Municipal re~
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
Rev. 8/95 OSS: haa.wk.doc
.Parcel I.D. #
MUNICIPALITY OF ANCHORAGE "--~
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. BoxY196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
GENERAL INFORMATION
· ~'~i Complete legal description
Chugiak, A'K~
Location (site address or directions)
perty owner
Mailing address
Lending agency
1347 E, 74~
22006 Clov~rl~zf
Avenue Anchoraqe,
· Mailing address
Day phone 344-5535
688-6578
AK 99518 -
Day phone
Agent
Address -
Day phone
otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
WATER SUPPLY:
Individual well
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-.
ing to the legality andstatus of system. - ~ -
TYPE OF WASTEWATER DISPOSAL:
Individual on-site Y, XX
NOTE:
Community on-site -
Public sewer:.`' ...... · :
tf co mmunity wastewater system,, provide written confirmation from State ADEC
attesting to the legality and status of system. '"' ':"'? ''
72-025 (Rev. 1/91) Front MOA #21
STATEMENT
OF iNsPEcTIoN BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify {hat 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 Anch°~ge':~il~ a~id from mYim/estigati0'~ 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 effecton the d_.ete-qf this inspection.
Nameof Firm s .&S___EN_G_I_ ~N~E.ERI_'I _ ~ '-- _ Phone ~,~'~.~-
~"'p~ r~ ,Lo~ R~a~'g~, 204:
Address
Engineer's signature Date
::' ~},DHHS SIGNATURE
- ,~ Approved for
!
.%',; '-
bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
Date
The Municipa ty of Anchorage r)epartment of Hea th and Human serVices (DHHS) issues Health Authority
Approval Certificates based only Upon the representations given in paragraph 5 above by an independent
rofessional engineer registered in thn State of Alaska. The DHH$ does th~s as a courtesy to purchasem of homes
aPnd their lending nstitutions in order to satisfy certain federal and state requirements. Employees of DHHS dO not
:::::~°nduct inspections or analYze data before a certificate~ is .'issued. ~TheMunicipali,ty of Anchorage is n°t '.:~,i?~i
'::'~Sponsible for errors or omissions in the professional engineer's work.. '
ta.,~..._...~___72-025(Rev. 1/91) Back MOA~Zl
Municipali~ of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~--~,~ ~ ~_.~,~>~,~.,(z,-~ ~ Parcel I.D.
A. Well Data
Well type
Log present ~)/N)
Total depth
Sanitary seal
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed L~ ~ ~ 1 -~ ~ "> Driller ~-~
Cased to '~-7~ ~ ~ Casing height
Wires properly protected {~N)
FROM WELL LOG AT INSPECTION
g.p.m. 5~ ~ ~ ~
g.p.m.
Date of test
Static water level
Well flow ~. (~
Pump level1 ~ Y-"-
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot i, ~ ~-~ ~
Absorption field on lot .~ o o
Public sewer main ~,~-
Sewer service line ~'~' ~ ~
; On adjacent lots \
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank -7.--~-
WATER SAMPLE RESULTS:
Coliform '~) Nitrate
Date of sample: ~-~ ~ ~ ~;~..- ~[ Z~
\ .~ \ Other bacteria
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed ~.~ ..- ,5, '5
Cleanouts (~N) ~
High water alarm (Y/~
Tank size \ os o Compartments
Date of pumping
Foundation cleanout (~J~l) ,,./ Depression (Y~)
l1
Alarm tested (Y/N) ~'~/~
~ ?..~ ~ c~ Pumper ~ .~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot \ ~ '~ [ On adjacent lots
To property line ~ o ~ ~' Absorption field
Surface water/drainage \ D o
Foundation
Water main/service line
72-026 (3/93)* Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Manufacturer
Size in gallons Manhole/Access (Y/N)
Vent (Y/N) "Pump on" level at "Pump o~
High water alarm level ~d
Meets MOA electrical codes (Y/N) ~
SEPARATION DISTA~CE~OM LIFT STATION TO:
On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date installed f~ ~ ~ ''~
Length ~c, ~ Width
Total absorption area ~¢c~ ~
Date of adequacy test z.~ .. ~,
Water level in absorption field before test
Peroxide treatment (past 12 months) (Yg_,~)
Soil rating (GPD/Ft2)
Gravel thickness
Cleanout present ~/N)
Results~ail)
\c~-/ ~ ~ System type '"~¢.~r.~
L~ Total depth 1
~' Depression over field (y~;~)
~-~ ~ for ~ Bed rooms
After test '~ ~ ~ t
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot t o ~
To building foundation
On adjacent lots
Surface water
Curtain drain
On adjacent lots \ o ,.~ Property line
'~ o To existing or abandoned system on lot
Cutbank ,...L(~ ~ Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
/certify that/have checked, verified~OAand HAA guidelines in effect on th~:~.clct~is inspection.
Signature S & S ENGINEERI~//
Engineers N~.
Date
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (3/93)* Back
APPLI(' NT FILLS OUT UPPER HAl ONLY
/ Phone
Realty Co. & A~nt Phone
Address Zip Code
Street Locati~ (., ,.; j'/ L~ ./ ~ ~ '- '
Type of Resi~nce
Single Family
Multiple Family No. of Bedroo~
~ Other
Water Supply
lndividual A~ACH WELL LOG. A w~l icg is required for all wells drilled since June 1975.
Community For wells drilled prior to that date, give well depth (attach Icg if available).
~ Public Utility
Sewer Disposal
~. Individual Year Individual Installed:
~ Public Utility When Connected to Public Utility:
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
Field Notes:
MUNICIPALITY OF ANCHORAGE
{~.._11~ ~ ~--'~'I~t" DEPT. OF Hc/'.LT~'~
~ ~',0~'~ ~ G~' j ~ ~ ENVIRONMENTAL pROTECTION
SEP
RECEIVED
( ~ ) APPROVED BEDROOMS *CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL*
8oils Rating Date ~wer Installed Well To Absorption Area !/~ Well Log Received
~ ~ 5-- ~ ~ WelltoTank IO ~ Septic T~k Size
CONSTRUCTION AND OPERATION CERTIFICATE
ALASKA DEPARTMENT OF ENVIRONMENTAL CONSERVATION.
PUBLIC WATER SYSTEM
APPROVAL TO CONSTRUCT
..... ~ - ' ~ ~ ~ ,'~ ~ ~ ~ _public water system located
approved,
, Alaska, submitted in accordance with 18 AAC 80.]00
have been reviewed and are
/D conditio..n~lly approved (see attached conditions).
,. x., .,¢..~.~...~ ~_. ';- ' ./ , ,
D'ATE
If construction has not staded within two years of the approval date, this certificate is void and new
plans and specifications must be submitted for review and approval before construction.
APPROVED CHANGE ORDERS
Change
(contract or(ler no.
or descriptive reference)
MUNICIPALITY OF ANCHOJ~A~I~
u~'~'l. OF HEALTH &
ENVIRONMENTAL PROTECTION
Approved by Date
JUL 1985
The "APPROVAL.~~V~cti°n must be completed before any water is made available to
the public. '
.APPROVAL TO OPERATE
ILl, x.r"-, I /7,
1'
.... ':-'~, :- ,' /'7 4":-!lb'ubli"c
water system was completed on C,. _ ~_. ,~ ,.~., .' -'
..... (date). The system is hereby
granted interim approval to operate for 90 days following the cpmpletion date.
ElM
TITLE DATE
As-built plans submitted during the interim appr~)val period, or an inspection by the Department has
confirmed the system was constructed according to the approved plans. The system is hereby granted
final approval to operate.
Ely · , , .
TITLE · - -
DATE