HomeMy WebLinkAboutELJAY LT 2Onsite File
Municipality of Anchorage
On -Site Water and Wastewater Section - (907) 343-7904 Page 1 of 3
ON -SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP221390 PID Number: 050-971-06
Dwelling: X Single Family (SF) ❑ with ADU ❑ Duplex (D.) ❑ Two Single Family Project: 9 New ❑ Upgrade
Name
Skyler Quinn
ABSORPTION FIELD
❑■ Deep Trench El Wide Trench El Bed El Mound
Site Address
20774 Melody Lane
❑ Other
Phone
(907)-229-8117
Number of Bedrooms
7
Soil Rating
Total depth from original grade
1.2 GPD/SF
9.O Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
3.0 Ft.
Gravel depth beneath pipe
6.0 Ft.
Subdivision Block Lot
Eljay 2
Fill added above original grade
2.3 Ft.
Gravel length
73 Ft.
Township Range Section
Gravel width
3.0 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
1
Dist. between trenches
From
Tank
Field
Tank
Line
876 Ftz
N/A Ft.
Well
>100'
>100'
N/A
N/A
>25
TANK ❑� Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
Greer
Capacity
1250 / 1000* Gal.
Surface Water
>100'
>100'
N/A
N/A
Material
Plastic
Number of compartments
1
Lot Line
>5'
>10'
N/A
N/A
NA
Foundation
> 10'
> 10'
N/A
N/A
L ATION
Manufacturer
Capacity
Remarks *2 Greer tanks with internal baffles
Gal.
removed.
Alarm location
Electri i tailed by
Installer
PIPE MATERIAL House to tank D3034 Tank to D3034
drainfield
Northern Excavation
Drainfield D3034 CO/MTD3034
Inspector Luke Tidwell
BENCH MARK (Assumed elevation) 100 ft
Inspection 15' 11/3/22 11/4/22
Location and description
2�a
Top of Flashing @ Point B
3ro 4th
ON -SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
'�OF>Ntl
Conditional Approval: Date
o*: 49TM •*�/
rt�7_'Benja
0
Septic System
CE 12592i11er ••��
�i •
Approved Date j 2 2c9 2aZ
�``'r
slF ., 12/11/23 ,. •*���,
lt`F�PROFESSIOW ���
Note: this approval does not include well permit requirements.
(Rev uoiuulu)
FCO
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEANOUT
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
GP - GROUNDWATER MONITORING PIPE
LEGEND
CO1
TH#2
ME
L
O
D
Y
L
A
N
E
PERMIT # OSP221390 PID # 050-971-06
ELJAY LOT 2
A B
FCO
MH 39.7
SV1 36.3
A
B
C
C
2CO1 35.3
SV2 32.7
SV3 31.1
2CO2 30.3
8.1
16.1
19.5
20.9
25.6
30.3
32.5
1"=50'
7-BDRM HOME
WELL
MT1
770
100500
FEET
Benjamin Schiller
CE 12592
R
E
GISTEREDPROFES S I O N A L E N G INEER
Dec 28, 2023
EXISTING COMMON
DRIVEWAY
TH#1
73' LONG x 6' EFFECTIVE
DEPTH ABSORPTION TRENCH
1,250 GALLON
SEPTIC TANK (BAFFLE REMOVED)
1,000 GALLON
SEPTIC TANK (BAFFLE REMOVED)
ALTERNATE SITE >12' AWAY
CO2 MT2
775765760
750
755
750
PLAN AS-BUILT
D
4.4
D
CO1 66.575.6
MT1 66.275.9
CO2 44.3 28.2
MT2 44.1 27.7
2CO2
2CO1
SV3 SV2 SV1
MHGPGP
PROFILE AS-BUILT
(NO SCALE)
93.7
89.6
94.4
99.5
SV
2
SV
3
PERMIT # OSP221390 050-971-06
ELJAY LOT 2
Benjamin Schiller
CE 12592
R
E
GISTEREDPROFES S I O N A L E N GINEER
Dec 28, 2023
1000 GAL
SEPTIC TANK
98.0 FINISH GRADE
73'
DRAINFIELD ROCK
MT
1
TH
#
1
NO GROUNDWATER 9/9/20
86.7
92.7
CO
1
CO
1
80.7
86.7
92.7
95.7 ORIGINAL GRADE MT
1
2C
O
2
93.5
94.0
89.1
94.7
100.3
FC
O
MH
SV
1
2C
O
1
93.8
1250 GAL
SEPTIC TANK
Certified Drilling Log
OWNER OF LAND: Michael Quinn Construction
ADDRESS:
LEGAL DESCRIPTION ELJAY LT 2
DATE: 8/17/23
PERMIT
NUMBER:
OSP221390 DATE OF ISSUE: 10/11/22
TAX IDENTIFICATION
NUMBER 05097106000
Is well located at approved permit location: Yes No
Method of Drilling: air rotary cable tool
Depth of Well: 304’
Casing Type: Steel Wall thickness .250 inches
Diameter: 6 inches, depth 304 feet
Liner type
Static Water Level: 217 feet
Recovery Rate 12 gpm gph
Method of Testing Air
Well Intake Opening Type: open end open hole
Screened Start feet Stopped
Perforations Start feet Stopped
Grout Type: Bentointe Volume: 50 Lbs.
Depth: from 2 feet, to 42 feet
Well Disinfected Upon Completion: yes no
Method of Disinfection: Chlorine 50 PPM
Comments:
Bore Hole Data
Depth
From To
0 2 Casing Stickup
2 4 Overburden
4 76 Tight and silty sand and gravel
76 80 Silty and sand
80 82 Tight silty sand and gravel
82 86 Sandy gravel water 5 GPM
86 92 Silt and sand with gravel
92 142 Tight silty sand and gravel
142 169 Loose sand and gravel
169 190 Silty sand and gravel
190 208 Silt and sand
208 296 Silty sand and gravel with clay
296 304 Sand and gravel water
Drillers Name: Cole Sullivan
ATTENTION: It is the responsibility of the property owner to submit a copy of the well log to the proper authority.
Municipality of Anchorage: Department of Health & Human Services and/or Department of Environmental Conservation.
MatSu Borough: Department of Environmental Conservation.
HOUSE DETAIL
Scale: 1" = 30'
r a n a.a
CANT
o
a
NOTE: DUE TO SNOW & ICE COVER, SOME
SURFACE LEVEL FEATURES ARE APPROXIMATE.
1 30.0' I
I�I
3C 1
M
0
v
Z
rn
I
nA
PLOT PLAN AS BUILT X SCALE 1 = 40' GRID SW 0057 Project No. 22-522/A3
1150 DarylAvenue,Anchorage, Alaska 99515-3049
Lang & Associates, inc. 22- Phone
(907) 522-4625 Fax
Professional Land Surveyors kenolongsurvey.com d , OF A
jonathanOlongsurvey.com
I hereby certify that I have surveyed the following described properly: Q0�
LOT 2. EWAY SUBDIVISION (PLAT No. 2017-8) 49TH•� ��
Alaska, and that the Improvements situated thereon are Anchorage Recording District, p
within the properly lines and do not encroach onto the property adjacent thereto, that
no Improvements on the properly lying adjacent thereto encroach on the surveyed 04"s;� :"KENNE7H. .... �G
promises and that there are no roadways, transmission lines or other visible c,
easements on sold property except as indicated hereon.
����' 520 '• � O
Dated this the Day of 7 � 4^r kz' , *> at Anchorage, Alaska ,o • • •..
�n
4Sslowx%- &g
It is the responsibility of the owner to determine the existence of any easements.-"v0�0oc
covenants, or restrictions which do not appear on the recorded subdivision plot. AECC963
Lot 1
57'58'E 270.26'
SEPTIC
N
MANHOLE SEPTIC
62.4'
Lot 2
40,045 s.f. ��/
SEE HOUSE DETAIL
SEPTIC-/
I
ot 3 ` \
i
1
75.0' \
ao,
Lot 5 ~ 1
` � SHARED ACCESS AGREEMENT
m
Lot 3
—DOCUMENT 2022-041163-0 /
Lot 4
i
Lot 5
`
Prepared by
Lang & Associates, inc.
Professional"J_ nc Surveyors
11500 Daryl Avenue
Anchorage, Alaska 99515-3049
(907) 522-6476
(907) 522-4625 Fax
kenOlongsurvey.com
jonathanOiangsurvey.co 0
� -4
Pump Installation Log
Arctic Pump & Well Inc .
Jim Sullivan
PO Box 770197
Eagle River, AK 99577
(907) 688 -2510
(907) 243 -2282
jim@arcticpump.com
OSP221390
05097106000
10/11/2022
Eljay L2
2
Quinn Construction
PO BX 772641
Eagle River AK 99577
9/20/2023
293 Feet
Franklin
10SDQP-1.5HP-3RC
1.5 HP
13 Feet
ss
Well Drilling Permit Number:
Parcel Identification Number:
Date Of Issue:
Legal Description
Lot:
Block:
Property Owner Name Address:
Pump Installaion Date:
Pump Intake Depth Below Top of Well Casing:
Pump Manufacturer's Name
Pump Model:
Pump Size:
Pitless Adapter Burial Depth:
Pitless Adapter Manufacturer's Name
Pitless Adapter Installer:
Well Disinfected Upon Completion?
Method of Disinfection:
u/k
Yes
Chlorine
Comments:
Pump Installer Name:
Arctic Pump & Well, Inc.
5Y
Friday, September 22, 2023
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
hftp://www.muni.org/onsite
On -Site Water & Wastewater System Permit
Permit Number: OSP221390
Work Type: WellSeptic Initial
Tax Code Number: 05097106000
Site Legal Address: ELJAY LT 2 G:0057
Site Mailing Address:
Owner: MICHAEL QUINN
Design Engineer: FORGE ENGINEERING
This permit is for the construction of:
Effective Date
Expiration Date:
Lot Size in Sq Ft:
Total Bedrooms:
tncnt S
0
a
i
Department
10/11/2022
10/11/2023
40045
Q Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy Q 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
Veronica Pope
kl�2022.10.11
Received By: 09:12:39 -08'00'
Issued By:
Date:
Date: i
0 1 Z o 22.
7
MUNICIPALITY OF ANCHORAGE
Community Development Department Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
On -Site Water & Wastewater Program
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 050-971-06
Property owner(s) Skyler E. Quinn
Mailing address 18548 Outlook Cir, Eagle River, AK 99577
Site address NHN Melody Ln
Day phone 229-8117
Legal description (Sub'd., Block & Lot) Eljay Lot 2
Legal description (Township, Range & Section)
Lot Size 40,045 Sq. Ft. Number of Bedrooms 7
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(M all that apply)
Absorption Field ❑X Initial
❑X Single Family (SF) ❑X
Septic Tank ❑X Upgrade
El(w/wo ADU)
(D) ❑
Holding Tank ElRenewal
ElDuplex
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: 'l?,26, 40,
Waiver Fees:
Date of Payment: q 1,26 L�2 0_
Date of Payment:
Receipt Number: 6 s 2Z 9 $L
Receipt Number:
Permit No. 65 Pga-1396
Waiver No.
Permit App_.:- ;
September 24, 2022
MOA Development Services, On-Site Water & Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
Subject: Eljay Sub, Lot 2 – NHN Melody Ln
Septic system design
Dear On-Site Services Engineer:
The owner of the above lot intends to build a 7-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 slopes moderately up from Melody Lane toward the back of the lot,
but is flatter in the front. It is in that flatter area that the new septic system is located. Contours 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. Due to the size of this system, instead of one large (2,500-gallon) septic tank, we are
proposing two tanks with their baffles removed- a 1,250-gallon tank followed by a 1,000-gallon
tank. This will provide the needed residence time in each tank before outflowing to the field.
Wells on this and adjacent lots are shown. The new system will be a minimum of 100’ from all
wells and surface water, and more than 5’ away from the septic tank. The alternate site is located
more than 12’ away.
Please refer to the attached test hole logs, plan and profile pages 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
OSP221390, Curtis Townsend, 10/11/22
ELJAY, LOT 2
DESIGN FACTORS:SYSTEM REQUIREMENTS:
1050 GPD PEAK FLOW
PERK RATE: 1-5 MIN/IN
APPLICATION RATE: 1.2 GPD/SF
6.0' DEEP TRENCH SYSTEM
1,250-GAL SEPTIC TANK WITH
1,000-GAL SEPTIC TANK (BAFFLES REMOVED)
TYPICAL TRENCH SECTION
(NO SCALE)
4" PERFORATED PVC (HOLES DOWN)
DRAINFIELD ROCK
3'
6"
3'
6'
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
BOTTOM OF TRENCH: 9.0' BELOW GRADE
FLOW LINE ELEVATION: 3.0' BELOW GRADE
TOP OF TRENCH: 0.5' ABOVE GRADE
1050 GPD / 1.2 GPD/SF / 6' DEEP / 2 SIDES = 72.9 LF TRENCH REQUIRED (73 LF SPECIFIED)
Benjamin Schiller
CE 12592R
EGISTEREDPROFESSIONA LENGINEERSep 24, 2022
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221390, Curtis Townsend, 10/11/22
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)
ELJAY, LOT 2
8/31/20
M. JAKUBISIN
DATE OF MONITORING:
WAS GROUND WATER ENCOUNTERED?
DEPTH TO WATER AFTER MONITORING:
IF YES @ WHAT DEPTH?-
1.2 6
3 4
050-971-06
Michael Quinn Construction
9:33
8/31
1
2
3
4
5
6
0 0
16 / 6 0
16
9:35
9:40
9:46
9:53
10:01
OB
Professional Engineers Stamp:
2:15
NO
NONE
9/9/20
GM (SILTY SANDY GRAVEL)
3:30
4:56
6:28
6:46
6:49
0 0
16 / 6 0
16
0 0
16 / 6 0
16
0 0
16 / 6 0
16
0 0
16 / 6 0
16
0 0
16 / 6 0
16
6 0
16
6 0
16
6 0
16
6 0
16
6 0
16
6 0
16
Benjamin Schiller
CE 12592R
EGISTEREDPROFE S S I O N ALENGINEE R9/24/22
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221390, Curtis Townsend, 10/11/22
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. 050-971-06 / o Z- Ll
Expiration Date: 3
Legal description ELJAY LT 2
Site address 20774 MELODY LN Eagle River AK 99577
Current property owner(s) MICHAEL QUINN CONTRUCTION INC
X The On -site system(s) is/are approved for 7 bedrooms
Conditional approval for
Comments or advisories:
bedrooms, with the following stipulations:
By: Original Certificate Date: Z y 2, Z
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory
Other
COSA Approval_June 2022
on
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 Application
1. GENERAL INFORMATION
Parcel I.D. 050-971-06
Complete legal description Eljay Lot 2
Location (site address) 20774 Melody Lane, Eagle River, AK 99577
Current property owner(s) Michael Quinn Construction Day phone (907) 229-8117
2. ON -SITE SYSTEMS SIZED FOR 7 BEDROOMS
3. TYPE OF WATER SUPPLY: ❑E Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: ❑■ Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: ❑ Steel X Plastic ❑ Concrete ❑ Fiberglass
Age l yr - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed❑ Deep Trench ❑ Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested: ❑■
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On -site staff
to verify the accuracy of the information provided.
COSA Fee $_ % 2 0 Waiver Fee $
Date of Payment
COSA # 05G231 yg6
Date of Payment
Waiver #
COSA Application —June 2022
Legal Description: ELJAY LOT 2 Parcel ID: 050-971-06
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system _
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled 8/17/23 Total depth 304 ft
Cased to 304 ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) >18 in.
Date of flow test for COSA New
Static water level at beginning of test 217 ft.
Comments
B. TANK DATA
Measured operating fluid level in septic tank N/A
Date of pumping NEW
❑ Required maintenance completed, if AWWTS
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed) 11/3/22
❑ ALL standpipes present per record drawing
Total measured depth from grade 11.3 ft (max)
Measured depth to pipe invert from grade 5•3 ft (min)
❑ N/A — pressurized field.
❑ Per record drawings, field is insulated.
❑ Monitor tubes go to bottom of effective.
If not, state depth into effective
❑ Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced N/A gallons N/A date
Any rejuvenation treatment (past 12 months) N/A
If yes, enter date
Comments/Deficiencies:
COSA Checklist June 2022
Well production at time of test 12 gpm
Water storage tank volume None gallons
Well disinfected for coliform test? ❑ Yes ❑ No
❑ Coliform bacteria is Negative
Nitrate mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by Forge Engineering
Date 12/13/23 & 12/18/23
C. LIFT STATION
Lis ired maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date NEW
esults � Pass
Fluid de h prior to test in
Water adde gal
New fluid depth in
Elapsed time m
Final fluid depth in
Absorption rate > gpd \
FIELD STATUS — POST RECOVERY
Effective depth (per record drawings) 72 in
Effective depth used 0 in
Effective depth remaining 72 in
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100'
Community Sewer Manhole/Cleanout > 100'
❑ Yes
if No
ft
❑ Yes
if No ft
Neighboring Tank > 100' ❑ Yes
if No
ft
Private Sewer/Septic Line > 25' X Yes
if No ft
Absorption Field on Lot > 100' ❑ Yes
if No
ft
Holding Tank > 100' ❑ Yes
if No ft
Neighboring Absorption Fields > 100'
Animal Containment > 50' RM Yes
if No ft
❑ Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' IRE Yes
if No
ftRN
Yes
if No ft
❑ N/A — Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
❑ Yes
if No
ft
Surface Water > 100'
❑ Yes if No ft
Tank to Property Line > 5'
no Yes
if No
ft
Wells on Adjacent Lots:
Field to Property Line > 10'
❑ Yes
if No
ft
Private Wells > 100'
❑ Yes if No ft
Water Main > 10'
On Yes
if No
ft
Community Wells > 200'
❑ Yes if No ft
Water Service Line > 10'
❑ Yes
if No
ft
If tank or field is under driveway comment below
F. ENGINEER'S COMMENTS
G. CERTIFICATION & 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, indicates that the on -site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm Forge Engineering Phone (907) 522-7773
Engineer's Printed Name Benjamin Schiller, P.E. Date 12/20/2023
COSA Checklist —June 2022
_40� OFIkk
.-
: 4� TH
• • . . . Benja ' , chiller
I�?I& .. CE 12592
�>i ROFESSION�