HomeMy WebLinkAboutCOSA ChecklistCOSA Checklist.docx
COSA Checklist
Legal Description: Hall Lot 12A Parcel ID: 051-092-65
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 8/10/1999 Total depth 160 ft
Cased to 117 ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) 36 in.
Date of flow test for COSA 6/27/24
Static water level at beginning of test 38 ft.
Well production at time of test 2.5 gpm
Water storage tank volume NONE gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate mg/L Nitrate less than MRL (ND)
Arsenic 17.3 ug/L Arsenic less than MRL (ND)
Collected by Date 6/27/2024
Comments __________________________________________________________________________________
B. TANK DATA
Measured operating fluid level in septic tank NA*
Date of pumping 6/27/24
Required maintenance completed, if AWWTS
Comments: FLOATS*_____________
C. LIFT STATION
Required maintenance completed
Age of lift station 23 years
Lift station material STEEL
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed) 4/19/2001
ALL standpipes present per record drawing
Total measured depth from existing grade 2.7 ft (max)
Measured depth to pipe invert from grade NA ft (min)
N/A – pressurized field.
Per record drawings, field is insulated.
Monitor tubes (MT) go to bottom of effective. (ED)
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) N
If yes, enter date
Adequacy test date 6/27/24
Results Pass
Fluid depth prior to test 0 in
Water added 600 gal
New fluid depth 1 in
Elapsed time 10 min
Final fluid depth 0 in
Absorption rate 600 gpd
FIELD STATUS – POST RECOVERY
Effective depth (per record drawings) 3 in (MOA 0.25’ ED)
Effective depth used 0 in (Final Fluid Depth)
Effective depth (ED) remaining 3 in
Comments/Deficiencies: Approximate total measured depths from existing grade. ED per elevation measured shots &
appears approximate.
COSA Checklist.docx
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 FIRST WATER CONSULTING Phone 907-350-9566
Engineer’s Printed Name CURTIS HUFFMAN, PE Date 8/23/2024
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. The assessment of the condition of the well and septic
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface, changes in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. The operational life of all well and septic systems are subject to
these various and dynamic characteristics and are outside the control of the evaluator of the
well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting &
8/23/24
