HomeMy WebLinkAboutEAGLE CREST #1 TR A LT 43MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: (907)343-7904
On -Site Water & Wastewater Section - Fax: (907)343-7997
Certificate of On -Site Systems Approval
OSC261190
Parcel ID 050 -304-08 Expiration Date: 5/27/2027
Legal description EAGLE CREST #1 TR A LT 43
site address 19512 SECOND ST
Current property owner(s)
TAVERNIER KENNETH S & SUSAN
X The On-site system(s) is/are approved for
3 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or conditions:
By: i1. ' /,�/ `J �'' Original Certificate Date:
6/11/2026
This,Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
�y&m(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage,
Development Service Department (DSD) issues COSAs based upon representations provided by an
independent professional engineer. The Municipality of Anchorage is not responsible for errors or
omissions in the professional engineer's submittal.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory X Arsenic Advisory
Other
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 050-304-08
Complete legal description EAGLE CREST #1 TR A LOT 43
Location (site address)
19512 SECOND STREET EAGLE RIVER, ALASKA 99577
Current property owner(s) TAVERNIER KENNETH & SUSAN
2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS
Day phone
3. TYPE OF WATER SUPPLY: ❑■ Private Well serving # 1 dwelling units
❑ Other Non-public well as regulated by MOA ❑ Water Storage
❑ Community Well or Public
4. TYPE OF WASTEWATER DISPOSAL: ® Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: ❑■ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass
Age 23 - See advisory if steel or fiberglass older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench ❑■ Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested: ❑
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $ ��� Li o Waiver Fee $
Date of Payment C' / P/ Z Date of Payment
COSA # C .SC Z- 4_ ( i C)i ; Waiver #
COSA Application_AW2025.doc
COSA Checklist.docx
COSA Checklist
Legal Description: EAGLE CREST #1 TR A LOT 43 Parcel ID: 050-304-08
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____
A. WELL DATA
Well log is filed with Onsite (or attached)
Date drilled 3/30/2003 Total depth 290 ft
Cased to 290 ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) 18 in.
Date of flow test for COSA 5/27/26
Static water level at beginning of test 248 ft.
Well production at time of test 4+ gpm
Water storage tank volume None gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate 2.45 mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by Date 5/27/26
Comments __________________________________________________________________________________
B. TANK DATA
Measured operating fluid level in septic tank 48"
Date of pumping 5/27/26
Required maintenance completed, if AWWTS
Comments:
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. DISPOSAL FIELD DATA
Which system tested (date installed) 4/3/2003
ALL standpipes present per record drawing
Total measured depth from grade 16.2 ft (max)
Measured depth to pipe invert from grade 6.4 ft (min)
N/A – pressurized field.
Per record drawings, field is insulated.
Monitor tubes (MT) go to bottom of effective (ED).
If not, state depth into effective
Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months) N
If yes, enter date
Adequacy test date 5/27/26
Results Pass
Fluid depth prior to test 0 in
Water added 450 gal
New fluid depth 3 in
Elapsed time 30 min
Final fluid depth 0 in
Absorption rate 450 gpd
FIELD STATUS – POST RECOVERY
Effective depth (per record drawings) 48 in (MOA 3.97’ ED)
Effective depth (ED) used 0 in (Final Fluid Depth)
Effective depth remaining 48 in
Comments/Deficiencies:
COSA Checklist.docx
E. SEPARATION DISTANCES
From Well on Lot to: (Please enter distances if less than required)
Septic Tank/Lift Station on Lot > 100’
Yes if No ft
Neighboring Tank > 100’ Yes if No ft
Disposal Field on Lot > 100’ Yes if No ft
Neighboring Disposal Fields > 100’
Yes if No ft
Sewer Line/Main > 100’ Yes if No ft
Sewer Manhole/Cleanout > 100’
Yes if No ft
Sewer Service/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
N/A – Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Disposal Field(s) on Lot to: (Please enter distances if less than required)
Tank to Foundation > 10’ Yes if No *5+ ft
Field to Foundation > 10’ Yes if No ft
Tank to Property Line > 5’ Yes if No ft
Field to Property Line > 10’ Yes if No ft
Water Main/Service Line > 10’ Yes if No ft
Surface Water > 100’ Yes if No ft
Wells on Adjacent Lots:
Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No ft
If tank or field is under driveway comment below
F. ENGINEER’S COMMENTS
*MET CODE AT TIME OF INSTALL, 5’+ SEPERATION FROM TANK TO FOUNDATION.
G. CERTIFICATION & 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, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Engineer’s Printed Name CURTIS HUFFMAN, PE Date 06/10/2026
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. The assessment of the condition of the well and septic
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface, changes in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. The operational life of all well and septic systems are subject to
these various and dynamic characteristics and are outside the control of the evaluator of the
well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting &
06/10/26
Septic Tank Advisory
Certificate of On -Site Systems Approval # OSC261190
Subdivision: Eagle Crest #1 Block:Tract A, Lot: 43
The septic tank for this property is 23 years old. The average life of an asphalt
coated steel septic tank is 20 years. Typical replacement costs are $15,000 or more,
not including engineering, surveying, MOA permitting fees or site restoration.
Steel septic tanks utilizing "Coal Tar Pitch" coatings are subject to corrosion as the
steel reacts to water and rusts. These tanks have a finite lifespan buried in the
ground. These tanks can become structurally compromised and pose a health risk.
They could collapse and/or leak untreated wastewater directly into groundwater.
In the interest of protecting public health and the environment, the Municipality of
Anchorage Development Services Department has issued Policy W.05 Standard of
Care Regarding the Inspection of Steel Septic Tanks when Performing COSA
Inspection. Please request a copy of this policy from the Department if interested.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
Mailing Address: P. 0. Box 196650 * Anchorage, Alaska 99519-6650 * www.muni.org
C) V/
CD
"q�
ce) (Y)
I- I—
CD
� 0)
W C (B
♦ ^ O LL
V �
a '
TO
i
U
Z
a_
LL
J
0
.o
cn
Z o
U)U)
U
o6
Cf) .
c >�
Q
O
00
Ali
LO
N
O
N
O
O
ai
cu
0
C
O
N
.Q
x
W
O
O
O
I
co
O
,It
O
M
0
O
a)
U
d
ti
LO
CD
cnQ
J >/
�Q N
r
*k W
CO CO
W 0
z
U O
W U
rJ Wn
V v )
W N
LO
c O
O
Q
U
N a)
a) �
ca
J (n
J
U)
Q
0
06
I..L
W
0
W
m
v
a)
c
O
Q-
0 O
Q
c
a)
7
U
U)
O
O
a
m
M
0
a)
>
O
Q
CL
m
()
c�
U)
E
a)
a
N
a)
c
O
H
m
c
O
co
a
U)
m
C
0
0
3
cn
0
O
a)
A
E
O
A
It
O
N
co
N
(i
a)
U
a)
U
c
0)
Al
v
O
00
O
d
-Q
O.
O
Y
a
a
-0
CL
O
3
N
.2
v,
Q
i
�
C
~
U)
~
�
O
f0
U
L
O
O
O
0
0
-
v
U
C
aNi
`
�
N
L-
co
r-
Q
CL
>
O U
•>
N
0
y
=
LL
O U
QO
=go
�t�
p
3
m
a.
o
.N
z Q
>
i
Q.
O
o
Rf
.Q
a)
C
L
O
Q
CL
C
Q
N
Q
OO
C
U
V
O
X
X
d
N
+'
p
`~
(j
=
o
+,
N
CO
u)
m
E
-0
o
0
Q
O
_
0
O
Q.
uJ
O
u
O
T)i
� >
y_
O
O
Qi
Q
L
U
IL -0
Q
N0
O
U
O
M
y
(nN
<
V)
0)
Z
W
(n
O
�
V
O
o
=
m
o
E
=
U
Q I— O
E
vii
I
m
a)
LL
aa))
,w
c
m
cJ
E
m co
Li d
0
O O
U o U
C
N
nLn♦♦
�y
/�-
LL
a)
c
N
_
U
0
>,
N
U
Q.
o
_
�
E
U
Q
E
U
N
�
U
U
A
0
CL
�.
Y
N
❑
U)
o
c>a
c
Q
a
�'
a)
>
o
O
~
LU
>
cn
Q
a)
❑
❑c
LLI0
Q
O
W
�
�
�
d
U
W
m
a
❑cm
a
^>
'm^
m
W
.�
W
W
�/�
N
I..L
��
•�
(n
�r
W
Q
❑
n�n''
L-
m
❑
N
T�!
LU
V�/
V_
•>
SIA
H
O
O
cm
d
=
�
>1
/�./�)
W
cn
UL
®
❑
U
N
0
Q
.�
V
0
❑
Q
(n
Z
06m
.J
L.
O
=M
I
>
cn
N
0
J
LU
CL
L
L
a
aS
a
L
-0
t9
r E
OW
N
cn
O
®❑❑
to
a_o
=,o
O
LL
Z
n
—)
Q
J
❑
a)
Q
ElE•�
V
O0
N
a
P:
oow❑
a.
U
M
a)
a
C)
W
®
>
Lu
=3
U) t)
OLL
o
fII
ui
H
w
H
F.
N
c�
w L
Z
o
°?
Z��?
a)
z
O
0
:
o
n.
co
a
ca
a)
W
LL
I- `�
a)
0) d
o
�.
-
L
= s
w
n
a
N
w
w
H
o
m
•�
LU
(0
0
o
7
W
0)m
N
-o
C. L
L7
a
U
J
U
O
1—
I—
N
Q
Q
r
N
M
�
CO
>>
>
n>
W
m w
m
a)
LL
aa))
,w
c
m
cJ
E
m co
Li d
0
O O
U o U
o
O
ICTO
M
O
LC)
O
p
a)
m
a
y
Y
y
T
fm
u
O
Z
w
®
Z
Z
J
J
rn
N
0
O
L
N
C
N
E
_O
❑
r
3
m
m
a)
O
N
"C
stl
w O
w
�,
U
O
N
o
] a
O
col
o
e%
> M
_
N
L
3 ,�
C
r/
Z
.r
_
O Z
cD
¢
a)
U
a)
N
C
w c
c
>
41
_
O
o
Z
®
O
T
r
NI
Q
LL
~ p
E
O
\❑
N. 1
@
I
U)
C
C
C1
C
O C)
>
o
�.
Z
cn
o
o
a,
col
o
NI
`nl
a
W
w
C:
@
-C
—`
C) ��
�.)
c
m
CO
N
-C
c
lnl
N
V I
L
I a
fn
C
�,
m✓
E
®
c
-C
a
a-
C
p L
S
a
o)
>
Q
-o
2
a�
a
-C
m
a)
a)
@
H n a
0-
C
O
c
N
c
UO
-0
-O
'0 -a
'0
a)
-oo
oE
LL
a)
m
'5
�
EN
> >N
>
co
a
o
o mt
U
.J
o
o
o
a
a)
�
m
(D
® z¢
tOLn
o
U❑¢
�
z
w
c
LL
mo
¢
w 0 0
u. w w
w
U
CO)
¢
E
0
U)
L
w
a)
E
c
p
o
E o
m
.E
w
o
zl
m
CD
o
mil
'-
0
E
N
I
M
C
>
C5
O
N
t
RQw
N
N
@
¢
N f6
N
-C
O
7�
C"OCac')
a
>�`
'L
o
M
o
c
Em
°
a)
�MC
+I
o
cl
a)
_0
- O
E
-0 ^ O
o
N
m
E
_
co
�U`
(n
c
N
o
a)
F
C'4
O
Q
D
O
L
O
m
0
F-
)
�)
>
E
o
w a
X
)
�
c o
dO
En
-EC
a)
O
�
C
O
O
O
UO
O
ce)O
O0
)
C
a)
^
-0
>C
E
N
N
C
�W
LL
"C c -
CL
N
o a
CM`j Y
N d
C
C
Z
N
6 O QC
fc6,
OaEa,N
n
Q_JQ.1
O
N
m
C
m
O
aC
a)
-C
C
Q
�
C141
QC
Q)
a
>
QU
o
E
C
C
c-
0
0
m
O
@
)
U)
p
L
p
o
a
0
I
a)
ca
Y
m
'EN
o
Z
-
o
m
(
o
'�
O
N m
Ln-
M
'0
m .0o N
O 7 M
a)
CD
N
=0
-0
-0
C
()
Z
n
a)
AU)
o
C
n
_
a)E N
.d
°LC�
W
a
N
C
O
E
:3
O
E
m
M
o
m ioi
2U••3
o
E
o
E
¢
U
®®
U
U
®
El
Q®
UU m
y
T
fm
u
COSA Checklist.docx
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
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
N/A – Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10’ Yes if No *5+ ft
Tank to Property Line > 5’ Yes if No ft
Field to 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
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No ft
If tank or field is under driveway comment below
F. ENGINEER’S COMMENTS
*5’+ SEPTIC TANK TO FOUNDATION SEPARATION PER CODE AT TIME OF INSTALLATION.
G. CERTIFICATION & 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, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Engineer’s Printed Name CURTIS HUFFMAN, PE Date 6/19/24
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. The assessment of the condition of the well and septic
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface, changes in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. The operational life of all well and septic systems are subject to
these various and dynamic characteristics and are outside the control of the evaluator of the
well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting &
6/19/24
O
L
Q
Q
Q
E
4.1
Ln
Ln
d N
o rn
4-
�
n
O
N
M
Q
fD
E
O
M
L
p
fB
Q
O
Qo1 `i
0
1
4�
(B
W
U_
al
v
a
tin
co
U
OLA
N
U
cu
p
U
�
a1
O
�
rn
Ln
•'
�_
U
L
a+
N
IL
d
°
�
a
v
O
cli
0
c
L'
Q
A
v
O
U
ro
u
�
L
O
bD
m
.y
Q
�C
N
O
4�
a
F -a _
Q
O
CD
QJ
v
Z p
°'
aJ
>
4J
�
L-.
`�
Zo,
+,
�%
N
cn
�_
co
Duj
Ln
cu
cu
NU
v@ v
O
N
O
u
N
Eb
Ln
> 3
O
�
w
�c
+�
a
C
w
W
a
bD
O
O
C
w 41
N
p
V
4J
'O
Q-
.1--i
O
O aj E
�
ro
J 41
w �n 3
L
-0
N
(p
i-.�
Ln
3
C
a O
U
cn
H
°
H
O
L
Q
Q
Q
E
4.1
Ln
Ln
LI V� U lJ V `CEJ PDi\ L. � TY 0 F /\ ll U C H ®R,/t GE
Development Services Department -343-7904
On -Site Water & Wastewater Section - Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 050 304 08
1. GENERAL INFORMATION
Complete legal description
Expiration Date
EAGLE CREST #1 TR A LT 43
Location (site address) 19512 SECOND ST
Current property owner(s) STENDER
Mailing address
Real estate agent
2. TYPE OF DWELLING:
Fx-1 Single Family (w/ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
Day phone
Day phone
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
0
Private Septic
0
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: NONE
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 55v Waiver Fee $
Date of Payment l y Date of Payment
Receipt Number dig 5 3J Receipt Number
COSA# 0SC2ZA35o Waiver#
Distance:
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater
disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in
effect at the time of installation.
Name of Firm C&M ENGINEERING Phone 8545558
Address 20182 TULWAR
Engineer's Printed Name CHARLES BALZARINI Date 7/11/22
OF Ak.
*: 49 TH •.* I
6. DSD SIGNATURE• •
r.... H .
System #1 Approved for bedrooms rr CHARLES G BALZARINf
System #2 Approved for bedrooms ��`���% CE -13854 , •. ��r�
Disapproved �i1i`��PROFE6s1oNP��r�
Conditional approval for bedrooms, with the following stipulations:
B
Original Certificate Date: —1 "
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
COSA Checklist
Legal Description: EAGLE CREST #1 TRACT A LOT 43 Parcel ID: 050 304 08
If more than 1 septic system on lot: COSA Checklist # 1 of 1 Structure served by this system 1
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled 2003
Total depth 290 ft
Cased to 290 ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) +18 in.
Date of flow test for COSA 7/8/22
Static water level at beginning of test 252 ft.
Comments
B. TANK DATA
Age of tank(s) 19 years
Tank type/material STEEL SEPTIC
Measured operating fluid level in septic tank 50
❑ Standpipes/foundation cleanout per record drawing
Date of pumping 7/12/22
D. ABSORPTION FIELD DATA TRENCH
Well production at time of test +4.1 apm
Water storage tank volume gallons
Well disinfected for coliform test? ❑ Yes ❑ N
❑ Coliform bacteria is Negative
Nitrate 1.08 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by A.LAMSON (C&M Engineering)
Date of Sample 7/7/22
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Which system tested (date installed) 2003
Adequacy test date 7/8122
❑ ALL standpipes present per record drawing
Results ❑✓ Pass For 3 bedrooms
Total measured depth from grade 10 ft (max)
Fluid depth prior to test 0 in
Measured depth to pipe invert from grade 6 ft (min)
Water added 450 gal
❑ N/A — pressurized field
0
New depth in
❑ Monitor tubes go to bottom of effective. If not, state
10
depth into effective
Elapsed time min
❑ Code -required soil cover over field
Final fluid depth 0 in
❑ System presoaked
Absorption rate 450 gpd
(Required if vacant for greater than 30 days prior to
Any rejuvenation treatment (past 12 months) NO
date of test)
Gallons introduced gallons
If yes, enter date NA
Comments/Deficiencies: DEPTH MEASUREMENTS AT WEST SIDE OF FIELD.
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'
111 Yes
if No
Community Sewer Manhole/Cleanout > 100'
Q Yes
if No
ft
M 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' M✓ Yes
if No
ft
Holding Tank > 100' R1 Yes
if No ft
Neighboring Absorption Fields > 100'
Yes
if No
Animal Containment > 50' n✓ Yes
if No ft
Q✓ Yes
if No
ft
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' Yes
if No
ft
0 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' Q Yes if No ft
Property Line > 5'
111 Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'✓Q
Yes
if No
ft
Private Wells > 100' Yes if No ft
Water Main > 10'
IZI Yes
if No
ft
Community Wells > 200' 0 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'
IZI
Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'✓Q
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'
0
Yes
if No
ft
Community Wells > 200' 0 Yes if No ft
Surface Water > 100'
0
Yes
if No
ft
F. ENGINEER'S COMMENTS
LANDSCAPING FEATURES OVER LEACHFIELD DO NOT APPEAR TO IMPACT
PERFORMANCE. ALL SEPTIC TUBES ARE CUT CLOSE TO GRADE AND MAY BE HARD.
TO FIND IN WINTER.
G. ENGINEER'S CERTIFICATION
l 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. 7/11/22
COSA Checklist yellow sheet
`®co -7-y
TH
.. ....
j
CHARLES G BALZARINd,_ 0
���sTF�• CE-13854AMW
•����
���F�pROFESSIONP