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HomeMy WebLinkAboutT15N R1W SEC 5 LT 6T15N PIW Sec 5
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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.
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PROFILE
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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
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109,039 S.F.
� LO O 2.503 ACRES
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Q 11
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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
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D .D
�O s Mark E. Davis
Q LS -7338 p
4��� •'•]2-4-2023.•' �`�
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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