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HomeMy WebLinkAboutCANYON VIEW ESTATES BLK 1 LT 10 Canyon View Estates Block 1 Lot 10 #021-021-43 (rcev uoiuzi-iu) Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 1 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP231029 PID Number: 021-021-43 Dwelling: ❑Q Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: 0 New ❑ Upgrade Name Hultquist Homes, Inc. ABSORPTION FIELD El Deep Trench XWide Trench El Bed F1 Mound ❑ Other Site Address 13819 Canyon Road Phone Number of Bedrooms Soil Rating Total depth from original grade 4' 1.2 GPD/SFJ 2-0 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 1.5 Ft. Gravel depth beneath pipe 0.5 Ft. Subdivision Canyon View Estates, Phase 1 Block Lot 1 10 Fill added above original grade 2.0+ Ft. Gravel length 100 Ft. Township Range Section Gravel width 5 Ft. Beds: Number of Lines NA Distance between lines NA Ft. SEPARATION DISTANCES To From Septic Tank Absorption Field Lift Station Holding Tank Sewer Line Total absorption area 500 Ftz Number of trenches 2 Dist. between trenches 6.0 Ft. Well 100'+ 100'+ NA NA 25'+ TANK p Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Greer Tank Capacity 1500 Gal. Surface Water 100'+ 100'+ NA NA Material Number of compartments Lot Line 5'+ 10'+ NA NA NA Polyethylene 2 Foundation 10'+ 10'+ NA NA LIFT STATION Manufacturer Capacity Remarks Gal. Alarm location Electrical installed by Installer Brownson Brothers PIPE MATERIAL House to tank 3034 Tank to drainfield 3034 Drainfield 3034 Co/MT 3034 Inspector PES BENCH MARK (Assumed elevation) 100 ft Inspdection 1s` 8/14/23 3`d 8/17/23 2nd 8/15/23 4"' 8/24/23 Location and description First tank compartment Manway Lid ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional Approval: Date OF e* 49TH 9 �� .................... 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BOX 1807 PALLIER, AK 99645 PHONE (907) 745-8200 FAX (907) 745-8201 DRAWN LJC/DRM CANYON VIEW EST PH1 E31 L 10 CHECKED ACP HULTQUIST HOMES, INC. SITE: 13819 CANYON ROAD SITE PLAN ANCHORAGE, AK 99516 REVISIONS V 08/23/2023 SCALE 1" = 50' P.I.D. NO 021-021-43 PERMIT NO. OSP231029 2 OF 2 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section M Fax: 907-343-7997 Well Log Permit Number: # 231029 Date of Issue: 3-29-23 Parcel Identification Number: Date Started: 6-14-23 Date Completed: 6-15-23 Is well located at approved permit location? Yes X No ❑ Legal Description: Canyon View Estates Blockl Lot10 G: 3042 Property Owner Name & Address: Hultquist Homes, Inc. Borehole Data: Depth (ft) Soil Type, Thickness & Water Strata From To casing stick up 0 2 fill 2 4 silt & gravel 4 13 bedrock 13 235 Lat: 61.095724 Lon: -149.704214 Water Sample Results: Arsenic: ug/L Nitrates: mg/L Total Coliform Bacteria: colonies/100mL Method of Drilling ❑■ air rotary ❑ cable tool Casing type: steel Wall Thickness: -250 inches Diameter: 6 inches Depth: 53 feet Liner Type: Diameter: inches Depth: feet Casing stickup above ground: 2 feet Static water level (from ground level): 87 feet Pumping level: feet after hours pumping _gpm Recovery Rate: ism Method of Testing: airlift Well Intake Opening Type: ❑ Open End Open Hole ❑ Screened Start feet Stopped feet ❑ Perforations Start feet Stopped feet ume: 20 Start 0 20' Well Disinfected Upon Completion? Yes No Method of Disinfection: tabs Comments: Well Driller: Johnny Kay ❑ ❑ Company: Hefty Drilling, Inc. Mailing Address: po box 112130 Anch AK 99511 Attention: The well driller shall provide a well log to the On-site Water and Wastewater Section within 30 days of completion. Development Services Department Building Safety Division a On -Site Water & Wastewater Program o 4700 Elmore Road P.O. Box 196650 Mark Begich Anchorage, AK 99507 s n E T Y Mayor www.rnuni.org/onsite (907)343-7904 Pump Installation Log Well Drilling Permit Number: Sw- 1023) 0) Date of Issue: Parcel Identification Number: Legal Descriptionr, Properly Owner Name & Address: CAP Pump Installation Date: V ._ Pump Intake Depth Below Top of Well Casing: , 1.) feet Pump Manufacturer's Name: G r U 0 U S Pump Model: / U ') 01f' 0'7- 2 )U Pump Size 31q hp Pitless Adapter Burial Depth: ) )_ feet Pitless Adapter Manufacturer's Name: C ✓� lit .j Pitless Adapter Installer: Well Disinfected Upon Completion? Yes ❑ No Method of Disinfection: CA Irv,, . t c 6 C7 Comments: I Pump Installer Name: Johnny Kay Hefty Drilling, Inc. Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation. Lot 10, Block 1, Canyon View Estates Subdivision Asbuilt Land Surveying Land Development Consultants Subdivision Specialists Construction Surveying AEC# 173042 S4 Group 124 E 7th Avenue Anchorage, Alaska 99501 (907) 306-8104 mail@S4AK.com 8/28/2023 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 http://www.muni.org/onsite On -Site Water & Wastewater System Permit Permit Number: OSP231029 Work Type: WellSeptic Initial Tax Code Number: 02102143000 Site Legal Address: CANYON VIEW ESTATES BLK 1 LT 10 G:3042 Site Mailing Address: 13819 CANYON RD, Anchorage Owner: HULTQUIST HOMES INC Design Engineer: PANNONE ENGINEERING SERVICES This permit is for the construction of: Effective Date: Expiration Date Lot Size in Sq Ft: Total Bedrooms: j»cnr 61 t�epartmc:nt 3/29/2023 3/28/2024 67973 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 u- J_ A 0 J ✓+/" C L Ti -r, ,+ -T wL e� T T --o Received By:15 5 Issued By: _ 0, Date: Date: J 2 % /'z, 3 4 MUNICIPALITY OF Community Development Department 3 Development Services Division On -Site Water & Wastewater Program �• ;�,-lir Phone: 907-343-7904 Fax: 907-343-7997 ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 021-021-43 Property owner(s) Hultquist Homes, Inc. Day phone Mailing address 12570 Old Seward Highway Anchorage, AK 99515 Site address NHN: Canyon Road Anchorage, AK 99516 Legal description (Sub'd., Block & Lot) Canyon View Estates Phase 1 Block 1 Lot 10 Legal description (Township, Range & Section) Lot Size 67,973 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (M all that apply) Absorption Field x❑ Initial X❑ Single Family (SF) X❑ (w/wo ADU) Septic Tank 191Upgrade ElDuplex ❑ (D) Holding Tank ElRenewal ElMultiple 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: `� sa® Waiver Fees: Date of Payment: 31q I A69-3 Date of Payment: Receipt Number: 0-7"o'a ! (7 Receipt Number: Permit No. 65 i9as /aa9 Waiver No. Permit App_.;- ::'-.,:c Pannone Engineering Services LLC Steven R. Pannone, Principal Registered Professional Engineer E-mail: steve@panensak.com 26 July 2023 Municipality of Anchorage Development Services Department On -Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, Alaska 99519 Subject: Canyon View Estates Block 1 Lot 10 Well & Septic System Permit Request This is a design narrative for a permit to install an initial well and septic system on the subject property. The proposed system will serve a proposed four-bedroom (4) house. Currently the lot is undeveloped. This lot and surrounding lots are to be served by private wells. Currently there are no wells within 100 feet of the proposed system. 1. Soils: A test hole was performed on this lot by Pannone Engineering Services, LLC on 10/03/2019. Groundwater was not observed during the excavation of the fest hole, bedrock was not encountered. Groundwater was observed in the test hole monitor tube at a depth of 6.0' below grade on (05/25/2023). Based on the results of the percolation test and overall soils appearance an application rate of 1.2 gpd/SF was used for the design of conventional wastewater treatment system in the area of the test hole. (See attached soils log). 2. Soil Absorption System Design. a. See Sheet 1 of the design package. 3. Surface Water: There is no surface water within 100 feet of the proposed septic tank and drain field. 4. Topography: See attached site plan for area topography. S. Drawing Markings: The Drawings are marked "For MOA Review Only". When written notification that the review is complete and no further comments are received from MoA On -Site Department, the note will be removed and "For Construction" drawings will be issued. The proposed installation will not affect the future development of this or the surrounding lots. If you have any questions or concerns, please contact me at (907) 745-8200. Sincerely, IsF_>i� Steven R. Pannone, P.E. F. ASCE Owner/Civil Engineer Mailing: P.O.Box 1807, Palmer, AK 99645 Telephone: (907) 745-8200 FAX: (907) 745-8201 ci7 N rn_ r O OC u mo Om WO �r 2 O V)co <O -i '00 z 0 0 �6m � r O r O y 0 Zc N N y :il � C O ;u o* ?m r CD m N D m 0 ��Ov7 Dcn -0 TI X D XM D p mz " cn mF � Z • cn fTl Z���D>1 Ln Do Ovm 0-1 ,N N70 m z = Z mo!'Io N G7 p m mo°'o00 > m Z D p U N m fTl _ m z v FFl o m .70 x U) � D Z , ONIU1 � �G �O m>o;a 0mrTl ztom- a r -v .. �Z- �m > (') A LZ: N) r D CHANGE ORDER DOZ-<;;oD�(/'o <Gi XF- p -d0 DIV DX --j mm0mz REV 2: 07/26/2023 O o mmLnP cn cn , o0 omo• 00 c>D N 0 / � 0 0 cz Ca� z o U) 0 c ) m,n -0-0 �oo m m o o o L„ x y 6 r6 020 D N z fox o C �Ao -i mco D oa Zn ��Ov7 Dcn -0 TI X D XM D p mz " cn mF � Z • cn fTl Z���D>1 Ln Do Ovm 0-1 ,N N70 m z = Z mo!'Io N G7 p m mo°'o00 > m Z D p U N m fTl _ m z v FFl o m .70 x U) � D Z , ONIU1 � �G �O m>o;a 0mrTl ztom- a r -v .. �Z- �m > (') A i/) r D CHANGE ORDER DOZ-<;;oD�(/'o <Gi XF- p -d0 DIV DX --j mm0mz REV 2: 07/26/2023 O o mmLnP cn cn , o0 omo• 00 c>D N _�u O p p -P cn� c)�to �D o SITE PLAN z o U) 0 c ) m,n -0-0 fel m m o o o L„ x �N m N o D N z fox o C nc�°'• a -i D ONo til D rrn / FQD O A, — A / �C,O r ll / / 1 0 / od() Z 0\ co �y a (At !'••' •• ••••••• •• gown a,nara CE 8149 '2023 REVISIONS o CHANGE ORDER REV 1: 03/27/2023 CANYON VIEW EST PH1 BL10 HULTQUIST HOMES, INC. SITE: NHN CANYON ROAD ANCHORAGE, AK 99516 REV 2: 07/26/2023 DRAWN mmLnP P.I.D. NO 1-43 / o SITE PLAN —PERMIT PERMIT No. N . SHEET 1 OF 2 a� o ,o >a �N m N o `o fox o 2 O nc�°'• a 0\ co �y a (At !'••' •• ••••••• •• gown a,nara CE 8149 '2023 REVISIONS o CHANGE ORDER REV 1: 03/27/2023 CANYON VIEW EST PH1 BL10 HULTQUIST HOMES, INC. SITE: NHN CANYON ROAD ANCHORAGE, AK 99516 REV 2: 07/26/2023 DRAWN LJC/DRM P.I.D. NO 1-43 \ o SITE PLAN —PERMIT PERMIT No. N . SHEET 1 OF 2 NOTES: PANNONE ENG SVC LLC (C.1. 1088) P.O. BOX 1807 PALMER, AK 99645 PHONE 907) 745-8200 FAX (907) 745-8201 (At !'••' •• ••••••• •• gown a,nara CE 8149 '2023 REVISIONS DATE 07/26/2023 SCALE 1" = 50'1 CHANGE ORDER REV 1: 03/27/2023 CANYON VIEW EST PH1 BL10 HULTQUIST HOMES, INC. SITE: NHN CANYON ROAD ANCHORAGE, AK 99516 REV 2: 07/26/2023 DRAWN LJC/DRM P.I.D. NO 1-43 CHECKED ACP SITE PLAN —PERMIT PERMIT No. N . 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VCA A Vz mA� O m nODT D -I c \ / c � n NOrrm�„�z" Z il n ulD�i nm m C Z Poo Z ` I\_—\ m D Z M mcxi�m m W G7 o 0 m<00 yD vm T z \ o -Di 2 Cf) u N I 51 m I O I 0 W 0 I W o I J OO D 0 u: x� n� O0 --1j Z Ln = CO G) < < M C m I �� O t 0 Z z z r { o� NOTES: PANNONE ENG SVC LLC (C.1. 1088) FOR CONSTRUCTION PHONE OX 10272482A$NCHFOR�A EE, AX 99510 (907) 272-8211 DRAWN LJC/DRM CANYON VIEW EST PHI B1 L10 CHECKED ACP HULTQUIST HOMES, INC. SITE: NHN CANYON ROAD SOIL LOG ANCHORAGE, AK 99516 Z� S o z� O A�c z o �v zm� P„0 3 3 Z � O z z 23 T m K � � rT y O Z _ on- znn ... VCA A Vz mA� F_ r��>r7 O 'jJ nODT D -I c \ / xx n NOrrm�„�z" Z il n ulD�i nm m C .\T•. Poo Z ` I\_—\ m D Z NOTES: PANNONE ENG SVC LLC (C.1. 1088) FOR CONSTRUCTION PHONE OX 10272482A$NCHFOR�A EE, AX 99510 (907) 272-8211 DRAWN LJC/DRM CANYON VIEW EST PHI B1 L10 CHECKED ACP HULTQUIST HOMES, INC. SITE: NHN CANYON ROAD SOIL LOG ANCHORAGE, AK 99516 CE 8149 Z� S z� O A�c z 71 D D Z � O A a A � DOD A � � n Z N -I WOO ... VCA A Vz ry m,�x m F_ r��>r7 O 'jJ mZZO D -I n.s 0 X �z��m�o _9 z Z C7 NOrrm�„�z" Z il n 0 A gym O c oz�°9a 0 Poo Z 03 x� a, 0 m W CE 8149 N J 3 0 REVISIONS -HI 07/26/2023 REV 1: 03/27/2023 SCALE REV 2: 07/26/2023 NTS K"gZ94YAC1fis I OSP231029 We] 9M NHd A p z 0 w o n z l z l z l i m N Go 0 m W 0 o o 0 o yD vm T z • • O m u N I 51 m I O I z O W 0 I W o I N N J 3 0 REVISIONS -HI 07/26/2023 REV 1: 03/27/2023 SCALE REV 2: 07/26/2023 NTS K"gZ94YAC1fis I OSP231029 We] 9M Canyon View B1 L10 Subject: 3/27/2023 Originator:ACP Checker: SITE PARAMETERS 1. No angle of repose on backfill material Weight of Water 62.4 lb/ft3 Weight of Soil 120.0 lb/ft3 Tank Bury Depth 4 ft TANK DIMENSIONS Diameter 58.0 in Diameter 4.83 ft Length 12 ft Area 18.35 ft2 Volume 220.17 ft3 Weight 0 lbf Manholes Yes Percentage of Tank in Groundwater 100% BOUYANT FORCES (weight of the displaced water) 13739 lbf UP RESISTING FORCES (weight of soil & tank) Is Backfill Material Saturated?YES Volume of Manholes 25 ft3 Volume of Soil 207 ft3 (Volume of Soil over Tank minus Volume of Manholes) Weight of Soil 11916 lb DOWN NET FORCE ON TANK -1823 lb UP Ballast Required, See Below Septic Tank Buoyancy Check Job Number:SRP Job Name: Buoyancy Check 1500-gallon STEP Tank ASSUMPTIONS 2. 120 lb/ft3 backfill material 3. Tank is empty 4. Tank is completely submerged. Buoyancy Control: 1.Discuss Buoyancy Control RESISTING FORCES (weight of concrete blocks) Height 2.0 ft Width 2.0 ft Length 6.0 ft Volume 24.0 ft3 Weight of Concrete 145.0 lb/ft3 Weight of Blocks 1982.4 lb Number of Blocks 2 ea NET FORCE ON TANK 2142 lb DWN Design OK Canyon View B1 L10 Subject: 3/27/2023 Originator:ACP Checker: ASSUMPTIONS SITE PARAMETERS 1. No angle of repose on backfill material Weight of Water 62.4 lb/ft3 2. 125 lb/ft3 backfill material 3. Vault is empty Weight of Soil 120.0 lb/ft3 Figure 1: Buoyancy Collar Diagrams Pump Vault Dimensions Diameter 24.0 in 2.00 ft Radius 1.00 ft Height 8 ft Area 3.14 ft2 Volume 25.13 ft3 BOUYANT FORCES (weight of the displaced water) 1568 lb UP RESISTING FORCES (weight of soil Buoyancy Collar based on 1ft ring around entire vault) Volume of Concrete 9.4 ft3 Unit Weight of Concrete 145 lb/ft3 Weight of Collar 778 lb RESISTING FORCES WEIGHT OF SOIL (based on truncated cone) Volume of Soil 326.7 ft3 Volume of soil minus volume of pump vault Weight of Soil 18819.4 lb NET FORCE ON PUMP VAULT 18030 lb DWN Design OK Auxillary Pump Vault Job Number:SRP Job Name: Buoyancy Check Pump Vault Buoyancy Check MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Parcel I.D. 021-021-43 Certificate of On -Site Systems Approval Expiration Date: Legal description CANYON VIEW ESTATES BLK 1 LT 10 Site address 13819 CANYON RD Current property owner(s) HULTQUIST HOMES INC X The On-site system(s) is/are approved for 4 bedrooms Conditional approval for Comments or advisories: 11/30/2023 bedrooms, with the following stipulations: Original Certificate Date: 8/30/2023 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 1��/�UHUP U f1 " OF AH CCHO R , CSC Development Services Department s 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. 02102143000 Complete legal description Canyon View Est 131 L10 Location (site address) 13819 Canyon View Rd Current property owner(s) Hultquist Homes 2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS Day phone 3. TYPE OF WATER SUPPLY: X 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 ❑ Plastic ❑ Concrete ❑ Fiberglass Age new - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench N Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: 0 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 J Waiver Fee $ Date of Payment 4 / Z 5/� Z—� Date of Payment COSA # 0S C- Z 3/" z y 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. In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC & MOA guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of this system. All systems eventually fail, and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore, we cannot provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed above. Name of Firm Phone Engineer’s Printed Name Date