HomeMy WebLinkAboutEAGLE RIVER VALLEY RANCHETTES LT 19D Municipality of Anchorage :5~ ~...
Development Services Depadment ~ ~:
Building Safe~y Division
On-Site Water and Wastewater Program. 4700 S. Bragaw St.
P.O. Box 196650 Anchorage. AK 99519-66§0 Page ~ of'~
www. cl.anchorage.ak.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: ~t)O 30 c.~7 ! PID Number.
"""'://~f,~..~J~[~.- Lt'-/L//E, WastewaterSystem: [-INew ~Z]Upgrade
ABSORPTION FIELD
~ Ft.
Well= ~ New ~ Upgrade ~
· ,.,. ~s.,.,:r"l~~ r. TANK
SEPARATION DISTANCES D Septic D Holding ~ S.T.E.P. D Othec
To ~ Septic Absorption Lift Holding Pubfl~at~ .
Tank Field Station Tank S~r ~e ~ I ~
s~..w.,., I~~ [~0~ ~/ LIFT STATION
""~'~': BENCH MARK
Development.Se~ices Depadment Approval
Reviewed and approved by: ~~/~ ~~Date: ~ -~-
PER,~I[T NO. SW030271
Municip. ~[it oF Anchor'oae
DEPARTMENT OF HE,~,~TH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P,D. Box 196650 eAnchor~ge, Aloska 99519-6650e Telephone: 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
LEGAL LOT 19D, EAGLE RIVER VALLEY RANCHETTES P.I.D. NO. 050-223-31
LOT 19A ' , LOT 19B '
.............. J L J
10' UTILITY EASEMENT
-I F .................. ] F-~
% I g ii NO WELLS ~ '
SEPTICb Il SI~ SEPTIC blb/bM ~
I I ~ / I
LOT 19C ' '"' - ' i_ ,' >
I I ---~\
I I EXiSTiNG
Jj ~ DRIVEWAy J
I ~ I
WHIRLAWAY ROAD ~.~: ,-. ~o.
LOT 10A ~ ,,~... ~..,~o, .~.
PERMIT NO. SW050271 PACE 5 OF 5
Hunicip. c~{i't oF AnchoroQe
DEPARTMENT OF HE,~,~_THAND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.D, Box 196650 ~Anchorage, A~osko 99519-6650~Te~ephone: 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
LEGAL LOT 19D, EAGLE RIVER VALLEY RANCHETTES P.LD. NO. 050--223--51
A B C
DV 32.5' 21.0' -
C01 ' 24.5' 30,0' -
C02 41.0' - 91.5'
MT1. 37.0' - 88.5'
FINAL GRADE
MTl=81.6'j
C01 =91.8'
C01=89.1'
C02=89.1'
A
NO WATER FOUND
75.6' B.O.H.
MUNICIPALITY OF ANCHORA GE
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
Date Issued: Jul 24, 2003
Expiration Date: Jul 23, 2004
Permlt Number: SW030271 Parcel ID: 050-223-31
Legal Description:;!EAGLERiVER VALLEY RANCHETTES LT 19D"
Design Engineer: 0003 S & S Engineering Site Address: 019127 WHIRLAWAY RD
Owner Name: Mary & Jack Little Lot Size: 17955 SQ. FT.
O~vner Address: 19127 WHIRLAWAY ROAD Total Bedrooms: 3 Permit Bedrooms: 3
EAGLE RIVER, AK 99577-8334
This permit is for the construction of:
[] Disposal Field [] Septic Tank [] Holding Tank [] Privy
[] Private Well ~ Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ).
3. The engineer must notify 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.
~ 5. The following special provisions.
;' AT THE TIME OF CONSTRUCTION THE WATER LINE IN THE UTILITY EASEMENT SHALL BE LOCATED AND IF
IT ENCROACHES ON THE CRIB (<10 FEET) THE THE CRIB SHALL BE DECOMMISSIONED IN ACCORDANCE
WITH THE U.P.C.
Received By:
Issued By:
I;legeloNtt~fit ~l-Vlcbs
bulldin~t Safel~ blvlslo,
On-Slle Waler ah~ WasleWater Program
4700 Soulh bragaW SI.
~ P.O. box ig6650 Anchorage, Ak 9951g-6650
_ ~ ~.cl.an~ho~age.ak.~s
~ · (907)
ON-SITE SEWER~ELL PERMIT APPLICATION
FOR A SINGL~ FAMILY DWELLING
Parcel I.D.
Permit Number SW O 70 27/
I~roperly owner(s) /V~,~ / ,.j~,/<. L i TT/_~
Mallin~ address ('1) /'~'/~-~-
Mallin~ address (2).
Legal descrlplion (Lot, ~lock & sub'd.)
Legal description (Section, ToWnship & Range)
APPLIcATIOH Is FOt~:
SeWer Only
Sewer and Well
Sewer Upgrade
I~I~OPI=RTY Col,,l'rAil, lS:
Hot 'rub
Swlmmlng 1~ool
'therapy Pool
HUmber of Bedrooms
I cigrllt'~/Ihal Itie above Inlormalioh Is Correc{. I furlher cetlify Iha~ this applicaUon Is being Inade for a
~htBle Fatnlly 13Welllud and Is In accordance wllh apbllcable Municipal Codes.
~~/~ ~_ S & S ENGINEERING
~70~ Eagla River L~p Road No.
~le River~ Alaska ~577
(SlgnalUre of properly owner or aUIhorlzed agen{)
Permlt ~'ees: ,~/fOO< ,o
bale of Paymen{: '7/,,z ]/0 .3
{Rev. '12/00)
Waiver I:ei~s:
I'{eci~lpt ~Umber:
Fl Jacuzzi
[] Waler Sollenlng
[]
Well Only []
Waler Slorage []
ROBERT C. COWS. N, RE.
ROBERTA. SHAFEFL RE.
SEWER & WATER
MAJN ID(TENSIONS
SEWER&WATER
INSPECTION
ENGINEERING STU~ES
AND REPOm's
WELL INSPECTION
& FLOW TEST
S~TE PLANS
GOILTEST
PERCOLATION
TEST
8TRt~"TURAL &
INSPeCTIOnS
ON S~TE
WA~TEWATER
DISPC::~J~L SY$ TE M
I~S~GN
July 18, 2003
CML ENGINEERS
(907) 694-2979
FAX (907) 694-12 ! I
MUNICIPALITY OF ANCHORAGE
Development Services Department
P.O. Box 196650
Anchorage, AK 99519
REFERENCE: Lot 19D, Eagle River Valley Ranehettes Subdivision
It is requested that you issue a permit to install new trenches to serve the existing
three bedroom dwelling on the referenced properbd.
A test hole was excavated, and a percolation test performed. The approximate location of
the test hole is located on the attached site plan. At the time of excavation 7/10/03 no
water w~ found. After monitoring, ground water was not found.
We do not anticipate any adverse effects on neighboring wells, septic systems, reserve
areas or drainage patterns by the installation of the proposed septic tank. The installation
of this septic tank will not prevent any future development on any of the adjacent
properties.
If you require additional information, please contact us.
Sincerely,
o~n J~. tCowan, P.E.
Rccroj
Enclosure
17034 NORTH EAGLE RIVER LOOP * SUITE 204 · EAGLE FflVER, ALASKA g,9577
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N91530 ;0~ = ,,l
Municipality of Anchorage
Development Services Department
Budding SafEly Divis;cn
On. Site Water ~nd Wastewater Program
47(~0 Scuth £mgaw SL
P.O. BOX 1966~0 Anchera~e,/~ -c951-~665,0
_www.cJ.~nchcr"~qe.ak.us
(~7) 343-7s04
Soils Log - Percolation Test
Slcpe Site
2-
3-
4.
5.
6-
7-
8-
9-
10-
11-
12-
13-
15-
16-
17-
I'll
wAS C- R Ot.,%'O WAT E.=,
IF yes. AT ¥,/HAT DEPTH? -'"-' L
O
Depth to Water A~er p
Uonitoring? J)~'Y' E
20-
COMMENTS
Re=ding D~e
Gross'rime I NetTime Depth to Water
I
I o I 0
(r:'. L"~tes-'.'-~) FERC HCtE OlA;.~ETEP,
· J" ~ ' ,A~ A~D,'U?ICiPALGUID L ,ESIIEFr CTOI . .
P=RFORM:Ol I~,CCOr~A,IC~%ITHA--$- -E ..' .. ' =_ ' '--- THISDATE DATE'
:meemnq
ROBERTC. COWAN, RE.
ROBERTA. SHAFER. RE.
SEWER&WATER
MAJN EXTEN~ION~
SEWER&WATER
ENGJNEERING STUDIES
W~LL INSPECTION
& FLOW TEST
SiTE
80~TEST
FERCOLATK:~I
TEST
STRUCTURAL &
MECHANCAL
INSPECTIC~S
WA~TEWATER
I:~S~GN
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION PRACTICES
and
MATERIAL SPECIFICATIONS
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-121 !
REFERENCE: Lot I9D, Eagle River Valley Ranchettes Subdivision
July lg, 2003
GENERAL:
The scope of this project includes the installation of new septic trenches to serve
the existing three bedroom residence located on the referenced property.
Construction shall be in accordance with the approved site plan and design
drawings, Municipal permit with any special provisions or conditions, and all
applicable State and Municipal Wastewater Disposal Regulations.
The contractor shall be responsible for obtaining any necessary underground utility
locates.
Unless specifically agreed otherwise, the property oxmer shall be responsible for
final grading areas subsequently depressed from soil settling.
Contractors installing xvastewater disposal systems must be certified by the
Municipal Health Department for system installations. Owners installing their
own systems must also receive prior approval from the Municipal Health
Department.
ABSORPTION TRENCH/DRAINFIELD INSTALLATION:
Excavate the proposed trench to the dimensions shown on the design. The bottom
of the excavation shall be within 2 inches of level. If the side,vails of the
excavation become smeared, they must be raked or scratched (ruffed-up) before
gravel (sewer rock) placement.
Once the gravel is installed, the distribution pipe is to be installed level with the
perforations faced downward. Gravel is then to be placed over the distribution
pipe to provide a minimum of 2 inches of cover over the pipe2
17034 NORTH EAGLE RIVER LOOP . SUITE 204 · EAGLE RNER. N..ASKA 99577
Page 2
Lot t9D, Eagle River Valley Ranchettes Subdivision
July 18, 2003
A silt barrier must be installed between the final gravel layer and the native soil backfill.
Ensure the silt barrier covers the entire gravel surface before placing backfill.
Monitor tubes shall be of four (4) inch diameter, installed approximately in the locations
shown on the design, and extend a minimum of 12 inches above final grade. The portion
of the monitoring tube extending through the gravel shall be perforated from the bottom of
the trench to the invert of the distribution pipe. This is equivalent to the effective depth of
the gravel as noted on the design.
Backfill over the final gravel layer must not be less than twenty-four (24) inches.
Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The
finish grade over the trench must be mounded to prevent the formation of a depression
after settling.
MINIMUM MATERIAL SPECIFICATIONS:
o
Any septic tank proposed for installation must be constructed by a Municipal approved
septic tank manufacturer.
The following pipe materials are approved for use in septic system installations in the
Municipality of Anchorage:
Type of Pipe .Perforated Solid
Cast Iron Yes Yes
ASTM D3034 (PVC) Yes Yes
ASTM F810 (HDPE) Yes No
ASTM D2662 (ABS) Yes Yes
Use ora type of pipe other than listed above must be approved by the inspecting engineer.
Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical
Company Styrofoam HI or equal).
Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Femco, or
equal).
A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed
between the final leachfield gravel layer and the native soil backfill.
All leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3%
passing the #200 sieve.
Page 3
Lot 19D, Eagle River Valley Ranchette$ Subdivision
July t8, 2003
When sand is being used as a filter material, its gradation specifications must conform to
current M.O.A. or D.E.C. requirements, which ever requirement applies.
INSPECTIONS:
Typically there will be a minimum of three (3) inspections required during the installation of the
wastewater disposal system. These inspections will occur as follows:
The first inspection must be conducted after the excavation of ditches, pits,
trenches, or beds and before the installation of any grovel. A septic tank ma)' be
set in place, but may not be backfilled before this inspection.
The second inspection must be conducted after the placement of the silt barrier,
gravel, distribution lines, standpipes, cleanouts, and insulation, but before the
placement of any other backfill.
3. The final inspection is to occur upon final grading of the property.
Often there will be mom than these 3 inspections required. Especially with the installation of
multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer
is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre-
construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or
control in any way the contractors activities.
The o~vner shall contract with the contractor to perform the work outlined in these specifications
and plans and in accordance with the attached M.O.A. permit. There will be no contractual
arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be
the owner's representative and will inspect the work as stated above to document the contractors
activities. Final acceptance of the contractors work rests with the owner and the M.O.A.
S & S Engineering shall have no liability to the owner or to others for acts or omissions of the
contractor or any other persons performing work on this project or the failure of the contractor to
carry out the work in accordance with these construction documents. S & S Engineering's
inspecting engineer will not be responsible for the construction means, methods, techniques,
sequence, procedures or the safety precautions incident to this project.
CONTRACTOR / INSTALLER
· ~'WER & WATER
MA~ I~TENSK~S
SEWER&WATER
INSPECTI(NNI
ENG/NEEI~NG STUOIES
ROAD DESIGN
SOIL TEST
TEST
O~ISITE
W~T~WATER
ROBERT C. COWAN, P.E.
August 5, 2003
CML ENGINEERS
(907) 694-2970
FAX (907) 694-1211
MUNICIPALITY OF ANCIIORAGE
Development Services Department
P.O. Box 196650
Anchorage, AK 99519-6650
REFERENCE: Lot 19D; E0gle River Valley Ranchettes
Request you grant a ~vaiver on the referenced property for the horizontal separation
distance between tile leachfield and tile south property line atz feet.
This is the lot line adjacent to Whirlaway Road. We do not anticipate any adverse
effects.
lfyou require additional information, please contact us.
Sincerely,
Robert C, Cowan, P.E.
RCC/ts
t 703,~ IdORTH I~GL~ RIVER L~ & ~UITE 20,1 -' EAGLE RIVER, ~J.A~KA 99577
WR#: 030064 PID#: 050-223-31
Date Received: 8/7/03
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Walcr and Wastewatcr Program
4700 Bragaw Street
P.O. Box 196650 Anchorage, AK 99519.~650
www. ci.anchorage.ak.us
(907) 343-7904
Waiver Review Worksheet
HA#: 030394 PermitO:
Legal Description: Eagle River Valley Rancheltes Lot 19D
Engineer: S & $ Engineering
'17034 N. Eagle River Lp
Applicant: Mary & Jack Little
Waiver Requested: ~ Foot hor~zort~:al dlsl~ance bel;weelt l~he Leachfleld and SPPth Property line
Criteria: Geology Points:
A. Water Table
B. Soil Sorption
C. Permeability
D. Water Table Gradient
E. Horizontal Separation
Total:
Waiver is Granted: ~ Waiver is not Granted:
List Conditions or Reasons for above:
Rec~: :~9679 AmOunt: $t50.00 Date Paid: 8fft2003
Municipality of Anchorage
Mark Begich, Ma~dor
Building Safety Dirision
P.O. Box 196650 · 4700 Bragaw Street
Anchorage, Alaska 99519-6650 · (907) 3~3-8301 · Ikux (907) 343-8200
h t tp://~v.mmd.org
8/7/2003
Robert C. Cowan
S & S Engineering
17034 N. Eagle River Loop Ste. 204
Eagle River, AK 99577
Subject:
Waiver Request for Eagle River Valley Ranchettes Lot 19D
Waiver Request #WR030064
Parcel ID #050-223-31
HA030394
Dear Engineer:
Your request for a waiver of the required 10 feet horizontal separation from the
absorption field to property line has been approved. The approved separation distance is
;.feet.
This waiver approval applies to the existing absorption field to property line separation
only. Any future upgrade to the on-site wastewater disposal system will require all
separation distances be met or another approval from this department.
If there are any further concerns or questions regarding this waiver, please call our office
at 343-7904,
Sincerely,
Jeffrey W. Poet
Engineering Technician
On-Site Water & Wastewater Program
Municipality of Anchorage -
Development Services Department
Building Safety Division
' On-Site Water and Wastewater Pro,ram.
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci, anchorage.ak.us.
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
...... POR A ~51NGLE PAMILY UWELLING'"
' O '
Parcel I.D. 050-223-31
GENERAL INFORMATION
Complete legal description Lot 1
Eocation (site address or directions)
Expiration Date: __~:~ - ~-) - O .L/..
Ea£1e River Valley RancheLr_e,~
19127. l~hir.l.away Rd., g_a~.le R.iver, AK_ 99577
Current Pr0pertyowneris)Hary & Jack Little
Day phone ..696-6966
Mailing address
Lending agency
Same
Day phone
Mailing address
Real Estate Agent
Day phone
Mailing Address
Un/ess otherwise requested, HAA will be held by DSD for pickup.
NUMBER OF BEDROOMS: 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 Health Authdrity
Approval (HAA).based.only upon,the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authcrity Approval are required for the transfer of
title (except between spouses) for propedies served by a single-family on-site wastewater 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. (Certificates may be reissued for a pedod 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 e.,TOrS 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 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
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 S & S Engineering .
Address17034 N. Eagle River LP RD, Eagle River,
Engineer's Printed Name Robert C, Cowan
bedrooms.
DSD SIGNATURE
~ Approved for i
Disapproved.
Conditional approval for
F;,o,,~694-2979 .'---
AK 99577
Date ~/~/~3
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advis. ory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: '.~_~..~.~
(Rev. 01/02)
Municipality of Anchorage
Development Services Department
Building Safety Dtvlslon
On-Site Water & Wastewater Program
4700 South Bmgaw St.
P.O. Box 196650 Anchorage, AK g9519-6650
www. cLanchorage, ak.us
(g07) 343-?g04
HEALTH AUTHORITY APPROVAL CHECKLIST
A. WELL DATA
Well type
Date completed
Total depth .~
Date of test
StetJo water level
Well production
_ Sanitary ~1 (Y/N),
ft. FROM Cased/t~ .___fi.
WATER SAMPLE RESULTS:
Coliform /g~onies/100 mi.
/
Arsenic: ~ rog.fl.
e. SEPTIC/HOLDlffi~3 TANK DATA
Ce
Nitrate g./l.
Date of ~m~
Tank Type/M~t,~..~..~'~/.~ /
Tank size'/?. ~'~. gal. I
Nu~r of Compa~en~
FounUaUon deano~ (Y~)
Da~ of pumping
AeSOR~ON
Well Log (Y/N7
Wires properly pm/t~ted (Y/N)
g.p.m.
/
Other bacte/ colonies/lO0 mi.
/
Collected lily:
Date installed '?-'~~_~.
Cleanouts (Y/N) ~/
High water alarm (Y/N) ,~
System type ~
Gravel below pipe ~', ~' ff.
Total depth ~ g~ft.
/ s/./~ '
Fluid depth in absorp?,~eld before test in.
Elapsed Time: ~ rain. ' Final fluid depth
Any rejuvena'don treatment (past 12 mo.) (Y/N & type)
Eft. absorption area
Monil~dng tube ~f/ Depression over field ~
Results (Pass/Fail)/'~6 For '~ bedrooms
Water added gal. / New depth in.
in. Absorptio~mte >= g.p.d.
if yes, give date -
D. LIFT STATION
Date installed J~/~. in,.0r
"Pump on" level at
Datum /
E, SEPARATION DISTANCES
Size in gallons
'Pump off" level at
Cycles tested
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Manhole./^_~>?_ ss (Y/N)
. in. High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots ' //
in.
Absorption field on lot
Public sewer main
Sewer/septic service line
./
/
On adjacent lots ./
/
Public sewer manhole/,~eanout
Holding tank /
SEPARATION DISTANCES FROM SEPTIC/H.~-DT~G TANK ON LOT TO:
Building foundation
Water main . /~
Wells on adjacent lots
Propertyline 5 ~-
Water service line
Absorption field. ~- fl"
/O '
/- Surface water / ~) '+ _
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ,. ,.~, (*~R # o3o o&¥)
. Building foundation
Water Service line /1~ ~L* Surface water
Curtain drain .~(~3~.,/1¢'/~)~?./A/ Wells on adjacent lots
COMMENTS
Water main · /(~ /'
Driveway, parki[Kl/vehide sto:age //(~/~
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 w~th MOA HAA guidelines in effect on this date.
t~%%-' /, tk
Engineer's Printed Name
Date ~ /*//0
HAA Fee $ '3 ') ~' ' '~ Waiver Fee $
Date of Payment $/{, /o $ Date of Payment
Receipt Number C~ ~ =1 C -7 ~ ~/~ Receipt Number
(Rev. 12101)
~ t~At Nd ~N~6AottklENI'8 ~lsl'.~:ct~Pl' A~ /
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