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Home My WebLink AboutCROSS VIEW ESTATES BLK 1 LT 22Cross View Estates Block Lot 22 #015-221-53 Municipality of Anchorage ~ Development Services Department Building Safety Division '~ On-Bite 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: swog0116 PIDNumber: 015-221.53 N~.: Harding Homes of Alaska, Inc. Wastewater System: [] New [] Upgrade Address: 9380 Autumn Ridge Clinic Anchorage, AK 99516 ABSORPTION FIELD 350-185o 6 ~'DeepTmnch r~ShallowTmncfl DBed DMound r~othen LEGAL DESCRIPTION .6 ~PD~FF 12-12.5 Ft. Block: 1 LO~: 22 Subdivision: Cross View Estates 3.5-4 Ft. 8 Ft. .2-1.5 Ft. 96 Ft. Well: [] New [] Upgrade a~ave~: Numberoflines: 3 Ft. 2 >16 Ft. Private 281 Ft. 281 Ft. 1,536 Ft2 ASTM D3034 PVC Alpine Drilling 9/27/09 245 Ft. Little Dipper 8/9-14/2009 Yield: 20 ~PM IPump s~"t:265 Ft. ICasing Height Ab°ye Gr°und:2 Ft. TANK SEPARATION DISTANCES [] septic [] Holding [] S.T.E.P. [] Other: To Septic Absorption LJf~ Holding .ublic/Private ~anufacturer: Caped[y: ~ Tank Field Station Tank Sewer Line Anchorage Tank 1,500 well >100' >100' N/A N/A >25' St_eel Two (2) Surfacewa~, >100' >100' N/A N/A ~ / LIFT STATION Lot Line >5' >10' N/A N/A Foundation >5' :>10' N/A N/A in in.I in. / ~ Pump Make & Model Electrical Inspections pen'on'ned by: Curlaln None Noted ,.~n~: BENCH MARK Lower Garage Slab ~gg.0 Pt. Inspections performed by: A. Hernia Dates: 1't 8/9/2009 ~,~-~_ .O~, ,~. _ · ., L'X~..°' ' °*' 2nd 8/11/2009 ~*"/-..~'" A Development Services Department Approval ~',...' 4~-u~ f./~, Conditional Approval Date: ~ 7'Y ~-6-,,.~ Reviewed and approved by: / g/~. to: ~-',,~.g~/-O 'l~,.F, fOrf,$$?~.~. Permit Number: swog0116 Municipality of Anchorage DEVEOPMENT SERVICES DEPARTMENT 4700 Elmore Road Anchorage, AK. 99519-6655 - 343-7904 PL~T NO. 2006-171 CROSS VIEW ESTATES SUBDIVISION LOT 2~.~,,~.~OCK 1 Page 2 of 3 PID No. 015-221-53 S2 C4 C5 M2 C6 g7 SV 10,4' 46.9' 80.4' 76.9` 61,4' 50.3' 79.4' 62.9` t. $'te Treatment System Six Bedroom Home 1 "=30' 'o HERITAGE HEIGHTS DRIVE PLAN AS-BUILT SCALE l' = 50' Permit Number: SW090116 Municipality of Anchorage DEVEOPMENT SERVICES DEPARTMENT 4700 Elmore Road Anchorage, AK. 99519-6655 - 343-7904 On-Site Wastewater Disposal System or Well Inspection Repor~ Page 3 of 3 PID No. 015-221-53 2,000 Gallon Septic Tank 89.8 Finished Grade ........... O_dgin_abGr_ound__ .... 94.2 Geotextile Fabdc Drainfield Rock % 89.8 81.8~' 75.0 48'(Trench Length) NoGmundwa~r 95.5 Finished Grade Geotextile Fabdc 89.6 ~ Dminfield Rock 81.6 48'(Trench Length) -- 89.6 PROFILE AS-BUILT No Scale ANDERSON ENGINEERING P.O. BOX 240773 ANCHORAGE, AK 99524 522-7773 677-7766 (FAX) MEMORANDUM DATE: June 23, 2010 TO: Jeff Poet FROM: Mike Anderson, P.E. SUBJECT: Lot 22, Block 1, Crossview Estates Subdivision Inspection ReportJCOSA We have made the following revisions in accordance with your comments: 1. The ground surface in the area of the absorption trenches was nearly flat once the organic material had been removed. The alignment of the trenches was modified by the contractor in the field for the ease of construction. The alignment of the trenches is parallel with the contours of the ground as required by Municipal code. 2. The legal description of the lot has been added to the water sample results. &700 DEPTH (fee0 ] 2 3 4 5 6 8 11 MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT BRAGAW STREET ANCHORAGE, AK 99519-6650 SOILS LOG - PERCOLATION TEST LEGAL DESCRIPTION: PERFORMED FOR: DATE: 9/8/2009 PARCEL ID#: OB/OG SILTY SAND WITH GRAVEL SN BOH @ 19' LOT 22, BLOCK I, CROSS VIEW ESTATES SUB. PROJECT No.: TECHNICIAN: HARDING HOMES OF ALASKA A. HARALA TEST HOLE A ] SLOPE No WAS GROUND WATER ENCOUNTEKED? __ · SITE PLAN SEE SITE [:LAN READING GROSS TItlE[NET TV'El INET DRoP < 'NUTES) I ( 'NUTES) I (,NCHES) I ('"C'ES) TEST HOLE PRESOAKED PRIOR TO TESTING: 1 7:13 2.75" 2 7:43 30 4.38" t.63" 3 7:45 2.25" 4 8:15 30 3.81" 1.56" 5 8:17 2.38" 6 8:47 30 3.94" 1.63" PERCOLATION RATE: 18.4 (MIN/INC~ PERC. HOLE DIA. 6" TEST RUN BETWEEN: 4.5 FT. and 5.5 FT. __frNc~s) 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 MUNICIPLE GUIDELINES IN EFFECT ON THIS DATE: 6/6/10 FROM :R1pin~ Drillin9 FRX NO. :907 345 0202 Jun. 02 2010 OI:04PM P2 Alpine Drilling & Enterprises Well Log Permit Number: ~SW090116 Date of Issue: 7-20-09 Date Started: 9-26-09 Date Completed: 9-27-09 Legal Description: Cross View Estates BIk 1 Lot 22 Property Owner Name & Address: Harding Homes of Alaska 9380 Autumn Ridge Circle Aqchorage, Alaska 99516 Borehole Data*. Depth (fi) Method of Drilling x air rotar~ [] ceble tool Soil Type, Thickness & Water $~ata From To Casing type.* stee! 0 2 Wall Thickness: .25 inches silt 2 gravelly silt 5 silty gravel 90 silt 141 gravelly silt 168 silty gravel 259 water sand & gravel 273 Parcel Identification Number: 050-221-53 is we[I located at approved permit location? x Yes [] No Diameter: _6 inches Depth: 28/feat 5 Liner Type: __ 90 Diameter: __ inches Depth: feet 141 Casing stickup above ground: 2 feet 168 Static water level (f~om ground level): 245 feet 259 Pumping level: 280 feet after 2_ hours pumping 20 gpm 273 RecoverY Rate: 20 gpm 281 Method of Testing: air lift Well Intake Opening Type: X Opon End [] Open Hole [] Screened Start __ fec, t Stopped__ feet [] Perforations Start__ feet Stopped ~,feet Grout Type: bentonite Eranul~ Volnme: 2 bgs Depth: Start 0 feet Stopped ? feet Pump: Intake Depth feet Pump size __ hp Brand Name __ Well Disinfected Upon Completion? x Yes [].No Method of Disinfection: chlorine]ablets Comments: Well Driller.* .4lpine Drilling & Enterprises PO Box 110496 ,4nchorage ,4K 99511 Mark Begich Mayor Development Services Department Building Sofety Division On-Site Water & Wastewater Program 4700 Elmore Street P.O. Box ).96650 Anchoroge, AK 995[9-6650 www.muni.orq/onsite (907) 343-7904 Pump Installation Log Well Drilling Permit Number: SW090116 Date of Issue: 6/1/10 Parcel Identification Number: 015-221-53 Replacement Only: YES NO Legal Description Lot 22, Block 1, Crossview Estates Property Owner Name & Address: IHarding Homes Pump Installation Date: 01/11/2010 Pump Intake Depth Below Top of Well Casing: 265 feet Pump Manufacturer's Name: Grundfos Pump Model: 15SQE15-290 Pump Size 1.5 hp Pitless Adapter Burial Depth: 15 feet Pitless Adapter Manufacturer's Name: Cambel Pitless Adapter Installer: N/A Well Disinfected Upon Completion? [] Yes [] No Method of Disinfection: Recirc Comments: Pump Installer Name: Aarow Pump & Well Service LLC PO Box l10496,Anchorage, AK. 99511 (907) 346- 9355 Attention: The pump installer shall provide a pmnp installation log to the DSD within 30 days of pump installation. Development Services Department On-Site Water & Wastewater Program 4700 South Bragaw Street (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM / WATER SUPPLY PERMIT Initial Date Issued: Jul 20, 2009 Expiration Date: Jul 20, 2010 Permit Number: SW090116 Legal Description: CROSS VIEW ESTATES BLK 1 LT 22 Design Engineer: 0014 ANDERSON ENGINEERING Owner Name: HARDING HOMES OF ALASKA Owner Address: 9380 AUTUMN RIDGE CIR ANCHORAGE, A 99516- Parcel ID: 015-221-53 Site Address: 5683 HERITAGE HEIGHTS Lot Size: 50687 SQ. FT. Total Bedrooms: 6 Permit Bedrooms: 6 This permit is for the construction of: [] Disposal Field [] Septic Tank [] Holding Tank [] Privy [] Private Well [] 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 engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. 5. The following special provisions. A. THE ENGINEER SHALL VERIFYTHE PERCOLATION RATE FOR THE ENTIRE DRAINFIELD, AND ALSO VERIFY THERE IS NO BEDROCK WITHIN SIX (6) FEET OF THE BOTTOM OF THE DRAINFIELD, PRIOR TO CONSTRUCTION. 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. ,,'.'; T. ,, ,. ,,. o ... ,,,..,, ,... Issued B .. Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, Alaska 99519-6650 www. muni.org/onsite (907) 343-7904 ON-SITE SEWER/WELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. 015-221-53 Property owner(s) Herding Homes of Alaska, Inc. Mailing address 9380 Autumn Ridge Circle Anchorage, AK Site address 5683 Heritage Heights Drive Anchorage, AK Day phone 350-1850 Zip Code 99516 Zip Code 99516 Legal description (Sub'd., Block & Lot) Lot,2~, Block 1, Cross View Estates Subdivision Legal description (Township, Range & Section) Lot Size 50,687 .Sq. Ft. Number of Bedrooms Six (6) THIS APPLICATION IS FOR ([~ all that apply): THIS APPLICATION IS AN: Absorption Field [] Initial Septic Tank [] Upgrade Holding Tank [] Renewal Privy [] Private Well [] Water Storage [] 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: 5'~-~)'~ ~) Receipt Number: (,~7C[ ~//~ (Rev. 11/05) Waiver Fees: Date of Payment: Receipt Number: July 8, 2009 Municipality of Anchorage Development Services Department On-Site Water and Wastewater Program 4700 South Bragaw Street Anchorage, AK 99519-6650 Su~e~: Lot 22, Block 1, Cross View Estates Subdivision Septic System Design and Permit Application Impacts to Adjacent Properties Dear Onsite Services Engineer: The owner of Lot 22, Block 1, Cross View Estates Subdivision intends to construct a new six-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 on the surrounding lots and 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 in the area of the absorption trenches and alternate site indicated silty sand and silt (SM/ML). The percolation rate of the soil was determined to be 7.5 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 .6 gallons per day per square foot was used in the design of the absorption system. We are proposing to place a new 2,000-gallon septic tank and 2-47' long by 3' wide by 8' 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 12'. A flow splitter valve will be placed to insure even flow to each trench. Only one test hole was placed on the lot during the subdivision process. The location of the new and alternate absorption sites are not entirely covered by the 30' radii from the test hole. The majority of the test holes placed in the subdivision however indicate similar soils. Most with faster percolation rates than those shown on the attached test hole log. Additional test holes will be placed during construction to verify soils conditions in the area of the absorption sites. Results will be forwarded with the Lot 22, Block 1, Cross View Estates Subdivision July 8, 2009 Page Two certified as built after construction has been completed. The ground surface on the lot in the area of the septic system slopes to the north at a shallow grade with some cross sloping from the east. The new trenches will be constructed parallel with the contours of the ground surface 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 23, BLOCK 1 ~ ~ Vacon~ ~C~K 1 l'~c.int V~c ant ~i,~--~~.~ ~~Z~--LZ~Z ZZZ LZ~ZZ Z ~ ~-L~Z AREA HAP PLAT NO. 2006-171 CROSS VIEW ESTATES SUBDIVISION LOT 22, BLOCK 1 50,687 S,F, 2-~-7" Lon x 3' Wide x 8' Effec~ve Depth Absorption Trenches Treatment System 2,000 Ballon Septic Tenk Six Bedroom Home Proposed Well SITE PLAN SCALE 1' = 50' LOT 22, BLOCK 1, CROSS VIEW ESTATES SUBDIVISION DESIGN FACTORS: SYSTEM REQUIREMENTS: Six Bedroom Home Deep Trench System Perc. Rate: 16-30 Min./Inch 2,000 Gallon Septic Tank Application Rate: .6 GPDtSF 8' Drainfield Rock 6 Bedrooms X 150 GPD/.6 GPD/SF (Application Rate) = 1,500 SF Absorption Area 1,500 SF116 SF/LF = 93.75 LF Trench Length THEREFORE: Construct 2 - 47' Long x 3' Wide × 8' Effective Depth Absorption Trenches at the Location Shown. Flow Line Elevation in Trench to be 4' Below Original Ground Surface. Total Depth to be 12' 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. ,.~"~Natu ral~ Backfill Geotextile Fabric 4" Perforated PVC (Holes Down) Drainfield Rock TYPICAL DEEP TRENCH SECTION -- -- ~SCA~E---~E~~ -- NOTE: Grade Area Over Trench to Drain Away. Minimum 61 Separation From Bedrock. ~.,..,~'......~..L.,~..,~.........~-~,.,.,~.},..~ Minimum 4 Separation From Groundwater. Minimum 100' Separation From Wells in the Area. ~.'£E"~'~:';,;~;~s'~'~'"'?.'~ Minimum 100' Separation From Surface Watar or Streams - ~:~ \ SOIL LOG - PERCOLATION TEST I~,j..I ...(:fT~...F~.......J!j LEGAL DESCRIPTION' HERITAGE HILLS SUBDIVISION ~1; TRACT CAD (PROPOSED LOT 2i) ' PERFORMED FOR: PROFESSIONAL TECHNICAL SERVICES DATE: 9/6/2005 ~A ~ LOAM SOIL C~SSFICATIONS 2~ ~ ~ 4~Ttt [I ~ GC ~ ~ OL I~Nt II ~ sw E ~ MH ~ ~ ~ ,~ SEE ATTACHED 7 a~*~ , DEPTH TO ATg 9 ~] ~ DRY 0/1~/2005 Ifllil II nAT~ ~ADINGI CLOCK I NETTIME I WATER LEVEL NETDROP IN'ti II 4 2:45 30 2" 4" 15 ~J~J ~ 6 3:15 ~0 2" 4" lg PERCOLATION RATE __ *7.5 ~MIN,/INCH) PERC. HOLE DIA. 6 (INCHES) ~ TEST RUN BETWEEN 5 FT. AND 6 FT. 20 A FOUR HOUR PRESOAK WAS PERFORMED: ~ YES ~ NO SOILS LOGGED BY: JODY MAUS PERCOLATION TEST PERFORMED BY: ~LEB GALL COMMENTS: * RECOMMEND USING A 0.6 APPLICATION RATE PERFORMED BY GEG, Ltd. I, dEFFREY A. GARNESS, CERTI~ THAT THIS WAS ~ERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDEUNES IN EFFECT ON THIS DATE: I~)J~i I DEPTH TO ~GROUNDWATER DATE DRY 9/6/2005 DRY 9/19/2005 Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Pamel I.D. 015-221-53 GENERAL INFORMATION Complete legal description Location (site address) COSA# ~-~-~'~4/~/4~' ~'- Expiration Date: C~ -. ~_~ ,~ Lot 22, Block 1, Cross View Estates Subdivision 5683 Hedtage Heights Drive Anchorage, AK 99516 --/'O Current Property owner(s) Harding Homes of Alaska Mailing address 9380 Autumn Ridge Cim[e Anchorage, AK 99507 Day phone 337-9109 Lending agency Day phone Mailing address Real Estate Agent MaitiagAddress Unless othe~vise requested, COSA will be held by DSD forpickup. 2. NUMBER OF BEDROOMS: Five (5) Day phone 3.- TYPE OF WAT~UPPLY: ............ ~PEOE WA,~TE~/ATERDJSPQSAL: Individual Well [] Individual On-site [] Individual Water Storage [] Individual Holding Tank [] Community Class __ Well [] Community On-site [] Public Water System [] Public Sewer [] The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems Approval (COSA) based onty upon the representations given in paragraph 4 by an indepepdent 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 ara 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 [] 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 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 Anderson Engineering Address P.O. Box 240773 Anchorage, AK 99524 Engineer's Printed Name Michael E. Anderson, P.E. 5. DSD SIGNATURE _..... L/'*~' APproved for ..~ Disapproved. Conditional approval for Phone 522-7773 bedrooms. Date 6/7/2010 ~,,';_~....,:~-. L/L: ..~ ;t. bedrooms, with the following stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory X Arsenic Advisory Maintenance Agreements S~pplemental 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 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.o~g/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: Lot 22, E]lock 1, Cross View Estates Subdivision A. WELL DATA Well type Pdvate Date completed 9/27/09 Total depth 281 ft. ifA, B, or C provide PWSlD # Sanitary seal (Y/N) Y Cased to 281 ft. FROM WELL LOG g.p.m. Nitrate 2.10 mg/L Date of sample: 5/03/10 Number of Compartments Two Depression over tank (Y/N) __ Pumper Date of test g/27/09 Static water level 245 Well production 20 WATER SAMPLE RESULTS: Coliform 0 colonies/100 mL Arsenic: NIP mg/I B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Tank size 2,000 gal. Foundation cleanout (Y/N) Y Date of pumping New Construction C. ABSORPTION FIELD DATA Date installed 11/10-14/09 Length 96 ft. Total depth 12-13 ft. Date of adequacy test Newconst. Parcel ID: 015-221-53 Well Log (Y/N) Y Wires properly protected (Y/N) Casing height (above ground) >24 AT INSPECTION g.p.m. Y in. Other bacteria 0 colonies/100 mL Collected by: M. Anderson N Date installed 8,9/09 Cleanouts (Y/N) Y High water alarm (Y/N) N Soil rating (g.p.d./ft2 or ff2/bdrm) .6 GPDISF System type Deep Trench Width 3 ft. Gravel below pipe 8 Eft. absorption area 1,536 ft2 Monitoring tube Y Depression over field __ Results (Pass/Fail) __ For bedrooms Fluid depth in absorption field before test in. Water added__ gal. New depth in. Elapsed Time: __ min. Final fluid depth in. Absorption rate >= g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date D. LIFT STATION Date installed "Pump on' level at __ in. Datum E. SEPARATION DISTANCES Size in gallons "Pump off" level at __ in. Cycles tested Absorption field on lot Public sewer main Sewer/septic service line Animal containment ames SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot >1oo' >100' N/A >25' None Manhole/Access (Y/N) High water elam3 level at Meets alarm & circuit requirements? On adjacent lots >1oo' On adjacent lots >1oo' Public sewer manhole/cleanout Holding tank N/A Manure/animal excrete storage areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Absorption field >5' Surface water >10o' Property line >1o' Water Service line >1o' Curtain drain None Noted F. COMMENTS: Water main >1 o' Driveway, parking/vehicle storage Building foundation >5` Property line >5' Water main N/A Water service line >1o' Wells on adjacent lots >1oo' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation >10' Surface water >100' Wells on adjacent lots >1oo' N/A in. CE.T,F,CAT,O. review of Municioal rec~rd.~ that thn nhnv= e~/etarn .... ;. ~.,o~a.~ wi. MOA COSA guidelines ,. effect on 'IS date. Engineers Printed Name M,chael E. ~de~n, P.E. Date 6~/2010 COSA Fee $ ~ ~ Waiver Date of Payment Receipt Number (Rev. ~11/05) Date of Payment Receipt Number Z