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HomeMy WebLinkAboutHEISLER LT 3Heisler Lot 3 #051-092-36 kmuv UO/UL/ 16) Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 1 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP 221070 PID Number: 015 092 36 Dwelling: ❑■ Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑Q Upgrade Name JONES ABSORPTION FIELD Trench ❑-Wide Trench ❑-Bed—❑-Mound Site_Address0-Deep 20875 S BIRCHWOOD ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 6 GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot HEISLER LOT 3 Fill added above original grade 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 absorption area Number of trenches Dist. between trenches From Tank Field Tank Line Ftz Ft. Well +100 _ _ _ _ TANK X Septic ❑ S.T.E. P. ❑ Holding ❑ Other Manufacturer GREER Capacity 1000 Gal. Surface Water +100 _ _ Material Number of compartments Lot Line +5 - - NA POLY 1 Foundation _ _ LIFT STATION Manufacturer Capacity 1+10 Remarks TANK ONLY - _ Gal. Alarm location Electrical installed by PIPE MATERIAL House to tank 3034 Tank to LINK drainfield Installer GUARANTEED SVCS Drainfield UNK CO/MT 3034 Inspector CHARLES BALZARINI BENCH MARK (Assumed elevation) 100 ft Inspeection 15` 4/$/22 4/9/22 Location and description ction 2nd 3`" 4th TOP OF FRONT PORCH ON-SITE WATER AND WASTEWATER SECTION APPROVAL 4/11/22 Engineer's Stamp OF q�q ll� Conditional Approval: Date ,r ��Q'� . • cS',f �� co 'i �•:9 *: 49 ..>k .. TH . rr r ' t:HARLES G BALZARINI .r �'# •. CE -13854 ��r� Septic System _ Approved V t,�, Date 13^2 (9is • •. 11\ PROFESSI�NA�'-� Note: this approval does not include well permit requirements. 11 �� kmuv UO/UL/ 16) t4TgSll 1 EXISTING WELL ;�r *; L9 TH ••* (J NFENCE ' •' r \\ HEISLER LOT 3 rJ ' CHARLES G BALZARIKI . CE.13854 \\ `ikQROFESSIONP�� AW 1 \ 0SWINGTIES 6=BEDROOM �� \1 \ 40.91 44.2 HOME / B \ NEW PVC LINE MONITOR TUBE AT TANK PER MOA REQUIREMENTS DRIVEWAY / E F EXISTING 12Ci0 GAL STEP TANK EXISTING DRAINFIELD . . 0 ------ ------ - - - - LEGEND O CLEANOUT UTILITY EASEMENT • MONITOR TUBE ® TEST HOLE PLAN - SCALE: 1" = 30' INSULATION OVER TOP OF BM:+100.0' BOTTOM SIDING AT HOUSE SCHEMATIC PROFILE VIEW SHOWS ELEVATIONS OF INSPECTED ELEMENTS BUT DOES NOT DEPICT SYSTEM IN ITS ENTIRETY. INSPECTION FOR GENERAL CONFORMANCE TO DESIGN AND MOA REQUIREMENTS ONLY. O WATER ENCOUNTERED IN TANK HOLE SCHEMATIC ELEVATION - SCALE: NTS LEGAL DESCRIPTION: HEISLER LOT 3 C&M ENGINEERING SERVICES OWNER: JONES DATE: 4/10/22 1 REV: I DRAWN: CBj REF: 907-854-5558 SEPTIC RECORD DRAWING MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP221070 Effective Date: Work Type: SepticTank Upgrade Expiration Date Tax Code Number: 05109236000 Site Legal Address: HEISLER LT 3 G:1357 Site Mailing Address: 20875 S BIRCHWOOD LOOP RD, Chugiak Owner: JONES HEATHER M & MATTHEW W Lot Size in Sq Ft: Design Engineer: C&M ENGINEERING SERVICES Total Bedrooms: This permit is for the construction of: 4/7/2022 4/7/2023 ❑ Disposal Field 10 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 Special Provisions: • A 4 -inch perforated monitor tube is to be placed adjacent to the tank. Received By: C&M ENGINEERING Issued By: 4/7/22 Date: Date: 0 MUHMP AUTY OF AHCHORAGE Development Services Department = Phone: 907-343-7904 On -Site Water & Wastewater Section - Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 051 092 36 Property owner(s) JONES Mailing address 20875 S Birchwood Loop Rd Site address 20875 S Birchwood Loop Rd Day phone Legal description (Sub'd., Block & Lot) HEISLER LOT 3 Legal description (Township, Range & Section) Lot Size 51,457 Sq. Ft. Number of Bedrooms 6 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) ❑ (w/wo ADU) Septic Tank X ❑ Upgrade x ❑ (D) El Holding Tank El Renewal Renewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. C&M ENGINEERING (Signature of property owner or authorized agent) Permit/Rush Fees: Z Z S Waiver Fees: Date of Payment: Date of Payment: Receipt Number: Og 50(Sp Receipt Number: Permit No. 0_'5)02,Z /070 Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc C&M ENGINEERING SERVICES Ph: 907-854-5558 Municipality of Anchorage Onsite Water & Wastewater Program 4700 Elmore Rd Anchorage, Ak 99507 RE: Proposed Septic System for HEISLER Lot 3 Dear Reviewer, The above referenced property is currently served by an older septic system with a leaking tank that needs to be replaced immediately. The owner wishes to replace the tank at once. Our review of available documentation and field investigation show that this project will not adversely impact any nearby Wells, Wastewater disposal systems, replacement disposal sites, or drainage flowing onto and off of the subject property. As shown on the plan, the tank will be greater than 10’ from the house foundation. The tank shall be covered with a minimum of 2” moa approved insulation and 3’ of cover or a minimum of 4’ of cover without insulation. The repair must be performed by a moa certified installer in accordance with MOA requirements. Repair of the proposed system will not negatively impact adjacent lots. Upon completion of the installation, a record drawing will be submitted showing the location of the new tank, leach field, well, and other applicable features. Thank you for your time in reviewing this permit request. Please do not hesitate to contact me at 907-854- 5558 or by email cgbalzarini@gmail.com with any questions or concerns. Sincerely, Charles Balzarini, PE 4/1/22 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221070, Deb Wockenfuss, 04/07/22 CHARLES G BALZARINI CE-13854R EGISTEREDPROFE S S IO N ALENGINEER4/1/22 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221070, Deb Wockenfuss, 04/07/22 Municipality of Anchorage •',- Development Services Department ~ '' ` Building Safety Division -4 On-Site Water and Wastewater Program, 4700 Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 Page of w'ww.d.anchorage.sk.us (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number. SW060067 PID Number: 051-092-36 Name Historic Equity, LLC Wastewater System: ❑ New © Upgrade AEbatia PO Box 499 Palmer, AK 99645 ABSORPTION FIELD Pnprr. 907-746-3772 N.Wd Badrems6 O Deep TrerrJn 0 Stlalbw Trwrll e Bw 13 m,,w Qplt„r. LEGAL DESCRIPTION Soo Rm g 0.7 Ta11Depth ftmtxv%; GPDIFe Sand Filter 5.5 Ft. BbrA La 3 Bubdm Heisler Dago ro pae la^om Irprn pnoaw awe Groes 69011IMnealn it" TowWp'. Rarye: swam 3.0 Ft. FA waw mw.e urig.^ ghee 0.5 Ft Gn.m L"n 0.44-1.02 73 FI. FI Well: ❑ NewN ❑Upgrade Gn.mw un olwwa. owarinuetween rloo Cmtie^mm (PINm1. A. e. C): Tam Down: Cassa w "Private -Existing 70+ 18 FI. Taal acaaaun anti ------ ------ FI Pp Nytw,w FI. 40+ Ft 1314 F r D3034 &.w Owe ON lea SIaIK Wmw L"MV.1lor pmti lrwtal4a 56 FI "Dean Const.4/26/06 -Per MOA Yw10 P.P Sat m. Cating Hegn Aa t~io 1.17 GM TANK Ft.1 FL SEPARATION DISTANCES ❑ Septic ❑ Holding El S.T.E.P. ❑ Other. To Septic Absorption Lift Holding ublrJPrfvaletlp1ir From Tank Field Station Tank sewer une Anchorage Tank 11250 Gm. 100'+ 100'+ 100'+ NA 25'+ wSte Steel !� ^ m Companmwne 2 svn.nwmw 100'+ 100'+ 100'+ NA LIFT STATION WL`m 51+ 10'+ 5'+ NA tie 1250 G•I .aauw Orenco 5'+ 10'+ 5'+ INA 'Peep W, M m. 44 'Pump w- Is.m al. 42 Hpn wmw mwm m. in F q g in. C an0 n NA " t 50+ NA INA Pump mol", b 1,0104101Eltiarcm In•poot a Ilw oP iw q STIIwwaCb Far4a2o Rising Son Elec. Remwaa `None known BENCH MARK ""See attached letter on well/septic Loulm wa Dewpron Door Sill documentation. e.auon100 Ft. �� Inspections performed by: ArcTerra Dates: 1m 11/07/07 p Engin Stam q�� ���O�F 2n Development Services Department Approval; * It ; 0 Conditional Approval Date: ••• •• •••�••• • •N »•••�••• a 1I tr Konnel: .if" J 4 10 C 711 •: ami j�7NP�``<>��! Reviewed and approved b : PP Y a Date: �'��O 9FOp j'\ 0FES; ti MA6) �~ . % AS -BUILT SYSTEM DETAILS / SITE PLAN HEISLER SUBDIVISION, LOT 3 6 BDRM \ HEISLER \ UBDIVISI HOME � B.M. \ 8 J A. COVERED PORCH \ r CO y� LOT 3 0 15• 30 •.: "..:. SCALE: 1"- 30' : k EXIST. n n n LOT 2 N 0 N in ABBREVIATIONS: M w BOH - BOTTOM OF HOLE GO - CLEANOUT FCO - FOUNDATION CLEANOUT MT - MONITORING TUBE MH - MANHOLE A-1=61.67 8-1-84.62 A-2-70.24 B-2-33.71 A-3-110.89 B-3=100.48 EXIST. 1000 S T. 1250 CAL S.LE.P. AW OF ALq 111111,� 44; TH KENN N UFRUS/ 16 �4 fESSI k SEPTIC - ;•GRAVEL, GO 0 1 Porcel ID. 051-092-36 Permit No. SW060067 JB wLLJl / zz >> Q Q MT 2 �r } W LJ N N J N W Q LLl o, i 2 rN mm � N NEW I �7'X 3 1B' BED r— 30 UTILITY R.O.W. 50' I R.O.W. i SILT BARRIER I■I 3f / ......... 71_ 1 i 73' PRESSURIZED PVC SECTION SCALE: NTS PREPARED FOR: ROBERT CAMERON PO BOK 499 PALMER. AK 99645 FIELD BOOKS savw` NA ST"W, NA Asanr. 0704& D.c rxE: HEISLER CowuTEO CRAM KI 04CKE0: BMW DATE` 11/26/ ueo: NW1357 07-113 I COVER PER L.S. SOILS LOC !!.TO BOH ea.2o PACE 1 OF 1 C K san•.1/� ,•. I N LOT 10 I 50' I I ~ 0 J N00'04'30"E –N—x-11—x x—x x—x—x—x — x I � x WELLi LOT 3 —x—x—x_Qx—xxI X " 7.4' I .. z' I WELL x 9 SHED to I ®6.1' Lr) (7)x x I I n O 04 I n 00 I " N O LLI^ xI 4'x8 ' I 71 N z x DECK N 0 I Lj Z 28.4' ate 04 EXISTING 12.5' Q N R SU/ LDING I— LOT 2 IS 9' n 293• ^ O 24.1• Isa b bw >_ W J J I Wej , COVERED W I J — O CN F—SEPTIC '?.`.•i;.z;."+-;; ,.. PORCH VENTS r ,:-.:1 O F— LEI J v U) En aLO N a Q 10 W :n W C) v :` GRAVEL,'. v V).MH D/W"00 N SEPTIC .'; VENTS 30' 50' PLANTER 15' UTILITY 102.08' EASEMENT I O Lr) _ BIRCHWOOD_LOOP ROAD 1 N00'05'00"W BASIS OF BEARING PLAT 68-23 ANCRORAGE RECORDING DISTRICT ASBUILT OF: HEISLER SUBDIVISION NI NN 3 PLAT 6&2] i r� O F AN91 SURVEY CERTIFICATION: I, John L. Schuller, have conducted a / �Q.,• s �' physical survey of this property as shown on this drawing and that the oe improvements situated thereon awithin the property lines and no / ••, encroachmenare ts exist other than noted. Under no circumstance should / a : 49TH any information on this drawing be used for construction of fences, . ........ structures, improvements, or for establishing boundary lines. / • • • /�J, • •% . tl ;b... y//111.. / ........ EXCLUSION NOTES:It is the owners responsibility to determine a -JOHN L SCHULLER! the existence of any casements, covenants, or restrictions which ,� LS do not appear on the recorded subdivision plat. —10408 / q 8 •: • J 00 NORM ORDER NUMBER: MR: rrL -M4a: I e •��',%/°,•:R / 6 i NOV 19, 2007 1'40' b:99n90M.w1\aA n 07-113 .4.: oras.\�nfesslonot�� JLS NW1357 0704/01 0 L0 � o �Y 4 g N. p l4 k •tK 99471-9116 AAROW PIJh1P & WER SERVICE, LLC P.O. Box 110496 Anchorage, AK 99511 Office: (907) 346.9355 • Fax (907) 333.8976 Eagle River; (907) 622.9335 CUSTOMER • 4 . ra O 94 • cr 11 J L JOB SITE N° 07890 J Thank You SIGNATURE. (1 Hereby Acknowledge the Satisfactory Completion of the Above Dosaibed Work and agree that II above work Is not paid for In e0 days 1 agree to allow Aamw Pump & Well Service, L.L.C. the right to remove unpsld for equipment and charge for labor already performed & labor to remove unpaid for equipment) TERMS: ACCOUNTS PAYABLE AT 10TH OF MONTH FOLLOWING PURCHASE. SERVICE CHARGE AT RATE OF 1.5% PER MONTH WILL BE CHARGED ON OVERDUE ACCOUNTS. T T'd £6-£890:01 tblUdi tw:20 -002-T-030 DESCRIPTION NINE FINE OINENNIN ENNENIN OINEM■ - DINNEEN SME �� .. NOME INNENNEINN� ME ME PAY THIS AMOUNT Thank You SIGNATURE. (1 Hereby Acknowledge the Satisfactory Completion of the Above Dosaibed Work and agree that II above work Is not paid for In e0 days 1 agree to allow Aamw Pump & Well Service, L.L.C. the right to remove unpsld for equipment and charge for labor already performed & labor to remove unpaid for equipment) TERMS: ACCOUNTS PAYABLE AT 10TH OF MONTH FOLLOWING PURCHASE. SERVICE CHARGE AT RATE OF 1.5% PER MONTH WILL BE CHARGED ON OVERDUE ACCOUNTS. T T'd £6-£890:01 tblUdi tw:20 -002-T-030 Nov 20 2007 11:57nN Rising Con Electric. Inc. C22 -C777 p.l Rising bon Electric. Inc. 0916 Voodland Priv %fit. Eagle River. ak 99577 (907) 622-6777 } f i November 29, 2007 Robert Cambron FAX #(888) 228-7495 Re: Heisler Lot 3 - 20875 S. Birchwood Loop Road - Chuglak, AK 99567 Dear Mr. Cambron: The lift station at the above referenced property has been wired in accordance with NEC and State/Local codes. Thank you. Sincerely, Kevin ornbu"ckl, e, Owner Administrator License Number 1284 Specialty Contractor License Number 27285 cc: file From: Tom Varneyctom@anchoragetank.com> Subject: RE: Hlesler Lot 3 — 20875 Birchwood Loop Date: November 7, 2007 5:00:27 PM AKST To: Brent Western <bmw.kndeng@ak.neb Brent, We were able to look through our records and discovered we delivered a standard 1250 gallon liftstation tank to that lot last year. It uses a standard model 20 (20 GPM) pump. Nothing special about this one. Sorry it took so long to get this. -tom -----Original Message --- From: Brent Western jmailto:bmw.kndeng@ak.netj Sent: Tuesday, November 06, 2007 10:13 AM To: Tom Varney Subject: Hiesler Lot 3 — 20875 Birchwood Loop Tom, We are documenting a septic system and I need to know what STEP system was delivered to the subject property—please provide tank size and pump description or any other materials provided by Anchorage Tank. To assist In this request, I've been told that Bob Dean of Dean Construction installed the system that was designed by Lars Spurkland whhin the last 16+/- months. Thanks, Brent M. Western ArcTerra Engineering 8 Surveying, Inc. Tel. 907-868-3792 Fax 907-868-3793 November 28, 2007 ArV RClERRA Dan Roth, Program Manager Municipality of Anchorage Development Services Department On -Site Water & Wastewater Program P.O. Box 196650 Anchorage, AK 99519-6650 AND SURVEYING, IVIG RE: HEISLER, LOT 3 — UNDOCUMENTED SEPTIC SYSTEM Dear Dan, Per your instructions, on November 7, 2007 each end of the absorption field and the pre-existing septic tank were excavated. Based on these visual observations, MOA record documents, combined with queries to Anchorage Tank and Rising Sons Electric and conducting an as -built survey—it appears that the above referenced property's on-site wastewater system was installed per the permitted design (MOA Permit Number: SW060067). Tobben & Lars Spurkland designed this septic upgrade (SW060067) for the previous property owner, Brian Lehuquet. We have been told that subsequently Dean Construction installed the system on April 26, 2006. The current property owner, Historic Equity, LLC bought the referenced property through a foreclosure auction and contacted Lars Spurkland to document the system. Unfortunately these parties could not reach an agreement and Historic Equity has retained our services to document the existing wastewater system. The pre-existing tank was found not to be the 1000 -gallon, fiberglass Sunset Plastic septic tank as shown in MOA record documents, but a 1000 -gallon, steel Anchorage Tank septic tank. It appears that this tank was installed in the late 1980s and the tank's integrity was deemed adequate. Also, no septic standpipes from the previously existing absorption field were evident and it appears that this field was properly abandoned. Heisler Lot 3 11/30/07 Page 2 of 2 Since no well log could be located, Brian Willey of AAROW scoped the well and determined that the well's casing and construction meets state and municipal codes. A well flow test was performed on November 9, 2007 and showed the static water level at 56' and water production at 1.17 gallons per minute. If you have any questions, please contact me at 868-3792 / FAX 868-3793. Respectfully submitted, ArcTeffa Engineering & Surveying, Inc. Kenneth 1. Duffu , E. Attachments: MOA On -Site Inspection Report AAROW Well Scoping Report Anchorage Tank Email — STEP Rising Son Electrical Letter As -Built Survey 20441 PTARMIGAN RIND • EAGLE RIVER, AK 99577.8736 • PI (907) 868.3791 • FAX (907) 868-3793 MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water & Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Permit Number: SW060067 Legal Description: HEISLER LT 3 Design Engineer: 0007 Tobben Spurkiand, PE Owner Name: BRAIN LEHUQUET Owner Address: PO BOX 672275 CHUGIAK , AK 99567 - Date Issued: Apr 24, 2006 Expiration Date: Apr 24, 2007 Parcel ID: 051-092-36 Site Address: 020875 BIRCHWOOD LOOP RD Lot Size: 28560 SQ. FT. Total Bedrooms: 6 Permit Bedrooms: 6 This permit is for the construction of. ❑v Disposal Field 0 Septic Tank Holding Tank ❑ Privy ❑ Private Well Ej 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 DSD at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 ( 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. Received By: Date: 1 b 6 Issued By: I I rY Date: '&-f -\ Municipality of Anchorage Development Services Department Building Safety Division e Onsite Water and Wastewater Program �s 4700 Bragaw Street P.O. Box 196650 .JO Anchorage, Alaska 99519-6650 19� www.muni.org/onsite u (907) 343-7904, ON-SITE SEWER/WELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Ir i Emsma Propertyowner(s)_Lebuysp Dayphone 830-3228 Mailing address Po• BoxOZZIS I Chw5!;4k . f%9_jsL; Zip Code Site address Zo875 Bird woeA Loop Road Zip Code Legal description (Sub'd., Block & Lot) r! d 3 Legal description (Township, Range & Section) Lot Size Z 5W Sq. Ft. THIS APPLICATION IS FOR (® all that apply): Absorption Field Septic Tank Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage ❑ Number of Bedrooms M THIS APPLICATION IS AN: Initial ❑ Upgrade Renewal ❑ certify that the above information is correct. I further certify that this application is being made for a Single Family Dwelling and is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: 62Y_i Waiver Fees: Date of Payment: _4 o Zl r 7v 4 Date of Payment: Receipt Number. Receipt Number. (Rev. 11105) VV tL V11, '�'W� 7--OO' SpuM and Enpounewo p Environmental Consulting and Design SEPTIC SYSTEM DESIGN LOT 3 HEISLER S/D Municipality of Anchorage Development Services Department On Site Water and Wastewater Program 4700 South Bragaw Street Anchorage, Alaska 99519 April 18, 2006 We are submitting an application for the upgrade of the septic system for this lot. The submittal consists of three (3) drawings showing the present improvements on the lot and the adjoining properties, (sheet 1/3), the proposed improvements of the lot, of which only the septic system is subject to this permit application, (sheet 2/3), and a schematic of the septic system, (sheet 3/3). Soil logs and percolation tests of applicable testholes are also enclosed. The septic system design is based on the following: Groundwater at 10 Ft. Soil Rating. From Testhole 05/16/05. <I min/in = 0.7 gal per day/sq.ft No. of Bedrooms 6 Required Area per Bedroom: 15010.7 - 214.29 sq.ft. Total area required: 214.29 x 6 - 1286 sgft t 1 SYSTEM CONFIGURATION 1e.1913 W-r8rBED W/ 1000 GAL TANK+ 1250 GAL STEP TANK TOTAL LENGTH 73 FT TOTAL WIDTII 18 FT TOTAL DEPTH 5.5 FT FILTER SAND 2 FT ROCK DEPTH 0.5 FT COVER 3 FT (MIN) The installation of this septic system will not prevent wells and septic systems from being installed on the adjacent lots. There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots. The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface runoff will not result from this installation. 203 West 15'" Avenue Suite 203, Anchorage, AK 99501, Phone: (907) 279-3916 Fax: (907) 276-6013, SpurklandEng@gci.net '� SpuMand Engofiewong ~Environmental Consulting and Design W7�11 April 24, 2006 Municipality of Anchorage Development Services Department Building Safety Division On Site Water and Wastewater Program 4700 South Bragaw Street P.O. Box 196650 Anchorage, Alaska 99519 Subject: Septic System Installation Permit Lot 3 Hiesler Attn: Joe Goodal Dear Joe Goodal, Due to site restrictions (i.e. the location of the subject lot well and the 15 foot electric easement along the west property lines) we are requesting approval to construct a 18 foot wide bed. This will enable us to reduce the total length of the bed by 13 feet. Heavy equipment will not be operated on the absorption area prior to or during construction. If you have any questions, please contact me a 279-3916. Sincerely, L�� Lars Spurkland 203 West 15th Avenue Suite 203, Anchorage, AK 99501, Phone: (907) 279-3916 Fax: (907) 276-6013, SpurklandEng a?gci.nct I sit I n 73' X 18' BED., N. T.S 18' Wide 73' Long 5.5' Deep 2' Feet Fitter Sand 0.5' Rock 3' Cover Nn) NO SCALE Monitor 1250 GAL STEP TANK 0 of f 49th ......................... T. '; TON SPURKLAND••; ° No. CE -2225 N.T.S C 1000 gal Septic tank Dj 1 1 II I' I I 1 Septic 1 Area S¢Q¢o I I / LOT I -¢ Well \ I -%ell c 1 1 OT 2 o I CABANDON LANK AVTIDA Y — — — am oun w ¢ Well 1 SrLpr Sx LOT 3 I -- - -- -- AVS1AfL 6-BEGVPOOY SCi7IC SYSICY 1250 CAL. SnP SMX TAW W115' x 60'UMM 7J FM ac *V7H 18 FW OF IX TER t7 — — — — = ��P.•• •...... i�•• ROCK 0.5 frrT COM 10 fm (W) . tx;` • I � 49tU�G� i ;.-..f.� ... ../ �� ; iDN SPURKLAND [}��� ----------------------••�S No.cE-2225=i 2s 0 n 50 75 SCALE: 1' = 50 FT. ix 125 150 •• � . �•• TOBBEN SPURKLANO P.E. LOT 3 HEISLER SID SEPTIC SYSTEM DESIGN 103 W 15TH. AVENUE BRIAN LEHUOUEP DATE: APRIL 18, 1006 ANCH. AK. 99501 SHEET. 213 GRID:NW1357 907 179-3916 20875 B/RCHWOOD ROAD PERMIT # plD # HEISLERL32.DV6 Municipality of Anchorage �'rnEnyaar>Ll i) Development Services Department i t� '' <'• ; 'F Building Safety Division 1 ii L' y,e On -Site Water and Wastewater Program .. 4700 South Bragaw St. ' • • • • • • • • • .. P.O. Box 196650 Anchorage. AK 99519650 • • ,1_ . ! eoTts4si9o4ae TOEE� SFURi ;F,?!D.\cr E 222:1 . i II Soils Log - Percolation Test `,'1� ......•• Performed For. gr i 3n Lei,,4 au D Date Performed: Legal Description: Lol' 3 Heeler Township, Range. Section: Show Silo Plan Depth 1 5- p 7. {�D 6- vt4YCl 9- V W�+tee 10- 0. oiF S;lt 11- 13- 14- 15- 16- 17- 18- 19- 20 - COMMENTS WAS GROUND WATER ENCOUNTERED? 1 B IF YES, AT WHAT DEPTH? �_ L s-• Depth to Water After 0 1 1 ... P Wyk Monitoring? Dale: 3Il Q� I D(7 6A•H. ice' PERCOLATION RATE (~a~) FERC HOLE DIAMETER TEST RUN BETWEEN FT AND FT PERFORMED BY: Lars 5O4F Wont, I L� Stt I � CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE TH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: L/ 1$ Oro Municipality of Anchorage Development Services Department Building Safety Division yr On -Site Water and Wastewater Program 0 1 a 11.0 L 0 4700 South Bragaw St. P.O. Box 196650 Anchorage. AK 995IM650 www.munl.org/onsite Performed For. Legal Description Depth (Feet) 1 2-�:• 3- 6 7- V 8- I 10- 11- 12- 13- 14- 15- 16- 17- 18- 19- 20 - COMMENTS (907) 343.7904 / lest "atc. * Z Soils Log - Percolation Test Lel%unv f0 Date Penia licicl� SID v Loi 3 Township, Range, Section: s44Ay Gatve.l W'tnit.G DE S11L ''Mi WAS GROUND WATER , ENCOUNTERE07 T e5 IF YES. AT WHAT DEPTH? 1 a 11.0 L 0 Depth to Water After t1o^ 10< Monitoring? Wt E one: 3 n3 06 Reading Date Gross Time Net Time Depth to Water Net Drop PERCOLATION RATE e-In,nwWicn) PERC HOLE DIAMETER (o TEST RUN BETWEEN y FT AND 5 FT LA ..t/ ter L♦ :..e4... r Je. _S 4f-�o rl�a:ned `•. i ISS �.•�' � p- PERFORMED BY: % Su,., �a.Kg— I L�-•e < CERTIFY THAT THIS TEST W S PERFORMED IN ACCORDANCE WI H ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: IB D Municipality of Anchorage Development Services Department Building Safety Division yr On -Site Water and Wastewater Program / 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 X �r www.muni.orWonsite (907)343-7904 Tcst Hole, AL3 Soils Log - Percolation Test Performed For: gr;a,. L t,Q tAt Date Perk Legal Description: Lel 3 N t i s (e, 516Township, Range, Section: Depth 15- 16- 1 1 Soil &4jj 64j WAS GROUND WATER ENCOUNTERED? Y2S S IF YES, AT WENT DEPTH? )ll L Depth to Water Aho1 J �f Monitoring? IbE Date: 3 8 b(o &O.N, -y- TEV ISPURIMAND Reading I Date I Gross Time Net Time I Depth to Water I Net Drop I I 1 I I PERCOLATION RATE 41 tnnwawrnl PERC HOLE DIAMETER 1 TEST RUN BETWEEN _FT AND 7 FT COMMENTS ie FOW wl V;, j�k-. , 5 +fes PERFORMED BY: LGFS pWrHcirick I jtwP Sgn%Ia-,9-- CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: Y 10 Oro �-, GREATER ANCHORAGE AREA BOR( dGH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM h NAME�c ��// � Ile-fS MAILING ADDRESS s'1pK�7o Zu?�PHONE LOCATION /7iriL �7 t cw �l �o a F' %fo 2 :?�2 LEGAL DESCRIPTION "�ICT SEPTIC TANK: DISTANCE NUMBER OF FROM WELL 6AI MANUFACTURER ,/y�scT/ C MAT ERIAL�����fCOMPARTMENTS INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY GALLONS. SEEPAGE PIT: NUMBER OF PITS - DIAMETER OR WIDTH LENGTH r DEPTH / I_ININr MATERIAL�/ / CRIB SIZE: DIAMETER —DEPTH V DISTANCE FROM: WELL L f� / C TOTAL EFFECTIVE � BUILDING FOUNDATION 7 NEAREST LOT LINES . ABSORPTION AREA (WALL AREA) SQ. FT. ADDITIONAL ABSORPTION WELL: TYPE r��!(� CONSTRUCTION_ BUILDINGNEAREST{� FOUNDATION, LOT LINE CESSPOOL OTHERSOURCES APPROVED DISAPPROVED DISTANCES: INSTALLED BY: PIPE MATERIAL: C /f y-- 5 ! r LOT SLOPE: / e V -c / REMARKS: S T-- C- DEPTH NEAREST SEWER LINE REMA SEPTIC TANK DIAGRAM OF SYSTEM DISTANCE FROM: SEEPAGE SYSTEM DATE 2 - 2 - 71 APPROVED THE REQUIRB}`5IZE`OF THE SOIL HBSORPTION SYSTEM IS: BIN IE: F:" -V . --- fl. Q, ���VA Kai --F- P-11 ;2 ���F" : �lf=, V-A= � THE LENGTH DIMENSION IS THE LENGTH (IN FEET)~0F'^HE TRENCH OR DRHINFIELD. THE DEPTH OF H TRENCH OR PIT IS THE DISTRNC::E.BETWEEN THE SURF'H�E THE GROUND HND THE BOTTOM OF THE EXCHVHTION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRHVEL DEPTH IS THE MINIMUM DEPTH OF GRHVEL BETWEEN, -THE OUTFHLL PIPE AND THE BOTTOM OF THE EXCHYHTION (IN FEET). ' IT! U W U 1: M M ID WET711"'Y" I �IF"If 004 1< 10 :1. Kai hot Q �M L- 1J.— P� BHCKFILLING OF HNY SYSTEM WITHOUT FINAL INSPECTION AND HPPROVHL BY THIS DEPHRTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTHNCE BETWEEN H WELL AND WAY ON-SITE SEWAGE DISPOSHL SYSTEM IS 100 FEET FOR H PRIVHTE WELL OR 200 FEET FOR H PUBLIC WELL S!ECIFICHTIONS AND CONSTRUCTION DIHGRHMS ARE HVHILHBI.-E TO INSURE PROPER INSTHLLHTION. ��Fit ��, I- owl L— I F-'11. F=' C: -,u P? W pWj M %-, FEE. H:,::u F�:- Fit R- 9 1���� I 1: I HM FHMILIHR WITH THE REQUIREMENTS FOR ON-SITE SEWERS HND WELLS HS SET FORTH BY THE MUNICIPHLITY OF HNCHORHGE. 2: I WILL INSTALL THE SYSTEM IN HCCORDHNCE WITH THE CODES. ]� I UNDERSTHND THHT THE ON~SITE SEWER SYSTEM MHY REQUIRE ENLHRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THHN ] BEDROOMS SIGNED: ~~-~�-~~~-~~~-~-~� HPPLICHNT BILL HEISLER ��1 -11"' "-w-' F-- P J j`C_.-1 U-1����� DEPHRTMENT HEALTH HND ENVIRONMENTHL/,'UTECTION ' ^~ 2516 E. /dDOR RD./ HNCHORHGE/ HK. ,^ 276~2221 , ��~~1 Y ��F-E. L. 0 FEE' V— EE: Flt" P-11 "A'�� PERMIT NO. ( 76522 > RPPLIMAI' BILL HEILEI SR BOX 870 CHUGIHK ]49-4111 LOCHTION BIRCHWOOD LOOP NORTH LEGHL L] HEISLER SUBDIVISION LOT SIZE ]2670 SQUHF:E FEET TYPE OF SOIL HBSORBTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS =: ] SOIL RATING (SQ FT/BR)= S5 THE REQUIRB}`5IZE`OF THE SOIL HBSORPTION SYSTEM IS: BIN IE: F:" -V . --- fl. Q, ���VA Kai --F- P-11 ;2 ���F" : �lf=, V-A= � THE LENGTH DIMENSION IS THE LENGTH (IN FEET)~0F'^HE TRENCH OR DRHINFIELD. THE DEPTH OF H TRENCH OR PIT IS THE DISTRNC::E.BETWEEN THE SURF'H�E THE GROUND HND THE BOTTOM OF THE EXCHVHTION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRHVEL DEPTH IS THE MINIMUM DEPTH OF GRHVEL BETWEEN, -THE OUTFHLL PIPE AND THE BOTTOM OF THE EXCHYHTION (IN FEET). ' IT! U W U 1: M M ID WET711"'Y" I �IF"If 004 1< 10 :1. Kai hot Q �M L- 1J.— P� BHCKFILLING OF HNY SYSTEM WITHOUT FINAL INSPECTION AND HPPROVHL BY THIS DEPHRTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTHNCE BETWEEN H WELL AND WAY ON-SITE SEWAGE DISPOSHL SYSTEM IS 100 FEET FOR H PRIVHTE WELL OR 200 FEET FOR H PUBLIC WELL S!ECIFICHTIONS AND CONSTRUCTION DIHGRHMS ARE HVHILHBI.-E TO INSURE PROPER INSTHLLHTION. ��Fit ��, I- owl L— I F-'11. F=' C: -,u P? W pWj M %-, FEE. H:,::u F�:- Fit R- 9 1���� I 1: I HM FHMILIHR WITH THE REQUIREMENTS FOR ON-SITE SEWERS HND WELLS HS SET FORTH BY THE MUNICIPHLITY OF HNCHORHGE. 2: I WILL INSTALL THE SYSTEM IN HCCORDHNCE WITH THE CODES. ]� I UNDERSTHND THHT THE ON~SITE SEWER SYSTEM MHY REQUIRE ENLHRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THHN ] BEDROOMS SIGNED: ~~-~�-~~~-~~~-~-~� HPPLICHNT BILL HEISLER (Ions¢zuetlon gest 1.a L7 "Ona test is worth a thousand npinions" 2204 Cleveland Anchorage, Alaska 99503 Performed For Bill Heisler Date Performed 7/13/76 Leaal Oescrintion: Lot 3 Block Subdivision Heisler Subdivision This Form Renorts Soils Lon Percolation Test_ penth Feet 2 4- 6- 8— -Soil Soil Characteristi Brown Sandy Gravel (GP - GW) 10- 12- 0-12— rown , we 14 — . Brown Silt (ML) 16 o es HoIe H� 20— Was Ground Water Encountered? No I¢ Yes, At what Depth? Ice! Readinq I Date I Gross Time I Net Time I Depth to H2O Net Dron Percolation Rate Hinute Proposed Installation: Seenaoe Pit Drain Field _ Deoth of Inlet Depth To Bottom Of Pit Or Trench CnMtAENTS: 85 square feet drainage area required per bedroom. No qround water or bedrock encountered. Test Performed By�l'�. Data Certified 9y:CONSTRUCTION TEST LAB T n Tse .v n_a 7/14/76 it) 5. LEGAL DESCRIPTION MUNICIPALITY OF`ANCHORAGE Z- c \ MUNICIPALITY OF ANCHORAGE MDEPT. OF HEALTH 8, STREET LOCATION DEPARTMENTOF LS Anchorage, 825 ® ENVIRONMENTAL ENGINEERING DIVISION NOV 15 1978 [`'SINGLE FAMILY Telephone 264.4720 RE CC FF tt// REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FAC1411T-%F® DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNERPHONE E,/Three ❑ Six 7. WATER SUPPLY eL *ATTACH WELL LOG. Awell log is required for all wells drilled MAILING ADDRESS since June 1975. For wells drilled prior to that date, give well PROPERTY RESIDENT (If different from above) PHONE 2. BUYER 1-6 �. by this Department. MAILING ADDRES� 76 3. LENDING INSTITUTION - '.�— %�� �// PHONE --� .S�rT�� of • MAILING ADDRESS 4. REALTOR/AGENT PHONE t✓% MAILING ADDRESS 5. LEGAL DESCRIPTION Z- c \ S P loll STREET LOCATION 6. TYPE OF RESIDENCE NUMBER OF BEDROOMS [`'SINGLE FAMILY ❑ One ❑ Four ❑ Other E] Two ❑ Five ❑ MULTIPLE FAMILY E,/Three ❑ Six 7. WATER SUPPLY ❑ INDIVIDUAL* *ATTACH WELL LOG. Awell log is required for all wells drilled COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) S. SEWAGE DISPOSAL SYSTEM ® INDIVIDUAL/ON-SITE** p(�) **If individual/on-site, give installation date If system is over two (2) years old an adequacy test is required El PUBLIC UTILITY by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) cam. I�C. THIS SIDE FOR OFFICIAL USE ONLY _ INSPECTION APPOINTMENTS DATE RECEIVED _ TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: , V<LG 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS Al Ur�aQ �U ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ six 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON -SITE El PUBLIC UTILITY Connection Verified PERMIT NUMBER DATE INSTALLED INSTALLER ❑Septi Tank or ❑ Holding Tank Size: 10Vv If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTURE TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS CLW , -��� [P— APPROVED FOR BEDROOMS ust accompany certificate) ❑ CONDITIONAL APPROVAL (letter mP Ci DISAPPROVED p DATE 1 F - � c:)' LEGAL DESCRIPTION 72-010 (Rev. 3/78) luJ December 7, 1978 Ruth Heisler % Abram Love Post Office Box 10--563 Anchorage, Alaska 99511 Subject: Lot 3 Heisler Subdivision The water storage serving the apartment buildings and the single family residence on the subject lot is not adequate. Before approval may be granted, the water storage must be contained so as to prevent rodent and insect investation. The existing water storage consists of pressuee tanks which are approved and a hole in the ground lined with visqueen which is not approved. If there are any further questions, please contact this office at 264-4720. Sincerely, Robert C. Pratt, R.S. Associate Specialist RCL /l j W N ti O M O ul JAZ= OJ N. J J J = t p (\ 1 L � l =34rp j H � LZ 000110- W � h 4 Z W Na Na W � m " 0000, a/'66 Bo'za, OE '00 OS \ Q B4 o LW O 0 n D o a b�U3 ° ------L------To--- 'o�ooi ai 66 aoi or oo'osL- ... 2J0 Wm,2 OVOd007& �819 M ob ° Q CC l b tpJ M N06 oa ore N M, OZ'O FF 90 00 --'� 0301Aio49nsNn N ti O M O ul JAZ= OJ N. J J J = t p (\ 1 L � l =34rp j H � LZ 000110- W � h �nOOp N Z W Na Na W \ B4 Q O 0 n D o a Q CC l tpJ M N06 W C U! w O y O i Q N 2\i w z W a F , V J z a w m uj m h U W m m 0 W \ = W_ V f 0 o u N ti O M O ul JAZ= OJ N. J J J = t p (\ 1 L � l =34rp j H � W � h �nOOp N Z W Na Na W N. (\ 1 L J N. MUNICIPALITY OF ANCHORAGE 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. 051 092 36 1. GENERAL INFORMATION Complete legal description Heisler Lot 3 Expiration Date: 7- /3 - F-0 7 - 2 - Location (site address) 20875 S Birchwood Loop Rd Current property owner(s) Jones Mailing address Real estate agent 2. TYPE OF DWELLING: 0 Single Family (w/ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 6 Day phone Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well El Private Septic ❑X Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: NONE q Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ CJ 5 d Waiver Fee $ Date of Payment I Date of Payment Receipt Number Receipt Number COSA # os c -'Z a 113 5 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-C&M-ENGIN€E-RING Phone 8545558 Address 20182 TULWAR Engineer's Printed Name CHARLES BALZARINI 6. DSD SIGNATURE System #1 Approved for lv bedrooms System #2 Approved for bedrooms Disapproved Conditional approval for Date 4/6/22 Alw OF A/gs�l A,�P.••• awl r . 49 TH• CHARLES G BALZARI�II � r 6? • CE -13854 • •�.�s* illF� PROFE5S10NP�'�. bedrooms, with the following stipulations: OF t tt��rri, Original Certificate Date: q– 3 – 202— Z 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 I AND ,TEP. AS T'_`IATER rA-cUfl�� �- - i :n f✓ f(\J J Original Certificate Date: q– 3 – 202— Z 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 COSA Checklist Legal Description: HEISLER LOT 3 If more than 1 septic system on lot: COSA Checklist # 1 of 1 A. WELL DATA ❑ Well log is filed with Onsite (or attached) _D–ate--dfilled—UNK Total depth LINK ft Cased to +70 ft ❑■ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) +12 in. Date of flow test for COSA 3/11/22 Parcel ID: 015 242 66 Structure served by this system 1 Well production at time of test 5.1 gpm Water storage tank volume NA gallons Well disinfected for coliform test? ❑ Yes ❑■ No X Coliform bacteria is Negative Nitrate ND mg/L ❑■ Nitrate less than MRL (ND) Arsenic 1.612 ug/L ❑ Arsenic less than MRL (ND) Collected by C.BALZARINI Date of Sample 3/15/22 Static water level at beginning of test 55 ft. Comments Pumped down to 96 -feet during testing as measured by acoustic sounder. B. TANK DATA Age of tank(s) 0 years Tank type/material septic PLASTIC Measured operating fluid level in septic tank na ❑ Standpipes/foundation cleanout per record drawing Date of pumping na D. ABSORPTION FIELD DATA bed Which system tested (date installed) 2007* ❑E ALL standpipes present per record drawing Total measured depth from grade 4.5 ft (max) Measured depth to pipe invert from grade NA ft (min) X N/A – pressurized field ❑0 Monitor tubes go to bottom of effective. If not, state depth into effective C. LIFT STATION ❑■ Required maintenance completed Age of lift station 15 years Lift station material steel Comments: Adequacy test date 3/11/22 Results Q✓ Pass For 6 bedrooms Fluid depth prior to test 0 in Water added 900 gal New depth 0 in Elapsed time 1440 min ❑■ Code -required soil cover over field Final fluid depth 0 in ❑■ System presoaked Absorption rate 900 gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) na date of test) If yes, na Gallons introduced 2000 gallons enter date Comments/Deficiencies: *Actual install date unknown permit was issued in 2006 and expired in 2007 COSA Checklist yellow sheet E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' Yes Community Sewer Manhole/Cleanout > 100' ft 0✓ Yes if No ft 0✓ Yes if No ft Neighboring Tank > 100' 0✓ Yes if No ft Private Sewer/Septic Line > 25' E✓ Yes if No ft Absorption Field on Lot > 100' Yes if No ft Holding Tank > 100' FZ Yes if No ft Neighboring Absorption Fields > 100' Surface Water > 100' F71 Animal Containment > 50' 0 Yes if No ft ft E✓ Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' 0✓ Yes if No ft P/ Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' Q✓ Yes if No ft Surface Water > 100' U Yes if No ft Property Line > 5'✓0 Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' Yes if No ft Private Wells > 100' ✓0 Yes if No ft ✓0 Yes if No .ft rnmrr! unity 1/\/elle > 200' (] Yes if No ft Water Service Line > 10' 0✓ 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' Yes if No ft If absorption field is under driveway comment below Property -Line - 10' Yes if No ft Wells on Adjacent Lots: Water Main > 10' Q✓ Yes if No ft Private Wells > 100' ❑✓ Yes if No ft Water Service Line > 10' ❑✓ Yes if No ft Community Wells > 200' Yes if No ft Surface Water > 100' F71 Yes if No ft F. ENGINEER'S COMMENTS New Septic Tank Previous Well tests yielded 1.17 gpm (2007) and 3.46 gpm (1999) G. ENGINEER'S CERTIFICATION I certify that l 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. 4/10/22 COSA Checklist yellow sheet OF q/,q ll � * TH i•• �r CHARLES G BALZARINI j CE -13854 , •`cv�r `l, pROFESSIONP -�- Scale 1" = 25' 1 50.0 R.O.W. I I i Legend Electric Meter/Outside Power y Gas Meter co_., Telephone Pole Septic —x— Fence ® Deck;f Mailbox Wi Water Well Light Pole _� S Septic Tank M.H.—ow— Overhead Utility EXPOSED TANK ACCESS CS" ;S` / \Si v —i Sc / I / / ZLOT 2 N90° 00'00"W- 280.19— EXPOSED 0'00"W-280.19— I . _ ONUS Q"" OHU / OHU� oHu� X X GREEN a-- oHu� oHu� oHu— o"U— \ ^ X X , X OUSE / — X — X X / o X x � N90° 00'00"E 280.20I 12.0 / A Oo o \ 7,4 OVER P.L. / � HEI SLER AVENUE ----------------- (PLA TTED) (PLATTED) / I \ � �>0 Q _WE L L RADL)—S I I I General Notes Disclaimer • �, AN AS -BUILT SURVEY OF 1. Excepting for gross negligence, the liability for this survey shall not 1. This survey complies with the ASKS Mortgage Location Standards. The survey represents visible improvements and conditions at the time of the survey. This document does not constitute a boundary % LOT 3 exceed the cost of preparing this survey. Dimensions to property lines survey and is subject to any inaccuracies that a subsequent boundary survey may reveal. It is the . • • . . . . • . • : . % HEISLER SUBDIVISION are plus/minus 0.1ft. responsibility of the Owner to determine the existence of any easements, covenants, Or restriction / - A 20875 S. BIRCHWOOD LOOP ROAD 2. This document is created by Frontier Surveys for the purpose of an Which do no appear on the record plat. Under no circumstances should this document be used for / . . / CONTAINING: 28,602 Sq. Ft. +/-(RECORD) as -built survey for Jayme Harris, only. construction or for establishing a boundary or fence line. A RECORD PLAT: 68-23 Pierre M. Str ier / 3. This document is based on Plat No. 68-23, Anchorage Recording 0 12.5 25 50 �+��� , No. L.S. - 9812 ���% PREPARED BY: District. 1 FFD • .04/11/2022LC . • .S�� 650 w. sotth AVE. ONTIER SUITE LE, ANCHORAGE, AK 99518 Scale in Feet %Pf0FESSIONk0y -AW 907-460-1686 � DRAWN BY: KC DATE: 04/11/2022 DRAWING ID: 22-179 `\\`"`~ CHECKED BY: PS SCALE: 1" = 25ft 1 SHEET 1 of 1 2.1 ' 1 X- X — X — — X \— X X 30.2 1 7.3 o 1 IGRAVEL DRIVEWAY IN SHED I I I LOT 10 w I o 0 Lot 3 12'' I ;S� o 1 Heisler Subdivision Z I 1 28,602 Sq. Ft. \ 20875 S. Birchwood Loop Road zs. � 121.3 / ;S� \ 2 Story Wood Frame House 4.0 ,n o X CU (D 0 C --k CD h�:Cvvr UnTv .") Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program " 4700 Bragaw Street •' "• P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D._051-092-36 COSA # 02 Or73y 1. GENERAL INFORMATION Expiration Date: -j3"— 2 r O Complete legal description_ HFISI FR I QT_3 Location (site address) 20875 RIRCHWOOD L OOP ROAD CHI ICIAK AK 99567 Current Property owner(s) HISTORI . FQI IrrY, 11 C Day phone 907-746-377 Mailing address PO BOX 499 PAL MFR AK 99645 Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: A 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ 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 On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems 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. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties 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. 4. 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 1 A rcle 1ra ..Enainep ring . • 1• 1 e- Phone AGA -3792 —1 Engineer's Printed Name KENNETH M. DUFFUS Date 02/21/08— Engineers 2/21/08Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are subiect to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future occupants or can ArcTerra guarantee that no unseen encroachments, deficiencies or discrepancies exist. S. DSD SIGNATURE Approved for G bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checklist X Arsenic Advisory Septic System Advisory Maintenance Agreements Well Flow Advisory Supplemental Engineer's Report Nitrate Advisory Other By. J Original Certificate Date: 2 B (Rw. IM Municipality of Anchorage ., • "~ Development Services Department Building Safety Division - On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: HEISLER LOT 3 Parcel ID: 0511-092-36 A. WELL DATA Well type PRIVATE If A. B, or C provide PWSID # Well Log (YIN) N Date completed 1969+/- Sanitary seat (Y/N)-Y Total depth 70+ it. Cased to 70+ it. FROM WELL LOG . Date of test Wires properly protected (YIN) Y Casing height (above ground) 12 In. AT INSPECTION, 1-1/09/200.7 Static water level - ft. 56 ft. Well production - g.p.m. 1 1 1 7 9.p -m. WATER SAMPLE RESULTS: Coliform _9_colonies/100mL Nitrate ND mg/L (Other bacteria _0J colonies/100 mL Arsenic: _ND_ mg/i Date of sample: 02/08/08 f 212006 Collected by:ArcTerra B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Date installed 4/26/06 & Late 80s Tank size 1250 & 1000 gal. Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) ,tit High water alarm, (YIN) Y Date of pumping 2/11108 Pumper Sanitary C. ABSORPTION FIELD DATA Date installed 4/26/06 Soit rating (g.p.d./feorfe/bdrm) 0.7 a�d_ System type Bed Length 73' ft. Width 18 ft. Gravel below pipe 0.5 ft. Total depth,r1,5 ft. i Eff. absorption area 1314 ftp Monitoring tube Y Depression over field rt Date of adequacy test .NA' -New System Results (Pass/Fail) Pass For 6 bedrooms Fluid depth in absorption field before test.NA in. Water added -NA -gal. New depth.NA-in. Elapsed Time: BA min. Final fluid depth.NA in. Absorption rate >= NA g.p.d, Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date ----- D. LIFT STATION Date installed 4/26/06 Size in gallons 1250 Manhole/Access (Y/N) Y "Pump on' level at 44 n. 'Pump ofr level at—AZin. High water alarm level at 48 in. Datum Bottom of Tank Cycles tested2.,, Meets alarm & circuit requirements? y E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption field on lot 100'+ Public sewer main _7.5'+ Sewer /septic service line 25'+ Animal containment areas 50'+ On adjacent lots 10 0'+ On adjacent lots 10 0'+ Public sewer manhole/cleanout 100'+ Holding tank 100'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main 10'+ Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main 10'+ Water Service line 10'+ !Surface water 10 0'+ Driveway, parking/vehide storage 1 ' + /- Curtain drain 50'+ Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION 1 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. Engineer's Printed Name KENNETH M. DUFFUS �- - M COSA Fee $430 00--,, Date of Payment���o8 Receipt Number (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number - —x—r—x WELL —x—x—x—gx—x io of to Cn � O N 00 N 28.4' -- I M 04 LOT 10 50' I 0 J N00'04'30" E x—x x—x—x—x — 1 2.0$' I Ix SHED PD I e.o• I LOT 3 14 7.4' I2. WELL x o SHED i ® I 6.1' I I 4'x8' DECK SEPTIC VENTS l_ i' PLANTER 15' UTILITY j02,0$' EASEMENT ON R BUILDIN LOT 2 000 293. G^ t5.9'n 24.1' 186 >- w W , n COV 0 SEPTIC W Q v N U) VENTS to a v ; W I 1+ , 0) v 1 �. GRAVEL .•<. CO D b SEPTIC VENTS l_ i' PLANTER 15' UTILITY j02,0$' EASEMENT 30' 1 50' BIRCHWOOD_LOOP ROAD N00'05'00"W BASIS OF BEARING PLAT 68-23 ANCHORAGE RECORDING DISTRICT ASBUILT OF: HEISLER SUBDIVISION LOT 3 PLAT 68-23 SURVEY CERTIFICATION: I, John G Schuller, have conducted s physical survey of this property as shown on this drawing and that Improvements situated thereon arc within the property lines and no eneroachto exist other than noted. Under no circumstance shoo any information on this drawing be used for construction of fences, structures, improvements, or for establishing boundary lines. EXCLUSION NOTES:lt is the owners responsibility m determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. N K ORDER NWSER. NOV 19. 2007 1'40' 9,.•9ngar.n9l 07-113..'r°•' •' L5 NW1357 0704/01 �a P�� .OF..!9Lgs�1 the / �;'� '•!f` � I md % *C'2: 49TH �.�... ...� .............. It a 'JOHN L. SCHULLER:' s LS -10408 '4t N 0 O W) 0 LO ON I LLJ W 000 z =)N I LLJ > Qa >- w w ILjj In io N W Q v :n W 0) 00 v N I 30' 1 50' BIRCHWOOD_LOOP ROAD N00'05'00"W BASIS OF BEARING PLAT 68-23 ANCHORAGE RECORDING DISTRICT ASBUILT OF: HEISLER SUBDIVISION LOT 3 PLAT 68-23 SURVEY CERTIFICATION: I, John G Schuller, have conducted s physical survey of this property as shown on this drawing and that Improvements situated thereon arc within the property lines and no eneroachto exist other than noted. Under no circumstance shoo any information on this drawing be used for construction of fences, structures, improvements, or for establishing boundary lines. EXCLUSION NOTES:lt is the owners responsibility m determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. N K ORDER NWSER. NOV 19. 2007 1'40' 9,.•9ngar.n9l 07-113..'r°•' •' L5 NW1357 0704/01 �a P�� .OF..!9Lgs�1 the / �;'� '•!f` � I md % *C'2: 49TH �.�... ...� .............. It a 'JOHN L. SCHULLER:' s LS -10408 '4t N 0 O W) 0 LO 0 MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH R 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 Parcell.D.# 051-092-36 1. GENERAL INFORMATION Complete legal description Heisler Lot 3 HAA # ;1 A 9905(L_ Location (site address or directioRstjchwood Loop North Property owner Debbie Kindred Mailing address Day phone 688-9705 Lending agency Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. 3 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: X Individual well Ej 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: 23 Individual on-site E3 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(A. 1/91) Front MOA .21 S. 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. KND Engineering Name of Firm Phone Address 20441 Ptarmigan Blvd., Eagle River, AK 99577 Engineers 6. DHHS SIGNATURE Approved for bedrooms. Disapproved. Conditional approval for Additional Comments By: • 696-6111 Date 11/12/99 bedrooms, with the following stipulations: 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 purchasersof homes and their lending institutions in order to satisfy certain federal and sate 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-=(R«.1/91 8. x MOA 41 f�E,CEIVEG Municipality of Anchorage �NOV' � DEPARTMENT OF HEALTH & HUMAN SERVICES, 1 5 199 Environmental Services Division OF ANCH 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907, 04 744SERVICES DNISION Health Authority Approval Checklist Legal Description: Heisler Subdivision Lot 3 Parcel I.D.: 051-092-36 A. WELL DATA Well type Individual If A. B, or C, attach ADEC letter. ADEC water system numberr: 1 • 7, Log present (YM) Not found Date completed SEE 47TACNCD 4AKE2 NAP I Total depth t wct6 t -&AVE ONKE Cased to .> yr'! Casing height (above ground) - 12" Sanitary seal (Y/N) Y Wires moDedv protected (Y/Ni <Y ' f'• FROM WELL LOG MOA i AoEG 14H46lt io la16 Date of test Static water level Well production WATER SAMPLE RESULTS: 0 Coliform Date of sample: 11/4/99 Nitrate g.p.m. ATINSPECTION 11/4/99 $Sr -3.46 --..._...__ -Fir- 0.500 9 Other bacteria— �_--- Collected by: KIND Engineering, B. SEPTIC/HOLDING TANK DATA -n. Date Installed 1976 Foundation cleanout (YM) _ 11/2/99 Date of Pumping - C. ABSORPTION FIELD DATA Date installed 1976 _Tank size 1000 Number of Compartments2 Cieanouts.(Y/N) Y Y Depression (Y/N) N High wateralarm(YIN) N:r^rte= JR's _Pumper Da`.c of Pu ;din; _-------__-- Soil rating (g.p.d./ft2 or ftz/bdrm) 85 ' S stemTrench Y tYPe ° ---- - Length 22' Width NA Gravel thickness below pipe 6' Total depth 12' _ Effective absorption area 336' Monitoring Tube present (YM) Y'/N)Depression over field (YN Date of adequacy test 11/4/99 Results (Pass/FaiQ P For +'^3^ ^' ^-• —bedrooms___.._ Fluid depth in absorption field before test (in.); 44'25 ' y 450 .g [i ) 65.5 Immediatei after al. water added:; n.: Fluid depth 43.75"'(ins)Minutes later. 1440 Absorption rate = 450+., ...a.p.d._�— Peroxide treatment (past 12 months) (Y/N) N If yes, give date 72-026 (Rev. 3196)' D. LIFT STATION Date installed N/A Size in gallons Manhole/Access (Y/N) . "Pump on" level at* High water alarm level at* Cycles tested E. SEPARATION DISTANCES 'Datum SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot 100'+ 100'+ Absorption field on lot Public sewer main Sewer /septic service line 100'+ 25'+ On adjacent lots On adjacent lots _ "Pump off" level at* 100'+ 100'+ 1001-1- Public sewer manhole/cleanout Lift station N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation 50'+ Property line 10+ Absorption field 101+ 25'+ 100'+ 200'+ Water maln/service line Surface water/drainage Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line 10+ Building foundation 10'+ Water maintservice line 25'+ .-,Surface, water 100+ Driveway, parkingNehicie storage area 25'+ Curtain drain 1009+ Wells on adjacent lots 1001+ F....ENGINEER'S CERTIFICATION _ I certify that I have determined thru field Inspections and review of Municipal records that ve systems are in conformance with OA HAA guidelines in effect on this date. e �� OF q 4L� ►► Signa tu rh�,^.r,•i,�Pt„i . . Cf:s, .gym• Kennet . Du P.E. m ?z:)21i” :a �• f t. k dp` Engineer's Name es 0. .. .... .... ..: "•,I n Date 11/12/99 ;' te ; ...... ..2 va�f�PROFESSIO� �+`� . JUDO. „� , Z'►oaae�na-'c' HAA Fee $ Waiver Fee $ Date of Payment —,��/ -/ Date of Payment Receipt Number ris 6 ( /O� 2 1 Receipt Number 72-026 (Rev. 3196)'