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HomeMy WebLinkAboutCANYON VIEW ESTATES BLK 1 LT 4 CANYON VIEW ESTATES Block 1 Lot 4 #021-021-37 v N O LO 0 CD LL LL LL to LL y LL @ @ m r -Lm o CL Q)L n MElM c c 0 ca a -n "s; cn / �u-: Q Zm oCL C O C Ln ° 0 c N a�i LJ�:SO//� ❑ O ... d M O 00 C1 CL m (j O (� R V N ,c Jo w m ;� a 0 @ U r E Z N a p @ L!7 U N W Q M a r LLI �•'. � :a) .•:`F�� �S • • U p r- o c o :`'''R�".r LL LL o = c Q) V @ 0 7 d IL N d M W >, L r c7 o 'm m m e Z N LL ~ a 2 a°i LL a> O O o Z N LL � El ° LL u ❑� J ¢ 0 m rn O_ o Z a) m Q) a Z o)O � W o m a) Q a) � a' @ O V -0 Cn W CL p N a a) 0 m 4 - � Y �, � H a� c m s@ F- a m O E E O O n a� c Un fn z I- Z O fn � ° o dN 3 m o Y Z s �a w w E' L)" o a) ;g W U Z c cn a Q Q p Q O a m - CO n. 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I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDLINES IN EFFECT ON THE DATE OF THIS TEST. SOILS LOG & PERCOLATIONTEST Pannone Engineering Services LLC Steven R. Pannone, Principal Registered Professional Engineer E-mail: steve@panengak.com Mailing: P.O.Box 1807, Palmer, AK 99645 Telephone: (907) 745-8200 FAX: (907) 745-8201 22 August 2024 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 4 Installation Information The conventional on-site system installed on the subject lot consists of a Steel-1500gallon STEP tank accompanied by two mounded five (5.0’) foot wide trenches both one-hundred (100.0’) feet in length. PES was present for the installation of the septic tank for the subject property on (12/20/2023) following 24-hour and two-hour notice forwarded to the on-site department. PES was not notified by the contractor or present for the installation of the drain fields on the subject property. It appears these drain fields were installed outside of the existing test hole radii. Surrounding soils information for Canyon View Block 1 Lot 3 (west) and Canyon View Block 1 Lot 5 (East)—of the subject property are attached. Canyon View Est. Block 1 Lot 3; utilized an application rate of 5.0 GPD/SF resulting from shallow groundwater at the time of excavation and percolation test yielding an absorption rate of 14.8MPI. Canyon View Est. Block 1 Lot 5; utilized an application rate of 0.6 GPD/SF resulting from a percolation rate of 17.1 MPI. Additional test holes and ground water monitoring was performed following the installation of the associated curtain drain, various lots were now able to switch to conventional and non-advanced treatment systems. The subject lot utilizes an application rate of 0.6 GPD/SF. Currently, there are no developments to the north of the subject property, with the southern developments a considerable distance away. The application rate used for the design on the subject lot is more conservative in accordance with these surrounding soils. PES performed final grade inspection to collect measurements and elevations for the installation. Per the installation photos provided to PES by the subject installer; it appears the drain fields were not installed to the correct depth as indicated on the permitted design drawings. PES had the undocumented absorption fields exposed by the installation contractor on (08/16/2024). Per the installation contractor, the original grade of the subject lot had been altered prior to and following construction. Due to this: PES is unable to confirm the true depth from original grade of the subject drain fields. The depicted field depths on record drawing and COSA documentation are PES’s assumption of the systems installation depth from representative installation photos provided by the contractor. On (08/16/2024) at the time the fields were exposed, PES performed an additional test hole and confirmed that the required separation from the bottom of the existing absorption fields to ground water was met. PES verified that in accordance with the permitted design: the addition of 2.0’ of filter sand was indeed installed below the bottom of the system and extends to the native receiving soils consistent with those documented in previously conducted test holes on the lot. If you have any questions or concerns, please contact me at (907) 745-8200. Sincerely, Steven R. Pannone, P.E. F. ASCE Owner/Civil Engineer SOILS LOG - PERCOLATION TEST TEST HOLE 2023-2 OR ORGANICS 1 CLOCK WATER READING DATE NET TIME LEVEL NET DROP TIME 2 READING � 10/23/23 3:00 --- 5.54 --- 3 GM/ SILTY GRAVEL 2 3:30 30 MIN 7.55 2.01 4 SM AND SAND 3 3:30 --- 5.54 --- a 4:00 30 MIN 7.30 1.76 5 WAS GROUND WATER s 4:00 --- 5.54 --- 30 MIN 7.29 ENCOUNTERED? Y 6 s 4:30 IF YES, AT WHAT 7 BOH DEPTH? -5.0' 8 DEPTH TO WATER AFTER 9 MONITORING? -4.5' DATE: 10/30/23 10 11 PEROLATION RATE 17.1 (min/inch) PERC HOLE DIAMETER 6 inches 12 TEST RUN BETWEEN 2 FT AND 3 FT 13 14 COMMENTS: Test hole excavated by BROWNSON BROTHERS. DATE PERFORMED: 10/23/23 PERFORMED BY: PANNONE ENGINEERING. I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDLINES IN EFFECT ON THE DATE OF THIS TEST. NOTES: T � PANNONE ENG SVC, LLC LLC P.O. BOX 102954 ANCHORAGE, AK 99510 PHONE (907) 272-8218 FAX (907) 272-8211 �.•�.. �_• ....... Date 11/9/2023 CHANGE ORDER le Scale NTS.... P.I.D. NO CANYON VIEW ESTATES, BLOCK 1, LOT 5 021-021-38 HULTOUIST HOMES INC. n PERMIT NO. 13747 CANYON ROAD 81 .��.. OSP231232 Sheet SOILS LOG ANCHORAGE, AK 3OF3 30 MIN 7.29 1.75 TH5A OR I TOPSOIL 1 DATE NETTIME WATER LEVEL READING 2 RATE (MPI) 1 030CT19 3 2 8 MIN 27MAY2( 4 GM/SM 3 5 SILTY SAND 4 10 MIN GRAVEL 6 1.9 5 7 5.9001, 8 6 10 MIN 11.119" SM/GM SILTY SAND 9 GRAVEL 10 11 12 11OCT19 13 14 15 16 DATE PERFORMED: 030CT19 HOLE EXTENDED: 060CT2020 SOILS LOG - PERCOLATION TEST SLOPE I :TEST HOLE SITE PLAN I PRIMARY RES RV GRAIN FIELD P \ 30LF x 5.0'W x 0.5'ED x 2.0' D 1.5" LATERAL W/ 1/8"' HOLES 4" 0. C. INSTALL MT AT EACH END. 48R SFO (P) 5 I L t 5 WAS GROUND WATER ENCOUNTERED? N IF YES, AT WHAT DEPTH? -NA- DEPTH TO WATER AFTER MONITORING? 13.5 DATE: 11 OCT19 DEPTH TO WATER AFTER MONITORING? 4.0' DATE: 27MAY20 COMMENTS: Test hole excavated by WHITE RAVEN PERFORMED BY: PES. I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDLINES IN EFFECT ON THE DATE OF THIS TEST. SLOPE TH 1 SOIL TEST RESULTS/ANALYSIS • PERCOLATION RATE 2.0 mpi(min/inch) (Hydrologic Soils Group: HSG A) • PERC HOLE DIAMETER 6" • TEST RUN BETWEEN 3 FT AND 4 FT. • TEST RUN FOR OVER AN HOUR, LAST THREE READINGS PROVIDED. READING DATE NETTIME WATER LEVEL READING NETDROP RATE (MPI) 1 030CT19 5.900" 2 8 MIN 11.900" 6.0" 1.3 3 5.900" 4 10 MIN 11.110" 5.210" 1.9 5 5.9001, 6 10 MIN 11.119" 5.219" 1.9 NOTES:Dote FOR CONSTRUCTION PANNONE ENG SVC, LLC Date 8�2i2a23 P.O. BOX 102954 ANCHORAGE, AK 99510 �••• •., PHONE (907) 272-8218 FAX (907) 272-8211•'•• Scale RL NTS •••• • •••••`• P.I.D. NO CANYON VIEW ESTATES, BLOCK 1, LOT 502)-02)-38 HULTQUIST HOMES INC. ••� ���� PERMIT NO. CE 13747 CANYON ROAD 8149 OSP231232 SOILS LOG ANCHORAGE, AK Sheet 3OF3 TH 3B 1 2 3- DATE NET TIME TOPSOIL NET DROP 4- 456 1 080CT20 5- 6 30 MIN 8.34 7 13.3 3 SM/GM SILTY SANDY 8 4 GRAVEL 9 2.01 14.9 10 6.09 11 12 6 13 8.12 2.03 14 15 16 17 BOH DATE PERFORMED: 070CT2020 On-site Water and Wastewater SOILS LOG - PERCOLATION TEST TEST HOLE SITE PLAN REMBMn FOR CODE\ OSP221 057, Rebecca MJ \ 1 SLOPE TH 1 WAS GROUND WATER SOIL TEST RESULTS /ANALYSIS ENCOUNTERED? N . PERCOLATION RATE 14.8 mpi(min/inch) (Hydrologic Soils Group: HSG A) IF YES, AT WHAT . PERC HOLE DIAMETER 6" DEPTH? —NA— . TEST RUN BETWEEN 2 FT AND 3 FT. • TEST RUN FOR OVER AN HOUR, LAST DEPTH TO WATER AFTER THREE READINGS PROVIDED. MONITORING? DRY DATE: 270CT2020 COMMENTS: Test hole excavated by FU RI5H PERFORMED BY: PES. I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDLINES IN EFFECT ON THE DATE OF THIS TEST. NOTES: FOR f DRAWN I JRL SOILS LOGS READING DATE NET TIME WATER LEVEL READING NET DROP RATE (MPI) 1 080CT20 6.09 2 30 MIN 8.34 2.25 13.3 3 6.09 4 30 MIN 8.10 2.01 14.9 5 6.09 6 30 MIN 8.12 2.03 14.8 PANNONE ENG SVC, LLC P.O. BOX 1807 PALMER, AK 99645 PHONE (907) 745-8200 FAX (907) 745-8201 CANYON VIEW ESTATES, BLOCK 1, LOT 3 SITE: CANYON ROAD ANCHORAGE, AK Date 03/09/2022 Scole NTS P.I_D. NO PERMIT NO. Sheet 4 OF 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1'6 TH3A 27MAY20 OR — RATE (MPI) TOPSOIL SM/GM SILTY SANDY GRAVEL SANDY SILT SM/ W/ GRAVEL ML AND COBBLES BOH DATE PERFORMED: 030CT19 NO GROUNDWATER: 11OCT19 SOILS LOG — PERCOLATION TEST SLOPE TEST HOLE 'i SITE PL I `1 I `\ \ TH3A I\ H2A \ SLOPE TH 1 or Hrlcrlorage Qd lns,._+a. _ REVIEWED FOR CODE WAS GROUND WATER SOIL TEST RESULTS /ANALYSIS ENCOUNTERED? N . PERCOLATION RATE 16.6 mpi(minlinch) (Hydrologic Soils Group: HSG A) IF YES, AT WHAT . PERC HOLE DIAMETER 6" DEPTH? —NA— . TEST RUN BETWEEN 2 FT AND 3 FT • TEST RUN FOR OVER AN HOUR, LAST DEPTH TO WATER AFTER THREE READINGS PROVIDED. MONITORING? DRY DATE: 11OCT19 DEPTH TO WATER AFTER MONITORING? 0.0' DATE: 27MAY20 COMMENTS: Test hole excavated by WHITE RAVEN PERFORMED BY: PES. I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDLINES IN EFFECT ON THE DATE OF THIS TEST. READING DATE NET TIME WATER LEVEL READING NET DROP RATE (MPI) 1 030CT19 5.900" 2 30 MIN 7.683" 1.783" 16.8 3 5.900" 4 30 MIN 7.679" 1.779" 16.8 5 5.900" 6 30 MIN 1 7.680" 1.780" 16.8 NOTES: PANNONE ENG SVC, LLC Date FOR P.O. BOX 1807 PALMER, AK 99645 P,�i.••. 03/09/2022 Cz 1 PHONE (907) 745-8200 FAX (907) 745-8201 �. Scale NTS .......P.I.D. NO CANYON VIEW ESTATES, BLOCK 1, LOT 3 "ewer anriome DRAWN JRL SITE: CANYON ROAD CE 8149 PERMIT N0. ANCHORAGE, AK Sheet SOILS LOGS 3 OF 4 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Well Log Permit Number: #__________ Date of Issue: ________ Parcel Identification Number: __________________ Date Started: _________ Date Completed: _________ Is well located at approved permit location? Yes No Legal Description:_________________________________________________________________________ Property Owner Name & Address: _______________________________________ _______________________________________ _______________________________________ Borehole Data: Depth (ft) Soil Type, Thickness & Water Strata From To Method of Drilling air rotary cable tool Casing type: _________ Wall Thickness: inches Diameter: inches Depth: feet Liner Type: _________ Diameter: inches Depth: feet Casing stickup above ground: feet Static water level (from ground level): feet Pumping level: feet after hours pumping gpm Recovery Rate: gpm Method of Testing: _________ Well Intake Opening Type: Open End Open Hole Screened Start feet Stopped feet Perforations Start feet Stopped feet Grout Type: _________ Volume: _________ Depth: _________ Start feet Stopped feet Well Disinfected Upon Completion? Yes No Method of Disinfection: Comments: Well Driller: _____________________________ Company: _____________________________ Mailing Address: _____________________________ Water Sample Results: Arsenic: _________ ug/L Nitrates: _________ mg/L Total Coliform Bacteria:_________ colonies/100mL Attention: The well driller shall provide a well log to the On-site Water and Wastewater Section within 30 days of completion. 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E _ w E @ 5-c 3 L0� ao > -0 Z F o 0 � c c 0 � N N� E— O U _� o m fn (0 O U 7 U O c '7 Cl) ❑ V H< 0 L w N� � � U)) y 0 x 4) W o d a -`N C,5 4 rn rn E r L M c co a ti W E E Qm +�+ a) �0 LL � = a E rn V) L U a;wco Z MOM O {.r ca Q 't o - LL N m ° 0 3 IL Cl /J Y c a L 06 w LL O 0 U X L- L Z = a Y �O a com `o r � U Q O N N N J O O � 6l N N c6 L ^^V { L f O O O C 1 N N U) Y Q) v N r Q O �. l O >El C �) O N ❑ a) c� LUL �; N O N a' E ym O �. ,r O — o c f4 o c L- 00 i 0 3:-oU o d' Z)a� O N m c cN om co LO CO cl 2 `1 > v (6 (6 � U) O U w w o � C a,CO- G ❑ ❑ d �°rc_ c"=- - O c� N LO N p1 - O Lf) L6 c U > (na) L c�. a ca Oma) l� n�-- U u El m� �a moo A- U)y� Q) C c 1J L70 V^ o Q CL 0 -0 c U) 0 w c n ca C° M f— cc — 0 ¢ O N 7 a) '0 L U ❑ z = �U� O 0+. w 3 QcLcoi >;aci _ Q Z W O 0) ad = t a a) T� h WO w ,� _ - � a2) � a) CL % Z Z O Y L N Q Lf) -0 E o r (j C c 'a U O C N O �S c�z r w Z a aa)) a>>¢r ct J C U _ N c cq o L as Q c N U N Y- z V 1� > a) f9 4) "' Q N n d O N ¢ a) LJ OL O- O O a) O 0-0 M O„ m Q N Q U a) y p ❑ w N L i 0 W a� E 4 0 0 E L� w-o� `)-o T o. E _ w E @ 5-c 3 L0� ao > -0 Z F o 0 � c c 0 � N N� E— O U _� o m fn (0 O U 7 U O c '7 Cl) ❑ V H< 0 L w N� � � U)) y 0 x 4) W o d a -`N C,5 4 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: OSP231394 Work Type: WellSeptic Initial Tax Code Number: 02102137000 Site Legal Address: CANYON VIEW ESTATES BLK 1 LT 4 G:3042 Site Mailing Address: 13729 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: ll�t.Ilr r t.)eI)aI-tIII ell t 11 /20/2023 11 /19/2024 71515 R1 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 Received By: S S t �t`1� �`� t'." I, - Issued By: Date: Date: I t ��� ` -a 4 RUSH 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. 021-021-37 Property owner(s) Hultquist Homes Inc. Day phone Mailing address Site address 13729 Canyon Road Legal description (Sub'd., Block & Lot) Canyon View Estates, Block 1, Lot 4 Legal description (Township, Range & Section) Lot Size 71,515 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (N all that apply) Absorption Field ❑X Initial ❑X Single Family (SF) ❑X Septic Tank ❑X Upgrade El(w/wo ADU) Holding Tank ElRenewal ElDuplex (D) El Privy ❑ Multiple Dwellings ❑ (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. Islz (P (Signature of property owner or authorized agent) Permit/Rush Fees: f 3 ) 2 Waiver Fees: Date of Payment: 1 S 7,02 3 Date of Payment: Receipt Number: Receipt Number: Permit No. 0,5 to 23 3 Waiver No. Permit App_ :- : ,'-..:c Pannone Engineering Services LLC Steven R. Pannone, Principal Registered Professional Engineer E‐mail: steve@panengak.com Mailing: P.O.Box 1807, Palmer, AK 99645 Telephone: (907) 745‐8200   FAX: (907) 745‐8201 17 November 2023 Municipality of Anchorage Development Services Department On‐Site Water & Wastewater Program 4700 Elmore Road Anchorage, Alaska Subject:   Canyon View Estates, Block 1, Lot 4          Septic System Permit Request This is a design narrative for a permit to install an initial septic system and well on the subject property. The proposed system will serve a proposed four‐bedroom (4) house. This lot and surrounding lots are served by private wells. There are no wells or septics within the minimum offset distances from this installation. 1. Soils: A test hole was performed on this lot by Pannone Engineering Services, LLC on 10/23/2023. Groundwater was observed during the excavation of the test hole at a depth of seven feet (7.0’), and bedrock was not encountered. Groundwater was observed in the test hole monitor tube after 7‐days at a depth of four and a half feet (4.5’).  A test hole was performed in the area for the subdivision in 2019 but the monitor tube in no longer in place.  Based on the results of the percolation test and overall soils appearance an application rate of 0.6 gpd/SF was used for the design of a conventional wastewater treatment system in the area of the test hole.    Additional soils information: The test holes performed in 2020 were before development of the subdivision.  An extensive network of curtain drains were installed across the subdivision after the intiial test holes were recorded. More current groundwater readings have been used on the other lots in the subdivision, unfortunately TH‐4 no longer exists (likely destroyed during drainage improvements).  Groundwater monitoring has been performed all around this location and has not been observed shalloweer than 4.5' after drainage inprovements were made. 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. There are no steep slopes in the area of the proposed system. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231394, Curtis Townsend, 11/20/23 Page 2 of 2              Canyon View Estates, Block 1, Lot 4 Mailing: P.O.Box 1807, Palmer, AK 99645 Telephone: (907) 745‐8200   FAX: (907) 745‐8201 5. 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, SRP Steven R. Pannone, P.E. F. ASCE Owner/Civil Engineer Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231394, Curtis Townsend, 11/20/23 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231394, Curtis Townsend, 11/20/23 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231394, Curtis Townsend, 11/20/23 ti ti CD CD 0') 0-) LU c c4 ♦ n o LL V � Q 0 U Z Q LL O� ZZ J Q^ C � o U U) U �L Q � Z � � U L �m^ 06 VJ L C Q. � O > C/) ❑O N O Q Q Q U) N U) a U) 0 4F - O a) m U N LO N O N N c•7 ai cu C O ((0 Q x W O 0 0 ti M N C) i r N Q a) U ca CL d• CO H LO J O7 rn J Q m N LU O r^�) U v w LU z > 0 Z >- 0 0 z Z U U N c M O Q U) U O � a) � (B J UJ VCI O E O O a) ka 0 m > O CL Q. cu a) (a cn a cn a) c O a) M c O cu Q C 0 0 0 Cli 0 O a) +J N C) N N N 00 ai m m m U a) U c 0) O M. 0 o 0 0 a� a a a O 3 •C1 fn .C> N � L CC� G O 0 E- , ♦ U L O M.N CD '& (n v = N C C A-ai Q. a > 0 c .NC mmQ > Q O N E O LL a) U a OL O -Q) cu "� N 3 C a .N z Q � N > C a a O ° Q .Q QCL Q N Q E N c) m O fn v v .j r L x E d m q m " O U) >% U) +m+ r O O C O_ O O O_ Cal)) U) O (n > ° Cl) ai Q L 0 U °) IL � Q � M o c r co U c o a) L) N Q N Q o _V W O a) cco Cl)ca E O = N ca O U Q I— O U= U N � r Q ~ T oCD U7 (A ti ti M CC) CY') C'') O O (3) O X W 0 (B r � O LL V n 0 U Z LL `® F" J �o � U Z v7 � U C,5 V J L (D >(D E O N � o0 O U Q Q Q ca O Q Q U) N ^>1 W :tf UP O O N U All Z O f� Q c? 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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 Lot 4, Block 1, Canyon View Estates Subdivision As-Built 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