r·-··---·--··-~····'~·----·-······-·~-··-··-,,·- L1IV- Ii! IiI...

$: r·-··---·--··-~····'~·----·-······-·~-··-··-,,·- L1IV- Ii! IiI ...5618C1B5-BAB5-4588... · 2014-07-03 · II\Iast6water , . System & Potablt> Water Supply$
IIIast6water System amp Potabltgt Water Supply Permit Application Revised 10142007

Wastewater Management Division - Permit Application

Wastewater S stem amp Potable Water Su shyDElJJ1THEHT OF EHViROIlHTAl COItSUVAnOl For Office Use -Only

-bullbullbull _-- ~_bull _- bull --- ~ _--_bull_ bullbull __bullbull_ bull po_ bull _bullbull_ bullbull _~ bullbullbull_ -----~-~--- -_bullbullbullbull - -bull _- bullbull_ bull--_- bullbullbullbullbullbull_bull _-middot--middotmiddot-~middotmiddotmiddotrmiddot-middotmiddot---middot--middotmiddot-~middotmiddotmiddotmiddot~middot----middot-middotmiddotmiddotmiddotmiddotmiddot-middot~-middotmiddot-middotmiddot-middotmiddot __ n_middot bullbull bull__ __ r

Application PIN i Dale Complete Applicallon Received

L1IV- L~amp- O~ 4 Ii IiI 1- -o~ A uthonty

10 VSA Chapter 64 the Environmental Protecllon RUles Chapter 1 Wastewater System amp Potable Waler Supply Rules and Chapter 21 Waler Supply Rules Appendix A Pan 11 bull Small Scale Waler Systems

Generanformation

The organization andor content of lhis form may nol be altered however the form is designed to expand to allow additional information to be entered Changes in the orgamzation andor content of the form may resull in an invalid application or permil

In most cases a licensed deSIgner will be reqUired for your project and 10 help complete lh s application form There are also lineby-line instructions available to assist with completing this form

NOT We strongly suggest referring to the application instructions While completing this application form

Applicant (Landowner) amp Project Contact Information

Section A bull Applicant Details (if Landowner is an lndividual or Individualsl

1 Lasl Name 2 First Name (and Middle Initial if appropriate)

Hawkins ~ Millicent

3 Mailing Address Une 1 4 Mailing Address line 2

130 Split Rock Road II 5 TownCity 6 StateProvince 7 Counlry 8 ZipPostal Code

ICharlotte IVermont IIUnited States 1105445

9 Email Address 10 Telephone

I 1802) 899-1253

I Remove This Applicant

Section B bull ~pplicant Details (if Landoner is other than an Individual or Indlvidu8ls e~ Corporations H_omeowners Associations etc1

1 Registered lLgal Enlily Of Organl7ati~ Name 2 Telephone I - II 3 Mailing Address line 1 4 Mailing Address Line 2

I Remove This Applicant

9 Certifying Official Lasl Name

II SlateProvince ZipPostal Code

11 Certifying Official Tille

L II

12 Cenifying Official Email Address 13 Telephone

bull ~ J bull

Page 1 of 10 vefSJon 13

Wastewater System amp Potable Warer Supply Permit Applicalon Revised 10142007

Sectlon Cmiddot Primary Contact Information (If other than Applicant)

1 Last Name 2 First Name (and Middle Iniljal if appropriate)

I II I 3 Mailing Address line 1 4 Mailing Address Line 2

I II I -shy

5 TownCity 6 StateProvince 7 Country 8 ZipPostal Code

1 II Ilunited States II I 9 Email Address 10 Telephone

I II I Section Dmiddot BuildingBusiness Owner Information

1 Last Name 2 First Name (and Middle Initial If appropriate)

I II I

3 Mailing Address Line 1 4 Mailing Address Line 2

I II I 5 TownCity 6 StateProvince 7 Country 8 ZipPostal Code

I II I IUnited States II I 9 Email Address 10 Telephone

I II I Certifying Designer(s) Information

1 Designer Last Name 2 Designer First Name (and Middle Initial if appropriate)

Keeney IIJeffrey M I 3 Designer lIcense 4 Company Name

100377 IjHigh Knob Design Associates LLC I 5 Mailing Address Une 1 6 Mailing Address Une 2

1981 Big Hollow Road II I 7 TownCity 8 StateProvince 9 Country 10 ZipPostal Code

IStarksboro Ilvermont I IUnited States 1105487 I 11 Email Address 12 Telephone

Ilimkeeneycolllcastnet 111(802) 453-5071 I 13 Designer Role(s) r Ii I I r

o Water Supply Designer

~ Wastewater Disposal System Designer

I Remove This Designer I Ii~middotj~lgomiddotr I Property Location Information

Section A bull Property ParceIID(s) and Localion(s

1 Please provide the property location information including Town or City ParcellD TownCity and Street or Road location In the table below

~~Od~ I I

Page 2 or 10 version 13

Nelsewetsr System 8 Potable Water Supply Permil Application ReVIsed 101412007

Section B bull Center of Property GPS Coordinates

1 Enter the approximate center of property coordinales using GPS set for NAD83 or as derived from a map map must be based on NAD83

(a Latitude (h) longilude (in deClmal degroos to five deCImal places ex 443881deg (111 decimal degrees 10 fIVe decimal places ex middot7231392)

N 442941981 0 We-) r=3227867 0

Project Information

Section A - General Project Information l Questions

1 Project Name (it appl1cable) 2 Total Acreage of Property

IHawkins ReSidence 11174 3 Business Name (it applicable)

4 Detailed Project Description

The project consists of a replacement wastewater system for an eXisting 4 bedroom house with a shared off site well

5 Were all bUlltiings or structures campgrounds and their associated potable water suppJjes and waslewater systems r Yes No substantiall oompleteltU~ore Jan-Yj 2007 and all improved and unimproved 10li11~xistence before Janua 1 20071

rYes e No 6 Does this applicabcQllcludesect~i~ll9the ro e __

( Yes e No7 Has anyone from the Wastewater Mallagemenl Divisions Regional Office been to the property

It Yes enler the staff persons nam~ and lile date of the visit

(a Name of Staff Person (b Date of ViSit-------- I =J 8 WIll any oonstructlon occur within 50 feet of a weiland boundary mapped or designated rYes bull No

If Yes contact the Wetlands Program of the Weter Quality Division at (802) 241-3770

9 WIll more than one acre be disturbed during the entire course of construclion including all lots and phases ( Yes Ie No

If Yes contaclhe Stormwater Program of Ihe Waler Quality Division at (802) 241-4320

10 WIll there be any stream crossings by roads utilities or other construclion I Yes r- No

If Yes conact tho RiVer Comdor Mgmt Program of Ihe Water Qualily DiviSion at

Cenlral amp Northwest Vermonl (802) 879-5631 Southern Vermolll (8D2 786-5906 Northeastern Vermont (802) 751-0129

--------------_ - ----------------------------- 11 Is the project localed in a spedal flood hazard area as designated on the flood Insurance maps prepared for a municipality by rYes (i Nothe Federal Emergency Management Agency

If Yes show the speCial flood hazard area limits on the site plan

12 Acl 250 Has the Applicant (Landowner) subdivided any other lOIS of any size within a five mile radius of this SUbdivision or ( Yes (i No within the environmental dlslricl within the lasllive years

If Yes enter the lown(s) Bnd the associated number of lois In Ihe lable below

(a Tovm (b) Number of LoIs

II

13 Is there any prior Ac1260 jurisdlcbon on the Iract of land bull eYes r No

(f Yes enter llie Act 250 permit number

(a Act 250 Permi Number

version 13Page Jot 10

wastewater System amp Potable Water Supply Perml Application Revised 10142007

Section B - Project Doed Reference

Please provide the Town Book and Page reference lor the current landowners deed(s) to this property in the table below

Section C bull Project Plan Reference

Please provide the following information for all water supply and wastewater disposal system plans being submitted

x x

1106-30-2008

1106-30-2008

Section 0 - Existing Project LotiBuildingOetalls

Please provide the existing project delails This section is used to describe what is existing for the project For example if you are subdiViding an undeveloped 21-acre parcel you would list lhe existing parcel If you are revising the boundary lines of two commerdallots in an industrial park and constructing an addition 10 an existing building you would list the exisling lot numbers existing acres existing buildings existing uses construction date(s) prior permits and answer the compliance questions

1 Lot

12 Lot Size (acres)

1174 3 Exisllng Use of the Lot

18ingle- Family house

4 Provide the following information lor each building on Ihe lot

Section E - Proposed Project LotiBuiJdlngOetaiis

ThiS section Is used 10 describe what you are proposing (0 do in this project For example if you were going to create 4 lots for construction of single lamily residences you would list each 101 proposed acreage proposed buildings and proposed use

1 lot 2 Lot Size (acres) 3 Proposed Use of Ihe Lot

11174 IIResidential

rYes r No

Yes ( No

6 If the lot is exem I lease indicate the s ecific exem tion from Ihe Wastewater S stem and Potable Waler Su i RUles

7 Provide the following information for each building on Ihe lot

IHouse

J

4 Is the lot bem

lied 10 this lot

Remove ThIs Lot J


5 LOIsBuildings SelVed by this Waler Suppl

Wastewaler System 8 Potable Waler Supply Permit Application Revised 101412007

Water Supply Information

Section A - Water Supply Screening QuestIons

rYes r NoAre

l Yes r No2 Are

3 Is there a conneclion 10 an exisllng waler supply for the projecl ( Yes r No

If yOIl answered No to al three of the above questions skiP to Part VI Oth6rwise proceed wI1I1 Part V

Section B bull General Water Supply Questions

( Yes r NoDoes this ro ect involve a failed waler su I

rYes bull No2 Will any of Ihe proposed waler sources selVe Z5 or more people or have 15 or more service connections

If Yes Ihe applJcant mllsl contact the Waler Supply DiVision at (802) 241middot3400 for source construction and operating

( Yes bull No

4 Are any of the existing orQr022~edwaler sources located withLsectlopdwa ( Yes (i No

5 Are any of Ihe proposed water sources located within 1 mile of a hazardous wasle site as designaled by lhe Wasle Management Division and identified on Ihe Agency mapping website rYes r No

If Yes please submil additional information on the site The Waste Management Division can be reached al (802) 241-3888

6 Does this projecl require an approvalletler from the Water Supply DIvision for lhe conslruction of a public waler system ( Yes r Nomunicipal water line extension over 500 leet or hydrants or sprinkler systems

If Yes please submit a copy of the approval letter from Ine Waler Supply DNislon

7 Does Ihe proposed or existing waler supply(ies) use a waler Ireatmenl device 10 obtain compliance wilh the qualily ( Yes r Norequirements in the Waler Supply Rule

If Yes please suomit additronal Informalion regarding the constiluent(s) that exceeds the standards and pl8ns details and specificeiOns of the treatment devJce

8 Is any portion of the proposed waler supply located in or near a Water Source Proleclion Area as desgnated by the Water eYes r NoSupply Division

If in IJreas of known mterference issues please conlact he Water Supply Orvislon at (802) 241-3400

Section C bull Individual Water Supply Details -

Please proVide the follOWing Information for each of the existing and proposed water supply(ies) seNing a bvilding or struclure or campground on the

ro ert

1 Water Supply Namefldentifier

II 2 Waler Supply Owner (H nol Applicant)

3 Water SourC6 Type

INon-Public Drilled Bedrock Well I

4 Type of Change 10 Supply

INo Change

9 Is this water su I located off-lot r Yes r No

(i Yes No - - 10 Is this water supply shared

If the water supply is loceted off-lol or shared submit a copy of the agreement to provide In easement prior to consruction

version 13 Page 501O

Wastewarer System amp Potable Water Supply Permit Application Revised 101412007

rYes r- No11 Is a vanance being requested for this water supply

If Yes please submit additional detailS related 10 the vanance request

Remove This Water SUPPly]

Section 0 - Water Supply Design Flows Summary Table

1 If the project includes more Ihan one waler supply please tist each water supply syslem and prOVide lhe lotal waler supply design flows for the project IMPORTANT Please donllnclude syslems that were Identified in this Part on Section C Line 4 as a Replacement Area DesignalionIn this summary table

490 1

Wastewater Disposal System Information

Section A bull Wastewater Disposal System Screening QIestions shy Yes No Are

t Yes l- Na 2 Are ou proposing changes to an eXisting wastewater disposal system for thiS prOJect - -

Yes r- Na3 Is here a connection to an existing wastewater disposal system for the project (~

If you answered No to all three of the above questions skip to Pari VII Otherwise proceed with Part VI

Section B - General Wastewater Disposal System Questions

(i Yes r NoDoes thiS roect Involve a failed wastewater disRosal 5 stem

Yes (e No2

r Ves (e No3

4 If Ihe project has a SOil-based wastewater disposal system with deSign flows thai exceed 1000 GPO is this projecl localed in a Class A Waterslted l Ves ( No r NA

If Yes indicate the Class A Watershed in which the system(s) IS located

(a) Class A WaeTshed Name

t Yes I- No

If Yes indicate where Ihe floor drains will discharge

5 Are there any existing or proposed floor drains as part of this proJect

(a) Floor Drain Discharge POint

L _ 6 IIlhe project utilizes an tnnovaliveAlternative Syslem or Product has Ihe applicant received a copy of lhe r Yes ( No t NAWastewater ManE ement Divi~lqns a Brovat teHer

7 ts any portion of the proposed wastewaler disposal system located in or near a Water Source ProtecUon Area as designated by the Waler Supply Division ( Yes [ No

If Yes contact the Water Supply Division at (802) 241-3400

Sectlon C bull Individual Wastewater Disposal System Details

Please prOVide lhe fOllowing informalion for each of Ihe existing and proposed wastewaler disposal systems serving a bUilding or structure or cam round on the ro ert

Page 60f 10 verSJon 13

Wastewater System 8 Potable Water Suppty Permit AppJiCJJtion Revised 101412007

3 Wastewater Disposal Syslem Type

5

1 Wastewater Disposal System Namelldenlifier

~lac~ment Area

lMound

2 Wastewater Disposal System Owner (if not Applicanl)

4 Type of Change 10 System

J I IIReplacemenl of Failed System

Olo

10 Is lhls wastewaler disposal system located offlot rYes r No

11 Is Ihis wastewater disposal system shared Yes r No

If the wastewater dispOSal system IS 10ClJted off-lot or silared submIt e copy 0 the agreement to prOVide an easement prior to miliatlon 0 construction

-__--~---------------------------------------I 12 Is a variance being requested for Ihis wastewater disposal system eYes r No

1 Yes please submit additional details related to the variance request

13 If this wastewater disposal system type is a connection to an Indirect Discharge System please provide the Indirect Discharge System 10 number

Indirect Discharge System ID Number

I ~ 14 If this wastewater disposal system Iype is a connection to a municlpal system please select the town

Town[----shy1S (I this wastewater disposal system is a soil-based syslem please select Ihe design approach used

Design Approacn Used

prescriPtive

16 For soil-based systems please check all that apply

o Slorage and Dose 0 Filtrate

17 If Ihis is an InnovativeAlternative soli-based system please seleci the system use type

InnovaliveAlternative Syslem Use Type

IGeneral

18 If th s is an InnovaliveAllernative sod-baseo system please select the InnovaliveAlternative sysllin or prOduc

InnovativeAlternalivo Syslem or Producl

[ I Remove This Wastewaler System I

bullbullbull 1

Selttion Dmiddot Wastewater Disposal Systems Design Flows SQmmary Table _

- I 1 If the project inhecudes mlorIMtph~~ degTnAeN~a~~~~e~~~f~~~~~~s~ey~~~~~1deSIgn Rows for I prOJec _ DeslgnalOn in Ihis summary lable

I tach system on Ihs page and provide Ihe lolal wastewater disposal ~e~e identified In this Part on Section C line 4 as a Replacement Area

Page 7 of 10 verSion 13

Wastewater System amp Potable Water Supply Permit Application Revised 10412007

Application Fees

Fee Amount 1$50000

2 Fee Calculation Details

1M Iee= $500

490 1

Page Sof 10 version 13

Waslewater System amp porable Waler Supply Permit Application Revised 101412007

-Designer Certification amp Copyright License

SectIon A - Certifying Designer 1 CertificatIon amp Copyright License

I hereby certify that in the exercise of my reltJsonltJble proffJssonaIIIJCigment the deslgn-relaled rnformatlOn submilled wih this appfjcatlon IS rue and corred and thaIhe deSign mcluded In this applicallOn for a permit complies with Ihe Vermont Wastewater System and Potable Waler Supply Rules and the Vermont Water Supply Rules

As the indIVidual WhO prepared thiS appllcalion includrng all documents thai are marked as copynghted I hereby grant a nonmiddotexclusive limited license 10 (he State 10 afow the documenls 0 be made available for publiC reVI6W and copymg In ord6r to properly Implement and operate the permilling programs for Wastewater Systems and Porable Weier Supplies and tor no other purposes As a condition to thiS license the Slafe agrees Ihat II Will nOI malte any changes to such documents nor will the Stale delete any copyright notlOes on S(JCll documents

1 Check lhe design(s) you are certifying This should be the same as the Designer Role(s) you selected in Part II Seclion A Line 13

0 Water Supply Designer

IZl Wastewater Disposal System Designer

1 Designer 1 Name 3 Signature Date

IJeffrey Keeney 2 DelJAZ

I - 7~ 63008

Section 8 - Certifying Designer 2 Certification amp Copyright Llc~se f f

I hereby certify that in the eXfKClse of my reasonable professional jlJdgment the deslgn-relaled information submitted with Ihs applicaflon IS true and correct and tliat the deSign Included in Ihs apphcation for a permit complies With the Vermont Wastewater System and Potable Waler Supply Rules and the Vermanl Water Supply Rules

As the mdlvldual who prepared this application mcluding all documents that are marked as copynghted I hemby grant a non-exclusive timiled license 10 the Slate 10 allow the documenls to be made available for publiC reView and copying In order 10 properly Implement and operate the permitting programs for Wastewater Systems an d Potable Water Supplies and (or no other pUlposes As a oondillon 10 Ihls license Ihe $liJte iJgrees that it will not make any changes to such documents nor willihe State delete any copyright notices on such documenls

1 Check the design(s) you are certifying This should be lhe same as lhe Designer Role(s) you selected in Part II Section B Line 13

Water Supply Designer 0 Wastewater Disposal Syslem Designer 0

1 Designer 2 Name 2 Designer 2 Signature 3 Signalure Dale

I I

Page 9 of 10 version 13

Wastewater System amp Potable Water Supply Permil Applicalon Revised 1042007

Applicant(s) Signature amp Acknowledgements

In order 10 insure compliance wlih the requirements of the regulations admmistered by the Deparlmenl of Environmental Conservation Wastewater Management Division il may be necessary to visit the property As this would mvolve a Department employee entermg pnvale property we request your approval 10 do so

1 If we do visit your property do you have any special instnJetions

As landowner of Ihe property for which I am requestmg a permit from Ihe Deparlment of Environmental Conservation I understand Ihal by signmg Ihls application I am grantmg permission for the Department employees to enter Ihe property dunng normal working hours to insure compliance of the property with the applicable IVies of the Department

I Dlso undersland thai I am not allowed 10 commence any sile work or consruclion on Ihls project without wnlten approval from the Departmenl of EnVironmenlal Conservation

If my project utilizes an InnovatiVeAlternatIVe System or Product I have received a copy of the Wastewater Management DiVisions approval leffer and agree 10 abide by the conditions of the approval

laso certify that to the best of my knOWledge and beiief the mformatlon SUbmitted above IS true accurate and comptete

~ 2 Print Applicant Name

IMillicent Hawkins

4 Signature Date

fJ 0 ~ 1 0 K

Page Waf 10 version 13

Wastewater System amp Potable Warer Supply Permit Applicalon Revised 10142007

Sectlon Cmiddot Primary Contact Information (If other than Applicant)

1 Last Name 2 First Name (and Middle Iniljal if appropriate)

I II I 3 Mailing Address line 1 4 Mailing Address Line 2

I II I -shy

5 TownCity 6 StateProvince 7 Country 8 ZipPostal Code

1 II Ilunited States II I 9 Email Address 10 Telephone

I II I Section Dmiddot BuildingBusiness Owner Information

1 Last Name 2 First Name (and Middle Initial If appropriate)

I II I

3 Mailing Address Line 1 4 Mailing Address Line 2

I II I 5 TownCity 6 StateProvince 7 Country 8 ZipPostal Code

I II I IUnited States II I 9 Email Address 10 Telephone

I II I Certifying Designer(s) Information

1 Designer Last Name 2 Designer First Name (and Middle Initial if appropriate)

Keeney IIJeffrey M I 3 Designer lIcense 4 Company Name

100377 IjHigh Knob Design Associates LLC I 5 Mailing Address Une 1 6 Mailing Address Une 2

1981 Big Hollow Road II I 7 TownCity 8 StateProvince 9 Country 10 ZipPostal Code

IStarksboro Ilvermont I IUnited States 1105487 I 11 Email Address 12 Telephone

Ilimkeeneycolllcastnet 111(802) 453-5071 I 13 Designer Role(s) r Ii I I r

o Water Supply Designer

~ Wastewater Disposal System Designer

I Remove This Designer I Ii~middotj~lgomiddotr I Property Location Information

Section A bull Property ParceIID(s) and Localion(s

1 Please provide the property location information including Town or City ParcellD TownCity and Street or Road location In the table below

~~Od~ I I






N 442941981 0 We-) r=3227867 0

Project Information






















II










x x

1106-30-2008

1106-30-2008



1 Lot

12 Lot Size (acres)







11174 IIResidential

rYes r No

Yes ( No



IHouse

J

4 Is the lot bem

lied 10 this lot

Remove ThIs Lot J






rYes r NoAre

l Yes r No2 Are







( Yes bull No












ro ert



3 Water SourC6 Type



INo Change











490 1








Yes (e No2

r Ves (e No3




t Yes I- No












5


~lac~ment Area

lMound




Olo











prescriPtive





IGeneral




bullbullbull 1






Application Fees

Fee Amount 1$50000


1M Iee= $500

490 1












I - 7~ 63008







I I











IMillicent Hawkins

4 Signature Date

fJ 0 ~ 1 0 K






N 442941981 0 We-) r=3227867 0

Project Information






















II










x x

1106-30-2008

1106-30-2008



1 Lot

12 Lot Size (acres)







11174 IIResidential

rYes r No

Yes ( No



IHouse

J

4 Is the lot bem

lied 10 this lot

Remove ThIs Lot J






rYes r NoAre

l Yes r No2 Are







( Yes bull No












ro ert



3 Water SourC6 Type



INo Change











490 1








Yes (e No2

r Ves (e No3




t Yes I- No












5


~lac~ment Area

lMound




Olo











prescriPtive





IGeneral




bullbullbull 1






Application Fees

Fee Amount 1$50000


1M Iee= $500

490 1












I - 7~ 63008







I I











IMillicent Hawkins

4 Signature Date

fJ 0 ~ 1 0 K







x x

1106-30-2008

1106-30-2008



1 Lot

12 Lot Size (acres)







11174 IIResidential

rYes r No

Yes ( No



IHouse

J

4 Is the lot bem

lied 10 this lot

Remove ThIs Lot J






rYes r NoAre

l Yes r No2 Are







( Yes bull No












ro ert



3 Water SourC6 Type



INo Change











490 1








Yes (e No2

r Ves (e No3




t Yes I- No












5


~lac~ment Area

lMound




Olo











prescriPtive





IGeneral




bullbullbull 1






Application Fees

Fee Amount 1$50000


1M Iee= $500

490 1












I - 7~ 63008







I I











IMillicent Hawkins

4 Signature Date

fJ 0 ~ 1 0 K






rYes r NoAre

l Yes r No2 Are







( Yes bull No












ro ert



3 Water SourC6 Type



INo Change











490 1








Yes (e No2

r Ves (e No3




t Yes I- No












5


~lac~ment Area

lMound




Olo











prescriPtive





IGeneral




bullbullbull 1






Application Fees

Fee Amount 1$50000


1M Iee= $500

490 1












I - 7~ 63008







I I











IMillicent Hawkins

4 Signature Date

fJ 0 ~ 1 0 K








490 1








Yes (e No2

r Ves (e No3




t Yes I- No












5


~lac~ment Area

lMound




Olo











prescriPtive





IGeneral




bullbullbull 1






Application Fees

Fee Amount 1$50000


1M Iee= $500

490 1












I - 7~ 63008







I I











IMillicent Hawkins

4 Signature Date

fJ 0 ~ 1 0 K




5


~lac~ment Area

lMound




Olo











prescriPtive





IGeneral




bullbullbull 1






Application Fees

Fee Amount 1$50000


1M Iee= $500

490 1












I - 7~ 63008







I I











IMillicent Hawkins

4 Signature Date

fJ 0 ~ 1 0 K



Application Fees

Fee Amount 1$50000


1M Iee= $500

490 1












I - 7~ 63008







I I











IMillicent Hawkins

4 Signature Date

fJ 0 ~ 1 0 K












I - 7~ 63008







I I











IMillicent Hawkins

4 Signature Date

fJ 0 ~ 1 0 K











IMillicent Hawkins

4 Signature Date

fJ 0 ~ 1 0 K


r·-··---·--··-~····'~·----·-······-·~-··-··-,,·- L1IV- Ii! IiI...

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Transcript of r·-··---·--··-~····'~·----·-······-·~-··-··-,,·- L1IV- Ii! IiI...