HomeMy WebLinkAboutLOMARU LT 1Lornaru
Lot 1
#051-101-29
GRE`'WER ANCHORAGE AREA 60r`UGH
Gfl�� Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
PECTIO
ITE SEWAGE DISPOSAL
- :: AILING ADDRESS PHON
LOCATION
LEGAL DESCRIPTION l�=i / R//i /
'
SEPTIC TANK:
DISTANCE
FROM WELL "'1r6r—' M/SNUFACTURER
NUMBER OF
MATERIAL—P/Jl','elLP, COMPARTMENTS
INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH — I (QUID CAPACITY
GALLONS
SEEPAGE PIT:
NUMBER OF PITS �, DIAMETER OR WIDTH -5—/ LENGTH, /DEPTH
LINING MATERIAL L4t/er,e�"Wit' CRIB SIZE: DIAMETER_Z�.DEPTH 3 DISTANCE FROM: WELL iry ,
yr
BUILDING FOUNDATION, NEAREST LOT LINE 02 / TOTAL EFFECTIVE
_ S ABSORPTION AREA (WALL AREA
ADDITIONAL ABSORPTION
WELL: C'0/77/77 111.12,1'71 4t IIVIE/Z
TYPE
BUILDING
FOUNDATION
CESSPOOL
APPR O V E(D/
CONSTRUCTION DEPTH
LOT LINE
OTHER SOURC
DISAPPROVED
DISTANCES:Q�^R= /�'Adecc�?'
INSTALLED BY:
PIPE MATERIAL:
w
o;
V
LOT SLOPE:
O
REMARKS:
Form No. EQ -031
NEAREST SEPTIC
SEWER LINE , TANK.
REMA
DATE
DIAGRAM OF SYSTEM
G.A.A.B.
SQ. FT.
DISTANCE FROM:
—Q20 oc, 7-
/,.Z$
/,.?,$ gal
L�OnCid4�� 7Rn��
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
ISM Tudor Road, Anchorage, Alaska 99507 279-9696
Date Received Julv 30, lo7z
Time of Inspection
Date of Inspection
REQUEST FOR APokOVAL OF
INDIVIDUAL SEWER b WATER FACILITIES
FOR
-_
CAM ationai
1. Anprovel Requested By: BOWICS - McCormick
Address: Boz 66), Eagle Hirer 99697 Phone:
2. Property Owner: Bowles - McCormick phones
I. Legal Description: Lot 1, Losmru Sub,
4. Locet:on: Men Creek
5. Tvre of Facility to he Inspected: Singly Fam1ly Dwelling
Number of Jedrooms: 2
6, Well Data:
A. Tyne Commaity B. Depth 220'
C. Construction Satisfactory D. Bacteria] Analysis
7, Sewage Dis"sal System -
A. installed 1973 B. Installer Wallace
C. Septic Tank: I. Size 1.250 2. Manufacturer Wallace
D. Seepage pit: 1. Size 2, Material
E. Disposal Field: Total Length of Lines
B. Distances:
A. well To: Septic Tank Absorption Area Sewer Lines
Nearest Lot Line Other Contamination
0. Foundation to Septic Tank 'o Absorption Area
C. Absorption Area to Nearest Lot Line
Lonittuction JC1E Zab
"One test is worth a thousand opinions"
5820 TUDOR ROAD, ANCMORA02, ALA4nA 04507 4 TIL2"MOMe 222.4472
Performed For Bowles - McCormack Oate Performed 4=5-73
Leoal Oescrintion: Lot i ,lock 1 Subdivision Lamereoux - Chuaiak
This Form Ren orts
Soils Lon Y)_ Percolation Test
Oenth North _O
Feet Soil Characteristics
1 Overburden I I
2 Coarse Sandy Gravel GW - 8 l_.
3
A
Coarse Silty Sandy Gravel
5 W Coarse Sandy Grave! G;i- 8;
E
7
R Medium Silty Sand
0 I I
Bottom o1' 'Pest hole ci-) 12Was (round Water Encountered? N
on - -
If ves, At what Depth?
R-adinq Date Grnss Time Net Time Denth to H2O Net Dro
Percolation Rate Hinute
Proposed InstaiTat o : Seenaae Pit YES Drain Field
Depth of Inlet Dept lo bottom of Pit Or rent 1.
COMMENTS: 150 sa ft Drainage area rAmiirA'i
70st Performed By Construction Test Lab Data Certified By: James D. Mnnir
Date:.4-5-73
•
•
80,
'tom Municipality of Anchorage G PGE
On-Site Water and Wastewater Program
(907) 343-7904 ��V i
SA ETY
Certificate of On-Site Systems Approval
Parcel I.D. 051-101-29
Expiration Date: 5---- s---i 7
1. GENERAL INFORMATION
Complete legal description Lomaru Lot 1
Location (site address) 23132 Melana
Current Property owner(s) Michael and Cindy Patino
Day phone
Mailing address 23132 Melana
Real Estate Agent
Day phone
��y
6 7 8 9 70 7
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU) `v +';I'h l ''
❑ Duplex a
MAY ;j _ i.;,,; 1.
❑ Multiple Dwellings (Single Family and/or Duplex)
1, AV
V
�
3. NUMBER OF BEDROOMS: h Sj
4 <<
Ol68Lg9
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ❑ Individual ❑
Individual Water Storage ❑ Holding Tank ❑
Community Class privt Well 0 Community 0
Public Water System ❑ Public Sewer 0
WaiverNariance request for:none
Distance:
f
/ . 676/(�'
Received b Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 57olio Waiver Fee $
Date of Payment (dila Date of Payment
Receipt Number CS(o (163 D Receipt Number
COSA# (3601lat Waiver#
5. 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 for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm
C&M Engineering ineerin Phone 854-5558
Address 20182 Tulwar
Charles Balzarini Date 05/24/18
Engineer's Printed Name
n-.,szkx� �
, • TH •* �
6. DSD SIGNATURE
System#1 Approved for T bedrooms ,00
CH•.:•---- LZARINI� 1
System#2 Approved for bedrooms (, F�• CE-13854 •,• e<
Disapproved �lFF• ' ar
• •• .-
.��PROFUSIOWs .
Conditional approval for bedrooms, with the following s;� �� ^�- °�
-•\y0GF ,
Qv Oda���O _�
O Q�0G 4--
ts___
�—� _By: Original Certificate Date: '—(9 �(
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
•
Septic System Advisory Arsenic Advisory -
Well Flow Advisory Other •' •. ;
COSA blue sheet_E - -
If more than 1 septic system is on the lot:
COSA Checklist# 1 of 1
Structure served by this system 1
Certificate of On-Site Systems Approval Checklist
Legal Description: LOMARU LOT 1 Parcel ID:051-101-29
A. WELL DATA
Well type Community* If A, B, or C provide PWSID# *213467 Well Log (Y/N) yes
Date completed Sanitary seal (Y/N) Wires properly protected (Y/N)
Total depth ft. Cased to ft. Casing height(above ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level ft. ft.
Well production g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrate mg/L
Arsenic ug/L Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material septic/concrete Date installed 5/1973
Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) yes
Foundation cleanout(Y/N) yes Depression over tank Y/N) no High water alarm (Y/N) no
Date of pumping &--(-1.-T Pumper " S
C. ABSORPTION FIELD DATA
Date installed 5/1973 Soil rating ( d.Lft.or ft2/bdrm) 85 System typecrib
Length 9-16 ft. Width 8 ft. Gravel below pipe 6 ft.
Total depth 12.5 ft. Eff. absorption area 396 ft2 Monitoring tube yes Depression over field n0
Date of adequacy test 5/18/18 Results (Pass/Fail)pass For 4 bedrooms
Fluid depth in absorption field before test 0 in. Water added 600 gal. New depth 8 in.
Elapsed Time: 1440 min. Final fluid depth 0 in. Absorption rate >= 600 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) no If yes, give date n/a
D. LIFT STATION
Date installed -- Size in gallons -- Manhole/Access (Y/N) --
"Pump on" level at-- in. "Pump off' level at -- in. High water alarm level at -- in.
Datum -- Cycles tested -- Meets alarm&circuit requirements?--
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot -- On adjacent lots --
Absorption field on lot -- On adjacent lots --
Public sewer main-- Public sewer manhole/cleanout --
Sewer/septic service line -- Holding tank --
Animal containment areas-- Manure/animal excrete storage areas --
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation +5 Property line +5 Absorption field +5
Water main +10 Water service line +10 Surface water +100
Wells on adjacent lots+200
ABSORPTION FIELD ON LOT TO:
Property line +10 Building foundation +10 Water main +10
Water Service line+10 Surface water +100 Driveway, parking/vehicle storage **
Curtain drain +50 Wells on adjacent lots +200
F. COMMENTS
* Lomaru Community Well is currently classified as a private community well.
** Crib is under asphalt area beside garage. Barrier installed to prevent vehicle access.
G. ENGINEER'S CERTIFICATION .�`( 4 L4 k
1 certify that I have determined through field inspections and �,`Qk.•• • A. 0.1;4_41• j
review of Municipal records that the above systems are in G-j • ••V f1
conformance with MOA COSA guidelines in effect on this date. * 9TH
Engineer's Printed Name Charles Balzarini
Date 05/25/18 , _ • • •
,
• • ES G BA •
�LLZARIP f
k,\ U PROFESS14NA�+'"`-
COSA canary sheet_2-6-15.doc
Municipality of Anchorage
Development Services Department
Building Safety Division
Onsite Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 051-101-29 COSA # 0 9 0 3 02
Expiration Date: cl - Lj -/ O
1. GENERAL INFORMATION
Complete legal description LOMARU LOT 1
Location (site address) 23132 Melana Circle Chugiak AK 99567
Current Property owner(s) Marcela S. Rooks Day phone 688-3703
Mailing address
Lending agency
Mailing address
PO Box 670138 Chugiak, AK 99567
Day phone
Real Estate Agent Paul Ames Day phone 273-7730
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
4
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
❑
Individual On-site
Individual Water Storage
❑
Individual Holding Tank
❑
Community Class A Well
®
Community On-site
❑
Public Water System
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of Onsite Systems Approval
are valid for 90 days from the date of Issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. 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 Onsite Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm _ArcTerra Consulting, Inc. Phone 8683792
Address 20441 PTARMIGAN BLVD. EAGLE RIVER AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 10/01/2009
Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. 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 inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the
water usage of the family being served by the system. 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 ArcTerra can not well
septic
ve any estimate 9 of how long OF qt`���
system will function satisfactory for current or future ,�.�P�.••"�••"••.qS',�
occupants or can ArcTerra guarantee that no unseen or CO .0
encroachments, deficiencies or discrepancies exist 0"* 149TH --%i* �i
5. DSD SIGNATURE
1/ Approved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
vvvn v11U ,Anal A Arsenic Advisory
Septic System Advisory Maintenance Agreements
Well Flow Advisory Supplemental Engineer's Report
Nitrate Advisory Other
By: 'v • 4 Original Certificate Date: — O
(R" 11/05
Municipality of Anchorage s°
C Development Services Department
t y�
Building Safety Division °
Onsite Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF.ON-SITE SYSTEMS APPROVAL. CHECKLIST
Legal Description: LOMARU LOT 1 Parcel ID: 051-101-29
A. WELL DATA
Well type Community— Class A If A, B, or C provide PWSID # 213467 Well Log (Y/N)
Date completed Sanitary seal (YIN) _ Wires properly protected (YIN)
Total depth ft. Cased to ft. Casing height (above ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform colonies/100ml- Nitrate
ft.
g.p.m.
mg/L Other bacteria colonies/100 mL
Arsenic: mgll Date of sample: Collected
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Concrete Date installed 5/1/1973 Tank size 1250 gal.
Number of Compartments 2 Cleanouts (YM) Y Foundation cleanout (YIN) Y Depression over tank (YM) N
High water alarm (Y/N) N_Date of pumping 7/29/09 Pumper Sanitary
C. ABSORPTION FIELD DATA
Date installed 51111973 Soil rating (g.p.d./fe or fe/bdrm) 85 System type Crib
Length 9-16 ft. Width 8 ft. Gravel below pipe ift. Total depth 12.5 ft. (measured 7/29/09)
Eff. absorption'area 396 fe Monitoring tube Y ,Depression over field N
Date of adequacy test 7/29109 Results (Pass/Fail) Pass For 4 bedrooms
Fluid depth in absorption field before test 25 in. Water added 600 gal. New depth 27.6 in.
Elapsed Time: 75 min. Final fluid depth 25.8 in. Absorption rate >= 600+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date
I
D. LIFT STATION
Date installed_ Size in gallons Manhole/Access (Y/N)
'Pump on' level at _in. "Pump off" level at _in. High water alarm level at —in.
Datum Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
Sewer /septic service line
Animal containment areas
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Holding tank
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 51+ Property line 51+
Absorption field 5'+
Water main 101+ Water service line 101+ Surface water 1001+
Wells on adjacent lots 200'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main 101+
Water Service line 101+ Surface water 1001+ Driveway, parking/vehicle storage 10'+
Curtain drain 501+ Wells on adjacent lots 2001+
F. COMMENTS
G. ENGINEER'S CERTIFICATION 1 R f " * !
eM• •.
I certify that I have determined through field inspections and •• •• P
review of Municipal records that the above systems are in I �'• Kenneth
conformance with MOA COSA guidelines in effect on this date. !I s�'� yrC E 1
Engineer's Printed Name KENNETH M. DUFFUSpR.. ..ONP.�,r
Date 1010112009
COSA Fee $490 00 Waiver Fee $
Date of Payment
Receipt Number
(Rev. 11105)
Date of Payment
Receipt Number
vDRI E
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ARcTERIZA
t CONSULTING, INC
1 F 212 E. 51° Ave, Anchorage, AK. 99503
to Office (907) 868-3791, Fax (907) 868-3793
October 1, 2009
Municipality of Anchorage
Development Services Department
On -Site Water R Wastewater Program
P.O. Box 196650
Anchorage, AK 99519-6650
Subject: Lomaru Lot 1—On-Site Wastewater System Sue
Based on a review of the record documents, the subject property's on-site wastewater
system is appropriately sized for a 4 -bedroom residence. We respectfully request that the
property be designated as a 4 -bedroom septic system for the following reasons:
❑ The soils log shows 85 sf/bd.
❑ The crib consists of two 3' concrete rings (6' total absorption depth) combined
with a width of 8' and run lengths of 16' and 9' from the rings.
❑ The total effective absorption area based on the system dimensions and shown in
the record documents is 396 s.f.
❑ The total effective absorption of 396 s.f. / 85 sf/bd = 4.66 bedrooms.
o The septic tank is sized appropriately at 1,250 gallons.
❑ The MOA tax records show it as a 4 -bedroom residence.
❑ The recent adequacy test shows that the crib absorbed 600+ g.p.d.
If you have any questions, please contact me at 696-6111 / FAX 696-8111.
Respectfully submitted,
ArcTerra Consulting, Inc.
Kenneth M. of E.
Attachments: MOA Tax Records
Municipality of of Anchorage
.. Development Services Department :.,
!�Building Safety Division
On -Site ?
/ Water and Wastewater Program
-" 4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL.-
FOR
PPROVAL:FOR A SINGLE FAMILY DWELLING
Parcel I.D. 051-101-29 COSA# 09 0303
Expiration Date: !3 — %)< —/ 0
1. GENERAL INFORMATION
Complete legal description LOMARU LOT 1
Location (site address) 23132 Melana Circle
Chugiak AK 99567
Current Property owner(s) Marcela S. Rooks
Day phone 688-3703
Mailing address PO Box 670138 Chugiak AK 99567
Lending agency
Day phone
Mailing address
Real Estate Agent . Paul Ames
Day phone 273-7730
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 2
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well ❑
Individual On-site
Individual Water Storage ❑
Individual Holding Tank
❑
Community Class A Well ®
Community On-site
❑
Public Water System ❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of Onsite Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of Onsite Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions In the professional engineer's work.
4. 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 for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage riles and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm ArcTerra Consulting Inc Phone 868-3792
Address 20441 PTARMIGAN BLVD. EAGLE RIVER AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 08/31/2009
Engineer's Comments: This Investigation was completed in compliance with ADEC and MOA regulations. The
assessment of the condition of the well and septic applies only to the conditions as of the day tested. The now
and absorption rates may change due to subsurface conditions that may not be observed from the surface,
changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the
water usage of the family being served by the system. 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,
ArcTerra can not give any estimate of how long a
system will function satisfactory for current or future
OF At
,q 11
occupants or can ArcTerra guarantee that no unseen p •..•••••••..•• P 1�
encroachments, deficiencies or discrepancies exist iG�.•' _� '•.'1=1.
5. DSD SIGNATURE
-Z Approved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
PROGRAM .'
By: 6L Original Certificate Date:
(R«.,,MS)
Municipality of Anchorage
• Development Services Department
% Building Safety Division
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
SSI ITT
CERTIFICATE OF,ON-SITE SYSTEMS APPROVAL. CHECKLIST ; ,. -:
Legal Description: LOMARU LOT 1 Parcel ID: 051-101-29
A. WELL DATA
Well type Community— Class A If A. B, or C provide PWSID # 213467 Well Log (YIN)
Date completed Sanitary seal (YIN) _ Wires properly protected (YIN)
Total depth ft. Cased to tt. Casing height (above ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level ft.
Well production g.p.m.
WATER SAMPLE RESULTS:
ft.
g.p.m.
Coliform colonies/100mL Nitrate mg/L Other bacteria colonies/100 mL
Arsenic: mglt Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank type/Material Septic/Concrete Date Installed 511/1973 Tank size 1250 gala
Number of Compartments Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) N
High water alarm (Y/N) N_Date of pumping 7129109 Pumper _Sanitary
C. ABSORPTION FIELD DATA
Date installed 5/111973 Soil rating (g.p.dJft? or ft?1bdrm) 85 System type Crib
Length 9-16 ft. Width 8 ft. Gravel below pipe 3 ft. Total depth 12.5 ft. (measured 7129109)
Eff. absorption area 492 ft? Monitoring tube Y Depression over field N
Date of adequacy test 7/29109 Results (Pass/Fail) Pass For 2 bedrooms
Fluid depth in absorption field before test 25 in. Water added 600 gal. New depth 27.6 In.
Elapsed Time: 75 min. Final fluid depth 25.8 In. Absorption rate >= 600; g.p.d.
Any rejuvenation treatment (past 12 mo.) (YiN & type) N If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
'Pump on' level at _in. 'Pump ofr level at _in. High water alarm level at _in.
Datum Cycles tested Meets alar & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot On adjacent lots
Absorption field on lot
Public sewer main
Sewer/septic service line
On adjacent lots
Public sewer manhole/cleanout
Holding tank
Animal containment areas Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 51+ Property line 51+
Absorption field 51+
Water main 101+ Water service line 10'+ Surface water 1001+
Wells on adjacent lots 200'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 101+ Building foundation 10'+ Water main 10'+
Water Service line 101+ Surface water "100'+ Driveway, Parking/vehicle storage 10'+
Curtain drain 50'+ Wells on adjacent lots 2001+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name KENNETH M. DUFFUS
Date 08/31/2009
COSH
Fee Umoo
Date of Payment 9 Vo 9
Receipt Number_ D / 5"� �o ,2 G
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
Kenneth