HomeMy WebLinkAboutT15N R1W SEC 5 LT 6T15N PIW Sec 5 kr[Cv V.7/VGlr) Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP221428 PID Number: 051-032-03 Dwelling: ❑■ Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑■ New ❑ Upgrade Name Hall Quality Homes ABSORPTION FIELD ❑ Deep Trench X Wide Trench ❑ Bed ❑ Mound Site Address 22727 Davidson Drive ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 4 1.0 GPD/SF 6.0 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 5.0 Ft. Gravel depth beneath pipe 1.0 Ft. Subdivision Block Lot 6 Fill added above original grade 0 Ft. Gravel length 2@60 Ft. Township Range Section 15N 1W 5 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 600 Ft2 2 10.8 Ft. Well 100'+ 100'+ NA NA 25'+ TANK M Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer GREER Capacity 1500 Gal. Surface Water 100'+ 1001+ NA NA Material Number of compartments Lot Line 5'+ 101+ NA NA NA HDPE 2 Foundation 10'+ 101+ NA NA LIFT STATION Manufacturer Capacity Remarks Schd 40 ABS Gal. Alarm location Electrical installed by Installer PIPE MATERIAL House to tank ABS* drainfield Tank to 3034 Fisher Brothers Excavation Drainfield 3034 CO/MT3034 Inspector PES BENCH MARK (Assumed elevation) 35.0 ft Inspdeact Sn est 7/6/23 d 7/7/23 Location and description 3m 7/8/23 2 4" 7/9/23 See Site Plan, Bottom of house flashing ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional Approval: Date �G ••. •••• .... .. . ....... ••$even I�. anrioiae Septic Syste Approved / r Dat lI CE 8149 ;o2�.sz.2�.• ,Note: this approval does not include well permit require encs. kr[Cv V.7/VGlr) PROFILE PA N N O N E E N G S V C , L L C ( C . I . 1 0 8 8 ) Wheaton Water Well, Inc. 1190 N. Wasilla-Fishhook Road Wasilla, AK 99654 Name: Hall Quailty Homes Address: PO Box 1987 City: Palmer State: AK Zip Code: 99645 Well Site: T1 5N, R1 W, Sec 5 Lot/Block: L6 Additional: 22727 Davidson Dr, Chugiak (Previously 22731 Davidson Dr.) Well Depth; 59 ft' From: To: Formation: 0 7 Sand, Gravel, Cobble Below Ground: 57 ft. 7 18 Silty Gravel Above Ground: 2 ft. 18 46 Wet Gravel and Silt Gal/Min: 30 46 60 Gravel, Sand, Water Static Level: 23 ft. Casing: 55"ft. of 6 in. x .25in. steel" Liner Pipe: N/A Screened: 18 Slot 59-54 Perforated: N/A Grouted: Grouted Depth: Develop. Method: Air Use of Well: Residential Drilling Method: Rotary Misc: Other: The well was pumped Y off the bottom with 100% draw down for 2 hours and recovered at 30gpm . Date Drilled: 7/17/2023 Driller: Ben Mattison MUNICIPALITY OF ANCHORAGE Awe Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: OSP221428 Date of Issue: 10 - 27 - 22 Parcel Identification Number: 051 _ 032 _ 03 Legal Description TN 15N R1 W Sec 5 22727 Davidson Dr, Chugiak Block Lot 6 Property Owner Name & Address: Selway Corp PO Box 1987 Palmer, AK 99645 Pump Installation Date: 11 -08 -2023 Pump Intake Depth Below Top of Well Casing. 54 feet Pump Manufacturer's Name: Meyer Pump Model: 3NFL52-12-P4-02 1/2 Pump Size: hp Pitless Adapter Burial Depth: 11 '611 feet Pitless Adapter Manufacturer's Name: Martinson B-10 Pitless Adapter Installer: Unknown Well Disinfected Upon Completion? 5(yes ❑ No Method of Disinfection: Stedlene Comments: Pump Installer Name: Company: Wheaton Water Well, Inc Mailing Address: 1190 N Wasilla Fishhook Rd ii City Wasilla State. AK Zip. 99654 11 Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. S89° 58' 48 "E CONLEY AVENUE zo 50' ROADWAY RESERVATION F - Q ryry BARN W U) W Q FEN CE 0 o LO 0 LOT 6 109,039 S.F. � LO O 2.503 ACRES O < O N CO Z w O aO ry Z Z � O Cl) C) III Q WELL > > Q 11 0 24.3 N 0 N 019.0 1. N �./ 6 8.00 O O 0 EXISTING d o BLDG. 0 12.0 SEPTIC PIPES N 110.1 39'8 5.4 5. OSHED S89° 58' 48 "E 33.0 329.70' OF A 00000p��� LOT 11B TH D 49* p p..� D .D �O s Mark E. Davis Q LS -7338 p 4��� •'•]2-4-2023.•' �`� 44a10 ... �d o rofessiono\ �Qo EXCLUSION NOTES: It is the owners' responsibility to determine LEGEND: SET FINDoRoe eo BY. the existence of any easements, covenants, or restrictions 5/8"RB W/CAP* 5/8" RB OO R e b e CCC G C m ICI e which do not appear on the recorded subdivision plat. NOTE: It 3.25" AL.MON. Q� MONUMENT is the contractor's responsibility to check top of foundation HUB & TACK O grade and building setbacks in relation to lotlines and esm'ts. FENCE- xx— SURVEYCERTIFICATION: SLANA has conducted a OVERHANG— physical survey this property as shown on this WOOD DECKS- th drawing and to the best of our knowledge and CONCRETE— O abilities, all dimensions have been measured true ASPHALT— 0 and correct. SEPTIC STANDPIPES - WATER WELL- 0 LAND &CONSTRUCTION SURVEYORS -PLANNERS -ENGINEERS ASBUIET SURVEY OF: LEGAL DESCRIPTION: ELEV.(NO DATUM)— 100.0' 1200 E. 76th AVE., UNIT 1226 BLM LOT 6 ANCHORAGE, ALASKA 99518 (907) 562-6103 WORK ORDER NUMBER: DATE: SCALE: PLAT NUMBER: NOVDRAM 14, 2KED 1ER: N/A OO SECTION 5, T15N, R1 W, S.M., ALASKA �_IIICr DRAWN BY: CHECKED BY GRID NUMBER: BOOK/PAGE: m JV MD. t. NW 1557 999/99 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 http://www.muni.org/onsite On -Site Water & Wastewater System Permit Permit Number: OSP221428 Work Type: WellSeptic Initial Tax Code Number: 05103203000 Site Legal Address: T15N R1 W SEC 5 LT 6 G:1557 Site Mailing Address: 22731 DAVIDSON DR, Chugiak Owner: BACHMAN TED M & ADRIENNE P Design Engineer: Engineering & Excavating LLC This permit is for the construction of: Effective Date Expiration Date: Lot Size in Sq Ft: Total Bedrooms: r L)epartment 10/27/2022 10/27/2023 '1:•11 Q Disposal Field 2 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 Special Provisions: • Record Drawings submitted with the Inspection Report will be required to be to -scale. -R�seeived-B�� �S S I,�e c9. 'f"'U �. �n q ►�n er►�v�g � X A Vrn'f-I �a q Issued By: J Date: 1017--71Z Date: /012.717-2 4 MU ICIPAUT Y OF ANCHORAGE Development Services Department � P Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTICIWELL PERMIT APPLICATION Parcel I.D. r;�/07 ;Z12_3 06') Property owr Mailing addrE Site address Legal description (Sub'd., Block & Lot) _&&Y Z9 Legal description (Township, Range & Section) �E-�� J%�" lei Lot Size /j V- Sq. Ft. Number of Bedrooms APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption. Field t Initial Single Family (SF) i,e; Septic Tank �] Upgrade ❑' (w/wo AD b' Holding Tank ❑ Renewal ❑ Duplex (p) ❑ Privy ❑ Multiple Dwellings [] (SF and/or D) Private Well Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: - I certify that -the -above information is correct. I further certify that applicable Yf nicipal",Codes, this is in accordance with 1) of property owner or authorized agent) Permit/Rush Fees: Waiver Fees: Date of Payment: 10/1 3122_ Date of Payment: Receipt Number: 0511`i;�' Receipt Number: Permit No. _ 0 S e Z2)!-(2$ Waiver No. GADevelopment Services\Building SafetylOn Site Water and WastewaterTormsUient FormslPermit Application.doc 10100 ETern Drive, Palmer, AK 99645 (907) 240-0713 steve@eng-exc.com October 13, 2022 Municipality of Anchorage OF On -Site Water and Wastewater Program .��, • • ' ' .9 . '4 4700 Elmore Road �•'� •� ' Anchorage, AK 99507 RE: SEPTIC SYSTEM CONSTRUCTION PERMIT ' ' • e /f Sfev j?�••, bare%, �R elli' . LEGAL: 8LM Lot 6, Section 5, T51N R1W. Seward Meridian ( c� • No " ---j' fF�F CE 1057 • .W ��� pRaFESSIONA�`��. PHYSICAL: 22731 DAVIDSON DRIVE, CHUGIAK, AK 99567 Ladies and Gentlemen, Engineering & Excavating, LLC (E&E) has been retained to design, permit, and construct a conventional onsite waste water disposal system to serve a new four bedroom home with a single garbage disposal at the above referenced location. Visual classification of soil types resulted in about three feet of organics and tan silt overlying well graded sands with little fines to the bottom of the 17 -foot -deep test hole. A percolation test was not conducted due to the sand absorbing 20 gallons of presoak water at a rate too fast to complete the observations. Therefore, the percolation rate is faster than one minute per inch and a sand liner under a shallow trench leach field is proposed. A required absorption area of 150 sq ft per bedroom requires 600 sq ft of infiltrative area. Therefore, 120 linear feet of 5 ft wide trench satisfies the minimum requirements. Since the maximum length of a trench is 100 ft, two 60 ft trenches have been engineered. Materials will be sourced from supplies that are confirmed to be MOA compliant. Slopes on the site are generally less than 2 percent. To both the south and east there are private wells and septic systems within 200 ft of the proposed system, which will not be impacted by the design. The client would like to complete construction this year. E&E will observe required measures to prevent ground freezing during construction. Please contact us if you have any questions. Sincerely, Steven D. Cinelli, PE LOT 7 CONLEY AVE PROPERTY LINE 5d' ROADWAY RESERVATION Q j •° Steven D. Cinelli w { v 4 `� ��••° No. CE10571EL Lu �)� PROHSSIONP { c I PROPOSED PROPOSED SEPTIC SYSTEM { o I HOUSE AND RESERVE SITE I � / 1 PROPOSED { I?� BARN y � I I A\ I �f — — — — — — — LOT 6 LOT 5 LOT 1 .B LOT i2 011 NGINEERING & XCAVATING, LL 10100 E Tern Dr. Palmer. AK 996•15 (907)240-0713 V �`O {y�Q } l I N `'1 0 30 60 120 22731 DAVIDSON DRIVE SEPTIC SITE PLAN CHLIGIAK, AK 99567 BLM LOT 6 SECTION 5, T1 5N. R1 W, S.M., ALASKA Project No.: 22073 rilcName: mrsrm,c:ax GENERAL NOTES` I. BUILDING SEWER! SCHEDULE 40 ABS (ASTM F628) 2. DISPOSAL SEWER AND DRAINFIELD! SCHEDULE 40 PVC / (ASTM D1785 OR ASTM D2665) OR SDR 35 PVC (ASTM 3034) / 3. SOLID PIPE WITH NO JOINTS SPANNING 10 FT AT j INLET AND OUTLET OF SEPTIC TANK 4. NO WELLS OR OPEN WATER WITHIN 100 FT OF SYSTEM 5. LOFT MIN TO PROPERTY LINE, TYP. 6. INSULATION BOARD SHALL BE TYPE IV EXTRUDED OR EXPANDED POLYSTYRENE, 25 PSI MIN S. WATERTIGHT MECH COUPLINGS TO BE USED AT / O SEPTIC TANK ONLY 9. SEWER ROCK AND SAND LINER SHALL CONFORM TO THE LATEST MOA / STANDARDS AND SPECIFICATIONS FOR COMPONENT PARTS AND MATERIALS USED IN THE CONSTRUCTION OF ON-SITE VASTERVATER DISPOSAL SYSTEMSA SYSTEM DESIGN KEYNOTES / a� 01 1500 GALLON GREER POLY SEPTIC TANK (D 60 FT SHALLOW TRENCH WITH 2 FT SAND LINER 3O MONITOR TUBE, SOLID ABOVE SEWER ROCK ®TEST HOLE & MONITOR TUBE LOCATION Q 4' PVC PERF PIPE LAID LEVEL & HDLES DOWN, SEE NOTE 2 © FOUNDATION CLEANOUT 2 FT MIN/ 4 FT MAX FROM WALL \� \ 07 SO/50 SPLITTER VALVE BEFORE SOLID HEADER LAID FLAT © TWO-WAY CLEANOUT WITHIN 10 FT OF TANK OUTLET ® 20' MANWAY RISER, 4' MIN INSULATION TO 4 FT BELOW GRADE. BUILDING SEVER, 4' ABS, SEE NOTE I \_ ® CLEANOUT, TYP IF 4 �.� e • eye./o / /s .... y . Steven D. Cinelli No. CE10571 �� �® 0 20 40 F�P • .. �� ROFE5S10��.�,�% -'OPOSED BARN \�T 10 FT MIN rl LAJ 03 GRADE TO DRAIN -� LEACH FIELD/PROFILE KEYNOTES: Q FINE GRADE SEWER ROCK, 1 FT DEEP BELOW PIPE AND 2IN MIN COVER OVER PERF PIPE SEE GENERAL NOTE 9. 20 SAND LINER, 2 FT DEEP. SEE GENERAL NOTE 9. 03 MONITOR TUBE, SOLID ABOVE SEWER ROCK ® SEPERATION FABRIC, TYPAR 3401 OR EQUAL OS 4' PERF PIPE LAID LEVEL & HOLES DOWN, SCH 40 OR SDR 35 PVC © FOUNDATION CLEANOUT- 2 FT MIN/4 FT MAX FROM WALL Q BUILDING SEWER! MIN 2% SLOPE, MAX 20% SLOPE EXCEPT 10 FT PRECEEDING TANK MIN 1/8'/FT MAX 1/4'/FT. SEE GENERAL NOTE 1. 80 DISPOSAL SEVER, 10 FT PRECEEDING FIELD MIN i/8'/FT, MAX 1/4'/FT. SEE GENERAL NDTE 2. 90 1500 GALLON GREER POLY SEPTIC TANK ® TWO-WAY CLEANOUT- MAX 10 FT FROM TANK OUTLET ® 20' MANWAY RISER, 4' MIN INSULATION TO 4 FT BELOW GRADE. CLEANOUT AT BOTH PERFORATED PIPE ENDS EXTERIOR WALL SYSTEM PROFILE SCALE! NOT TO SCALE NGINEERING & XCAVATING, LL 10100 E Tem Dr. Palmer, AK 99645 (907) 240-0713 FT MIN. i11 FT MAX DEPTH FT LEACH FIELD AT MONITOR TUBES SCALE! NOT TO SCALE 22731 DAVIDSON DRIVE SEPTIC CHLIGIAK, AK 99567 BLM LOT 6 SECTION 5, T15N, R1W, S.M., ALASKA lnR F4LRIi baFaflal9�'SO`�'v0u sWl. SD MRfM:SmLCnLv lG SYSTEM DESIGN Project No.: 22073 File Name: TH #1 TH #2 TH #3 1 1 1 2 OL 2 OL 2 OL 3 3 3 4 4 4 �\ 5 5 5 6 SM 6 SM 6 SM 7 7 7 8 8 8 9 9 9'� r 10 10 10 11 11 11 12 12 12 13 13 13 14 14 14 15 15 15 16 16 16 17 17 17 TH #1 PERFORMED: 9/15/2022 GROUNDWATER NOT ENCOUNTERED MONITOR TUBE CHECKED: 9/25/2022 WATER NOT ENCOUNTERED TH #2 PERFORMED: 10/16/2022 TH #3 PERFORMED: 10/16/2022 GROUNDWATER NOT ENCOUNTERED TEST HOLE #1 HOLE #3 NET WATER N0. DATE CLOCK TIME TIME LEVEL (MIN) READING '° °°° °° SOIL PERCOLATION RATE TOO FAST TO TEST AFTER 20 GALLON PRESOAK f %•`: 0 ° ° 20 ° PERCOLATION RATE AT TH #1, TH#2, AND TH3: FASTER THAN ONE MPI PERC HOLE DIAMETER: 6 Steven D. Cinelli TESTS RUN BETWEEN 8 AND 10 FEET •Na. CE10571° PR OI ESStONP PERFORMED BY. STEVEN D CINELLI. 1, STEVEN D CINELLI, CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE NTH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 9/15/2022 22731 DAVIDSON DRIVE SEPTIC NGINEERING & CHUGIAK, AK 99567 XCAVATING, LL 10100 E Tern Dr. BLM LOT 6 Palmer, AK 99645 SECTION 5, T15N, R1K S.M., ALASKA (907) 2.10-0713 misi>a+rsMnv��iw+irz.'`«°sc�'„um a+.iino ��u-nm'�'rn'iiii�"yi'r SOIL LOG AND PERCOLATION TEST Project No.: 22073 Filc Name: MUNICIPALITY OF ANCHORAGE 0� Development Services Department ` 1 Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 051-032-03-000 Expiration Date: Legal description T1 5N R1 W SEC 5 LT 6 Site address 22727 DAVIDSON DR Chugiak AK 99567 Current property owner(s) SELWAY CORP 11/8/2024 X The On-site system(s) is/are approved for 4 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: Original Certificate Date: 12/19/2023 Tfiis 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 Absorption Field Advisory Tank Age Advisory Other X Well Flow Advisory Nitrate Advisory Arsenic Advisory COSA ApprovaLJune 2022 MUNICIPALITY C E Development Services Department �r�4 p P `T 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. 051-032-03 Complete legal description T1 5N R1 W Sec 5 Lot 6 Location (site address) 22727 Davidson Drive Current property owner(s) Hall Quality Homes 2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS Day phone 3. TYPE OF WATER SUPPLY: 0 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: [W Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel # Plastic ❑ Concrete ❑ Fiberglass Age <1 - 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 $ 7.5 Date of Payment COSA # 0!5 C 2 3 4r.. Waiver Fee $ Date of Payment Waiver # COSA Application—June 2022 COSA Checklist_June 2022 COSA Checklist Legal Description: Parcel ID: 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 Total depth ft Cased to ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) in. Date of flow test for COSA Static water level at beginning of test ft. Well production at time of test gpm Water storage tank volume 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 Date Comments __________________________________________________________________________________ B. TANK DATA Measured operating fluid level in septic tank Date of pumping Required maintenance completed, if AWWTS Comments: C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade 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 gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Adequacy test date Results Pass Fluid depth prior to test in Water added gal New fluid depth in Elapsed time min Final fluid depth in Absorption rate gpd FIELD STATUS – POST RECOVERY Effective depth (per record drawings) in Effective depth used in Effective depth remaining in Comments/Deficiencies: COSA Checklist_June 2022 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 ft Neighboring Tank > 100’ Yes if No ft Absorption Field on Lot > 100’ Yes if No ft Neighboring Absorption Fields > 100’ Yes if No ft Community Sewer Main > 75’ Yes if No ft Community Sewer Manhole/Cleanout > 100’ Yes if No ft Private Sewer/Septic Line > 25’ Yes if No ft Holding Tank > 100’ Yes if No ft Animal Containment > 50’ Yes if No ft Manure/Animal Excreta Storage > 100’ 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 Tank to Property Line > 5’ Yes if No ft Field to Property Line > 10’ Yes if No ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ 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 Phone Engineer’s Printed Name Date 2023.12.12