HomeMy WebLinkAboutZIMMERMAN LT 1Onsite File
Zimmerman
Lot 1
#015-484-22
Formerly T12N R3W Sec 15
Lots 142 S180’ & L143 S180’
GREA,ER ANCHORAGE AREA BOR .JGH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska !)9503
.......... IN~PiiC:fioN REPORT ON]~ITE SE~/'AGE DISPOSAL SYSTEM
LOCATION LEGAL DESC R IPTION~d~'I
SE. PTI C TANK:
DISTANCE
FROM WELL.
INSIDE LENGTN
INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY//~::~.~_-~)GALLONS.
TILE DRAIN FIELD:
DISTANCE FROM WELL //O~___FOUNDATION 7 NEAREST LDT LINE
NUMBER OF LINES [ ~ DISTANCE BETWEEN LINES _ TRENCH WIDTII IN. TOTAL EFFECTIVE
ABSORPTION AREA ~ SQ, FT. LENGTH OF EACN LINE
DEPTII: TOP OF TILE TO FINISH GRADE ~ MATERIAL BENEATH TILE ~ABOVE TIle IN.
BUILDING
FOUNDATION .....
CESSPOOL
APPROVED .
NEAREST
LOT LINE
OTI4E R SOURCES
DISAPPROVE[)
DEPTH
NEAREST SEPTIC SEEPAGE
SEWER LINE TANK , SYSTEM
REMARKS_
DISTANCE FROM:
DISTANCES:
INSTALLED BY:
SEWER LINE DEPTH:
LOT SLOPE:
REMARKS:
DIAGRAM OF SYSTEM
Form LQ-032
WATER WELL LOG
FOSS DRILLING
1336 Ingra Street
Anchorage, Alaska 99501
~ S 15. ~>~ / ·
SIZE OF CASING~DEPTH OF HOLEc~T. CASED TO
FEET OF DRAWDOWN.
FT.
REMARKS
/ f~ t
",~ ,~. ,, WATER %~Z-LL LOG /~/~ __.
· -~ ,' cF!
-, ' ~o,~ ~+ ~i, V. FOSS DRILLING
, .~ ~/.
~F~ OF D~DO~.
o
Pou 6-650, 9950~, - 25181'1. Tudm'I~.
Ancho~'a~e, Alnska
Ih~s fort, reports: So, Is log ~-~ Percox~t]on tesL . ~,o~Z~.~
~_ / ~.~X~ t ~z...~ - ~ ........ ~'/4~ ......
~,las ground water encountered? /~{~ If yes, at what depth?
Reading Date
Gross Time [ Net: Time Depth to 1t20 Net Drop
Z-~ --'I ........ '-
........... Z
........................ ................ i~;_-'""~£1Li Z] .................. _Z Z.'ZZU_-Z_-__ZYZ -__ZL
,'ercolation rate .......... nil rule,
roposed installation: Seepage Pit Orain Field
~2l:': of In}et . Depth to bottom of pit or ~h . . .
er~'orl.led [~y:/~(?~/JT~?~ ~Z:Cert'lfled By~'h ~--WZ2 Date: ~--~-
Certificate of On -Site Systems Approval
Parcel 1. D. 015 484 22
1. GENERAL INFORMATION
Complete legal description ZIMMERMAN LOT 1
Location (site address) 4901 E 104th
Current property owner(s) Castle
Mailing address
Real estate agent
2. TYPE OF DWELLING:
❑ Single Family (w/ADU)
❑ Duplex
Fx� Multiple Dwellings (Single Family and/or Duplex)
Expiration Date:. -b{' C tI � d
Day phone
Day phone
3. NUMBER OF BEDROOMS:
3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
El
Private Septic
2
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
COSA # O s C 2 11.5 a V 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
Address 20182 TULWAR
Engineer's Printed Name CHARLES BALZARINI
6. DSD SIGNATURE
System #1 Approved for 3 bedrooms
System #2 Approved for bedrooms
Disapproved
Phone 8545558
Date 7/22/21
7701
491 TH
. ,'......
CHARLES G BALZARKI
FFG • CE -13854 •��`��
PROFESSlO�A�
Conditional approval for bedrooms, with the following stipulations:
By: Original Certificate Date:
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
Well 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. TANK DATA
Age of tank(s) years
Tank type/material
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
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:
3ODVWLF
Measured operating fluid level in septic tank
Standpipes/foundation cleanout per record drawing
Date of pumping
D. ABSORPTION FIELD DATA ______________________
Which system tested (date installed)
Zimmerman Lot 1 015 484 22
11 1
+4.8
7/29/77 na
268
268
3.24
+12 C&M ENGINEERING
8/16/21
237
8/23/21
44
SEPTIC
48
8/9/2021
Trench
1977 8/16/21
3
7.5 9
4 800
9
0
3.5
0
750
NA
NA
Monitor tube is a capped steel pipe. Water depth measurements relative to bottom of monitor tube
✔
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.8/30/21
✔✔
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✔✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
Cleanouts have been added to both sides of tank since construction.
✔
PLAT NO. 2019-42
ZIMMERMAN SUBDIVISION
LOT 1
60,045 S.F.
BUILDING DETAIL
SCALE: 1 "=20'
-AS-BU 1 L,T
I HEREBY CERTIFY THAT I HAVE SURVEYED THE
GAS fALDI LAND
PROPERTY DEPICTED ABOVE AND THAT NO
SURVEYING, LLC
ENCROACHMENTS EXIST EXCEPT AS INDICATED.
JEFF A. GASTALDI, R.LS.
IT IS THE RESPONSIBILITY OF THE OWNER TO
2000 E. DOWUNG RD., SUITE 8
DETERMINE THE EXISTENCE OF ANY EASEMENTS
ANCHORAGE, ALASKA 99507
COVENANTS OR RESTRICTIONS WHICH DO NOT
PHONE 248-5454.
APPS ON THE RECORDED SUBDIVISION PLAT.
UNDER NO CIRCUMSTANCES SHOULD ANY DATA
GRID DATE
JESTABLISHING
HEREON BE USED FOR CONSTRUCTION OR FOR
SW2536 $/25/2021
BOUNDARY OR FENCE LINES.
F.B. JOB N0. ANCHORAGE RECORDING DISTRICT, ALASKA
BLM142AB I
NOTE: NO CORNERS SET THIS DATE
OF
40; A4
e'IN •. s -
• Co
°: s
49TH
■
m A A. Gastaldi : AF
LS -6091 ; AV
5/25/2021 .• a�
♦ f ■'ss*r
1 "=40'
• Municipality of Anchorage
On -Site Water and Wastewater Program <� -
(907) 343-7904
Certificate of On -Site Systems Approval
Parcel I.D. 015-484-11 Expiration Date:
1. GENERAL INFORMATION
Complete legal description TI 2N R3W Section 15 Lot 142 S180'
Location (site address) 4901 East 104th Avenue Anchorage, AK 99516
Current Property owner(s) Kimberly Michalek Day phone
Mailing address P.O. Box 110810 Anchorage, AK 99511
Real Estate Agent Cody Kelm Day phone 250-9558
2. TYPE OF DWELLING:
Q Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: Three
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
i]
Individual
i]
Individual Water Storage
❑
Holding Tank
❑
Community Class Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver/Variance request for:
Distance:
by the engineer.
COSA Fee $ 5 { 3 i 5 �= �%f Waiver Fee $
Date of Payment G — I Date of Payment
Receipt Number 00-1 y L( C7 Receipt Number
COSA # n SSC I (o 1-2 co Waiver #
17q— &-2_,Ih
0µ1 5&G
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 Anderson Engineering
Address P.O. Box 240773 Anchorage, AK 99524
Engineer's Printed Name Michael E. Anderson, P.E.
Phone 522-7773
Date 5/3
49 TH
94e80leo Leeba++.pn •. aTr'd.es!•e:a. •d
6. DSD SIGNATURE l'A I <_
_ RSON
System #1 Approved for bedrooms
r eT{ Slrg381 4>
System #2 Approved for _ bedrooms ��$�<y�o % ,� •. ���`
Disapproved ���� "�OF�s X10 a `a
Conditional approval for bedrooms, with the following stipulations:
DF A
I
62-2
By: \ \ V �t �� Original Certificate Date:
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 [he Stale: 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 blue shed/!'. :.t c - - - -
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: T1 2N R3W Section 15 Lot 142 S180'
A. WELL DATA
Parcel ID: 015-484-11
Well type Pdvate If A, B, or C provide PWSID # Well Log (Y/N) Y
Date completed 7/29/77 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y
Total depth 268 ft. Cased to 268 ft. Casing height (above ground) >18 in.
FROM WELL LOG AT INSPECTION
Date of test 7/29/77 5/28/2016
Static water level 243 ft 247 ft
Well production 8 g.p.m. 6.1 g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 mL Nitrate 4.89 mg/L
Arsenic ND ug/L Date of sample: 5/23/16 Collected by: And. Engineering
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Plastic Date installed 8/3/77
Tank size 1,000 gal. Number of Compartments 2 Cleanouts (YIN) Y
Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N
Date of pumping 4/29/2016 Pumper A Plus Home Services, Inc.
C. ABSORPTION FIELD DATA
Date installed 8/3/77 Soil rating (g.p.d./ft2 or fe/bdrm) 100 SF/BDRM
Length 33 ft. Width 3 ft.
Total depth 9 ft. Eff. absorption area 330 ff Monitoring tube.
Date of adequacy test 5/28/16 Results (Pass/Fail) Pass
System type Deep Trench
Gravel below pipe 5 ft.
Y Depression over field N
For 3 bedrooms
Fluid depth in absorption field before test 0 in. Water added 1.200 gal. New depth 10 in.
Elapsed Time: 1,440 min. Final fluid depth 0 in. Absorption rate >= 450 g p.d
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date
D. LIFT STATION
Date installed
"Pump on" level at
Datum
Size in gallons
in. "Pump off level at
E. SEPARATION DISTANCES
WELL ON LOT TO:
Cycles tested
Septic tank/lift station on lot >100,
Absorption field on tot > 100'
Public sewer main >75'
Sewer /septic service line >25'
Animal containment areas >50'
Manhole/Access (Y/N)
in. High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots >100'
On adjacent lots >100,
Public sewer manhole/cleanout >100,
Holding tank >75'
Manure/animal excrete storage areas >100'
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation >51 Property line >5
Water main >10 Water service line >10
Wells on adjacent lots >100'
ABSORPTION FIELD ON LOTTO:
Property line >10' Building foundation >10'
Water Service line >10' Surfacewater >100'
Curtain drain None Noted Wells on adjacent lots >100,
F. 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.
Engineer's Printed Name Michael E. Anderson, P.E.
Date 5/31/2016 N
COSA brown sheet 10-10-12.doc
Absorption field >51
Surface water >100'
Water main
>10'
Driveway, parking/vehicle storage > 10
U
in.
L E. ANDERSON w a
E-4381
8379SI
I N 100'± Lot 142 N 100'± Lot 143 ,
I I i I
I � I
I I
I S89°5$'32"E
I 164.96 — 164.96
gyp, a0
v I
r I
I
p CO S 230'± Lo 142 S 230'± Lot 143
J C7 I
r 2 Story Frame House M I M
with Basemen r I c
000 O Co O C!
�-• 00 I r i0 Q
M
7 I O
$. 26.3 ui 25.7' LU I llj
a _ I� m
r N 25.0 N (V
ca
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0 27.0 a i Io.� ' 10
z deck I h In link O I� _J
deck I m fen a kennelLO
m
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164.97 i i 164.97
o i N89058'25' W
I
50' BLM Road Reservation
SATE 1104th Avenue
t�. h q �01'
00.
00 ��'�1'
.:.:7•I. 5 ,� al.Fr d Wal . �/
s' 3 S s
SCALE: 1"= 50' 10 ssioruL
1�%\x",-�
EASEMENTS OF RECORD, OTHER THAN
THOSE SHOWN ON THE RECORDED
PLAT ARE NOT SHOWN HEREON. FH 13-1, pg 68 BE
AS -BUILT NO CORNERS SET THIS DATE
I hereby certify that I have performed a
of the following described property: Lot
100'±. (Reception No. 2005-029911-0)
Anchorage Recording District, Alaska, and that the
improvements situated thereon are within the property lines
and do not overlap or encroach on the property lying -
adjacent thereto, that no improvements on the property lying .
adjacent thereto encroach on the premises in question and
that there are no roadways, transmission lines or other
visible easements on said property except as indicated
hereon.
Dated at Anchorage. Alaska
this 20th dayof March ,2013.
FRED WALATKA & ASSOCIATES
Engineers and Surveyors
(907-246-1666)
15,
-_---------------I---------- -
I I C --50.0-
f
N 100'1 Lot 142 I N 100'± Lot 143
I
I
S89°58'32"E
164.96 164.96
S 230'± Lot 142 S 230'± Lot 143
QEast 140.00 (Book 19, 6 pg 958) I
J
Ce)
2 Story Frame House j M
with Basemen ,d r•
M I 0 1 0 a 0
•— tb 100
r
° 25.7 I
8. 26.3 N r? m LLI I W or X
m 1�
n - 25.0 a 29.
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N
• _
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27.0 > °IOdeck 00
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e °Well 0 I U c 'o I
w 1@ l n
E___ a-+—JIN890582511W
—V------------------ 0.0-�
164.97
z 1 i
164.97
MBLM Road Reservation
West 140.00 (Book 19, pg 958)04't tai t enue
REVISED 6-09-16 Added Lot Lines per Book 19, pg 958 Deed
a�
AS -BUILT NO CORNERS SET THIS DATE
SCALE: 1"= 50'
8379S
OF q�
A,
i '• 49th 0
00
00
rill' .Fred Walatka:Pa/
�T� • 3255 - S • ��e �.
&d oeW
'' �OFESSIONAI, ��
EASEMENTS OF RECORD, OTHER THAN
THOSE SHOWN ON THE RECORDED
PLAT ARE NOT SHOWN HEREON. FB 13-1, pg 68
1 hereby certify that I have performed a Mortgagee's inspection
of the following described property: Lots 142 & 143. Section 15,
T12N. R3W, S. M., AIC. Excepting therefrom the North
100'±. (Reception No. 2005-029911-0)
Anchorage Recording District, Alaska, and that the
improvements situated thereon are within the property lines
and do not overlap or encroach on the property tying
adjacent thereto, that no Improvements on the property lying
adjacent thereto encroach on the premises in question and
that there are no roadways., transmission lines or other
visible easements on said property except as indicated
hereon.
Dated at Anchorage, Alaska
this 20th day of March ,2013.
FRED WALATICA & ASSOCIATES
BE (907-248-1666) Engineers and Surveyors
Municipality of Anchorage
On-Site Water and Wastewater Program
(907) 343-7904
Certificate of On-Site Systems Approval
Parcel I.D. 015-484-1 1
Expiration Date:
1. GENERAL INFORMATION
Complete legal description T12N R3W Sec 15 Lot 142
Location (site address) 4901 E 104th Ave
Current Property owner(s) Martin & Kathryn Hoffer
Mailing address PO BOX 111633
Real Estate Agent
Day phone
Day phone
2. TYPE OF DWELLING: [] Single Family (w/wo ADU)
[] Duplex
[] Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
3
4. TYPE OF WATER SUPPLY:
Individual Well []
Individual Water Storage []
Community Class Well []
Public Water System []
TYPE OF WASTEWATER DISPOSAL:
Individual []
Holding Tank []
Community []
Public Sewer []
WaiverNariance request for:
.Distance
Received by:
COSA to be released to the engineer, unless otherwise requested by the engineer.
Date:
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 pr.o~e~res outlined in the Certificate of On-Site Systems Approval Guidelines for this application,
shows th~the~on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the nu'fflb~r of bedrooms and type of structure indicated herein. I further vedfy that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply in,d/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 Pannone Engineering Services LLC
Address P.O. Box 100217, Anchorage Ak. 99510
Engineer's Printed Name Steven R Pannone
bedrooms
6. DS~D .~¢~IATU RE
System #1 Approved for ~ bedrooms
System #2 Approved for __
Disapproved
Conditional approval for
Phone (907) 272-8218
bedrooms, with the following stipulations:
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 A~nic Advisory
Well Flow Advisory
COSAbluesheet ( '- !,,
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: T12N R3W Sec 15 Lot 142
A. WELL DATA
Well type Private
Date completed 7/29/77
Total depth 268 ft.
Date of test
Static water level 243
Well production 8
WATER SAMPLE RESULTS:
ifA, B, or C provide PWSID #
Sanitary seal (Y/N) Y
Cased to 268 ft.
FROM WELL LOG
7/29/77
g.p.m.
Coliform Neg colonies/100mL Nitrate 3.22 mgtL
Arsenic ND ug/L Dateofsample: 3/19/13
-~ / ~O JParcel ~D:015'484-11
Well Log (Y/N) Y
Wires properly protected (Y/N) Y
Casing height (above ground) 18 in.
AT INSPECTION
4/2/13
234 ft.
6.7
g.p.m.
Collected by: Nick Curtis
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Sunset/Plastic
Tanksize 1000 gal. Number of Compartments 2
Foundation cleanout (Y/N) Y Depression over tank (Y/N) N
Date of pumping ':~'~,/~-.,,~ Pumper
Date installed 8/3/77
Cleanouts (Y/N) Y
High water alarm (Y/N) N
C. ABSORPTION FIELD DATA
Date installed 8/3/77 Soil rating (g.p.d./ft2 or ft~/bdrm) 100sf/br
.3'
Length 33 ft. Width ff.
Total depth 9 ft. Eft. absorption area 300 r~ Monitoring tube Y
Date of adequacy test 4/2/13 Results (Pass/Fail) Pass
Fluid depth in absorption field before test 0 in. Water added 467
Elapsed Time: 70 min. Final fluid depth 0
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NO
System type Deep Trench
Gravel below pipe 5 ft.
--. Depression over field N
For 3 bedrooms
gal. New depth 0 in.
in. Absorption rate >= 450+ g.p.d,
If yes, give date
D. LIFT STATION
Date installed
"Pump on" level at __ in.
Datum
Size in gallons
"Pump off" level at in.
Cycles tested
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
in.
SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot 100+
Absorption field on lot 100+
Public sewer main 75-1'
Sewer/septic service line 25+
Animal containment areas 100'1'
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5+
Water main 10-t-
Wells on adjacent lots 100+
ABSORPTION FIELD ON LOT TO:
On adjacent lots 100+
On adjacent lots 100+
Public sewer manhole/cleanaut 100+
Holding tank '~ 00+
Manure/animal excrete storage areas 100+
Property line 5+
Water service line 10+
Property line 10+ Building foundation 10+
Water Service line 10+ Surface water '~ 00+
Curtain drain 50+ Wells on adjacent lots 100+
Absorption field 5+
Surface water 100+
Water main 10+
Driveway, parkingivehicle storage 10't'
F. 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.
Engineer's Printed Name Steven R. Pannone
Date
COSA brown sheet_10-10-t 2.doc