HomeMy WebLinkAboutUS SURVEY 3042 LT 74 E2SE4 T10N R2E SEC 19Lot 74 E25E4
#075�132�3%qvw
Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP221389 PID Number: 075-132-33
Dwelling: 0 Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New A Upgrade
Name
Stuart Greene
ABSORPTION FIELD
❑ Deep Trench AWide Trench El Bed E] Mound
Site Address
377 Toadstool Dr
❑ Other
Phone
(907) 782-7276
Number of Bedrooms
3
Soil Rating
Total depth from original grade
1.2 GPD/SF
6.0 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
2.0 Ft.
Gravel depth beneath pipe
4.0 Ft.
Subdivision Block Lot
US Survey 3042 L74 E2SE4
Fill added above original grade
1.0 Ft.
Gravel length
38.0 Ft.
Township Range Section
T1 ON R2E SEC 19
Gravel width
5.0 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
380 Ft2
1
Ft.
Well
>100'
>100'
N/A
N/A
>25
TANK ❑C Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
Infiltrator
Capacity
1060 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
>10,
>1 0'
N/A
N/A
LIFT STATION
M'e er
Capacity
Gal.
Remarks Installation installed over both tank
and field
Alarm location
Elec ed by
Installer
PIPE MATERIAL House to tank D3034Tank to D3034
drainfield
A.C.E.S.
Drainfield D3034 co/MTD3034
Inspector L Tidwell
BENCH MARK (Assumed elevation) 100 ft
Inspdection 15' 10/26/22 10/27/22
Location and description
2nd
3'd 10/27/22 4 1
Bot of lowest log siding
ON-SITE WATER AND WAS W74"1 R SECTION APPROVAL
Engineer's Stamp
.� OF Ak4kl
Conditional Approval: Date [(/,2,1/�2 z
�co l�
QTH
.. .. .
/fit ��, BenCrrn592illerAr �/
Septic System
Approved Date
�,�'srF9• ,11/9/22 , •��c,��
Illi PROFESSl*�-`
Note: this approval does not include well permit requirements.
trcev uDivu ia)
Benjamin Schiller
CE 12592R
E
GISTEREDPROFES S I O N A LENGINEER1"=50'
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEANOUT
FS - FLOW SPLITTER VALVE
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
LEGEND
COMT
TH#1
PERMIT # OSP221389 PID # 075-132-33
US SURVEY 3042 LOT 74, E2SE4, T10N R2E SEC 19
A B
MH1 24.94
SV1 30.64
2CO 29.77
A
B
C
C
-
-
-
CO1 20.84
MT1 22.13
CO2 33.56
-
-
44.71
MT2 35.14 46.80
30.76
33.28
35.67
36.61
37.75
-
-
FEET
0 50 100
FCO
1-BDRM
H
O
ME
30
SHED
SHOP
ADJ SEPTIC
ADJ SEPTIC
40
5060
38' LONG x 5' WIDE, 4' EFFECTIVE
DEPTH ABSORPTION TRENCH
1060-GAL INFILTRATOR
SEPTIC TANK
11/8/22
WATER LINE (LOCATED
DURING INSTALLATION)
MT CO
FCO 23.03 -13.55
PLAN AS-BUILT
2CO
LANDSCAPE BLOCKS
PLACED OVER TRENCH
10.9
PROFILE AS-BUILT
(NO SCALE)
93.9
89.9
94.4
97.4FCOMH SV1060-GAL
SEPTIC TANK
96.1 FINISH GRADE
38'
DRAINFIELD ROCKMT
TH#2NO GROUNDWATER 9/13/22
89.1
93.1 COCO81.6
89.1
93.1
95.1 ORIGINAL GRADE MT2CO93.8
Benjamin Schiller
CE 12592
R
E
GISTEREDPROFES S I O N A LENGINEER11/9/22
PERMIT # OSP221389 PID # 075-132-33
US SURVEY 3042 LOT 74, E2SE4, T10N R2E SEC 19
2" FOAM INSULATION
2" FOAM INSULATION
MUNICIPALITY OF ANCHORAGE cnt
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 n
http://www.muni.org/onsite v
t�epartment
On -Site Wastewater Disposal System Permit
Permit Number: OSP221389 Effective Date: 10/11/2022
Work Type: Septic Upgrade Expiration Date: 10/11/2023
Tax Code Number: 07513233000
Site Legal Address: US SURVEY 3042 LT 74 E2SE4 T1 ON R2E SEC 19 G:5012
Site Mailing Address: 377 TOADSTOOL DR, Girdwood
Owner: BERCEE LOVERNE Lot Size in Sq Ft: 24000
Design Engineer: FORGE ENGINEERING Total Bedrooms: 3
This permit is for the construction of:
Q Disposal Field Q 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
1, Special Provisions:
1. Locate the water service line prior to construction to ensure that the 10' separation to the tank is met.
Show the water line location on the Record Drawing.
2. The trench may not have a driveway or parking over it. The trench is to be protected with bollards or
similar.
Veronica Pope
kl�2022.10.11
Received By: 10:25:51 -08'00'
Issued By: '78
Date:
Date: 0 A % Z
MUNICIPALITY OF ANCHORAGE
Community Development Department Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
On -Site Water & Wastewater Program
ON-SITE SEWERM/ELL PERMIT APPLICATION
Parcel I.D. 075-132-33
Property owner(s) Loverne Bercee
Mailing address PO Box 465, Girdwood, AK 99587
Site address 377 Toadstool Dr
Day phone
Legal description (Sub'd., Block & Lot) US Survey 3042, Lot 74 E2SE4
Legal description (Township, Range & Section) T1 ON R2E SEC 19'
Lot Size 24,000 Sq. Ft. Number of Bedrooms - 3
APPLICATION IS FOR: APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field ❑X Initial ❑
Single Family (SF) ❑X
Septic Tank ❑X Upgrade X
pg ❑
(w/wo ADU)
❑
Duplex (D)
Holding Tank ElRenewal ❑
Multiple Dwellings ❑
Privy ❑
(SF and/or D)
Private Well ❑
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: 4 611T
Date of Payment: 91a l /a0
Receipt Number: 0 it �g3ji
Permit No. 0<5pq a 3 �9
Permit App_::- :- .....:c
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
September 24, 2022
MOA Development Services, On-Site Water & Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
Subject: US Survey 3042 L74 E2SE4 T10N R2E SEC 19 - 377 Toadstool Dr
Septic system design
Dear On-Site Services Engineer:
The owner of the above lot has an existing 1-bedroom home on the property, but the current septic
system is undocumented. They would like to sell the home, so we are submitting this permit
application for the construction of a new septic system. The attached site plan identifies the
location of the home as well as the proposed septic location and alternate site.
The ground surface on the lot slopes up a little bit to the house pad and back yard, and then drops
off to the east and south. The area available for the septic system is very flat. There are no slopes
greater than 25% within 50 feet downslope of either the primary or alternate site. 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.
Wells on this and adjacent lots are shown. There is a shared well on the lot to the east that serves
this house. The location of the buried water line can be traced in a general way by following the
cleared path through the trees. Closer to the house it is more difficult to determine the exact path,
but the supply line comes in to the home just on the south side of the existing septic cleanout. We
have placed the new septic system more than 10’ away from the projected path of the water line.
Additionally, we do not have any information about the existing crib, leach field, or holding tank.
We have noted on the plans where there is an existing septic pipe, and that this must be
decommissioned.
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
OSP221389, Deb Wockenfuss, 10/11/22
Benjamin Schiller
CE 12592R
EGISTEREDPROFES S I O N ALENGINEER
1"=50'
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEANOUT
FS - FLOW SPLITTER VALVE
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
LEGEND
CO
MT
TH#1
US SURVEY 3042 LOT 74, E2SE4, T10N R2E SEC 19
FEET
0 50 100
FCO
NOTE:
NO SLOPES >25% WITHIN 50' OR 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.1-BD RM
HOM
E
30
SHED
SHOP
ADJ SEPTIC
ADJ SEPTIC
40
5060
38' LONG x 5' WIDE, 4' EFFECTIVE
DEPTH ABSORPTION TRENCH
REMOVE GRAVEL: PARKING OR
DRIVING PROHIBITED OVER TRENCH
1060-GAL INFILTRATOR
SEPTIC TANK - MIN 10'
SEPARATION FROM
WATER LINE
9/23/22
DECOMISSION EXISTING
SEEPAGE PIT- LAYOUT
UNKNOWN
MAINTAIN 5' SEPARATION
5.0 MIN
WATER LINE (BEST
ESTIMATED LOCATION
BASED ON EXISTING
TREES)
MT
CO
10.9
ALTERNATE SITE:
CAT III SYSTEM
15LF 5-WIDE, 4' EFF
8' SEPARATION FROM
EXISTING TRENCH AND
10' SEPARATION FROM
FOUNDATION
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221389, Deb Wockenfuss, 10/11/22
US SURVEY 3042 LOT 74, E2SE4, T10N R2E SEC 19
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
Benjamin Schiller
CE 12592R
EGISTEREDPROFES S I O N ALENGINEER6"
3'-6"
4'
DESIGN FACTORS:SYSTEM REQUIREMENTS:
450 GPD PEAK FLOW
PERK RATE: 1.7 MIN/IN
APPLICATION RATE: 1.2 GPD/SF
5' WIDE TRENCH SYSTEM
1000-GAL SEPTIC TANK
BOTTOM OF TRENCH: 7.5' BELOW GRADE
FLOW LINE ELEVATION: 3.5' BELOW GRADE
TOP OF TRENCH: 0.5' ABOVE GRADE
450 GPD / 1.2 GPD/SF (/ 5' WIDE * 0.5 RED FACTOR) = 37.5 LF TRENCH REQUIRED (38 LF SPECIFIED)
5'
4" PERFORATED PVC
(HOLES DOWN)
DRAINFIELD ROCK
GEOTEXTILE FABRIC
9/23/22
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221389, Deb Wockenfuss, 10/11/22
LEGAL DESCRIPTION:
PERFORMED FOR:
DATE: PARCEL ID#:
SOILS LOG AND PERCOLATION TEST
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
DEPTH
(feet)
TEST HOLE 1
DATE READING START TIME NET TIME
(minutes)
DEPTH to
WATER NET DROP
PERCOLATION RATE: (MIN/INCH)
(inches)(inches)
DATE OF MONITORING
WAS WATER ENCOUNTERED?
DEPTH TO WATER AFTER MONITORING
IF YES @ WHAT DEPTH?
1.7
9/6 1
2
3
4
5
6GM (SILTY SANDY GRAVEL)
Professional Engineers Stamp:
NO
US SURVEY 3042 L74 E2SE4 T10N R2E SEC 19
9/6/2022 075-132-33
PROPERTY OWNER
12:21 0
12:30
12:42
12:54
1:05
1:17
0.5' OB
9:27
Benjamin Schiller
CE 12592R
EGISTEREDPROFES S I O N ALENGINEER9/23/22
PERC TEST LOCATION
TECHNICIAN: L. TIDWELL
6
-
NONE
9/13/22
COMMENTS:
6" DIAMETER TEST HOLE PRESOAKED PRIOR TO TESTING
SITE PLAN
6
USCS SOIL CLASSIFICATION WAS VISUALLY DETERMINED
0 5 14
16" 5 14
16"
0 5 15
16" 5 15
16"
0 5 13
16" 5 13
16"
0 5 13
16" 5 13
16"
0 5 12
16" 5 12
16"
10:00
10:00
10:00
10:00
10:00
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221389, Deb Wockenfuss, 10/11/22
I
I
I Portion
Lot 74B Lot 74
\ I \
Lot 74C w \
I0
0
Av
S9.
61
I a`=99
J2
she
I CO d
I
I co M�
I Portion
49t1x� Star I Lot 74 0 19
o
Surveying Is
II '4
0 20 40 I fa
I M
I ]P'io in iuo int W
US SURVEY _
FEET _> ]L�O t `v
0
o)
Lot 73
(AK DOT/PF)
of !gl�l�y� t
* •49, Shop
/
re` 9011 M `
e rj%A �Hursl�_�`ss9.
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cc��%�,,. AKRR IS,4�'.
4' / • 0 9
lel PROFESS16N`Y��
NOTES
-All dimensions shown are grid bearings ground distances; record boundaries are per USS 3042, Plat No. 70-363 & Statutory Warranty
Deed Doc.# 2002-048328-0.
-49th Star has conducted a physical survey of the property and all details shown on this Asbuilt Survey are correct. Under no
circumstances should any data hereon be used for construction or the establishment of property lines.
-It is the owners responsibility to determine the existence of any easements, covenants, or restrictions; no title research performed.
AS BUILT SURVEY LEGEND 49th Star Surveying
PO Box 738
SE Portion of Lot 74, ® Sewer Cleanout Girdwood, AK 99587
USS 3042, O Well (907)891-6111
Girdwood, Alaska Jeremy@49thStarSurveying.com
W.O. 2242 DATE: 8/5/22
SCALE: 1•=40'
49th Star
Surveying
0 20 40
US SURVEY
FEET
I �
Lot 74B \
OF Atq,ll1
w
Al 1
• Jer Hurst
d-
r
Iill� �fESSIOOOY
NOTES
Portion
Lot 74
Portion
Lot 74
Iv s.
9
912
Lot 73
(AK DOT/PF)
-All dimensions shown are grid bearings ground distances; record boundaries are per USS 3042, Plat No. 70-36, Statutory Warranty
Deed Doc.# 2002-048328-0 and Deed Book 344 Page 353.
-Deed Book 344 Page 353 reserved "The access road across the S.E. corner of Lot 74, US Survey No. 3042, Alaska shall at all times
remain open for access to Lot No. 74 only. The deep well situated on Lot No. 74, US Survey No. 3042, shall be a joint ownership of
both easterly and westerly parts of Lot No. 74, and access and use is granted to the purchaser... of easterly part of Lot 74."
-49th Star has conducted a physical survey of the property and all details shown on this Asbuilt Survey are correct. Under no
circumstances should any data hereon be used for construction or the establishment of property lines.
-It is the owners responsibility to determine the existence of any easements, covenants, or restrictions; no title research performed.
AS BUILT SURVEY
SE Portion of Lot 74,
USS 3042,
Girdwood, Alaska
LEGEND
® Septic Cleanout
QS Septic Tank
OW Well
49th Star Surveying
PO Box 738
Girdwood, AK 99587
(907)891-6111
Jeremy@49thStarSurveying.com
W.O. 2242 I DATE: 11/2/22
SCALE: 1•=40'
M UMUPA U T V OF A MCH0R G;-:
4 t;�
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Parcel I.D. 075-132-33
Certificate of On -Site Systems Approval
Expiration Date: Z Z / Z -o -2-
Legal
Legal description US SURVEY 3042 LT 74 E2SE4 T1 ON R2E SEC 19
Site address 377 Toadstool Dr Girdwood
Current property owner(s) Loverne Bercee
X The On-site system(s) is/are approved for 3 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or advisories:
y ULA.
By: � Original Certificate Da 11/21/2022
g Date:
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
MUNICIPALITY OF ANCHORAGE
Development Services Department X_;
-- Phone: 907-343-7904
On -Site Water & Wastewater SectionFax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 075-132-33
Complete legal description US Survey 3042 Lot 74 E2SE4 T10 R2E Section 19
Location (site address) 377 Toadstool Drive, Girdwood, AK 99587
Current property owner(s) Loverne Bercee
2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS
Day phone
3. TYPE OF WATER SUPPLY: ❑ 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: ❑E Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: ❑ Steel X Plastic ❑ Concrete ❑ Fiberglass
Age < 1 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 $ C2 Waiver Fee $
Date of Payment ( IIS) f z -p a. Date of Payment
t� S C �.�; i Waiver #
COSA #
COSA Application—June 2022
COSA Checklist
Legal Description: US Survey 3042 L75 E2SE4 T10N R2E Section 19 Parcel ID: 075-132-33
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 9/14/88 Total depth 50 ft
Cased to Illegible ft
itary seal is functioning correctly
❑ Wires are p I protected
Casing height (above groun in.
Date of flow test for COSA
Static water level at beginning of test ft.
Comments Served by well on neighboring property
B. TANK DATA
Measured operating fluid level in septic tank N/A
Date of pumping N/A
❑ Required maintenance completed, if AWWTS
comments: New Installation
D. ABSORPTION FIELD DATA
Which system tested (date installed) 10/27/22
❑® ALL standpipes present per record drawing
Total measured depth from grade 7.0 ft (max)
Measured depth to pipe invert from grade 3.0 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/Defici
COSA Checklist June 2022
'Well production at time of test gpm
Water storage tank volume N/A gallons
Well disinfected for coliform test? ❑ Yes ❑ No
0 Coliform bacteria is Negative
Nitrate 0.835 mg/L ❑ Nitrate less than MRL (ND)
Arsenic 7.20 ug/L ❑ Arsenic less than MRL (ND)
Collected by Forge Engineering
Date 11/6/22
C. LIFT STATION
A
fired maintenance completed
ge of lift station years
Lift station material
Comments:
Adequacy test date New Installation
Results ❑ Pass
F�,yid depth prior to test in
Wat added gal
New fluffepth in
Elapsed time min
Final fluid depth in
Absorption rate gp
FIELD STATUS — POST
Effective depth (per record dr ings) in
Effective depth used in
Effective depth remaining 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'
❑ Yes
if No
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' ❑ Yes
if No ft
Absorption Field on Lot > 100' W Yes
if No
ft
Holding Tank > 100' RN Yes
if No ft
Neighboring Absorption Fields > 100'
if No
ft
Animal Containment > 50' FE] Yes
if No ft
❑ Yes
if No
ft
ft
If tank or field is under driveway comment below
F. ENGINEER'S COMMENTS
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ❑Yes
if No
ft
❑ 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'
❑ Yes
if No
ft
Wells on Adjacent Lots:
Field to Property Line > 10'
❑ Yes
if No
ft
Private Wells > 100'
0 Yes if No ft
Water Main > 10'
OR 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
Engineer's Printed Name Benjamin Schiller, P.E.
COSA Checklist—June 2022
Phone (907) 522-7773
Date 11/20/22
.,q0
TH
• _ Benjarr$5chiller
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