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HomeMy WebLinkAboutROSEBERRY PARK ESTATES BLK 3 LT 3Roseberry Park Estates Biock 3 Lot 3 #050-315 - 50 Municipality of Anchorage · Development Services Department Building Safety Division On-Site Water and Wastewater Program, 4700 Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 Page of www.ci.anchorage.ak.us (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number: 0SPl11130 PID Number: 050-315-50 Spinell Homes, Inc. Wastewater System: [] New [] Upgrade Address: 1900 E. Northern Lights, Suite 200 Anchorage, AK 99517 ABSORPTION FIELD 344-5678 Four [] Deep Trench ~ Shallow Trench [] Bed [] Mound [] Other: LEGAL DESCRIPTION Se, Rating: Total Depth from original grade: 1.2 GPD/Ft2 6.8 Ft. Block:3 Lot: 3 Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe: Roseberry Park Estates 2.65-2.8 Ft. 4 Ft. Township: Range: Section: Fill added above odginal grade: Gravel Length: 1-1.5 Ft. 50 Ft, Well: [] New [] Upgrade erave~ width: Number of lines: I Distance between lines: 5 Ft. I - Ft, Classification (Private, A, B, C): Total Depth: Cased to: Total absorption area: Pipe Material: Private 112 Ft. 112 Ft. 500 Ft2 ASTM D3034 PVC Driller: Date Ddlled: Static Water Level: Installec Date Installed: Sullivan Water Wells 8/3/2011 0 Ft. Pomraning Excavation 8/2/2011 Yield: 7 GPM Pump Set at:90 Ft. Casing Height>2Above Ground:Ft. TANK SEPARATION DISTANCES [] Septic [] Holding [] S.T.E.P. [] Other: T~ To Septic Absorption Lift Holding ~ublic/Private Manufacturer: Capacity: From% Tank Field Station Tank Sewer Line Anchorage Tank 1,250 Gal. WeU >100' >100' N/A N/A >25' Steel Two (2) Surface Water >100' >100' N/A N/A % / LIFT STATION Lot Line >5' > 10' N/A N/A Gal. Foundation >5' >10' N/A N/A in. in. Pump Make & Model Electrical Inspections performed by: Cur[aNn Drain None Noted Remarks: BENCH MARK Garage Slab. 100.00 Ft, Inspections performed by: A. Harala Dates: 1st 8/2/2011 2nd 8/2/2011 Development Services Department Approval '[' '4,~*.,,/'** .~*...~,o..,,,.,,'.'3......,. ~" Conditional Approval Date: - --~ '*'"'**""'"" and approved by ./' [/// Date: I ~¢ i/ Reviewed n Z ,0~'6c3~ 3,,9~,L [.00 N 0 Ill 7:" I N I,I Municipality of Anchorage DEVEOPMENT SERVICES DEPARTMENT 4700 Elmore Road Anchorage, AK. 99519-6655 - 343-7904 On-Site Wastewater Disposal System or Well Inspection Report Permit Number: OSP111130 Page 3 of 3 PID No. 050-315-50 99.6 Ground 1,250 Gallon Septic Tank 94.35 Finished Grade Existing Grade 97.0 / 98.0 Geotextile Fabric Drainfield Rock 78.0 No Groundwater 50' (Trench Length) 94.2 90.2 PROFILE AS-BUILT No Scale 4700 DEPTH (feet) 1 2 3 4 5 6 7 8 9 11 201 IX'IUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT BRAGAW STREET ANCHORAGE, AK 99519-6650 SOILS LOG - PERCOLATION TEST LEGAL DESCRIPTION: PERFORMED FOR: DATE: 8/2/11 PARCEL ID#: LOT 5, BLOCK 5, F~OSEBERRY PARK ESTATES SUB. SPINELL HOMES PROIECT No.: TECHNICIAN: TEST HOLE A OB/OG CLEAN WELL GRADED SAN WITH GRAVEL SW/SH WAS GROUND WATER ENCOUNTERED? __ IF YES ~ WHAT DEPTH?.__ DEPTH OF WATER AFTER MONITORING: A. HARALA SLOPE No BOH @ 19' NONE DATEOF MONITORING: 8/15/20tt SITE PLAN SEE SITE PLAN  5% E DEPTH TO DATE READING GROSS TIME NET TIMEi WATER NET DROP (MINUTES) (MINUTES) (INCHES) (INCHES) TEST HOLE PRESOAKED PRIOR TO TESTING: 8/2 1 9:14/9:24 10 2.13"/8.25" 6.12" 2 9:25/9:35 10 2.oo"/8.oo" 6.00" 3 9:36/9:46 10 2.13"/8.25" 6.12" 4 9:47/9:57 10 12.25"/8.25" 6.00" 5 9:58/10:08 10 2.2y'/8.2s" 6.00" 6 10:09/10:19 10 2.25"/8.25" 6.00" PERCOLATION RATE: 1.7 (MIN/INCH) PERC. HOLE DIA. 8" TEST RUN BETWEEN: 4.5 FT. and 5.5 FT. ~.(INCHES) COMMENTS: TEST HOLE PRE SOAKED PRIOR TO TEST. TEST PERFORMED BY ANDERSON ENGINEERING. I, MICHAEL E. ANDERSON CERTIFY THAT THIS WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE: 11/28/2011 I/ 219 Permit Number: OSP Date of Issue Date Started: 8tat2011 Date Completed: lht3120'l'l Property Description ROSEBERR¥ PARK Lot 3 Block 3 Property Owner Name & Address: i~orehole Data: Depth Soil Type, Thickness & Wmer Strata From To Casiag SUckup 0 2 Overburden 2 4 Silt Sand Gravel W/~o~ldem 4 27 Gravel Sandy 27 32 Silt Sand Gra'cei W/Clay 32 3~ Silt Sand Gravel Dense 36 58 Sand 58 60 I..l~-dpan EO 103 Sand & Gravel 103 112 Water Sample Results: Arsenic: N iWates mgm1 Total Coliform Bacteria colonies? 100m L Other bacteria' cob'100mL Well Log Parcel Identification Numbe~: Is well located at approved permit location? So.ion: Town: SPINELL HOMES 1900 W. NORTHERN LIGHTS BLVD. SIJITE 200 ANCHORAGE, AK 99517 Method of DrilUng tX- air rotaD' Casing type: Wall thickness 0.2~ inches Diameter 6 inches Total: Liner type: Diameter inches Depth: Casing stic~-up above ground: 112 feet feet 2 feet Statie Water Level(from top of casing) Pumping Level: feet after I hours pumping Recovery Rate 7 g~m Method of Te~tiug: o feet Well Intake Opening Type Ix Ope. E.d i' '! ['-- SvTeened Start Feel Stopped feet { Pc rfo ral-icq~ Start feet Stopped --- Gront Type: Benlon~l~ dr~ §ranula. r . Volume: 50 Pounds Depth 4a Start 0 feet Stopped 44 feet Pump Intake Depth: feet Pump size: HP brand name Well disinfected upon Completion? 'iX Yes i [ No Method of disinfection CHLORINE 50 PPM Comme~: WELL AT COMPLETION WAS FLOWING 3 GPM OVER THE TOP Welt Driller: Cole Sullivan Sullivan Water Wells P.O. Box 8702?2 Chugiak, AK 99567 (S07) 6as-z759 Attention: The property o~aer shall provide this log to DSD (onsite) and D~WR withha 30 day's of completion. ARCTIC PumP & WELL iNC, Jim Sullivan PO Box 770197 Eagle Pdver, AK 99577 (907) 688-2510 (907) 258-2510 (907) 745-2510 apw@gci net Pump _Installation Log Well Drilling Permit Number: Parcel Identification Number: ospl 11130 Date Of Issue: 05031550000 7/9/2011 Legal Description Roseerry Park B3 L3 Property Owner Name Address: Spinnelle Homes Lot: 3 1900 W Northern Lights BLVD # 200 Block: 3 Anchorage AK 99517 Pump Installaion Date: 8/10/2011 Pump Intake Depth Below Top of Well Casin 122 Feet Pump M an ufacturer's N am e Fran kiln Pump M od el: 10JS05P4-2W230 Pump Size: 1/2 Pitless Adapter Burial Depth: 10 Feet Pitless Adapter Manufacturer's Name S-50 Pitless Adapter Installer: U/K Well Disinfected U pon Corn pletion? Yes Method of Disinfection: Chlorine Comments: PumplnstallerName: Arctic Pump & Well, lnc, Tuesday, November 08, 2011 On-Site Water & Wastewater System Permit MUNICIPALITY OF ANCHORAGE Development Services Department On-Site Water & Wastewater Program 4700 Elmore Road, PO Box 196650 Anchorage, AK 99519-6650 Telephone: (907) 343-7904 Permit Number: OSP111130 Tax Code Number: 05031550000 Work Type: WellSeptic Initial Permit Effective Dates: July 08, 2011 to July 07, 2012 Design Engineer: ANDERSON ENGINEERING Subdivision: ROSEBERRY PARK ESTATES Site LegalAddress: ROSEBERRY PARK ESTATES BLK 3 LT 3 G:0154 Owner/Address: ROSEBERRY PARK ESTATES, LLC. 10230 RONALD PLACE JOHN STEINER EAGLE RIVER AK 99577 Site Mailing Address: 18712 ROSEBERRY PARK DR, Eagle River Lot Size in Sq Ft: 45121 Total Bedrooms: 4 This permit is for the construction of: Y Disposal Field Y SepticTank N Holding Tank N Privy Y Private Well N Water Storage All construction must 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 must notify the Development Services Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either: A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing. r Special Provisions: :~, ~,~ The Engineer needs to do an additional test hole prior to the construction of the septic field. Construction may proceed at your own risk before the 7 day water monitoring is complete. Please submit stamped and signed results with the As-built Inspection Report. If the results require a design change, construction of the system will stop pending On-Site review and approval. Date: 7/~//// Date: 7'//~/,/// MUNICIPALITY Community Development Department Development Services Division On-Site Water & Wastewater Program Mayor Dan Sullivan OF ANCHORAGE ~ Phone: 907-343-7904 Fax: 907-343-7997 ON-SITE SEWER/WELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. ~-~%-O ~'~ .... Property owner(s) ~'"p~j~--L~ /-~/~,¢~d_~, ~'C-, Day phone Legal description (Sub'd., Block & Lot) ~S~i[~ ~ Legal description (Township, Range & Section) Lot Size ¢%~ l E i Sq. Ft. Number of Bedrooms THIS APPLICATION IS FOR: (1~ all that apply) Absorption Field Septic Tank Holding Tank Privy Private Well Water Storage THIS APPLICATION IS AN: Initial [~ Upgrade [] Renewal [] THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: I certify that the above information is correct. I further certify that this application is being made for a Single Family Dwelling and is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: Date of Payment: Receipt Number: Permit No. ~O ¢ Waiver Fees: Date of Payment: Receipt Number: Waiver No. G:\Building\On Site\Forms\Client Forms\Permit App_010411 .doc (Rev. 1/11 ) ANDERSON ENGINEERING p.o. BOX 240773 ANCHORAGE, AK 99524 ,522'7773 677.7755 (FAX) June 26,2011 Municipality of Anchorage Development Services Department On-Site Water and Wastewater Program 4700 South Bragaw Street Anchorage, AK 99519-6650 Subject: Lot 3, Block 3, Roseberry Park Estates Subdivision Septic System Design and Permit Application Impacts to Adjacent Properties Dear Onsite Services Engineer: The owner of Lot 3, Block 3, Roseberry Park Estates Subdivision intends to construct a new four-bedroom home on the lot. We are therefore requesting a permit be issued for the construction of a new well and septic system to accommodate the home. The attached Site Plan and backup documentation identify the location and configuration of the proposed septic system along with the alternate site. No existing wells or septic systems are closer than 100' from the proposed well or septic system. The Drainage arrows are shown on the site plan showing the grade and direction of flow on the lot. The drainage pattern will not be changed as a result of this project. The test hole placed during the subdivision phase of the project indicated well graded gravel with sand and silt (SP/GW). All of the test holes completed in the subdivision revealed similar soils with similar percolation rates. The percolation rate of the soil on this lot was not determined nor required by the Municipality for acceptance of the subdivision. The City apparently thought and we expect the percolation rate to be between 1 and 5 minutes per inch. Verification of the percolation rate will be made during the construction of the absorption trench and the results will be submitted with the certified as built. Groundwater was not found during the placement of the test hole. A recent inspection indicated no water in the monitoring tube at any level. An application rate of 1.2 gallons per day per square foot was used in the design of the absorption system. We are proposing to place a new 1,250-gallon septic tank and a 50' long by 5' wide by 4' effective depth absorption trench to treat and dispose of the effluent generated in the house. The elevation of the distribution line in the absorption trench will be 3.0' below the surface and the total depth will be 7.0'. A minimum of 3' of fill or 2" of insulation and 2' of fill will be placed over the absorption trench and 4' over the septic tank. Lot 3, Block 3, Roseberry Park Estates June 26, 2011 Page Two The ground surface on the lot in the area of the absorption trench slopes to the southwest at a grade approximating 5%. The new trench will be constructed parallel with the contours of the slope as much as possible in conformance with Municipal requirements. The new septic system will be constructed a minimum of 100' from all wells and any surface water and 10' from the proposed and existing water services in the area. If the system is constructed in accordance with our design the following statements apply: The system, if constructed as designed, will have no adverse impact on the wells in the area or those to be constructed in the future. The system, if constructed as designed, will have no adverse impact on existing septic systems in the area or those to be constructed in the future. The system, if constructed as designed, will have no adverse impact on reserve space, either surface or subsurface, on any lots located in the area. The system, if constructed as designed, will have no adverse impact on drainage patterns in the area. The current drainage pattern will be maintained. Sincerely, Michael E. Anderson, P.E. Attachments ANDERSON ENGINEERING P.O. BOX 240773 ANCHORAGE, AK 99524 522-7773 677-7766 (FAX) MEMORANDUM DATE: July 7, 2011 TO: Deb Wockenfuss FROM: Mike Anderson, P.E. SUBJECT: Lot 3, Block 3, Roseberry Park Estates Subdivision Septic System Permit No. OSPl11130 We have reviewed your comments pertaining to the design and permit application for the subject lot and have made the following revisions: 1. Measured distances have been added for the septic system and the well. Additional measured distances are not necessary as the Area Map shows the location of the wells in the area and their proximity to the proposed well and septic system. All are more than 200' away. 2. We are uncertain as to the location of the test holes as no detailed information was furnished with the subdivision development documentation. We are assuming the proposed absorption trench site is between Test Hole Nos. 14 and 28. The soil is very consistent in each of these holes and we assume the soils in the area of the new absorption system will be the same. A test hole will be placed prior to construction to verify the subsurface soils. A percolation test will also be performed. If conditions found vary substantially from those utilized in the design a change order will be submitted for approval prior to continuing with construction. 3. Test Hole No. 14 is attached which shows both water monitoring and a percolation test. The Site Plan has been modified to show Test Hole No. 14. 4. A note is on the Site Plan stating no slopes within 50' of the absorption site exceed 25%. The note further states no surface water is within 100' of the absorption system. Surface drainage arrows are shown on the drawing. PLAT NO. 2005-155 ROSEBERRY PARK ESTATES LOT 3, BLOCK 3 45,121 S.F. 1.250 Gallon Septic Tank CO / / / / / / / / 50' Long x 5' Wide x 4' Effective Depth Absorption Trench S 89'00'57"E 24-3.54' / / / / / / / / Proposed Well NOTE: No Slopes >25% Within 50' of the Septic System, Ground Surface Slopes to the Southwest in the Area of the Absorption Trenches. No Surface Water Within 100' of Septic System. SITE PLAN SCALE 1' = 40' LEGEND: CO - Cleanout SV - Septic Vent FCO - Foundation Cleanout TH - Test Hole MT - Monitor Tube ExieUng \ LOT 7, BLOCK 1 LOT 6, BLOCK 1 LOT 5, BLO~ 1 / / xNOVERLOOK DRIVE ~ / 7, BLOCK 2 k, LOT PATNODE HOMEST~D '%% ~ ..... . TRACT LOT 1, BL~CK VACANT Exlai;.[ng Well _OT 4, BLOCK "~CANT / / / / / / AREA MAP SCALE 1' = 100' LOT 3, BLOCK 3, ROSEBERRY PARK ESTATES SUBDIVISION DESIGN FACTORS: SYSTEM REQUIREMENTS: Four Bedroom House 5' Wide Trench System Perc. Rate: 1-5 Min./Inch (Est.) 1,250 Gallon Septic Tank Application Rate: 1.2 GPD/SF 4' Drainfield Rock 4 Bedrooms X 150 GPM/1.2 GPD/SF (Application Rate) = 500 SF Absorption Area 500 SF/5 SF/LF*.5 (Red. Factor) = 50 LF Trench Length THEREFORE: Construct an Abosrption Trench 50' Long x 5 Wide x 4' Effective Depth. Flow Line Elevation in Trench to be 3' Below Original Ground Surface. Total Depth to be 7' Below Existing Ground. Provide 4' Cover Over Septic Tank and 3' Cover Over Absorption Trench. 1611 11 1011 Natural Backfill ~O Geotextile Fabric 4" Perforated PVC (Holes Down) Drainfield Rock TYPICAL 5' WIDE TRENCH SECTION ....,-_.... (NO SCALE) NOTE: Grade Area Over Trench to Drain Away. Minimum 6' Separation From Bedrock. ~.,~.~_..¢.,~.,.~..~ .... ¢.,A..~ Minimum 4' Separation From Groundwater. ~~ ....... ,.~~ Minimum 100' Separation From Wells in the Area. ~.~ ~,c~ ~.~so, ./~ ' Minimum 100' Separation From Sudace Water -~ No. 0E4381 SOILS LOG - PERCOLATION TEST PerForMed For, Lee Coy 8 - 3- 4 - 5- 6- 7- 8- 9- 10- 11- 18- 13- 14- 15- 16- 17- 18- 19- 80- 21- DEPTH (FEET) SP/GW S~nd w/ Graver Groundwater Observed: None Depth To W~ter AFter Monitoring, None Dote oF Monitor, 11/23/03 & 5/1/04 # Dm~e Gross TIMe Net TIMe Dep~..h Net Drop Perco[otion R~¢e, 1 Min,/inch Pre-So~k Seeped Aw~y In Under 10 Minu~es Pert Hote DiaMeter = 6' Tes~ Run Between 3' ~nd 4' PerForMed in Accordance with Att Sto~e/Hunicip~t Guidetines in E??ec~ THRIM ~" .... 'i.~~., NOR . ~ ... -~NGIN-~gRING~ ...... 172~7 [~eor Pow Circle Ri~r, Alosko 99577 ..." ~ Eogle Roseberry P~rk GEnTECHNICAL Esi:. T, H, 14 9/05 ltl4 ' oF 2'~ SDIL~ LDG- PERCDLATIDN TE~T PerForMed For: Lee Coy 8- 3- 4 - 5- 6- 7- 8- 9- 10- 11 - 18- 13- 14 - 15- 16- 17- 18- 19 - 80- 21 - DEPTH (FEET> ,..0.' ~' Organic SP/GW Sand w/ Gravel Boulders Groundwater Dbserved: None Depth To Water AFter Monitoring, None Date o? Nonltor, 11/23/03 & 5/1/04 # Date Gross TIMe N, et TIMe D,epth Net Drop 5 4/21 7 -- 4, -- Percotatlon Rate, 1 Mtn,/Jnch Pre-Soak Seeped Away In Under tO Minutes Perc Hole DiaMeter = 6' Test Run Between 3' ond 4' PerForMed in Accordance with All State/Municipal GuideUnes in EFFect 9/05 N OR THRIM EN GINEERIN G '~-~7 igeor F~o~ Cir¢l~ rte River. Alosko 99577 T. H, 88 8~8' oF 2S Parcel I.D. 050-315-50 1. GENERAL INFORMATION Complete legal desc~ription Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Bragaw Street P.O, Box 196650- 5H~ Anchorage, AK 99519-6650 ~ www. muni. org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL ~'~,,~,/, FOR A SINGLE FAMILY DWELLING ° COSA # ©~C_. i/I of~ Expiration Date: ~/).c//! ~ Lot 3, Block 3, Roseberry Park Estates Subdivision Loc:ation (site address) 18712 Roseberry Park Drive Eagle River, AK Current Property owner(s) Spinell Homes, Inc. Day phone 344-5678 Mailing address' 1900 E. Northern Lights Blvd., Suite 200 Anchorage, AK 99517 Lending agency Day phone Mailing address Real E~state~ Agent ........................................................... q}ay-phene ~'ad~ng'Address Ut~less othe~ise request~;' COSA will be held by DSD for pickup. NuMBEROF ~EDR;o0~i' TYPE 'OF WATER SUPPLY: Individual Well' [] Individual 'Water Storage [] Community Class Well [] Public Water System [] Four (4) TYPE OF WASTEWATER DISPOSAL: Individual On-site [] Individual Holding Tank [] Community On-site [] 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 On-Site 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 files and from my investigation and ~,spection, the on-site water supp., y ~ar~d/or.. · wastewater disposal system is(are) n compliance with all applicabl~!~u~n'~b"~p~' and. State codes ordinances, and regulations in effect at the time of installation. ' ~ ~.~ ' ,.B"~me of Firm Anderson Engineering Phone 522-7773 Address P.O. Box 240773 Anchorage, AK 99524 Engineer's Printed Name Benjamin Schiler, P.E. DSD SIGNATURE ~ Approved for L~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory X Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report' Other Original Certificate Date: (Rev. 11/05) Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 www. muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: Lot 3, Block 3, Roseberry Park Estates Subdivision Parcel ID' 050-315-50 A. WELL DATA Well type Private If A, B, or C provide PWSID # Date completed 8/3/2011 Sanitary seal (Y/N) Y Total depth 112 ft. Cased to 112 ft. FROM WELL LOG Well Log (Y/N) Y Wires properly protected (Y/N) Casing height (above ground) >18 AT INSPECTION Y in. Date of test 8/3/2011 Static water level 0 ft. Well production ? WATER SAMPLE RESULTS: g.p.m. g.p.m. Coliform 0 colonies/100 mL Nitrate .844 mg/L Arsenic: N/D ug/I Date of sample: 11/16/11 SEPTIC/HOLDING TANK DATA Other bacteria 0 colonies/100 mL Collected by: A. Harala Tank Type/Material · Septic/Steel Number of Compartments Two Depression over tank (Y/N) Pumper Tank size ~ 1,250 gal. ~ate Of pumping New C~d~t. A~ORPTJON FIEED DATA .'~Dat~ i~all~d 8/~201~ ,~[ -., S~il rating (g.p.d.~2 or ~/bdrm) 1.2 GPD/SF ~Le~g~h ~b:'~.:~; ~ *~:~* ~.* ~ ~dth 5 ff. a so ,t,on area tu e Date of adequacy test New Const. Results (Pass/Fail) __ Fluid depth in absorption field before test Date installed 8/2/2011 Cleanouts (Y/N) Y High water alarm (Y/N) Elapsed Time: min. Final fluid dePth Any rejuvenation treatment (past 12 mo.) (Y/N & type) N System type 5' Wide Trench Gravel below pipe 4 ft. Y Depression over field N For bedrooms in. Water added gal, New depth in. in. Absorption rate >= g.p.d. N If yes, give date LIFT STATION Date installed "Pump on" level at~ Datum in, E. SEPARATION DISTANCES Size in gallons "Pump off" level at Cycles tested in, SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot >lOC' Absorption field on lot >100' Public sewer main N/A Sewer/septic service line · >25' Animal containment areas >50' Manhole/Access (Y/N) High water alarm level at Meets alarm & circuit requirements? in. On adjacent lots >1oo' On adjacent lots >1oo' Public sewer manhole/cleanout Holding tank N/A Manure/animal excrete storage areas N/A > 100' SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation >5' Property line >5' Water main N/A Water service line Wells on adjacent lots >100' >10' Absorption field >5' Surface water >1oo' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line >1o' Water Service line >1o' Curtain drain None Noted COMMENTS: Building foundation >1o' Surface water >1oo' Wells on adjacent lots >lOC' Water main >1o' Driveway, parking/vehicle storage >25' G. ENGINEER'S CERTIFICATION I certify that/have determined through field inspections and ~~9 review of Municipal reCOrds that the above systems are in 'conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name Benjamin Schiller, P.E. ' Date 11/22/2011 ........ ,.~Op~,,,.' .- -~.~r.,,. .. COSA Fee $ (~ 5 '" ~ ~ ~ - j~%)3 Waiver Fee $ Date of Payment II} o~/Jl C~' Date of Payment Receipt Number (~5:~ ~ ~ Receipt Number (Rev. 11/05) [ ~. o ~o ~ CO, o .~.~ - · . o _~ ~ ~ ~ 72.2' N 00°17'28"E 259.30' 0 r-r1 r~1 em~m~