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HomeMy WebLinkAboutTHUNDERBIRD HEIGHTS #1 BLK 6 LT 24Onsite File Thunderbird Heights #1 Block 6 Lot 24 #051-582-05 tKev Ub/UL/I t5) Municipality of Anchorage On-Site Water and Wastewater Section • (907) 343-7904 Page of ON-SITE WASTEWATER INSPECTION REPORT Permit Number: 0SP211032 PID Number: 051-582-05 Dwelling: 0 Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑ Upgrade Name Kameron Draper A ORPTION FIELD ❑ D,. Trench El Wide Trench El Bed El Mound Site Address 27607 Mallard Ct, Chugiak, AK Other Phone Number of Bedrooms Soil Rating Total depth from original grade 3 :�JSF Ft. LEGAL DESCRIPTION Depth to pipe invert from originalGravel depth beneath pipe N. Ft. Subdivision Block Lot Thunderbird Heights 91 6 24 Fill added above original grade G I length Ft. Ft. Township Range Section Gravel width Ft. Beds: Number of Lines Dist between lines Ft. SEPARATION DISTANCES To Septic Absorption Holding Sewer Total absorption area Number of trenches Dist, between hes From Tank Field Lift Station I Tank Line Ftz Well 1001+ 1001+ I 259+ TANK ® Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Capacity Surface Water 1001+ 1001+ I GREER 1000 Gal, Material Number of compartments Lot Line 5'+ 101+ NA plastic 2 Foundation 101+ 10'+ rM_iliATION Manufacturer Capacity Remarks Gal. Alarm location Elects: [led by Installer PIPE MATERIAL House to tank Tank to D3034 drainfield D3034 Northern Excavation Drainfield CO/MT D3034 Inspector Arcterra BENCH MARK (Assumed elevation) 100 ft Inspect'odates: 1' 2/24/21 2nd 2/24/21 Location and description 3'd 2/26/21 4th Top of foundation on NW building corner. ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp OF �1 Conditional Approval: Date .lPf��'""`^°"�.� 9m i Septic System � %. � KENNETH FFUS i 1� CE 711 Approve ( Date 3 +2 J,� I i ��FA t+� Note: this approval does not include well permit requirements. 'F��a ���aa�a+��'ESS\�A�� tKev Ub/UL/I t5) AS -BUILT SYSTEM DETAILS/SITE PLAN Permit OSP211032 THUNDERBIRD HEIGHTS #1 BLOCK 6 LOT 24 PID# 051-582-05 NEW 1000 / \ GAL TANK/ APPROX. WATER „a f E LINE LOCATION, A % deckAsphalt StoryFray "=� � r ,. �•� id �k Y ~h `\\\\ House 'DH e J + /�—( / C)7 SCALES 1' = 20' W A—C=43.6' COMPUTED: B—C=17,8 97.87 97,9 m A—D=43.6' W s �s lip B—D=18,7'0 DATE 2/26/ o A -E=46;8' GRID: NW18E o B—E=20.4' 'ADB No' 21004 A—F=51,6' B—F=19`0' A A-13=555'1000 GAL m B—G=18,1` SEPTIC n A—H=56.2' TANK o B—H=17.6' A—I=62:2' 92,73 92.4 Allow 4 TH S: CE— tin .' xv '�?QMsSJO PREPARED FOR: KAMER❑N DRAPER 2440 R TUDOR ROAD STE 1030 ANCHORAGE, AK 99507 FIELD BOOKS COMPUTED: BOUNDARY: N A. DRAW KSD- S MNG: N/A CHECKED: KMD ASBUILT: WALATKA DATE 2/26/ DM. FlLE: GRID: NW18E ACRD FILE. FILE 'ADB No' 21004 SCALEt NTS E -71 NEW pe 'I - ,n 0 x Lot 1 N o� O O p LOT 24 7tr� \\ septic tank 1 septic vent (typ) �0 9 o O 8-" CO \ o\ A G �\ 2$.0 deckj; N $,0 ) o 2 Story Frame House y 1> '511 6 3a a j CP a aIL SCALE: 1 "= 40' 4.5 / X0.2— 0016 Req Lot 23 0 0 C15 6 N�-! J fy� r 11 O /�� OJAR W� OF • q�qs / ®P a q� O� `? • 49th00 •!r9 ®® 00 �p = 00 k , •.`Elizabeth L. Walatka : Q ®�.off 8036 — LS • •0 5°_�,AW 30 � � ,�`Z DO � AR ... • P� Note: Asphalt location is approximate due to snow and ice. EASEMENTS OF RECORD, OTHER THAN THOSE SHOWN ON THE RECORDED FRED WALATKA &ASSOCIATES, L.L.C. PLAT ARE NOT SHOWN HEREONEngineers and Surveyors UNLESS OTHERWISE NOTED. FB 20-7, pg 60 & 64 BE 907-248-1666 This drawing is a representation of conditions found at the time the mortgage location survey was performed. This document does not constitute a boundary survey and is subject to any inaccuracies that a subsequent boundary survey may disclose. The information contained on this drawing shall not be used to establish any fence. structure or other improvements. This drawing shall only be used for a single property transaction. Use of this drawing by the original client or by others at a later date without the consent of Elizabeth L. Walatka is a violation of Federal Copyright law. Unless gross negligence is discovered, the liability extent of the preparer is limited to the amount of fees collected for services in preparation of this product. 30 RECERTIFIED 2-24-21 O 97 N 2� AS -BUILT NO CORNERS SET THIS DATE ©Q 1 hereby certify that I have performed a Mortgagee's inspection in accordance with ASPLS Standards of the following described property: LOT 24, BLOCK 6, THUNDERBIRD HEIGHTS SUBDIVISION ADDITION No. 1 Anchorage Recording Precinct, Alaska, and that the improvements situated thereon are within the property lines and do not overlap or encroach on the property lying adjacent thereto, that no improvements on the property lying adjacent thereto encroach on the premises in question and that there are no roadways, transmission lines or other visible easements on said property except as indicated hereon. Dated at Anchorage, Alaska this 8th day of February , 2021. EASEMENTS OF RECORD, OTHER THAN THOSE SHOWN ON THE RECORDED FRED WALATKA &ASSOCIATES, L.L.C. PLAT ARE NOT SHOWN HEREONEngineers and Surveyors UNLESS OTHERWISE NOTED. FB 20-7, pg 60 & 64 BE 907-248-1666 This drawing is a representation of conditions found at the time the mortgage location survey was performed. This document does not constitute a boundary survey and is subject to any inaccuracies that a subsequent boundary survey may disclose. The information contained on this drawing shall not be used to establish any fence. structure or other improvements. This drawing shall only be used for a single property transaction. Use of this drawing by the original client or by others at a later date without the consent of Elizabeth L. Walatka is a violation of Federal Copyright law. Unless gross negligence is discovered, the liability extent of the preparer is limited to the amount of fees collected for services in preparation of this product. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211032, Rebecca Carroll, 02/17/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211032, Rebecca Carroll, 02/17/21 MUNICIPALITY OF ANCHORAGE \ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION I ENVIRONMENTAL ENGINEERING DIVISION 825 L Street • Anchorage, Alaska 99501 Telephone 264-4720 ONSITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE 0 V.�NEW ❑ UPGRADE MAILINGADDRESS G•JIR 0 Y,3 0 C LEGAL DESCRIPTION (< o 't0 �1 ) LOCATION J&AJ NO. OF BEDROOMS DISTANCE TO: Wells .,• l.(, Absorption area Dwelling PERMIT NO. O Y Lu Q Wf Manufacturer Material No. of compartments v' Liq. � city in gallons IF HOMEMADE: Inside length Width Liquid depth 6 Y DISTANCE TO: Well Dwelling PERMIT NO. t7?i Z H Manufacturer Material Liquid capacity in gallons p W = DISTANCE TO: Well Foundation Nearest lot line PERMIT NO. j LL Z •Z W No. of lines Length of each line Totallength Pf lines Trench idjh i..W" Distance between lines h O Top of tile to finish grade I r Material beneath tile inches Total ef�t� /absorption area W Length Width Depth PERMIT NO. f7 i F- L Type of Crib Crib diameter Crib depth Total effective absorption area W W DISTANCE TO: Well Building foundation Nearest lot line r Depth Driller Distance to lot line PERMIT NO. W T+ Fss DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS J 3a3 SOILTEST RATING J INSTALLER REMARKS 0 APP ED DATE LEGAL c S/2 -317 1 72-013 (Rev. 31781 q� MLJtJ I � I f 9L I TY OF RtJCI-I^'PRE DEPARTMENT L. HEALTH AND ENVIRONMENTALL95,OTECTION 825 'L' STREET, ANCHORAGE, At'. 01 264-4720 OtJ —SITE SEWER P E R M I T PERMIT NO. ( 790471 ) APPLICANT FORESTEDGE HOMES PO BOX 310 CHUGIAK LOCATION MALLARD COURT LOT SIZE LEGAL L24 86 THUNDER.BIRD HTS TYPE OF SOIL ABSOR.BTION SYSTEM IS: TRENCH 23500 SQUARE FEET MAXIMUM NUMBER. OF BEDROOMS = 3 SOIL RATING (50 FT/BR>= 85 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: E>EPTH= S LErJGTH= 25 C3FZFgitEL E>EPTH= 4- S THE LENGTH DIMENSION IS THE LENGTH CIN FEET> OF THE TRENCH OR DRAINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION CIN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION CIN FEET). RECAU I RE[? SEPT I co TFmr4K 'SIZE= 1 cDC3C3 C3FlLLOt40— PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER. OF RESIDENCES THAT THE WELL WILL SERVE. TWO C 2 7 I tJSPECT I ON'S RRE RECALJ I RECD --- BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN R'WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL: OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. OTHER RREQUIREIENTS MAY PROPEP,INSTALLATION. Y. AND CONSTRUCTION DIAGRAMS ARE AVAILA LE TO PERM I T EXP I RES E>EGEMEER :1'1+ nLnA7" ' I CERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SE FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: 1 WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. 3: I UNDERSTAND THAT THE ON-SITE SEWER. SYSTEM MAY REQUIRE ENL RRGEMEhJT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 3 BEDROOMS. SIGNED: ISSUED V3. 2 Russell Oyster 694-2774 too O & E ENG.JEERING & DEVELOiMENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 SOIL LOG Earl Ellis 688-2280 Performedfor. Name:-s>'UAQT Z5:IJS7-AF3 0 I Tel. No. 54 Mailing Address: .P Q• Box 3/10 , C'NUl�/RK i�rC. 99s 6 7 Legal Description: Zoz- .Ltz 6"ez< 4 , T rnvoc col eo /SST$. SUB. Depth (feat) Soil Characteristics 0 1 ML Sirs T 2 3 3.51� 4 � �s101 6 5;v o p �4f1r/EG� G'GEyN' /DIED,.9� I/B .P 1iE rll/ TY 10 —�P G2A✓EDGY G'eA¢tE 11 — �IEo. �qNd /DD.��B•.Q. 12- 13 Borro.K ©F �T 14 15 _ 16 — H v O Sor � J A v e Tqu.vD�e ei,¢ o D,Q. Ground Water Encountered: Yes fr No If yes, what depth IZ " Proposed Installation: Seepage Pit_ Drain Field PLOT PLAN Al. YeACE PERC.TEST Performed by: /�1��� / �P,,�J Date: /S- • \�y�k`i�:� M� �J • (Zc'� \(\��. ,;\ 1, . � .1�).tn ql;�c�.` iZ�o . t'�\ .0+� . CC.i l54)�<', `'��ir'vt \ill. '�`\\c�i�\'�fll.`�i%t\'t�C l—�i�.�:•� .;� \; _i.., i ,5571 � l•to Time _• Time a Date Date Dale Inspector Inspector Inspector Comments Conditional Approval CrVA*V Date Sewer Installed Permit No. Septic Tank Size l C� g"� '� Holding Tank Size Soils Rating Well To Absorption Area Well Log Received Well to Tank APPLICANT FILLS OUT LOWER HALF ONLY Property Owner 1h4 /JAS tone Mailing Address Sr,•6 2 C L 41 je Gov2 1 , Buyer Address Lending Institution E •" L A. :/L E G E � t ' � r` c ' `' Phone Address 1 hT Realty Co. 6 Agent 1J o N E — Phone Address Legal Description ! a T L , Ijj �- ° c ^ `' r• StreeettLocation / c i i t C L /7 s^ C a d 4-2l TyI Residence P`IC Single Family Z O Multiple Family No. of Bedrooms O Other Water Supply O Individual/ !; ^, /t � .L ' r4 SATTACH WELL LOG. A well log Is required for all wells drilled since June • Community t 1975. For wells drilled prior to that date, give well depth (attach log If J Public Utility available. Sewage Disposal D Individual Year Individual Installed: O Public Utility When Connected to Public Utility: O Holdina Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. rte, 1I ML.—jIPAL:7Y C. ANC!'OPA.^,r F: ��::P:L'i�iA1 IFCIcCTION MUNICIPALITY Of ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION SS801 an L Stria" • AnN&M Alsske S t P 1 L 1979 • ENVIRONMENTAL 61N EEI G DIVISION E C E I 284 V WD ephone REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete NI pens on page 1. Ineurnplele 411111610 0" will not M Mated• F! chow an 001 days Ica proeealMa. PHONE /. /RO►ERTY OWNER f0 MAI LING ADDRESS �. PHONE PROPERTY RESIDENT (11 tlif/event from above) 2. BUYER Q}/COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY MAILING ADDRE _ PHONE 3.—TwEilad INSTITUTION MAILING ADDRESS 4. REALTORIAGENT PHONE MAILING ADDRESS S. LEGAL DESCRIPTION / / C T" ['� IL�i rr, / 1.�� STREET LOCATION 0. TYPE OF RESIDENCE NU 8 ❑ ❑ Four ❑ Other ��SINGLE FAMILY Two ❑ Five ❑ MULTIPLE FAMILY ❑ Three ❑ Six 7. WATER SUPPLY ❑ �{BIVIDUAL- ' ATTACH WELL LOG. A well log is required for all wells drilled Q}/COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) L SEWAGE 018POSAL SYSTEM **If individual/on-site, give installation date INDIVIDUAL/ON-SITE" If system is over two (2) years old an adequacy test is required ❑ PUBLIC UTILITY by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72 010(3/7a) i9 72-010 (Rev. 3/78) THIS SIDE FOR OFFICIAL USE ONLY INSPECTION APPOINTMENTS DATE RECEIVED TIME TIME ME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY PERMIT NUMBER ❑ INDIVIDUAL DEPTH OF WELL ❑ COMMUNITY ❑ PUBLIC UTILITY DATE DRILLED Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER ❑INDIVIDUAUON•SITE ❑PUBLIC UTILITY DATE INSTALLED Connection Verified INSTALLER ❑Septic T nk or ❑ Holding Tank Size: / G If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER ^' TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic Idine Tenk Absorption Arm Nearest Lot Line WELL T0: Absorption Arm to reerm Lot Line 5. COMMENTS 6r—APPROVEDFORBEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE BY Title LEGAL DESCRIPTION 72-010 (Rev. 3/78) IS o rG� BLc • Municipality of Anchorage On -Site Water and Wastewater Program (907) 343-7904 5 A F E T Y CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 051-582-05 1. GENERAL INFORMATION Expiration Date: Z -Z& - 202Z Complete legal description Thunderbird Heights #1 Block 6 Lot 24 Location (site address) 27607 Mallard Ct; Chugiak, AK Current Property owner(s) Kameron Draper Mailing address Real Estate Agent Day phone 2440 E Tudor Road Ste 1030, Anchorage, AK 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: Individual Well ❑ Individual Water Storage ❑ Community Class _ Well ❑ Public Water System ❑ WaiverNariance request for: Day phone TYPE OF WASTEWATER DISPOSAL: Individual Holding Tank ❑ Community ❑ Public Sewer ❑ Received by: _ .... Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 880 (RUSH) Date of Payment 3T da 1 Receipt Number 01 Z G COSA # OSC211071 Waiver Fee $ Date of Payment Receipt Number Waiver # Distance: 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 ARCTERRA CONSULTING, INC. Phone 696-6111 Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577 Engineer's Printed Name KENNETH M. DUFFUS Date 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 well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future+�\ occupants or can ArcTerra guarantee that no unseeni OL encroachments, deficiencies or discrepancies exist. SSS,7f-1--f `L`fS , s� + .I nc�{ 6. DSD SIGNATURE System #1 Approved for 3 bedrooms. System #2 Approved for bedrooms. Disapproved. _ Conditional approval for bedrooms, with the following stipulations: ---- -- --- xC�QP�\���////moi ON-SITE G� WATT m� 1r) ----- -- =0 WAST'IEv,"ATER oz PROGF\A _ JJ J Cj a �-z Original Certificate Date: 1 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 10-10-12 doc Legal Description: Thunderbird Heights #1 Block 6 Lot 24 If more than 1 septic system on lot: COSA Checklist # of ELL DATA ❑ Well to ed 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. Comments B. TANK DATA Age of tank(s) New years Tank type/material Se tic/Plastic Measured operating fluid level in septic tank New Standpipes/foundation cleanout per record drawing Date of pumping New tank 2/24/21 D. ABSORPTION FIELD DATA Which system tested (date installed) 8/23/79 ALL standpipes present per record drawing Total measured depth from grade 9.6 ft (max) Measured depth to pipe invert from grade 5.8 ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of effective. If not, state depth into effective 3.8' Parcel I D : 051-582-05 Structure served by this system 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) c ug/L ❑ Arsenic less than MRL (ND) Collected Date of Sample FT STATION ❑ Requi aintenance completed Age of lift station years Lift station material Comments: Adequacy test date 2/26/21 Results 0 Pass For 3 bedrooms Fluid depth prior to test 0 in Water added 500 gal New depth 8 in Elapsed time 10 min Code -required soil cover over field Final fluid depth 0 in F-1 System presoaked Absorption rate 500 gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) date of test) Gallons introduced gallons If yes, enter date Comments/Deficiencies: COSA Checklist yellow sheet E. SEPARATION DISTANCES rivate Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift n Lot > 100' if No Community Sewer Manhole/Cleanout > 100' Yes if No ft ❑ Yes if No ft Neighboring Tank > 100' ❑ Yes i _ ft Private Sewer/Septic Line.>j 25' ❑ Yes if No ft Absorption Field on Lot > 100' ❑ Yes if No ft ng Tank > 100' ❑ Yes if No ft Neighboring Absorption Fields > 100' if No Animal Contain 50' ❑ Yes if No ft ❑ Yes if No ft Water Main > 10' ® Yes if No Manure/Animal Excreta Storage _ Community Sewer Main > 75' ❑ Yes if No ft ❑ Yes ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' Yes if No ft Surface Water > 100' ® Yes if No ft Property Line > 5' ® Yes if No ft Wells on Adjacent Lots: ® Yes Absorption Field > 5' ® 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 septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' Yes if No ft If absorption field is under driveway comment below Property Line > 10' ® Yes if No ft Wells on Adjacent Lots: Water Main > 10' ® Yes if No ft Private Wells > 100' ® Yes if No ft Water Service Line > 10' ® Yes if No ft Community Wells > 200' ® Yes if No ft Surface Water > 100' ® Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION I certify that l 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. COSA Checklist yellow sheet