HomeMy WebLinkAboutSCIMITAR #1 BLK 2 LT 6CScimitar #1
Biock 2
Lot 6C
#051-132-93
O
Municipality of Anchorage ,,~ .... '" ,:
Development Services Department .~ ~
Building Safety Division ~ ~
On-Site Water and Wastewater Program, 4700 Elmore Road
P.O. Box 196650 Anchorage, AK 99507 Page [ of
www.ci.anchorage.ak.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: (~ ~ /~9 /~) Z-e'0/' PID Number: O~[ -( '~ 2_.-~ ?>
Name: '"~"(~ ~ "' ~. ~' 'Ct nLt' 5 Wastewater System: [] New ~ Upgrade
Address: ~), (~, I~o'~ ~d' '~ '~ ~'"~ 'Z- ABSORPTION FIELD
Phone: Number of Bedrooms:
,~/ Deep Trench [] Shallow Trench [] Bed [] Mound [] Other:
Total Depth from original grade:
LEGAL DESCRIPTION SoilRating: ~ '~ GPD/Ft2 '~, ff Ft.
Depth to pipe bottom from od. ginal grade: Gravel depth beneath pipe:
Block: Lot: Subdivision: ,
I Gravel Length:
Township: Range: Section: Fill added above odg g :/fO Ft. 7~' ~' Ft.
Number of lines: Distance between lines:
Well:[] New [] Upgrade Gravelwidth: ~t ~ Ft. ( / Ft.
Classification (Private. A, B. C): Total Depth: / .~'~o: Total absorption area: Pipe Material:
Driller: / Date Ddlled: Static Water Level: Installer: Date Installed:
Y~ GPM Pump Set at: Casing Height Above Ground:
Ft. Ft. TANK
SEPARATION DISTANCES ~.Septic [] Holding [] S.T.E.P. [] Other:
T~ m m~'~...~o Septic Absorption Lift Holding ~ublic/Private Manufacturer: Capacity:
Tank Field Station Tank Sewer Line ~.~ I- ~ ~,/'" ! ~.,~'-~ Gal.
Material: Number of CompaCtments:
Size: Manufacturen
Lot Line Zvf~L '~ O ' Jl~. Gal.
Foundation ?O'+ ~OlJe "Pump on" level at: "Pump ~ in. High water alarm at:
Curtain Drain #~[. /~('//A ~ Electrical Inspections performed by:
Location and Description~
/0 (9 Ft.
Inspections performed by: fi4t~t'/~-,~g,-e~,,~,,1 Dates: 1at ~',/~,///o E~e~is~t.amp
2nd
Development Services Department Approval "'~-' ~ '.17
Conditional Approval ..... Date:._
.........~ ~~~-,~O_. MICHAEL N. ANDERSON
DESIGN CRITERIA: , ~-MOUND OVER
4 BDRM X 150 -- 600 GPD __ ORG ,
SOILS -- 600/0.8 -- 750 GPD 0.5 0.5
750 GA/11 -- 68' `3.0 -- SM `3:3.0 -- SM FABRIC
(1), TRENCH ~SEWER ROCK
8.0 DEEP
5.5' EFFECTIVE: CM CM -8.5
2.0' WIDE , I_~.0'. I
70' LONG 18 __ 18
SEPTIC FIELD SECTION
Septic Design Prepared For
~.'~MICHAEL N. ANDERSON!,~'-
, Permit No. OSP 101028
Page 2
of 2
Municipality of Anchorage
DEPARTMENT OF' HFALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone: 3~-3-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: LOT 6C, BLK 2 SCIMITAR i~1 S/D PID No.: 015-152-95
i!..~u . ,.., GRNE ~IPE/ - -- / ! I' ~ t., I IVI I
....... E,Ev. E~. / / LOT
/ C01 30 10 98.1 96/ ~
,~. C02 38 12 98.1 ~(5.8 / I J
c03 39 13 i98.1 '95.8
~'~2 4.9 22 ~5 /
C04'-,, 52 24. ,, 97.3 95.3 / ~
C05 ~ 53 2.5 / 97.3 95.3 / / /I ~, -
co6 ~ 4.8~ .,-- 35 98.1 95.1 / / ~ / '
~ _ ~ .... ~ 4~ 98.2 J / / I
/ / ~ ~/,~NO., ~oP o~
/ , ~ HOUSE ~/
/~----~', ~ 3c I
( s~.,c ~ ~ ~
.... co~ ~ / ~
SECONDARY ~ NCH,~ ~ ~ ~ J~ ~ / -
~ ~ ( Ii ./ !% ~TOE OF SLOPE // / m SCIM
I lO[ ~:r / ~ / ~ / '
/ SCALE:
S~EL TANK % ~ S" ~ MICHAEL N. ANDERSON
~: ~ NO.
~ ~ ~;~.. , ..... :..
-LOT 6B-
~ // EXISTING HOUSE
IIIII//
SEPTC TANK ~.:~n~ -~.~.. ~ / .~/
I ,'"~ ,, ', , /
I ~I~ / * '~ ~ I~TANK ~0
SECONDARY SEP~C~ ~ ' ~; · bOUm,r ~n ~
I FIE~ ~ ~m ~ J~ / ...... ~ ~
~ ~ J J ~]) / I
'~0 ~ SLOPE ORdeR
~ ~ ..... ~ ~ 25~ WITHIN 100
~ OF ~E
PROPOSED N~ ~CH
RELD.
Septic Design Prepared For
T~A ~ITIS
LOT 6C, BLOCK 2, SCIMIT~ ~1 SUBD~SION ~F~ "" - "'-~'~
Anchorage, Maska
MIC~L N. ~D~RSON, P.E.
$.~MICHAEL N. ANDERSON/~'
(0o,) ~,~-.~,, / ,~ (0o,).,~-,... .;& ..... ~Lr/~......~.~
IT IS THE RESPONSIBILITY"OF THE OWNER OR BUILDER
PRIOR TO CONSTRUCTION TO VERIFY PROPOSED BUILDING
GRADE RRTATIVE TO.FINISH~3,.?GRADE AND UTILITY
CONNECTIONS. AND~,.T07, D,~ ~NEi THE:EXISTENCE OF ANY
EASEMenTS, 'CO~NTS?iO~[~f~ICTIoNS ~ICH DO NOT
APPEAR ON THE RECORDFJD SUBDMSION PLAT.
NOTE:ELEVATIONS ARE ASSUMED DATUM.
SEWARD & ASSOCIATES LAND SURVEYING
I HEREBY CERTIFY 1THAT I HAVE SURVEYED THE SCALE.'
FOLLOWING DESCRIBED PROPERTY: '/'"'"-~'"'~'---
>'~'/'~×?',,~.~'~.'~.~,,.r//-/-/...'o. /. ~ ~ ~ ~ DATE:
AND ~AT NO EN~OACHMENTS EXIST ~CE~ AS ~~ /~"'"
INDICA~D. IT IS THE RES~NSIBILITY OF THE
OWN~ TO D~ERMINE THE EXISTENCE OF ANY GRID:
COVE. NTS, OR . ST. CT O.S
WHICH DO NOT ~PEAR ON THE RE~D~ ~BDI- ' ' ·
VISION PLAT, UND~ NO CIRCUMSTANCES S~ FB: ~", LS-~]8 /."~.~
~Y DATA H~EON BE US~ FOR CONS~UCTION //~-'~
OF FENCE LINES, OR FOR EST~LISHING ~ND- DRAWN,
ARY LIN ES. ~/ ~~ -
ARCTIC PUMP & WELL INC.
Jim Sullivan
PO Box 770197
Eagle River, AK 99577
(907) 688-2510
(907) 258-2510
(907) 745-2510
ap w~ gci_n ~
Pump Installation Log
Well Drilling Permit Number: SW Date Of Issue:
Parcel Identification Number: 051-132-93-000
Legal Description Scimitar # 1 Property Owner Name Address:
Tamara Leitis
Lot: 6c Po BX 670522
Block: 2 Chugiak AK 99567
Pump I nstallaion Date: 8/10/2009
Pump Intake Depth BelowTop of Well Casin 186
Pump Manufacturer's Name Franklin
Pump Model: Constant Pressure System: 20-SDQP-1.5HP
Pump Size: 1.5 HP
Pitless Adapter Burial Depth: 8 Feet
Pitiess Adapter Manu factu rer's N am e Baker
Pitless Adapter Installer: Arctic Pump & Well, Inc.
Well Disinfected Upon Completion? Yes
Method of Disinfection: Chlorine
Comments: well casing 40 + with no perforations
PumplnstallerName:
Arctic Pump & Well, Inc.
Wechwsda3~ Au#d~t~t 31, 2011
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, Alaska 99507
www.muni.org/onsite
(907) 343-.7904
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D.
Property owner(s).
Day phone
Mailing address Zip Code
Site address
Legal description (Sub'd., Block & Lot) ~i~
Legal description (Township, Range & Section)
Lot Size 0o"~."~0~'~ Sq. Ft.
Zip Code
Number of Bedrooms
THIS APPLICATION IS FOR ([~ all that apply):
Absorption Field []
Septic Tank []
Holding Tank []
Privy []
Private Well []
Water Storage []
THIS APPLICATION IS AN:
Initial []
Upgrade
Renewal []
I certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling an~. ccordance with applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees:
Date of Payment:
Receipt Number:
(Rev. 11/05)
Waiver Fees:
Date of Payment:
Receipt Number:
Michael N. Anderson, P.E.
Civil/Structural Engineering & Construction
4661 Natrona Avenue
Anchorage, Alaska 99516
Phone 345-3377
Fax 345-1391
May 12, 2010
Municipalities of Anchorage
Depa~ments ofHealthand Human Services
P.O. Box 196650
Anchorage, Alaska 99519-6650
Fax 249-7847
Re: Blk 2, Lot 6C, Scimitar #1 Subd.
To Whom it may concern:
This is a request for a new septic permit on the above referenced lot. One test hole was excavated along the
south west property line, which showed sandy silt in the top 3 feet, then silty gravel for the remainder of the
test hole depth of 18 feet, with no water observed after the 7 day monitoring period. The perc rate for the
test holes was 2 minutes per inch. A five wide trench as been designed parallel to the slope of the hill. The
old system has been shown on the site plan and the two systems will be separated by the required distance.
The old records are not clear therefore some additional excavation will be required during the installation of
the system.
The lot has a gentle slope of about 3 to 5 percent from the east to the west, as shown on the plan. The area
behind the house slopes up at over 25 percent. There are no cut banks within 100 feet, downhill of the
proposed system. The other neighboring lots will not be impacted or affected by this upgrade due to the
large lot size.
If you have any question please call me at 345-3377
DESIGN CRITERIN
/-MOUND OVER
(TH#l) ~ I f ~//-ORADE
4 BDRM X 150 = 600 OPD --ORO I\ \~ /~FLL~TEpRip~A
SOILS =. 600/1.2 = 500 GPD 0.5
500 GA/5 = 50' 3.0- SM -~. BRIC
-3,0- ~
(1~, TRENCH ~SEWER ROCK
7.U DEEP
4.0' EFFECTNE eM -7.0
I .o.I
50' LONO 18__ ' '
SEPTIC FIELD SECTION
'\ /
....... ~ '~ ~ ...... =~W H A L E Y A V E N U E -
/ < ~OE ~ ~~-.. ~ EXI~NO WELL
.. / o/ / PROPOSED ~~~ [ -LOT 7-
Septic Design Prepared For
DENNIS MoCOR~ICK ~ u ......
LOT 6C, BLOCK 2, SCIMIT~ ~1 SUBD~SION ~.,.' &'.~'ee
~chorage, Maska ~ f ~TH
MIC~L N. ~DERSON, P.E. ~:~~.5...~ .....
4640 SHOSHONI DR~ ~.~ MICHAEL N. ANDERSON/~g
~,y~% No. CE 9469
(90?) 84~-8877 / ~ (90?) 8~-1891
-LOT 6B-
-.LLOT 6A- ~:' ''!'' ii':
-'.! .i': '..' :;'..'.:....'...:.'.'i .. '; . ).ii:. i .'.i,. ".... :..'...';. :': :'. ::i.' :i
· ,. ,~, · .,..../,...? .... .......,~ . . : . ~.. ,~., ;....
\ ~ /"',' ! ',
~ k/ ~/ ,' ', .-~/
PROPOSED SEPTIC RELD~',,,, .f //' x,
NO SLOPE GREATER xx
THAN 25% WITHIN 100 '"~
FEE-r OF THE ~-.
PROPOSED NEW LEACH "'-..
FIELD. "--......~ ~
Septic Design Prepared For
~.~zs UoCO~UZCK ,,%%. ...... ...¢~,.~.
LOT 612, BLOCK g, SCIMITAR #1 SUBDMSION ~ ~.-" ~ '...~7-~
Anchorage, Alaska ~ ..-'
Prepared By ~. ~~.~..~
MICHAEL N. ANDERSON, P.E. ~-.:~.~a..~.....'~.- .....
4640 SHOSHONI DRIVE ~,,':¢~: MICHAEL N. ANDERSON.:,~'--
~"',';"o.". No. CE 9469 :
(007) 34[-3377 / FAX (007) 345-1301 ~;~. ....~
SCAI.F.: 1"=30' APRIL 16, 2010
Performed For:
Legal Description:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650 Anchorage, AK 99507
www.ci.anchorage,ak.us
(907) 343-7904
Soils Log - Percolation Test
Slope
7-
8-
9-
19-
20-
COMMENTS
rj ~:;:'M. CE - 94 59 ,...,:7::" ,.1
Date .
Township, Range, Section:
Site Plan
WAS GROUND WATER
ENCOUNTERED? N ~'
S
IF YES, AT WHAT DEPTH? L
O
Depth to Water After
P
Monitoring?
Reading Date Gross Time Net Time Depth to Water Net Drop
PERCOLATION RATE '"~...~ (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN g~' FT AND ~' FT
! '
PERFORMED BY: IL///4 ~ ~k ,,~/~ 4 C"¢-, ~ I CERTIFY THAT THIS TEST/WAS /
PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
Performed For:
Legal Description:
8-
9-
10-
11-
13-
14-
15-
16-
17-
19-
20-
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650 Anchorage, AK 99507
www.ci.anchorage.ak.us
(907) 343-7904
Soils Log - Percolation Test
J Slope
Date Pedormed:
Township, Range, Section:
Site Plan
WAS GROUND WATER
ENCOUNTERED? ~
S
IF YES, AT WHAT DEPTH? L
O
Depth to Water After -- p
Monitoring? ~ ~ ~ ~'"~ E
Date:
Reading Date Gross Time Net Time Depth to Water Net Drop
~ '~ Z,C"
~,,, ?,<"
PERCOLATION RATE
TEST RUN BETWEEN ~ FT AND ,Z~ FT
COMMENTS
PERFORMED BY: ~'t"/',1/~-, I CERTIFY THAT THIS TEST~W/~S
PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ~/t'//!
MUNICIPALITY OF ANCHORAGE
BUILDING SAFETY DIVISION
ON SITE WATER AND WASTEWATER PROGRAM
NOTICE OF VIOLATION
PLEASE READ CAREFULLY
ANCHORAGE ADMINISTRATIVE CODE SECTION 15.55 AND 15.65
The Building Official is authorized to serve a notice of violation or order on the person responsible for the
construction, alteration, extension, repair, or moving of a wastewater disposal system and/or water well in
violation of the provisions of this code, or in violation of a permit or certificate issued under the provisions
of this code. Such order shall direct the discontinuance of the illegal action or condition and the abatement
of the violation.
Be advised that this notice is issued because:
[] Work without a permit
Using a wastewater system or water well that is not approved by the Municipality of Anchorage
[] Municipal code violation 15.65.020 Wastewater Discharge Restrictions
Must have wastewater system pumped and spills cleaned up and sanitized in accordance with the
attached procedure within 24 hours. No further overflows spills will be tolerated,
[] A civil engineer licensed in the State of Alaska must be retained to evalutate the wastewater
system. The wastewater system must be repaired or upgraded within two weeks.
[] Other
Comments:
Property Legal Description:
Site Address:
Owner's Name:
Permit Number:
Phone Number:
Be advised that a Warning Letter will be sent by certified mail to the owner of the property in violation of this
notice. Please respond to Building Safety as soon as possible or other actions may be required (stop work
orders, notices to vacate, additional fees, shut off of utilities, etc.) Immediate discontinuance of the violation is
required. For further information, contact Building Safety at 343-7904, visit us online at www. muni.org/onsite
or in person at 4700 Bragaw Street.
Inspector's Name:
Date:
84-031 Ver. 7_06* DISTRIBUTION: WHITE - OFFICE CANARY - JOB SITE
MUNICIPALITY OF ANCHORAGE
i
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
051-132-93
Parcel I.D. I
1. GENERAL INFORMATION
Expiration -Date: 1--,2
Complete legal description SCIMITAR #1 IBLK 2 LT 6C
Location (site address) 24236 Whaley Ave
Current property owner(s) Leitis
Day phone 244-1930
Mailing address
Real estate agent Cindy Wilson Day phone 244-1930
2. TYPE OF DWELLING:
1 8 9 70 117
Fx_1 Single Family (w/wo ADU)
1 4)
H! -0
❑ Duplex
OCT J 8 2019 >
❑ Multiple Dwellings (Single Family and/or Duplex)
4
ti
3. NUMBER OF BEDROOMS:
ZZ 1\
01 6 8 L 01 C �
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
Z
Private Septic RX
Water Storage
R
Holding Tank R
Community Well
El
Community R
Public Water System
R
Public Sewer R
Waiver request for:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee$ Waiver Fee $
Date of Payment 1012,( [1,
Receipt Number
COSA# MC M 50;?
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. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm NorthRim Eng. Phone 694-7028
Address PO Box 770724, Eagle River
Engineer's Printed Name Steve Eng Date 10/17/19
By. 1
1* OTS/ T o�
FAST AND m
A�
O R
Original Certificate Date: 10 7
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
Septic System Advisory
Well Flow Advisory
COSA Checklist blue sheet
X Nitrate Advisory
Arsenic Advisory
Other
_ _ __ _ _.
_ _ ___._ as .. - - -
•. <_�
�
,aMn
6. DSD SIGNATURE
System #1 Approved for
bedrooms �� •,
,
System #2 Approved for
bedrooms sly •�, `.`
Disapproved
P0�'7�(':'
Conditional approval for
bedrooms, with the following stipul,T;'
By. 1
1* OTS/ T o�
FAST AND m
A�
O R
Original Certificate Date: 10 7
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
Septic System Advisory
Well Flow Advisory
COSA Checklist blue sheet
X Nitrate Advisory
Arsenic Advisory
Other
Legal Description: SCIMITAR #1 BLK 2 LT 6C
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
Parcel ID: 051-132-93
Structure served by this system
Al Well log is filed with Onsite (or attached) Well production at time of test 3+ gpm
Date drilled 3/23/68 Water storage tank volume 0 gallons
Total depth 201 ft Well disinfected -for coliform test? ❑ Yes ❑ No
-- _
Cased to 71 ft NO Coliform bacteria is Negative
OR Sanitary seal is functioning correctly Nitrate 1.6 mg/L ❑ Nitrate less than MRL (ND)
❑ Wires are properly protected _ _ _ _ _ Arsenic_ _ug/L ._❑ Arsenic less than MRL (ND)
Casing height (above ground) 12+ in. Collected by NRim Eng
Date of flow test for COSA 10/9/19 Date•of Sample 9/27/19
Static water level at beginning of test 42 ft.
Comments
B. TANK DATA
Age of tank(s) 9/09 years
Tank type/material Steel
Measured operating fluid level in septic tank 46
❑ Standpipes/foundation.cleanotit per record drawing
Date of pumping 8/9/19
D. ABSORPTION FIELD DATA -9/09'
Which system tested (date installed) 9/09._
❑ ALL standpipes present per record drawing
Total measured depth from -grade 10.5 ft (max)
Measured depth to pipe invert from grade 3.5 ft (min)
❑ N/A — pressurized field
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective
❑ Code -required soil cover over field
❑ System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced gallons
Comments/Deficiencies:
COSA Checklist yellow sheet
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 10/9/19
Results ❑✓ Pass For 4 bedrooms
Fluid depth prior to test 35 in
Water added 600 gal
New depth 50 in
Elapsed time 30 min
Final fluid depth 40 in
Absorption rate 600 and
Any rejuvenation treatment (past 12 months) no
If yes, enter date
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
✓0
Yes
Septic Tank/Lift Station on Lot > 100'
ft
Surface Water > 100'
Community Sewer Manhole/Cleanout > 100'
Property Line > 5'
✓❑
E✓ Yes
if No
ft
M Yes
if No
ft
Neighboring Tank > 100' M Yes
if No
ft
Private Sewer/Septic Line > 25' 0✓ Yes
if No
ft
Absorption Field on Lot > 100' F Yes
if No
ft
Holding Tank > 100' 0✓ Yes
if No
ft
Neighboring Absorption Fields > 100'
Water Service Line > 10'
Animal Containment > 50' 0 Yes
if No
ft
D Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75` E] Yes
if No
ft
Yes
if No
ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
✓0
Yes
if No
ft
Surface Water > 100'
❑✓ Yes if No ft
Property Line > 5'
✓❑
Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
if No
Yes
if No
ft
Private Wells > 100'
❑✓ Yes if No ft
Water Main > 10'✓❑
ft
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'
✓0
Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
1 certify that 1 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