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Home My WebLink AboutWYNTER PARK #1 BLK 2 LT 20Wynter P rk Block 2 Lot 20 #051-492-21 Municipality of Anchorage On-Site Water and Wastewater Section • (907) 343-7904 Page 1 of 1 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP 201285 PID Number: 051 492 21 Dwelling: ❑ Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑ Upgrade Name GROSKREUTZ ABSORPTION FIELD ❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 21049 SPARKLE ❑ Other Phone Number of Bedrooms Soil Rating depth from original grade 3 1.2 GPD/SF JTotal 7.5 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 4.5 Ft. Gravel depth beneath pipe 3 Ft. Subdivision Block Lot WY.NTER PARK #1 B2 L20 Fill added above original grade 0.5 Ft. Gravel length 44 Ft. Township Range Section Gravel width 5 Ft. Beds: Number - of Lines Distance between lines - Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line 380 Ft2 1 Ft. Well _ _ _ _ _ TANK ❑® Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer GREER Capacity 1000 Gal. Surface Water + 100 +100 _ _ Material Number of compartments Lot Line +5 +10 - _ NA POLY 2 Foundation +10 +10 - _ LIFT STATION Manufacturer Capacity Remarks — Gal. Alarm location Electrical installed by PIPE MATERIAL House to tank 3034 Tank to 3034 drainfield Installer OWNER INSTALL Drainfield 3034 CO/MT3034 Inspector CHARLES BALZARINI BENCH MARK (Assumed elevation) 100 ft Inspdeatio 15 9/2!20 9/5/20 Location and description 2nd BTM SIDING 31119/6/20 4th ON-SITE WATER AND WASTEWATER SECTION APPROVAL 2!19/21 Engineer's Stamp OF ACgS� Conditional Approval: Date 49 Septic System Approved k'i Z i� Date y l3 a l CHARLES G BALZARINI �F�is •.. CE-13854 Note: this approval does not include well permit requirements. �� pROFESS1Q* tr,ev uoiuu i u/ CHARLES G BALZARINI CE-13854R E GISTEREDPROFE S S I O N A LENGINEER12/28/20 i1/Z7_ d�Z�/1%'mss✓'"" i/7_/�� • 5 cY � d O I HEREBY CERTIFY -THAT 1 HAVE SURVEYED THE SCALE= e e FOLLOWING DESCRIBED PROPERTY -OF A It Ot� DATE- AND THAT NO ENCROACHMi:NTS EXIST EXCEPT AS Ib INDICATED. 1T IS THE RESPONSMILITY OF THE IN DINNER TO DETERMINE THE EXISTENCE OF ANY EASEMENTS, COVENANTS., OR RESTRICTIONS e er 'Q Z7 z A/-�/.W�/ ` WHICH DO NOT APPEAR ON THE RECORDED SUBDI- ' oenaiMser . ss d � = VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD orl►vtu'u cY A001JUTA1r,J LAND JUKVLYll\lb by4—UdZy I HEREBY CERTIFY -THAT 1 HAVE SURVEYED THE SCALE= FOLLOWING DESCRIBED PROPERTY -OF A It Ot� DATE- AND THAT NO ENCROACHMi:NTS EXIST EXCEPT AS INDICATED. 1T IS THE RESPONSMILITY OF THE DINNER TO DETERMINE THE EXISTENCE OF ANY EASEMENTS, COVENANTS., OR RESTRICTIONS GRID= A/-�/.W�/ ` WHICH DO NOT APPEAR ON THE RECORDED SUBDI- ' oenaiMser . ss d � = VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD Fly :` � •. LSI ANY DATA HEREON BE USED FOR CONUMUCTION �� ' • ° f`.b/ 5�� OF FENCE LINES, OR FOR ESTABLISHING BOUND- DRAWN: ARY LINES. ,,,CIPA "T"OA MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite 9NCM0 RP6F' On -Site Wastewater Disposal System Permit Permit Number: OSP201285 Work Type: Septic Upgrade Tax Code Number: 05149221000 Site Legal Address: WYNTER PARK #1 BLK 2 LT 20 G:1361 Site Mailing Address: 21049 SPARKLE DR, Chugiak Owner: GROSKREUTZ NOAH G Design Engineer: C&M ENGINEERING SERVICES This permit is for the construction of: Q Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy Effective Date Expiration Date: Lot Size in Sq Ft Total Bedrooms: gent 'S' Depai-tment 8/20/2020 8/20/2021 20120 ❑ Private Well ❑ Water Storage All construction shall 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 shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Special Provisions: 1. The water service line shall be located prior to construction of the septic system to confirm minimum 10 ft separation. 3 2. Prior to inspection report approval, a test hole shall be completed to confirm the alternate drainfield design (or the alternate drainfield shall be relocated to be within the 30 ft radius of the test hole that has been completed for the primary drainfield). Received By: Date: Issued By:Date: 1' Lij'� . aO�2o MUNICIPALITY OF ANCHORAGE Development Services Department `��' y g Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 051 492 21 Property owner(s) GROSKREUTZ Mailing address Site address 21049 Sparkle Day phone 7480878 Legal description (Sub'd., Block & Lot) WYNTER PARK BLOCK#1 BLOCK 2 LOT 20 Legal description (Township, Range & Section) Lot Size 20,120 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (M all that apply) Absorption Field Q Initial ❑ Single Family (SF) 0 (w/wo ADU) Septic Tank ElUpgrade EDDuplex (D) ElHolding Tank F-1Renewal ElMultiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: none Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. C&M ENGINEERING (Signature of property owner or authorized agent) Permit/Rush Fees:$�i `16.25 COW Date of Payment: 3 0 D,2C� Receipt Number: Permit No. 0592.01285 Waiver Fees: Date of Payment: Receipt Number: Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc C&M ENGINEERING SERVICES Ph: 907-854-5558 Municipality of Anchorage Onsite Water & Wastewater Program 4700 Elmore Rd Anchorage, Ak 99507 RE: Proposed Septic System replacement for WYNTER PARK#1 B2 L20 Dear Reviewer, The above referenced property is currently being developed. The owner would like to install a new septic system to go with the new home. The subject parcel and adjacent parcels are served by a public well. We are proposing to install a new septic tank, and a new drainfield. The drainfield will be sized for 3 bedrooms. There is an existing septic system on the lot. The existing tank was located, but the absorption system appears to reside on lot 21. The existing tank will be demolished per moa requirements. Included with this letter is a permit application and design package, including plans, and calculations. A test hole was excavated and revealed good soils with no groundwater encountered. The Homeowner intends to install the septic system himself. Thank you for your time in reviewing this permit request. Please do not hesitate to contact me at 907-854- 5558 or by email cgbalzarini@gmail.com with any questions or concerns. No significant impacts to adjacent properties are likely due to lot sizes and the nearby public water system. Sincerely, Charles Balzarini, PE 7/07/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201285, Rebecca Carroll, 08/20/20 Residence: number of bedrooms 3 br Water usage/bedroom 150 gpd/br Water Usage 450 gpd type: SHALLOW Application Rate 1.2 gpd/sqft For sand liner required absorption area 375 sqft width (W) 5 ft minimum effective depth 3 ft below distribution pipe see narrative Shallow Trench Factor 0.5833333 Min Required Length: 43.75 ft Effluent Pipe: Calc By: CGB Date: 7/5/2020 C&M ENGINEERING SERVICES 907-854-5558 Septic Design Calculations RESIDENCE/LOT INFO DRAINFIELD 4" ASTM 3034 CALCULATIONS ARE FOR REFERENCE PURPOSES ONLY USE DIMENSIONS SHOWN ON PLANS CALCULATIONS ARE FOR REFERENCE PURPOSES ONLY USE DIMENSIONS SHOWN ON PLANS WYNTER PARK#1 B2 L20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201285, Rebecca Carroll, 08/20/20 F0 CLEANOUT • MONITOR TUBE Z TEST HOLE APPROX WATERLINE LOCATION LOCATE DURING CONSTRUCTION *'49 TM '*fel I / • • I CHARLES G BALZARM • � I •, i Sp �'c� •• CE -13854 �RK�F �R II isTF�Fo • ;i2 i ;o . �AN" >>�_ pROFESSIONP .� 200' WELL RADIUS 1 FLAG PRIOR TO Q CONSTRUCTION cp �c9 EST HOLE / — 5X4 AINFIELD �j WITH 3' EFFECTIVE SEWER ROCK 8' MAX PROPOSED 427 / EXCAVATION 2 BEDROOM HOUSE — DOUBLE CLEANOUTS I 5X,44 RESERVE SITE ADD'L SOILS EXPLORATION A6 DESIGN REQUIRED 0� 0 WYNTER PARK#1 B2 L21 0 NEIGHBORING SEPTIC 0 WYNTER PARK#1 B2 L25 \ WYNTER PARK#1 V @� B2 L19 / / WYNTER PARK#1 B2 L20 / 1000 GAL HDPE TANK / WITH INSULATED MANHOLE RISER AT / FIRST COMPARTMENT / DEMOLISH OLD TANK PER MOA REQUIREMENTS WYNTER PARK#1 / B2 L27 WYNTER PARK#1 B2 L26 SEPARATION DISTANCE NOTES: ALL ADJACENT LOTS SERVED BY PUBLIC WELL THE PROPOSED SEPTIC IS GREATER THAN: 100' FROM ANY PRIVATE WELLS 200' FROM ANY PUBLIC WELLS 100' FROM ANY SURFACE WATER 10' TO ANY PROPERTY LINE OR FOUNDATION SCALE: 1" = 30' LEGAL DESCRIPTION: WYNTER PARK #1 BLOCK 2 LOT 20 C&M ENGINEERING SERVICES OWNER:GROSKREUTZ DATE: 7/12/20 1 REV. DRA 907-854-5558 SITE PLAN <v= J O / *'49 TM '*fel I / • • I CHARLES G BALZARM • � I •, i Sp �'c� •• CE -13854 �RK�F �R II isTF�Fo • ;i2 i ;o . �AN" >>�_ pROFESSIONP .� 200' WELL RADIUS 1 FLAG PRIOR TO Q CONSTRUCTION cp �c9 EST HOLE / — 5X4 AINFIELD �j WITH 3' EFFECTIVE SEWER ROCK 8' MAX PROPOSED 427 / EXCAVATION 2 BEDROOM HOUSE — DOUBLE CLEANOUTS I 5X,44 RESERVE SITE ADD'L SOILS EXPLORATION A6 DESIGN REQUIRED 0� 0 WYNTER PARK#1 B2 L21 0 NEIGHBORING SEPTIC 0 WYNTER PARK#1 B2 L25 \ WYNTER PARK#1 V @� B2 L19 / / WYNTER PARK#1 B2 L20 / 1000 GAL HDPE TANK / WITH INSULATED MANHOLE RISER AT / FIRST COMPARTMENT / DEMOLISH OLD TANK PER MOA REQUIREMENTS WYNTER PARK#1 / B2 L27 WYNTER PARK#1 B2 L26 SEPARATION DISTANCE NOTES: ALL ADJACENT LOTS SERVED BY PUBLIC WELL THE PROPOSED SEPTIC IS GREATER THAN: 100' FROM ANY PRIVATE WELLS 200' FROM ANY PUBLIC WELLS 100' FROM ANY SURFACE WATER 10' TO ANY PROPERTY LINE OR FOUNDATION SCALE: 1" = 30' LEGAL DESCRIPTION: WYNTER PARK #1 BLOCK 2 LOT 20 C&M ENGINEERING SERVICES OWNER:GROSKREUTZ DATE: 7/12/20 1 REV. DRA 907-854-5558 SITE PLAN CHARLES G BALZARINI CE-13854R EGISTEREDPROFESSIONALE NGINEER 8/10/20 NOAH GROSKREUTZ WYNTER PARK#1 B2 L20 10/27/18 NO 6/19/20 NA 6/19/201 4:24 0 2-0/16" 2 4:34 10 5-5/16" 3 4:35 0 2-0/16" 4 4:45 10 5-4/16" 5 4:46 0 2-0/16" 6 4:56 10 5-4/16" TOPSOIL SM 0" 3-5/16" 0" 3-4/16" 0" 3-4/16" LAST 6 READINGS SHOWN, PERFORMED FOR 1 HOUR. 5 6 3 CHARLES BALZARINI CHARLES BALZARINI 6/29/20 SW W/ GRAVEL AND COBBLES 6" None FILL 6/19/20 6/19/20 6/19/20 6/19/20 6/19/20 6"+ Water drained from perc hole within 30 minutes during pre-soak phase Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201285, Rebecca Carroll, 08/20/20 C&M ENGINEERING SERVICES Ph: 907-854-5558 SPECIFICATIONS FOR ONSITE SEPTIC SYSTEM LEGAL: WYNTER PARK#1 BLOCK 2 LOT 20 7/7/2020 A. GENERAL 1. The septic design is for a 3 bedroom, single family residence only. 2. The site plan and drawings shall be a part of this specification. 3. The Wastewater system shall be installed by a certified installer or qualified homeowner. All materials and workmanship shall meet the Anchorage Department of Health requirements. 4. All soil tests are advisory to the design and are to be verified or modified in the field by the engineer. The engineer shall perform percolation tests and groundwater monitoring prior to finalizing design. An additional Test hole and percolation test is required during construction. 5. All excavations and depths are advisory and are to be verified in the field by the contractor to meet Municipality of Anchorage. 6. A licensed surveyor should locate all nearby lot lines, easements, exact well radius from the neighboring on-site wells, and any nearby surface water. 7. The excavation is to be exactly in the area shown on the site plan, any deviation requires engineer approval. 8. Any remaining open test hole excavations shall be filled and monitor tube removed, after construction of the Drainfield. 9. The installer shall familiarize himself with the current code requirements for inspection notification and notify the engineer at least 24 hours prior to beginning work. 10. The installer is responsible for the correct installation of the system and adherence to construction requirements. 11. The contractor shall check the grades for the tank and leach field prior to commencing work to ensure gravity flow is achieved. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201285, Rebecca Carroll, 08/20/20 B. SEPTIC TANK 1. Septic tank shall be a HDPE, 1000 GALLON tank capacity of MOA approved construction. Installed to meet MOA and manufacturer requirements. The tank must have an insulated manhole riser serving the first compartment. 2. A combination of soil and 4” minimum of insulation shall be placed over the tank, to prevent ponding and promote drainage. The insulation shall be rated for burial and meet moa requirements. 3. Tank shall be bedded and backfilled per manufacturer recommendations. C. DRAINFIELD 1. The Drainfield is to be located as shown on the site plan. Notify Engineer of any changed site conditions. 2. The total depth of the initial drainfield excavation is to be at maximum depth as shown on the plans. The maximum depth is measured from the highest point of existing grade at the trench excavation. Bottom of excavation shall be level +/- 1.5” max. If bedrock or inconsistent soils are encountered, notify the engineer immediately. 3. In the event of over-excavation, a moa filter sand shall be used to maintain the required depth.The top of the sand layer shall be level, plus or minus 0.5”, and raked, prior to placing sewer rock. Care shall be taken to not compact the sand. 4. The effective layer of sewer rock is to be placed in the trench at the depth shown on the plans. The 4” effluent piping is to be buried within the gravel layer with 2” of sewer rock cover over the piping. 5. The Distribution pipe shall be 4” perforated pvc pipe conforming to ASTM D3034. 6. The complete Drainfield gravel and piping is to be covered with a geotextile filter fabric. 7. Soil or combination of soil and extruded board insulation to a depth of 3’ or equivalent is to be placed over the drainfield(s). Mounded side slopes shall not to exceed 3:1. The minimum insulation thickness shall be 2”. Insulation shall be moa approved and rated for burial. 8. The soils at this site may contain fines such as silt and clay. Rake sidewalls and bottom of trench to remove any smears from excavation. 9. Any old septic system components shall be demolished or decommissioned in accordance with moa requirements. MUNICIPALITY OF ANCHORAGE Development Services Department _ Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Septic System Owner -installer Agreement The On-site Water and Wastewater Section (On-site) may issue an approval for a homeowner to perform work on an on-site wastewater disposal system to serve that individual's owner - occupied, single-family or duplex home if the homeowner meets and agrees to the following requirements: 1. The property owner and excavation equipment operator may perform work on no more than one owner -installation project in a 12 -month period. 2. Owner's projected active involvement with the installation: AXI �/ , SkT 7' r. r im 4- �� 5�/4ti_ �W741.i�/ F/Jit/ - - eci -+ , 7 3. The name of the excavation equipment operator:�,��.; 4. 1 agree that there will be no monetary compensation for installation services rendered. 5. The name of the inspecting engineer: L'}�i7_ Z' , Cy -m 0� /- r9 6. 1 agree to discuss the following items with the inspecting engineer: a. Permit design criteria and specifications. b. Inspection requirements set forth in AMC 15.65.070. c. Advance notice given to the On-site Water & Wastewater Section for all required municipal inspections (AMC 15.65.070A). 7. 1 agree to have the project -specific On-site Wastewater Disposal System Permit available at the construction site for the duration of all related work. 8. 1 agree that if the system is an advanced wastewater treatment system (AWWTS), I will obtain additional installation instructions and approval from the equipment distributor. Yes As owner of (legal description) 1ASYA)IR TAICk- 41 I agree that the information above is true and accurate. Owner's printed nar Owner's signature: j ate:-�- ~6R~ ANCHORA6E AREA Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 ~H INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM LOC^T,D~ ~ G'4 . LEGALDESCR,PTION /.z o ~ ~ay,~,~ 5// SEPTIC TANK: INSIDE WIDTH LIQUID DEPTH , , INSIDE LENGTH LIQUID CAPACITY GALLONS. SEEPAGE PIT: NUMBER OF PITS LINING MATER AL ~'~ BUILDING FOUNDATION . · DIAMETER ~/~ OR WIDTH /'~/, LENGTHI21 DEPTH , , CRIB SIZE: DIAMETER , DEPTH r DISTANCE FROM: WELL TOTAL EFFECTIVE NEAREST LOT LINE . ABSORPTION AREA (WALL AREA) ~ ADDITIONAL ABSORPTION WELL: TYPE ~,~4~1~/~1/'~ CONSTRUCTION DEPTH DISTANCE FROM: BUILDING NEAREST NEAREST SEPTIC SEEPAGE FOUNDATION LOT LINE SEWER LINE TANK . SYSTEM CESSPOOL OTHER SOURCES APPROVED , ~ ~'V ~_ ,, .OT SLOPe: ~A.XS: ~m~ ~rm~ / I I ~ ~A.A.B, Form NO. EQ~31 �V/�UNC� /� L0TY 0 F° H C H 0 Ri,GEE Development Services Department �` Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Parcel I.D. 051 492 21 Certificate of On -Site Systems Approval Expiration Date: 1. GENERAL INFORMATION Complete legal description WYNTER PARK #1 BILK 2 LT 20 Location (site address) 21049 Sparkle Dr Current property owner(s) GROSKREUTZ Day phone Mailing address Real estate agent Day phone 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) F, ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ❑ Private Septic 0 Water Storage ❑ Holding Tank ❑ Community WellX❑ Community ❑ Public Water System [] Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 1 a Date of Payment 4- 12--'Z ( Receipt Number. ®1 2 3 � P COSA # 0 5 C 1)11 1( 3 Waiver Fee $ Date of Payment Receipt Number 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 Phone 8545558 Address 20182 TULWAR Engineer's Printed Name CHARLES BALZARINI Date 4/2/2021 6. DSD SIGNATURE .% System #1 Approved for System #2 Approved for Disapproved Conditional approval for 3 bedrooms bedrooms of ALgst�� C7 H 17 •�*7• •� CHARLES G BALZARINI . ��F�j•, CE -13854 .•��`�� ® pROFE5S10�4�"0� bedrooms, with the following stipulations: .1t(t(U flJ/i, r r 9, WAST_v`+1;AI TERIZ z J PROGRAM a By: Original Certificate Date: Lii 13.0 2 i 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 Checklist blue sheet COSA Checklist yellow sheet COSA Checklist Legal Description: Parcel ID: If more than 1 septic system on lot: COSA Checklist # of Structure served by this system A.WELL DATA W ell log is filed 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. 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) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date of Sample Comments __________________________________________________________________________________ B.T ANK DATA Age of tank(s) years Tank type/material Measured operating fluid level in septic tank Standpipes/foundation cleanout per record drawing Date of pumping C. LIFT STATION Required maintenance completed Age of lift station years Lift station material 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 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 Adequacy test date Results Pass For bedrooms Fluid depth prior to test in Water added gal New depth in Elapsed time min Final fluid depth in Absorption rate gpd Any rejuvenation treatment (past 12 months) If yes, enter date Comments/Deficiencies: septic COSA Checklist yellow sheet E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100’ Yes if No ft Neighboring Tank > 100’ Yes if No ft Absorption Field on Lot > 100’ Yes if No ft Neighboring Absorption Fields > 100’ Yes if No ft Community Sewer Main > 75’ Yes if No ft Community Sewer Manhole/Cleanout > 100’ Yes if No ft Private Sewer/Septic Line > 25’ Yes if No ft Holding Tank > 100’ Yes if No ft Animal Containment > 50’ Yes if No ft Manure/Animal Excreta Storage > 100’ Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10’ Yes if No ft Property Line > 5’ Yes if No ft Absorption Field > 5’ Yes if No ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ 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 Property Line > 10’ Yes if No ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft If absorption field is under driveway comment below Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No ft F. ENGINEER’S 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.