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Home My WebLink AboutEAGLE RIVER HEIGHTS BLK 3 LT 11AEagle River Heights Block 3 Lot I I A #050- 271- 59 • ', W GRVOO�'R ANCHORAGE AREA BOR�)GH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME 1 dN2MAILING ADDRESS�� Ox SA/8% (IJAS/I�/9 PHONE 37G-'�� LOCATION eW14�irlOF WO C/C• LEGAL DESCRIPTION14T,/�,410CA-3, �A/jlL.(/, '-e ATS SEPTIC TANK: DISTANCE r NUMBER OF FROM WELL Z� MANUFACTURER /I G'�X MATERIAL S T«l COMPARTMENTS INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITYI640GALLONS. TILE DRAIN FIELD: TOTAL LENGTH SySTti1 rNST�/�/d /�y %%f J G Ke gi��'11�PAy� DISTANCE FROM WELL � FOUNDATION 16�' NEAREST LOT LINE ZO / ''��,, OF LINES / S NUMBER OF LINEDISTANCE BETWEEN LINES TRENCH WIDTHZ// / IN. TOTAL EFFECTIVE ABSORPTION AREA SQ. FT. LENGTH OF EACH LINE a? -o" 3 ' ll� DEPTH OF FILTER O/ /,„ DEPTH: TOP OF TILE TO FINISH GRADE 7 MATERIAL BENEATH TILE 4 IN. ABOVE TILE T IN. WELL: TYPE O'e//lei CONSTRUCTION s %/J'V d/%Ca DEPTH u'd' 'Vo DISTANCE FROM: BUILDING / / NEAREST !j jt NEAREST SEPTIC �J`0 SEEPAGE �. FOUNDATION ? LOT LINE 50 , SEWER LINE , TANK , SYSTEM /4ZZ CESSPOOL . OTHER SOURCES APPROVED DISAPPROVED REMARKS DISTANCES: INSTALLED BY: SEWER LINE DEPTH: PIPE MATERIAL: & e457- lko,u W iM AeF 14A,. LOT SLOPE: REMARKS: Form EQ -032 DIAGRAM OF SYSTEM Ty(PL /$ a Ss y/ FK,eL it O.",S S 'q 0.w/ 4N TiYis c,T A,,V�i/!f,(sa geever r 7-1o, &z v eA'3,. III ZH e Qtd A SO/'7 % QST APPROVED ,'r0 . G.A.A.B. •h/im��4%Qr 3'•30 �i.3-75 to 3,Ob- lhL2 . . / i� Qom- fIS�an /`1W✓ _ AAel rlUr4I C I F}FIFL I TY OF FIMCHOFZFIGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 3330 C STREET, ANCHORAGE, ALASKA 99503 274-4561 OhJ—S I TE SEWER FP'EFZM I T PERMIT NO.( RALPH LONG SR BX 5489-WASILLA 3765994 LOCATION CHAIN OF ROCK RD LEGAL L11 B3 EAGLE RIV HTS SD LOT SIZE 30000 SOFT TYPE OF SOIL ABSORPTION SYSTEM... TRENCH NUMBER OF BEDROOMS 3 SOIL RATING,SQFT/BR 125 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:DEPTH= 12 LENGTH= 23.4375 THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE EXCAVATION BOTTOM IS 8 FT THERE IS NO SET WIDTH FOR TP.ENCHES.FOR DRAINFIELDS,THE WIDTH IS 3 FT. THE DEPTH OF TRENCH OR PIT IS THE DISTANCE BETWEEN THE GROUND SURFACE AND THE BOTTOM OF THE EXCAVATION. THE LENGTH DIMENSION IS THE LENGTH OF EACH SIDE FOR A SEEPAGE PIT OR THE LENGTH OF THE TRENCH, OR DRAINFIELD. THE REQUIRED SEPTIC TANK SIZE IS 1000 GALLONS BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE FROM WELL TO ANY SEPTIC TANK/PACKAGE PLANT OR SOIL ABSORPTION SYSTEM IS 100 FT FOR A PRIVATE WELL AND 200 FT FOR A PUBLIC WELL. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE AND WILL INSTALL IPJ ACCORDANCE WITH THE COO,," _ SIGNED,V. ISSUED BY -.... _ ... �..... . .......... . eDATE. . Ze�_ JZ_ >o r' 'GREATER ANCHORAGE AREA IIOROUr-L+^1 'Jepartment of Environmental Qu, .,.y 3330 'IC" Street Anchorage, Alaska 99503 Performed forTr, Legal Description: This form reports: Depth Feet 2- 3- 4- 5- 5 SOILS LOG - PEROLATION TEST 6- ? _ SVl SW - Well Graded II - Sands & Gravel 9 125 Square feet 10 - per bedroom 11 - 12 13 14 Date Performed0et. X0.75 Iver_ Heights ation test -ras1 groundlwater encountered? no — If yes, at what depth? T T CiT. Reading Date Gross Time Net Time Depth to Water Net Drop r!' • •svr u�r Un IY1111 I I U GC. •Proposed install1•Ct of na- Seepage Pit Drain Field Depth of Inlet Depth to [ettom of pit or trench -----`-----_- COMENTS: --'- Performed Cyi Harol_d_Eide_,—•__Certified fiy: Diii�ide _Jr,. UateOCt.-3o-; 197 LQ -040 (G/74) S a1 v Eagle River GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 330 "C" Street, Anchorage, Alaska 99503 274-4561 Date Received November 15, 1976 Oka Time of Inspection tf)-M aryl. Date of Inspection _11 -At/. y(„ /i )a. REQUEST FOR APPROVAL OF 81achhe13. INDIVIDUAL SEWER & WATER FACILITIES FOR VAU 1. Approval requested by: Coast Mortgage Company Mailing Address: Post Office Box 1200 Phone: 279-0665 2. Property Owner: J. Frank Prewitt, Jr. Phone: Mailing Address: 344-7669 3. Legal Description: N 65' Lot 11 Block 3 Eagle River /%A 4. Location: 6th house, log, on Eagle River Road after turn 5. Type of facility to be inspected Single Family No. of bedrooms 2 6. Well Data: A. Type Individual B. Depth C. Construction �},,,,,,�� D. Bacterial Analysis p 7. Sewage Disposal System: on—site system A. Installed (`)7 �� B. Installer C. Septic Tank: 1. Size 2. Manufacturer D. Seepa a Pit: 1. Absorption Area 2. Material Disposal Field: otal length of lines _ &,eo ih�,2 r?,7 8. Distances: A. Well to: Septic tank , Absorption area Sewer Lines , Nearest lot line Other contamination B. Foundation to septic tank Absorption area C. Absorption area to nearest lot line a EQ -034 (1/74) Page 1 of two pages G �nicipality of Anchorage r� c516 East Tudor Road Anchorage, AK 0 W &BIMEN T OI• -eN % 6 I40NMeNTAt`Q6"AEIiY '-'.SNeaC'Aeebofege,`Alesks.9%"=GP6*61 REQUEST FOR APPROVAL OF INDIVIDUAL SEWER and WATER FACILITIES 1. Type of Inspection: CMRO VA = FHA 2. Property Owner: J. Frank Prewitt, Jr. Mailing Address: 3. Name of Buyer: Kirby J. Long Mailing Address: SRA Box 268 L 4. Name of Lending Institution: Coast Mortgage Co. MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH d ENVIRONMENTAL PROTECTION NOV 151976 RECEIVED CONV Day Phone 344-7669 Day Phone 277-7541 Ext 17 Mailing Address: P.O. Box 1200 Anchorage Phone 279—o665 5. Name of Realtor or Agent: none Mailing Address: - n/a Phone 6. Legal Description: N 65 feet of Location: 'Tarn N off Eagle River Road 6th house —it is a loa house 7. Type of Facility to be inspected: Individual Water & Sentic No. Bdrms. 2 B. Water Supply Type of Supply: Public Utility Individual _X= If Individual, number of dwellings presently served 1 If Individual, depth of well not known 9. Sewage Disposal System Type of System: Public Utility Individual (on-site) XXX If Individual, date of installation not known EQ -097 (1/74) Page 2 of two pages - Re(t for Approval of Individual 1^ r & Water Facilities Legal Description N 65' Lot it Block 3 Eagle River Comments Approved Disapproved Date j�L1--1(n pproval,Valid for one year from date signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM e Z �Go I certify that the information contained in this request for approval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating satisfactorily. SIGNED Date EQ -034 (1/74) FAIL ICu�fn _ IC f' do OlLeuL-) .lae-/Z- Lo �W 1 la-46L. Lr v AAnLi v qAJ-4 ,2 s is q//v / 5,f c/ Or ZUA YL 0p` �` kUe A L DLE'�f'/✓ tAu ~r ', j Shoo e Grp lnL,c� i2snfldu OQPC b` �0`, GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3330 "C" Street, Anchorage, Alaska 99503 274-4561 Date Received IAO -/)-f)6 Time of Inspection lAO_/ - Date of Inspection/;.S,O Q/ I REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR 1. Approval requested by: Mailing Address: &)y Vl9- 4&Uj-),Ln (?9&U4 Phone: 2. Property Owner: _& IwL Agyla Phone: Mailing Address' 3. Legal Description: �j[[L3 /l•fo� N d�p� l C� e ,(�„yn 4y hf� 4. Location: 5. Type of facility to be inspected �Q.� No. of bedrooms 6. Well Data: A. Type D oCll/e;-) ESS 71 5�.�///"_�� Depth C. Construction ST9v/7A.2/-)e D. Bacterial Analysis .5 S{y9L'�RPsj 7. Sewage Disposal System: %Q /6 A. Installed s175, B. Installer C. Septic Tank: 1. Size 4,0 0 gly'd 2. Manufacturer ig 44e c,E D. Seepage Pit: 1. Absorption Area 369 2. Material 5P,Peeoe/7— E. Disposal Field: Total length of lines 1 X Z, 8. Distances: A. Well to: Septic tank 1"Z Q• , Absorption area % Z Sewer Lines Nearest lot line, Other contamination B. Foundation to septic tank Absorption area /06' C. Absorption area to nearest lot line Z O r EQ -034 (1/74) Page 1 of two pages CkVE R't 1-o.xl C'tAI Form FHA -OR 424-6 (11-9-72) • UNITD STATES DEPART11M OF AGRICULTURE FAMMS H014E A311IJISTRATIOI4 HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND/OR SMIAGS DISPOSAL SYSTM Applicant: Seller or Contractor: Return to: James F. Prewitt, Jr. and Karyl A. Prewitt Ralph Long and Louise W. Long Farmers Home Administration Box 819 Palmer, Alaska 99645 Total Rumber Subdivision Name: Eagle River Heights Blk. No. 3 Lot No. North.6° Living Arca He ems Baths 1143 sq. ft. 2 -M—mss: 1h of Lot ] Property Chain -of -Rock Road Basement /% New Installation Z7Yes Aldo AV Existing Can attic or other area be made into additional bedroom? /% Yes A7 No r IT yes, how many? %tater Supply by: /7 Public System /7 Community System Individual System Designed for Not Bdrms I Dspos no Se7FDisposal by: Public System /% Community System /X/ Individual This space and back for Health Authority Inspector's use FOLW..-MM TO BE C014PLF,TED BY HEALTH AUTHORITY It is the opinion of the /% State %% County %/ Local Department of Health that this individual water supply system /% is /7 is not satisfactory as a domestic water supply for subject property. It is the opinion of the State County Local Department of Health that this individual sewage system Mh proper naintenanco_ can be expected to function satisfactorily and cannot be expected to %% is not likely to create an insanitary condition /% function satisfactorily Date: I Signature: 1Title - ,Cq pogoadsul ova •dglsoggnv TMUDH TE001 L 7 �fgunoDO wgEgsD :.tq aptu uoTgoadsul •uorgd:Tx,;:•oo UL -=q su3 Sso,oE3sTgEs qou ST. 2:7 sr [J sagEM 30 .CgTTExta :agrp aaT2 'epEu uaoq sEq sagEM 3o u014eaTt:=8 TEoT2oToTsagoeq 3I ,cgToedES •asnssosd(. dgutesoO :gdi, 02es04S i.gg2TgsageM !UTguttou d3rld asnoti 33o TO UT u00s0::md asnot[dnmd(J qumosic o resel)v :U -F pagEoo'l •md`d—AT0Edv0 dund •g3 tipuaT odTd do.a 'TTaM daoa U TjQm MoTTme U :duhi P0s0g U -9n/ Q / uaeTszL/ PoTZT-xa Ll :ST TTw1 0u1 -jgtl2Tgsa4EM s2uTu0d0 oxv TET.xaqu= TTT3 ooEdo 2ursEo ToTzoj-%"7 ET T 04= sanoo TT01. •43 So ggdap 04 ;gSTgsagara poluos agnuW sad •sTE2 pTaT-* •xosddv •43 TaeaT 2urdund og ggdop •xosddv •g3 g,dap puE 2upro 3o adl-1 'q3 tndop TEgoy •uT soga.mTQ _ - :L'OTgozugsu0o TTa14 - '43 uoTquTTod aTgTssod 3o cawws iaggo •43 Toodssoo •43 04 CL 02udoos 'q3 PTaT3 TEsodsTQ •43 :ILmg oTgdoS ' •g3 sales airy -•g3 swigs uosT VrD •43 euTT 401 gsaseoll "u u0FgEPun03 2uTPTTnll :uos,F TTOM 30 03ue49TQ • auZT lgs:ido ld guo.T uo x3 g3 2tsmatt I 32Ts 407 �.Sa•iws segEM TEnprnrpuT ggoq uo paaoTo.�wp 2uTag poogsogg2Tou uT saTq.xedosd 0sv sagE:: 3o .STddns v4mbapE t;srumj o, ATuTO,A u: sTToM 30 oxnTFE3 3o ps000s qu000s ,Sou anTo zpootlsogg2Taa srttg UT GzEuogsno sTTat: TEnpThrPUT ON OUT, true: 3o ozTS 'q3 uTEu sagr . oTTgnd gsoseau aqq oq ootm,4M 121M xgdcIm-u2Ivr, 'Ivf]CILIMIll - yiiOd_--I Ilo_izom- SIlI Zq pagoodsul a",EQ SgTsog;nv g4TE0H TE001 L/ rf,unoo Z 0qE4S L/ :.SE wpEll uoTgo:xisul auTT PT 4sa=0il 'g3 coTgE un •43 TTa;: :L"os3 oouejsTII `-' itTuri ti;doa 9g3 saga:mTP oPTsgnO sgFd •0II gFd a2:doo, aTTg uo TETswgt:u s0gTT3 30 gv=a 'UT— aTTg s. -pun TeTsegEu sogTTS 3o 4gdoa .10g10 4^ auo,s uo:losg U ToArJO (J r so3o td :TETsagrgr3 &T &T opE.Io gPTur3 04 TFos doq 3o Kgdoa •q3 auTT 110 -aa 3o tl,2uo7 •g3•bs uoggoq tlouosq UT EOSE uoT,dsosgE weT40033w TEgoy OUT ggPTrl 140ua.xy sauTT uaa<ag0q 00uEgsTQ sourT 3o swgunll •43 sourT 3o q;2UOT TEgOd, •g3 OUTT g0T gsaxeetI 043 uoT,Epuno3 •q3 TTw;: :ue0s3 0MLISTQ :PTGTd TEsodsTQ aTTS _ salgo U sgTd a2Ed0aS L/ PT0T3 'c'�U TETa wTTy 3o sgsrsu0 yllEdyv ii XLY,o2 TS 2uTuT'I - .Sgucdeo •g3 ggdoa 'g3 Iagx.2Tp auFsul.. •43 suTT 101 gs=alu 'q3 uoT,Epun03 •g3 . TTwr, :-aos3 aouegsTcl T00c'_s a� •q3 ggdoP PTnbTj 'q3 141PFM OPTsuI •43 g;�aT oPTsul •TE2 guaugsedr:too g*Tur Igmdeo •TE3 I:gT0EdC3 prrbTT TagOy squa4at' 00 3o •oiI TETzOgElI 'q3 TTwM uo.x*, wOt:EgsTQ ::R. -CT oTgda, Toodssao U :(trey vpdaS U 3o sgsrsuoo Jjr-jtI,vSNy XUVIIrL'd YL'x= 'IvSodSIQ-Ewss Zvortrnmur - ytiodau floIlo7cisfll Page 2 of two pages - Re�!st for Approval of Individual r'?r & Water Facilities Legal Description �l�,rQ 3 Ln n� ds� ��CQGZo '�'f/J 4 Comments Approved - Disapproved Date- Approval,Valid for one year from date signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM I certify that the information contained in this request for approval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating satisfactorily. SIGNED Date EQ -034 (1/74) i i ,' STATE OF ALASKA 5013 DEPARTMENT OF NATURAL RESOURCES DIVISION OF MINING, LAND & WATER Alaska Hydrologic Survey ''r•F. o. „.°"'` WATER WELL LOG Revised 08/18/2016 Drilling Started: / / Completed: 7 / 19 / 1958 Pump Install: City/Borough Subdivision Block Lot Property Owner Name & Address G E O WATSON Municipality of Anchorage EAGLE RIVER HEIGHTS Ll 1 A Well location: Latitude Longitude Meridian S Township 014N Range 002W Section 12 , NE 1/4 of SE 1/4 of SE 1/4 of SW 1/4 BOREHOLE DATA: (from ground surface) Drillinq method: it rotary, able tooloOther Suggest T.M. Hanna's hydrogeologic classification system* Well use:OPublic supply,❑ Domestic, ❑Reinjection,❑Hydrofracking https://my.ngwa.org/NC Product?id=a185000000BYub3AAD ❑Commercial,❑Observvation/Monitoring,❑Test/Exploratory,❑Cooling, ❑Irrigation/Agriculture,❑Grounding,❑Recharge/Aquifer Storage, []Heating, [:]Geothermal Exploration,❑Other Fluids used: Depth From To Depth of hole: 151 ft Casing stickup: ft Casing type: Casing thickness: inches Casing diameter: inches Casing depth: ft Liner type: Depth: ft Diameter: inches Note: Well intake opening type: Open end, pen hole, ■ Other Screen type: , Screen mesh size: Screen start: ft, Screen stop: ft, Perforated❑Yes El No Perforation description: Perf from: ft, Perf to: ft, Perf from: ft, Perf to: ft Gravel packed❑Yes El No Gravel start: ft , Gravel stop: ft Note: Static water (from top of casing): 138 ft on / / Artesian well Pumping level & yield: feet after hours at gpm Method of testing: Development method: Duration: Recovery rate: gpm Grout type: Volume Depth: From ft, To ft Include description or sketch of well location (include road names, buildings, etc.): Final pump intake depth: ft Model: Pump size: hp Brand name: Was well disinfected upon completion? LJ Yes Lmj No Method of disinfection: Was water quality tested?❑Yes E]No Water quality parameters tested: Welldriller name: .................................................................................. ................................................... Company name: SWAEEORD .......DRILLIN..G Mailingaddress: .................................................................................... N City: State: AK Zip: Phone number: �) AS 41.08.020(b)(4) and AAC 11 AAC 93.140(a) require that a copy of the well log be submitted to the Department of Natural Drillers signature: Resources within 45 days of well completion. Well logs may be submitted using the online well log reporting system available at: Date: Anchorage Municipal Code 15.55.060(1) and North Pole Ordinance 13.32.030(D) require that a copy of this well log be submitted to the Development Services Department/City https://dnr.alaska.goy/welts/ within 30 days of well completion. OR email electronic well logs to City Permit Number: Date of Issue: —/—/ dnr.water.reports(a)alaska.gov Parcel Identification Number: *Guide for Using the Hydrogeologic Classification System for Logging Water Well Boreholes by Thomas M. Hanna NGWA Press J I >S \ Oh � Lvr ficid �►�s�.��J+;+� I N Q to X105 90 'd J� OIL I:: oT" �. ,1 a r 999L 69Z L06 'ON XVA 3MM IGS/IVM MING 03GV RV 9Z, it NODI V,, 040 �« d ST. . 9LU ISO Ail� i r ; .Apwit 1: .4 Ste ,1 a r 999L 69Z L06 'ON XVA 3MM IGS/IVM MING 03GV RV 9Z, it NODI V,, MUNICIPALITY OF ANCHORAGE Development Services Department �� Phone: 907-343-7904 On -Site Water & Wastewater Section / Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 050-271-59-000 Expiration Date: Leqal description EAGLE RIVER HEIGHTS BLK 3 LT 11A Site address 10142 CHAIN OF ROCK ST Eagle River AK 99577 Current property owner(s) BENNETT EDWARD W & GEORGIA E O 9/10/2025 X The On-site system(s) is/are approved for 3 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: By: :' ; ,77 Original Certificate Date: 11/12/2024 is 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 MUNICIPALITY OF ANCHORAGE Development Services Department 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. 05027159000 Complete legal description Location (site address) EAGLE RIVER HEIGHTSBLK 3 LT 11A 10142 CHAIN OF ROCK ST Current property owner(s) BENNETT 2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS Day phone 671-2863 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 na - 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 $ 2— -_ F. Waiver Fee $ Date of Payment2 p �Z Date of Payment COSA # C 2 l `� Waiver # COSA Application—June 2022 COSA Checklist Legal Description: EAGLE RIVER HEIGHTS B3 Ll 1A Parcel ID: 05027159000 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 7/19/58 Total depth 151 ft Cased to 151 ft ❑■ Sanitary seal is functioning correctly ❑■ Wires are properly protected Casing height (above ground) 14 in. Date of flow test for COSA 8/5/24 Static water level at beginning of test 138 ft. Comments B. TANK DATA Measured operating fluid level in septic tank Date of pumping ❑ Required maintenance completed, if AWWTS 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 Comments/Deficiencies: public sewer COSA Checklist June 2022 Well production at time of test 7+ gpm Water storage tank volume0 gallons Well disinfected for coliform test? ❑ Yes ❑■ No ❑■ Coliform bacteria is Negative Nitrate 2.04 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L aArsenic less than MRL (ND) Collected by Nrim Eng Date 9/10/24 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date _ Results ❑ Pass Fluid depth prior to test Water added gal New fluid depth in Elapsed time min Final fluid depth in in Absorption rate gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) Effective depth used in Effective depth remaining in in 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' Community Sewer Manhole/Cleanout > 100' -Yes if No na ft Yes if No 50+* ❑ [-]ft Neighboring Tank > 100' Q Yes if No ft Private Sewer/Septic Line > 25 ❑■ Yes if No ft Absorption Field on Lot > 100' ❑ Yes if No na ft Holding Tank > 100' Yes if No ft Neighboring Absorption Fields > 100' Animal Containment > 50' ❑■ Yes if No ❑■ Yes if No ft * Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' [:]Yes if No 50+ ft r■ Yes if No ❑ 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) 61 ft Building Foundations > 10' ❑ Yes if No ft Surface Water > 100' ■❑ Yes if No ft Tank to Property Line > 5' ❑■ Yes if No ft Wells on Adjacent Lots: Field to Property Line > 10' ❑■ Yes if No ft Private Wells > 100' Yes if No ft Water Main > 10' ❑■ Yes if No ft Community Wells > 200' *Yes if No ft Water Service Line > 10' ❑■ Yes if No ft If tank or field is under driveway comment below F. ENGINEER'S COMMENTS * Previous Regulations G. CERTIFICATION & STATEN-IENT 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 NorthRim Engineering Phone 694-7028 Engineer's Printed Name Steve EngUi� 4 4 AV TH �.� .. ` ......... M1 ..moi Steve Eng CE -625621 11-/1 /2 A= COSA Checklist June 2022 + 133&S >100�1� J0 NI'dH� �•x;`:r.r, ,_,�'•r W OQt VU W� 'AA 1/ 1.11V 0 Z I•Q � r � OD ,LO'S9 M„OZ ,00 .0S) re;