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HomeMy WebLinkAboutDENALY ESTATES BLK 2 LT 17Onsite File Denaly Estates Block 2 Lot 17 #067-062-24 Municipality of Anchorage On-Site Water and Wastewater Section - (907) 343-7904 Page 1 of 3 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP211094 PID Number: 067-062-24 Dwelling: 0 Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ■❑ New ❑ Upgrade Name EKLUTNA INC. ABSORPTION FIELD El Trench AWide Trench El ❑Mound Site Address 25551 MCINTYRE ROAD ❑ Other P Phone hone0-2501 Number of Bedrooms 4 Soil Rating Total depth from original grade 1.2 GPD/SF 4.0 /4.0 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 3.5/3.5 Ft. Gravel depth beneath pipe 0.5/0.5 Ft. Subdivision Block Lot DENALY ESTATES 2 1 Fill added above original grade 0.5/0.3 Ft. Gravel length 50/50 Ft. Township Range Section Gravel width 5 / 5 Ft. Beds: Number of Lines N/A Distance between lines N/A Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line 500 Ft2 2 6.0 Ft. Well >100' >100' N/A N/A >25' TANK 0 Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer GREER Capacity 1250 Gal. Surface Water >1 >100' N/A N/A Material PLASTIC Number of compartments 2 Lot Line >5' >10' N/A N/A NA Foundation >.1 0' >10' N/A N/A LTITATION Manufacturer Capacity Remarks.. Gal. Alarm location Electra i talled by Installer PIPE MATERIAL House to tank D3034Tank to D3034 drainfield NORTHERN EXCAVATING Drainfield D3034 CC/MT D3034 Inspector L.TIDWELL BENCH MARK (Assumed elevation) 100 ft Inspection 15` 5/28/21 5/28/21 Location and description ection 2nd 3`d 6/01/21 4116/01/21 TOP OF FOUNDATION AT SE CORNER ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp -4 01F\l Conditional Approval: Date ®*: 419 ...�.... .:-. Benjarr� chiller % Septic System r Approved '4., l.. Date �- ,Z �•.. �� �lF . CE /$522 k PROFESSION���-r Note: this approval does not include well permit requirements. ® . �I\GV VJ/VG/IV� DENALY ESTATES SUB, BLOCK 2 LOT 17 PERMIT # OSP211094 PID # 067-062-24 LOT 17 _`3('TkE EASEMENT -20' M.E.A. EASEMENT LUT 1&VAC T' 445_ + i -i TACT 13 ,1 _ 1 00'WELL RADII `777 435 1250 -GAL SEPTIC '� TANK w120" MANWAY 425, O A ` 4-BDRM HOME ry A\ MOT E 5 WIDE 0.5' 415 EFFECTIVE ®— PTH MH1 s SV1 ' 2C0 ABSORPTION TRENCHES 1 ` 1 MAINTAIN 6' MIN SEPARATION BETWEE TENCHES 2C01 FS - MT '';MT3 TH#3 CO3 ALTERNATE SITE--CAT.-I'll SYSTEM: A(� RATE 6.0, 20' LONG X,5' WIDE, Co3 .5' EFF DEPTH ABSORPTION-- .,,..,. TRENCH ' MT ®ENALY BLOC1 LUT 1 , ®-- EXISTING WELL w or- .. ,�¢�¢ PLAN AS 0 40 80 Benja m Schiller FEET CE 12592��' 1 "=40' .12i07/21,`��,� pROFESSIO�A .�. FCO 28.2 1 6.4 MH1 41.9 1 12.6 SV1 46.6 1 16.8 2CO 49.8 19.0 FS 53.8 23.7 MT1 64.3 32.5 C01 61.3 28.4 MT2 84.4 65.2 CO3 1 73.8 43.3 MT3 1 73.8 1 43.3 C04 1 110.4 83.2 MT4 1 107.0 83.2 LEGEND CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FS - FLOW SPLITTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE DENALY ESTATES SUB, BLOCK 2 LOT 17 PERMIT # OSP211094 [NGIN![lING PROFILE AS -BUILT (NO SCALE) ........... Benja in Schiller 12n%21 s � �i�� pROf DENALY ESTATES SUB, BLOCK 2 LOT 17 PERMIT # OSP211094 PID # 067-062-24 o C\j CN 100.9 FINISH GRADE 100.4 ORIGINAL GRADE :Eo 96.9 DRAINFIELD ROCK 96.9 96.4 96.4 50' 90.3 GROUNDWATER 5/27/21 89.4 F- Co (h ' o 2 100.6 FINISH GRADE F- ! N G I N!! R I H C 90.2 GROUNDWATER 5/27/21 89.3 F- O 100.3 ORIGINAL GRADE 2E .0 PROFILE AS -BUILT (NO SCALE) Ql Al 49 TH Senin ...i.. � Schiller I� pFc CE 12592 � ��r ' • . 12m21 . • •�U�,� jo SOILS LOG AND PERCOLATION TEST 4-- E R I N 6 LEGAL DESCRIPTION: DENALY ESTATES B2 L17 PERFORMEDFOR: HULTOUIST HOMES DATE: 5/27/21 PROJECT No.: PARCEL ID#: 067-062-24. TECHNICIAN: L. TIDWELL DEPTH TEST HOLE 3 (feet) 2 3 • t e 4 5 6 7 8 LL .•4. 9 10 11--� 12 13 14 15 16- 17- 18- 19- 20- •C GM (SILTY SANDY GRAVEL) SLOPE WAS GROUNDWATER ENCOUNTERED? YES IF YES @ WHAT DEPTH? 9' DEPTH TO WATER AFTER MONITORING: 10. 1' DATE OF MONITORING: 12/9/21 L P E OF . 49 TH Senj, in Schiller CE 125928/13/21 SI I E PLAN DATE READING GROSS TIME (MINUTES) NET TIME (MINUTES) WATER (INCHES) NET DROP (INCHES) 5/28/21 1 1:58 10 0 - 5%6 55/16 2 2:20 10 0 - 31Y6 31Y16 3 2:57 10 0 -31Y16 31Y16 4 3:08 10 1 0-33/16 3Y,6 5 3:19 10 0 - 3%6 39/16 6 3:31 10 0- 2'%6 21%6 PERCOLATION RATE: 3.4 (MINANCH) PERC. HOLE DIA. 6 JINCHES) TEST RUN BETWEEN: 3 FT. and 4 FT. COMMENTS: Soils absorbed 6" of water prior to recorded data Wheaton Water Well, 1190 N. Wasilla-Fish hook Road Wasilla, AK 99654 1Qn71:z7ti_7na1 Name: Hultquist Homes, Inc Address: 12570 Old Seward Hwy #204 City: Anchorage State: AK Zip Code: 99515 Well Site: Denaly Lot/Block: 1-17132 Additional: 25551 McIntyre Rd, Eagle River Well Depth: 141 ft. From: To: Formation: 0 2 fill Below Ground: 139 ft. 2 18 silt/gravel Above Ground: 2 ft. 18 21 silt/gravel/water Gal/Min: 40 21 53 silt/gravel 53 74 silt Static Level: Artesian, 10 GPM 74 82 silt/clay layers 82 114 clay Casing: 141ft. of 6 in. x.25 in. steel 114 122 clay/gravel/some water 122 141 gravel/water Liner Pipe:. N/A Screened: N/A Perforated: N/A Grouted: Yes needs submersible pump well is 6' below basement Depth: 7 bags Develop. Method: Air Use of Well: Residential Drilling Method: Rotary Misc: Rings on casing Other: Chlorinated to 50ppm The well was pumped 5' off the bottom with 100% draw down for 2 hours and recovered at 40. Date Drilled: 5/5/2021 Driller: Ben Mattson Development Services Department �® Building Safety Division G I, ftw E On -Site Water & Wastewater Program o r 4700 Elmore Road Z z. P.O. Box 196650 a Mark Begich Anchorage, AK 99507 s n E T Y Mayor www.muni.org/onsite (907) 343-7904 Pump Installation Log Well Drilling Permit Number: SW OSP211094 Date of Issue: 04/13/2021 Parcel Identification Number: Legal Description Property Owner Name & Address: Denaly 621_17 Hultquist Homes 25551 Mcintyre Rd, Eagle River, AK 11 12570 Old Seward Hwy #204 Anchorage, AK 99515 Pump Installation Date: 02/11/2022 Pump Intake Depth Below Top of Well Casing: feet Pump Manufacturer's Name: Pump Model: Pump Size hp Pitless Adapter Burial Depth: feet Pitless Adapter Manufacturer's Name: Pitless Adapter Installer: Unknown Well Disinfected Upon Completion? ✓❑ Yes ❑ No Method of Disinfection: Sterilene Comments: Artesian well- Jet Pump Installed inside of house Pump Installer Name: Wheaton Water well, Inc. 1190 N. Wasilla-Fishhook Road Wasilla, AK 99654 Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation. MUNICIPALITY OF ANCHORAGE' On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7944 Fax- (907) 343-7997 http:/!www-mun i_org/onsite On -Site Water & Wastewater System Permit Permit Number: OSP211094 Work Type: WellSeptic Initial Tax Code Number: 06706224900 Site Legal Address: DENALY ESTATES BLK 2 LT 17 G:0362 Site Mailing Address: 25551 MC INTYRE RD, Eagle River Owner: EKLUTNA INC Design Engineer: FORGE ENGINEERING This permit is for the construction of: Effective Date Expiration Date: G �o a r- w v. apartment Lot Size in Sq Ft: Total Bedrooms: 4/13/2021 4/13/2022 61273 0 Disposal Field 0 Septic Tank ❑ Holding Tank ❑ Privy 0 Private Well ❑ Water Storage 4 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 (I8AAC72) and Drinking Water Regulations (I8AAC80) 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 (2417). 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: The recorded plat for this subdivision nates that artesian wells are common and that special drilling methods may be required to prevent waste of wafer via surface discharge. Veronica Pope GE 2021.04.13 Received By: 12:10:05 -08'00' Issued By: Date: Date: On -Site Water & Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 067-062-24 Property owner(s) Eklutna Inc Day phone 310-2501 Mailina address 16515 Centerfield Drive, #100, Eagle River, AK 99577 Site address NHN McIntyre Road Legal description (Sub'd., Block & Lot) Denaly Estates Sub, Block 2 Lot 17 Legal description (Township, Range & Section) Lot Size 61,273 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑X Initial ❑X Single Family (SF) ❑X ADU) Septic Tank ❑X Upgrade 1-1(w/wo Duplex (D) EJHolding Tank ❑ Renewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑X Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: $820 Waiver Fees: Date of Payment: 151 ,uw Date of Payment: Receipt Number: 0'-1 � D Receipt Number: Permit No. OSP211094 Waiver No. Permit App_:- :- March 31, 2021 MOA Development Services, On-Site Water & Wastewater Program 4700 Elmore Rd Anchorage, AK 99507 3/31/21 Subject: Denaly Estates Sub, block 2 Lot 17 – McIntyre Rd Septic system design Dear On-Site Services Engineer: The owner of the above lot intends to build a 4-bedroom home on the property, so we are submitting this permit application for the construction of a new well and septic system. The attached site plan identifies the location of the home as well as the proposed well, septic location and alternate site. No conflicts exist between this proposed system and any other well or septic system, whether on this lot or adjacent lots. The ground surface on the lot is variably sloped with grades between 25-40% running to the south. The system will be placed near the south propertyline on a slope at or under 35% and will be located up gradient from a slope at or under 40% with an elevation drop less than 10’. The current design meets all steep slope provisions as stated in 15.65.210.B.4 of the MOA Wastewater Code. Contour lines are shown on the site plan showing the grade and direction of flow. Stormwater drainage will not impact this septic system. The new trench will be constructed parallel to the slope as much as possible. The new system will be greater than 100’ from all wells and surface water. The alternate site is located greater than 6’ away from the primary site, and the tank will be a minimum of 5’ from proposed trenches. Please refer to the attached plan, profile page, and test hole logs for the septic design. If this design is followed, there will be no adverse impacts to adjacent properties. Sincerely, Benjamin Schiller, PE Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211094, Rebecca Carroll, 04/13/21 ALTERNATE SITE CAT III SYSTEM: APP RATE 6.0, 20' LONG X 5' WIDE, 0.5' EFF DEPTH ABSORPTION TRENCH 1"=40' 2-50' LONG x 5' WIDE, 0.5' EFFECTIVE DEPTH ABSORPTION TRENCHES MAINTAIN 6' MIN SEPARATION BETWEEN TRENCHES 4-BDRM HOME 1250-GAL SEPTIC TANK w/ 20" MANWAY MAINTAIN 10' MIN FROM FOUNDATION NOTE: NO SLOPES >25% WITHIN 50' EXCEPT WHERE NOTED. NO SURFACE WATER WITHIN 100' OF THE PROPOSED SEPTIC SYSTEM ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS PROPERTY ARE SHOWN. NO CONFLICTS WITH WELLS OR SEPTIC SYSTEMS. CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FS - FLOW SPLITTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE LEGEND TH#1 DENALY ESTATES SUB, BLOCK 2 LOT 17 MC I N T Y R E R O A D FEET 0 40 80 4/12/21 ≥10' PROPOSED WELL EXISTING WELL 100' WELL RADII T H # 2 445 435 425 415 405COCO CO MTMT FCO 2COFS EXISTING SLOPE IN THIS LOCATION IS ABOUT OR UNDER 40%. THE CURRENT SEPTIC DESIGN MEETS STEEP SLOPE PROVISIONS AS STATED IN 15.65.210.B.4 OF MOA WASTEWATER CODE. ≥6' MT MT CO Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211094, Rebecca Carroll, 04/13/21 DENALY ESTATES SUB, BLOCK 2 LOT 17 TYPICAL TRENCH SECTION (NO SCALE) NOTES: 1. GRADE AREA OVER TRENCH TO DRAIN AWAY 2. PROVIDE 3' OF COVER OVER TRENCHES AND 4' OVER SEPTIC TANK, OR 2' WITH 2" OF INSULATION 3. CHECK GROUNDWATER AT TIME OF CONSTRUCTION. IF LEVEL IS HIGHER THAN PREVIOUSLY OBSERVED, CALL ENGINEER IMMEDIATELY 4" PERFORATED PVC (HOLES DOWN) DRAINFIELD ROCK 5' 6" 6" DESIGN FACTORS:SYSTEM REQUIREMENTS: 600 GPD PEAK FLOW PERK RATE: 1.7 MIN/IN APPLICATION RATE: 1.2 GPD/SF 5' WIDE SHALLOW TRENCH SYSTEM 1250-GAL SEPTIC TANK w/ 20" MANWAY BOTTOM OF TRENCH: 4' BELOW GRADE FLOW LINE ELEVATION: 3' 6" BELOW GRADE TOP OF TRENCH: 6" ABOVE GRADE 600 GPD / 1.2 GPD/SF / 5' WIDE * 1.0 RED FACTOR = 100 LF TRENCH REQUIRED (100 LF SPECIFIED) 3/31/21 3' 6" Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211094, Rebecca Carroll, 04/13/21 LEGAL DESCRIPTION: PERFORMED FOR: DATE: PARCEL ID#: SOILS LOG AND PERCOLATION TEST TECHNICIAN: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 DEPTH (feet) PROJECT No.: TEST HOLE 1 SLOPE SLOPE SITE PLAN DATE READING GROSS TIME (minutes) NET TIME (minutes) DEPTH to WATER NET DROP PERC. HOLE DIA. (INCHES)PERCOLATION RATE: (MIN/INCH) TEST RUN BETWEEN: FT. and FT. COMMENTS: (inches)(inches) L. TIDWELL DATE OF MONITORING: WAS GROUND WATER ENCOUNTERED? DEPTH TO WATER AFTER MONITORING: IF YES @ WHAT DEPTH?14' 3.2 6 3 4 3/24 1 2 3 4 5 6 GM (SILTY SANDY GRAVEL) Professional Engineers Stamp: YES 11.5' 3/31/21 DENALY ESTATES B2 L17 3/24/21 067-062-24 HULTQUIST HOMES 2:461 2 3 4 5 6 0 0 16 / 4 0 16 2:57 3:08 3:19 3:31 3:42 1' OB 10 10 10 10 10 10 0 0 16 / 3 1 16 0 0 16 / 2 15 16 0 0 16 / 3 0 16 0 0 16 / 3 2 16 0 0 16 / 3 1 16 4 0 16 3 1 16 2 15 16 3 0 16 3 2 16 3 1 16 3/31/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211094, Rebecca Carroll, 04/13/21 LEGAL DESCRIPTION: PERFORMED FOR: DATE: PARCEL ID#: SOILS LOG AND PERCOLATION TEST TECHNICIAN: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 DEPTH (feet) PROJECT No.: TEST HOLE 2 SLOPE SLOPE SITE PLAN DATE READING GROSS TIME (minutes) NET TIME (minutes) DEPTH to WATER NET DROP PERC. HOLE DIA. (INCHES)PERCOLATION RATE: (MIN/INCH) TEST RUN BETWEEN: FT. and FT. COMMENTS: (inches)(inches) L. TIDWELL DATE OF MONITORING: WAS GROUND WATER ENCOUNTERED? DEPTH TO WATER AFTER MONITORING: IF YES @ WHAT DEPTH?13' 1.7 6 3 4 3/24 1 2 3 4 5 6 GM (SILTY SANDY GRAVEL) Professional Engineers Stamp: YES 10.5' 3/31/21 DENALY ESTATES B2 L17 3/24/21 067-062-24 HULTQUIST HOMES 2:481 2 3 4 5 6 0 0 16 / 6 0 16 2:59 3:09 3:20 3:33 3:44 1' OB 8:23 10 10 10 10 10 0 0 16 / 5 15 16 0 0 16 / 5 13 16 0 0 16 / 5 12 16 0 0 16 / 5 13 16 0 0 16 / 5 12 16 6 0 16 5 15 16 5 13 16 5 12 16 5 13 16 5 12 16 3/31/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211094, Rebecca Carroll, 04/13/21 MUNICIPALITY OF ANCHORAGE Development Services Department p p i r� Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 06 7-062-24 1. Expiration Date: . z(' -2©z 2! - GENERAL GENERAL INFORMATION Complete legal description Denaly Estates Block 2 Lot 17 Location (site address) 25551 McIntyre Road Current property owner(s) E kl Utn a Inc. Day phone 907-310-2501 Mailing address 16515 Centerfield Drive, #100, Eagle River, AK 99577 Real estate agent 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well Private Septic Q Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ �s'� �/S Waiver Fee $ Date of Payment Date of Payment Number_ Receipt2 3�� ii �7 Receipt Number COSA # C9%C Zl 1 72 C( 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. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm Forge Engineering Phone (907) 522-7773 Address 1399 W. 34th Ave Suite 101, Anchorage, AK 99503 Engineer's Printed Name Benjamin Schiller, P.E. Date 12/8/21 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 q� 1l TH TH 6. DSD SIGNATURE % :".. ....:. System #1 Approved for ......... bedrooms 9.: Benjaur ySchiller System #2 Approved for bedrooms �� �isl •. �2i82292 . • •�,�``�� Disapproved ti;\ROFESSl Conditional approval for bedrooms, with the following stipulations: g ON-SITE WAST! .V'ATEP J� PROGRAM ?W By: Original Certificate Date: 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 Legal Description: Denaly Estates Block 2 Lot 17 If more than 1 septic system on lot: COSA Checklist # 1 of 1 A. WELL DATA 9 Well log is filed with Onsite (or attached) Date drilled 5/5/21 Total depth 141 ft Cased to 139 ft Q Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) 24 in. Date of flow test for COSA N/A Static water level at beginning of test NIA ft. Comments New Artesian Well B. TANK DATA Age of tank(s) <1 years Tank type/material Septic / Plastic Measured operating fluid level in septic tank New FE -1 Standpipes/foundation cleanout per record drawing Date of pumping New D. ABSORPTION FIELD DATA 5' Wide Trench Which system tested (date installed) 5/28/2021 ALL standpipes present per record drawing Total measured depth from grade 4.5/4.3 ft (max) Measured depth to pipe invert from grade 4.0/3.8ft (min) ❑ N/A — pressurized field Monitor tubes go to bottom of effective. If not, state depth into effective Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Comments/Deficiencies: COSA Checklist yellow sheet Parcel ID: Structure served by this system 1 067-062-24 Well production at time of test 40 gpm Water storage tank volume NSA gallons Well disinfected for coliform test? ❑ Yes ❑ No F01 Coliform bacteria is Negative Nitrate 0.5 mg/L ❑ Nitrate less than MRL (ND) Arsenic 2.5 ug/L ❑ Arsenic less than MRL (ND) Collected by Wheaton Water Date of Sample IFT STATION 8/27/21 ❑ Requl dmaintenance completed Age of lift station years Lift station material Comments: Adequacy test date Results ❑ Pass For bedrooms f4<d depth prior to test in Water ad& -d, _ gal New depth 'rn� Elapsed time min Final fluid depth in Absorption rate gpd Any rejuvenation treatment (past 12 months) If yes, enter date 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' n✓ Yes Community Sewer Manhole/Cleanout > 100' M✓ Yes if No ft Q Yes if No ft Neighboring Tank > 100' Yes if No ft Private Sewer/Septic Line > 25' F71 Yes if No ft Absorption Field on Lot > 100' Q Yes if No ft Holding Tank > 100' Yes if No ft Neighboring Absorption Fields > 100' 0✓ Yes if No ft Water Main > 10'✓1 Animal Containment > 50' ❑✓ Yes if No ft P/1 Yes if No ft ❑✓ Yes if No ft Water Service Line > 10' 0✓ Yes if No Manure/Animal Excreta Storage > 100' If septic tank is under driveway Community Sewer Main > 75' M,'Yes if No ft rVJ Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' n✓ Yes if No ft Surface Water > 100' Q✓ Yes if No ft Property Line > 5' Yes Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' Q✓ Yes if No ft Private Wells > 100' 0✓ Yes if No ft Water Main > 10'✓1 ft Yes if No ft Community Wells > 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' 0✓ Yes if No ft Wells on Adjacent Lots: Water Main > 10' Yes if No ft Private Wells > 100' Yes if No ft Water Service Line > 10' Yes if No ft Community Wells > 200' QQ Yes if No ft Surface Water > 100'✓❑ Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. COSA Checklist yellow sheet -q0v 14010 of Cq�1l� Tf '.Benjam ,Schiller CE12/8/21 $22 92 ..����� p � ,, PROFESSI4NP� ��'°d ko ZO�Q. O,M W 0D N V A AO Gl CO � f /r CD Z • PO I ` y 0)Al �/ O / 63s.e CA D () Ix zn a —• I / 0 -q Z, D07 r N m / a rn r'1 V) + 71 �• SII + m / D cin \� o w \� * / / // m ,0 r n � IL �m (n m 9. ®V V O p /?> O• / x S S / ---I=r 0x 9 co N N p I 1-Y x g�%�Z+ S ww 2ss 68, O C N N� i X x ��0� �- l r P 7 � 'P CD I (Q m 0b' N / 4J �G V IW N C n (J1 O) ? 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