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HomeMy WebLinkAboutCROSS VIEW ESTATES BLK 2 LT 29Cross View Estates Block 2 Lot 29 #015-221-87 Permit Number: Tax Code Number: Work Type: On-Site Water & Wastewater System Permit 0SP121260 01522187000 WelISeptic 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 Initial Permit Effective Dates: September 17, 2012 to September 17, 2013 Design Engineer: ANDERSON ENGINEERING Subdivision: CROSS VIEW ESTATES Site Legal Address: CROSS VIEW ESTATES BLK 2 LT 29 G:2737 Owner/Address: H2L INVESTMENTS LLC 633 E 81ST AVE ANCHORAGE AK 995180000 Site Mailing Address: 5026 HERITAGE HEIGHTS DR, Anchorage Lot Size in Sq Ft: 47299 Total Bedrooms: 4 Department This permit is for the construction of: Y Disposal Field Y Septic Tank 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. Special Provisions: 7-Day groundwater monitoring results have not been provided for TH-1 (the design test hole). The results shall be submitted prior to or with the final inspection report. The contractor may proceed at his own risk pdor to obtaining the results with the understanding that the bottom of the drainfield shall be installed 4 feet minimum above the 7-day groundwater reading adjusted up 1 foot per month to an assumed October or May seasonal high level. Date: Date: MUNICIPALITY OF ANCHORAGE Community Development Department Development Services Division On-Site Water & Wastewater Program Mayor Dan Sullivan Phone: 907-343-7904 Fax: 907-343-7997 ON-SITE SEWERNVELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. 015-221-87 Property owner(s): H2L Investments Day phone: 350-1860 Mailing address: 633 East 81"t Avenue Anchorage, AK 99516 Site address: Heritage Heights Drive Anchorage, AK 99518 Legal description (Sub'd., Block & Lot): Cross View Estates, Block 2, Lot 29 Legal description (Township, Range & Section) Lot Size: 47,299 Sq. Ft. Number of Bedrooms: Four (4) THIS APPLICATION IS FOR: ([~ all that apply) Absorption Field X Septic Tank X Holding Tank [] Privy [] Private Well X Water Storage [] THIS APPLICATION IS AN: Initial X 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. Waiver Fees: Date of Payment: Receipt Number: Waiver No. C:~Users~AndEng\Desktop\Mike\Cross View Estates~Permit Application Lot 29 H2L.docC:\Users~AndEng\Desktop~Vlike\Cross View Estates~Permit Application Lot 29 H2L.doc ANDERSON ENGINEERING P,O. BOX 240773 ANCHORAGE; AK 99524 522-7773 677-7766 (FAX) August 16, 2012 Municipality of Anchorage Development Services Department On-Site Water and Wastewater Program 4700 South Bragaw Street Anchorage, AK 99519-6650 Su~e~: Lot 29, Block 2, Cross View Estates Subdivision Septic System Design and Permit Application Impacts to Adjacent Properties Dear Onsite Services Engineer: The owner of Lot 29, Block 2, Cross View 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 well and septic system along with the alternate site. Also identified on the plans are the existing wells in the area and septic systems on surrounding lots. No conflicts exist between the proposed septic system and well or septic systems and wells on adjacent lots. 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 on the lot during the subdivision phase in the area of the absorption trenches and alternate site indicate silty sand with gravel (SM/ML). The percolation rate of the soil was determined to be 60 minutes per inch. No groundwater was found during the placement of the test hole and none was noted during the monitoring period. An application rate of .45 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 2-56' long by 3' wide by 6' effective depth absorption trenches to treat and dispose of the effluent generated in the house. The elevation of the distribution line in the absorption trench will be 4' below the surface and the total depth will be 10'. A flow splitter valve will be placed to insure even flow to each trench. 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 29, Block 2, Cross Point Estates Subdivision August 16, 2012 Page Two The ground surface on the lot in the area of the septic system slopes to the west at a 5% grade with some cross sloping from the east. The new trenches 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' 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 LOT 2, 8LOCK l~w.~l~g LOT 26, BLOCK 2~ / / LOT 27, BLOCK 2 LOT 5, BLOCK 4 HERff.~E HILLS UNDEVELOPED LOT 1, BLOCK 1 UNDEVELOPED AREA MAP SCALE 1' = 100' CROSS PLAT NO. 2006-171 VIEW ESTATES SUBDIVISION LOT 2g, BLOCK 2 47,299 S,F. CO CO CO CO · 5% sv ' I I A.C. DRIVE 2-.5,6' Lon~ x 3" Wide x 8 Effecbve Depth Absorption Trenches ALTERNATE SITE Advontex Treatment System w/50' Long x 5' Wide x 6' Effective Depth Absorption Trench. 1 GPD/SF - App, Rote Proposed LEGEND MT - Monitor Tube Fao - Foundation Cleon Out TH - Test Hole CO - Clean Out 2C0 - Double Clean Out FSV - Flow Splitter Valve 2C0 1,250 Gallon Septic Tank Home N 89'58'30"£ 192.97' [--~--ELEVATIONS BASED ON 1972 NGS DATUM (TYP) NOTE: No Areas of Excessive Slope or \ \ \ \ \ \ \ \ / / / / / / / / Surface Water are Within 100' of Any Part of the New Septic System. SITE PLAN SCALE 1' = 40' LOT 29, BLOCK 2, CROSS VIEW ESTATES SUBDIVISION DESIGN FACTORS: SYSTEM REQUIREMENTS: Four Bedroom Home Deep Trench System Perc. Rate: 60 Min./Inch 1,250 Gallon Septic Tank Application Rate: .45 GPD/SF 6' Drainfield Rock 4 Bedrooms X 150 GPD/.45 GPD/SF (Application Rate) = 1,333.3 SF Absorption Area 1,333.3 SF/12 SF/LF = 111.1 LF Trench Length THEREFORE: Construct 2 - 56' Long x 3' Wide x 6' Effective Depth Absorption Trenches at the Location Shown. Flow Line Elevation in Trench to be 4' Below Original Ground Surface. Total Depth to be 10' Below Existing Ground. Provide 4' Cover Over Septic Tank and 3' Cover Over Absorption Trench. Maintain 100' Separation from Wells in the Area. Place Splitter Valve to Insure Even Flow to Each Trench. Natural Backfill \© Geotextile Fabric 4" Perforated PVC (Holes Down) Drainfield Rock t TYPICAL DEEP TRENCH SECTION -- -------~--s~ ~ M' ' ' ' · : 49th ~nlmum 6 Separation From Bedrock ...... ~.~..,.,.,~ .............. Minimum 4' Separation From Groundwater. ~~ Minimum 100' Separation From Wells in the Area, ~"'~'~'"'?~ Minimum 100' Separation From Sudace Water or Streams.~'~ ~' ~FESS~~ LE;AL DESCRIPTION' HERITAGE HILLS SUBD~ISION ~1 T~CT CaD (PROPOSEO LOT 60~ ~ '.~f [~ y~ A~S~/ , t DEPTH ~ (fa --- O.OANtCS [TH~eO/PTS~504] ¢~ SOIL C~SSIFICATIONS  GM CL GC OL  · ~ S~ MH Isc SITE PLAN DEPTH TO DATE GROUNDWATER DRY 8/50/2005 SM/ML '15' 9/19/2005 10 l~ DATE READING ELOGK NET TIHE WATER LEVEL NET DROP TIHE (HINUTES) READING (INCHES) 12 9/1/05 1 2:02 - 6- - 2 2:32 50 5 1/2" 1/2" 15 5 2:52 - 6- - 4 5:02 50 5 1/2" 1/2" 14 5 3:02 - 6- - 6 3:52 50 5 1/2" 1/2" 15 ~7 PERCOLATION RATE *60 (MIN./INCH) PERC. HOLE DIA. 6 (INCHES 19 TEST RUN BETWEEN 5 FT. AND 6 FT. 20 A FOU~ HOUR PRESOAK WAS PERFORHED: ~ YES ~ NO SOILS LOGGED BY: JODY MAUS PERCOLATION TEST PERFORHED BY: ~LEB GALL PERFORMED BY GEG, Ltd. I, JEFFR~ A. GARNESS, CERTI~ T~T THIS WAS PErFORmED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE: ttNl~ ~ DEPTH TO DATE GROUNDWATER DRY 8/50/2005 '15' 9/19/2005 MUNICIPALITY CSF be Development Services Department On -Site Water & Wastewater Section Parcel I.D. 015-221-87 ANCHORAGE Certificate of On -Site Systems Approval 1. GENERAL INFORMATION Phone: 907-343-7904 Fax: 907-343-7997 Expiration Date: 1 -2 ^ 20 Z f Complete legal description CROSS VIEW ESTATES BLK 2 LT 29 Location (site address) 5026 HERITAGE HE DR, ANCH. AK Current property owner(s) DANA & MICHELLE FITCHETT Day phone Mailing address SAME Real estate agent Day phone 2. TYPE OF DWELLING: ❑ Single Family (w/wo ADU) ❑ Duplexes ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well Fx_1 Private Septic Z Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ y 50 Coil I b - A 0 + 5 Waiver Fee ` Date of Payment 0' 2- Z O 2 O 1 1 I WV Date of Payment Receipt Number 00Z_ 775-1 0 0"79$gyp Receipt Number COSA # OS C -015 39 Waiver # Distance: r. 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 MIKE N ANDERSON, P.E. Phone 727-8864 Address 4661 NATRONA AVE ANCH AK Engineer's Printed Name MIKE N ANDERSON, P.E. Date 9-25-20 OFAW_ r 49TH 6. DSD SIGNATURE 4` .,•........ ... .....:... System #1 Approved for bedrooms .......,.... •• MICHAEL N. ANDERSCN System #2 Approved for bedrooms f �� c 9a Disapproved{;%�F� • 3i°;'-� 10 • e -•- Conditional approval for bedrooms, with the following stipulations ON-SITE j2 ON-SITE �n AST,,y'ATER g J PROGRAM By �� �C�G? Original Certificate Date: Z©ZC� 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 Septic System Advisory Well Flow Advisory COSA Checklist blue sheet Nitrate Advisory Arsenic Advisory Other Legal Description: CROSS VIEW ESTATES BLK 2 LT 29 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA ❑ Well fog is filed with Onsite (or attached) Date drilled 172912 Total depth 262 ft Cased to 262 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 20"+ in. Date of flow test for COSA 9130/20 Static water level at beginning of test 160 ft. Comments B. TANK DATA Age of tank(s) 2013 years Tank type/material StBBU rn. Measured operating fluid level in septic tank 48" ❑ Standpipes/foundation cleanout per record drawing Date of pumping Sept 2020 D. ABSORPTION FIELD DATA Which system tested (date installed) 3/8/13 ❑ ALL standpipes present per record drawing Total measured depth from grade "'13.25 ft (max) Measured depth to pipe invert from grade 7.25 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 0 gallons Comments/Deficiencies: 'West trench tested COSA Checklist yellow sheet Parcel ID: 015-221-87 Structure served by this system Well production at time of test 5+ gprn Water storage tank volume 0 gallons Well disinfected for coliform test? ❑ Yes ❑ No ❑ Coliform bacteria is Negative Nitrate 2.69 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by MNA Date of Sample 9125120 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 9/30/20 Results [✓ Pass For 4 bedrooms Fluid depth prior to test 13 in Water added 600+ gal New depth 26 in Elapsed time 1440 min Final fluid depth 13 in Absorption rate 600+ gpd Any rejuvenation treatment (past 12 months) If yes, enter date 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' Q✓ Yes if No Community Sewer Manhole/Cleanout > 100' ❑✓ Yes if No ft✓� Yes if No ft Neighboring Tank > 100' ✓❑ Yes if No ft Private Sewer/Septic Line > 25' ✓ Yes if No ft Absorption Field on Lot > 100' ❑✓ Yes if No ft Holding Tank > 100' ❑✓ Yes if No ft Neighboring Absorption Fields > 100' if No ft Animal Containment > 50' ❑✓ Yes if No ft [D Yes if No ft ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Manure/Animal Excreta Storage > 100'n Yes Community Sewer Main > 75' Q 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' Q✓ 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' [✓] Yes if No ft Private Wells > 100' ❑✓ Yes if No ft Water Main > 10' Q 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 *8 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' Q Yes if No ft Surface Water > 100' 0 Yes if No ft F. ENGINEER'S COMMENTS * SEE MOA FILE FOR WAIVER TO THE PROPERTY LINE G. ENGINEER'S CERTIFICATION I certify that 1 have determined through field inspections and review .� ���' ° • • • • ` �� t a of Municipal records that the above systems are in conformance with ,d h .• ` MOA COSA guidelines in effect on this date. ...r . • .......•.. f 1 •• MICHAEL N. ANDLRSCN;�ck- COSA CE -9 69 Checklist yellow sheet fQ P •t • • . • '�`�c.� ,71ii • • O �£ BU •- Municipality of Anchorage On-Site Water and Wastewater Program a iw I lik (907) 343-7904 SAFETY Certificate of On-Site Systems Approval Parcel I.D. 015-221-87 Expiration Date: I ^ Z U 1. GENERAL INFORMATION: Complete legal description CROSS VIEW ESTATES; BLOCK 2, LOT 29 Location (site address) 5026 Heritage Heights *Anchorage 99516 Current Property owner(s) Evan Budd Day phone 350-7218 Mailing address Real Estate Agent Day phone 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Distance: Received by: /1 Date: /�//(8 COSA to be released to the engineer,unless otherwise requested by the engineer. COSA Fee $ %t4 1 • (P0 Waiver Fee $ Date of Payment 1 i i?O1 g Date of Payment Receipt Number O s Li I Li `4 Receipt Number COSA# 05G(S)3O g Waiver# Dir' 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: Garness Engineering Group, Ltd (GEG) Phone: 907-337-6179 Address: 3701 East Tudor Road, Suite 101-Anchorage,Alaska 99507 Engineer's Printed Name: Jeffrey A. Garness Date: (0/261/v' �oQ000gO04 In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system o ' in accordance with the guidelines and regulations established by the Municipality of Anchorage and �� .• '1 industry practices. The reported results describe the condition of the system/s on the date/s of the Q P.• .•v 44Q evaluation. Separation distances were measured to readily identifiable features. Hidden defects or n_,0( � `►� •.encroachments may exist that were not identified during the evaluation. The operational life of all wells 1and septic systems depend upon a variety of variables, including but not limited to, soil conditions, t Q groundwater levels (that may fluctuate during the year), quality of construction (materials and 4 l ' vA workmanship),and the water usage of the family utilizing the system/s. These conditions can vary, and . . are outside the control of GEG. Satisfactory test results do not guarantee future performance of the ••.J f - . ness. system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of �Q E-795 QQ the well or septic system. GEG makes no representation whether an alternative well or septic system V 9 • j3 \c- can be installed on the property in the event either of the current systems fail to perform adequately in u4�,. 2./i.. the future. The content of this report is for the sole benefit of the person/party that retained GEG to 40 dprofes(s�ono\ perform the evaluation. Reliance upon the information provided in this report by any other person or �pOp• party (including subsequent property purchasers) is not authorized, nor will it confer any legal right whatsoever. #AECC884 6. DSD SIGNATURE System #1 Approved for I( bedrooms System #2 Approved for bedrooms OF /VC Disapproved /5' Conditional approval for bedrooms, with the followingpulaOIs$ITE Q WATER AND rr' m WASTEWATER o n; PROGRAM G • By: vL 1_.. ..-414.10it�,�1C ( Original Certificate Date: 1 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 Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheet 10-10-12.doc • If more than 1 septic system is on the lot: COSA Checklist# of Structure served by this system Certificate of On-Site Systems Approval Checklist Legal Description: CROSS VIEW ESTATES; BLOCK 2, LOT 29 Parcel ID: 015-221-87 A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N) YES Date completed 11/29/12 Sanitary seal (Y/N), Y Wires properly protected (Y/N) YES Total depth 262 ft. Cased to 262 ft. Casing height(above ground) 18+ in. FROM WELL LOG AT INSPECTION Date of test 11/29/12 6/21/18 Static water level 151 ft. 151 ft. Well production 20 g.p.m. 5.1+ g.p.m. WATER SAMPLE RESULTS: Coliform NEG colonies/100 ml. Nitrate-"I mg./L. Collected by: GEG, Ltd. - - Arsenic: 5 ug./L. Date of sample: 6/18/18 B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC/STEEL Date installed 3/8/13 Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) YES Foundation cleanout(Y/N) YES Depression over tank(YIN) NO High water alarm (Y/N) N/A Date of pumping 9/14/17 Pumper A+HOME SERVICES C. ABSORPTION FIELD DATA *BELOW EXISTING GRADE AT MONITORING TUBE WEST/EAST Date installed 3/8/13 Soil rating`q.p.d./ or ft2/bdrm) •45 System type DUAL DEEP TRENCH Length 56+56=112 ft. Width 3/3 ft. Gravel below pipe 6/6 ft. Total depth '13.1+ ft. Eff. absorption area 1344 ft2 Monitoring tube YES Depression over field NO Date of adequacy test 6/21/18 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test 23 in. Water added 811 gal. New depth 43 in. Elapsed Time: 150 min. Final fluid depth 32 in. Absorption rate >= 600+ g.p.d. Any rejuvenation treatment(past 12 mo.) (Y/N &type) NO If yes, give date - TESTED EAST TRENCH ONLY.WEST TRENCH WAS DRY. "1' • D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at in. "Pump off' level at •• •• wa er alarm level at in. III -•• Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ On adjacent lots 100'+ Absorption field on lot 100'+ On adjacent lots 100'+ Public sewer main 75+ Public sewer manhole/cleanout 100'+ Sewer/septic service line 25'+ Holding tank 75'+ Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation "5'+ Property line 5'+ Absorption field 5'+ (ASSUMED) Water main 10'+ Water service line 104 Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ""8 Building foundation 10'+ Water main 104 Water service line 10'+ Surface water 1004 Driveway, parking/vehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS "MET CODE AT TIME OF INSTALLATION ""WR#131065 10111.1rni II �E OF '•4 G. ENGINEER'S CERTIFICATION :�P,.••• �� I certify that I have determined through field inspections and • 1 49 • /N •\".• review of Municipal records that the above systems are in • • • conformance with MOA COSA guidelines in effect on this ••• it• .` hp" : cr• date. ♦�^'. J:" -y A. •f ess. Vn Engineer's Printed Name JEFFREY A.GARNESS •••.,,'�/ •CE S 4t�.. e,_r Date 6/2°I/l'd •�4k PR ESS‘�P4.• LICENSE �I\it"`ik**� #AECC884 (Rev.10/12/12)