The URL can be used to link to this page

Home My WebLink AboutWILKEN LT 2Wl*lken Lot 2 #051-082-46 ,l RESERVE DRAIN FIELD (P) (2EA) 42LF x 5'W x 2.0'ED x 5.0'TD NEW PRIMARY DRAIN FIELD TH-2 SEPTIC AR (E) (2EA) 42LF x 5'W x 2.0'ED x 5.0'TD j- -7. 1�.a / --,,,,,,SEP-TIC AREA (E) C3C4 M3 Ma p NEW 12508 z 1 ��rr rz /-SEPTIC TANK w � NOTES: RECORD DRAWING DRAWN BY: NJC PLAN (T17f NEW 4BR HOUSE FC FC B M1 c' ICS A 1 I /M w Z2 1 W w > w• I o ~ U- Z w I�U 1 NEW WELL � 0✓11/'� I Z� -�� W- 5 WELL (E) PANNONE ENG SVC, LLC P.O. BOX 100217 ANCHORAGE, AK 99510 PHONE (907) 272-8218 FAX (907) 272-8211 WILKEN, LOT 2 KURT WILKEN C.O. MICHAEL ANDERSON SCENIC DRIVE CHUGIAK, AK 99567 �. OF A B FC 35.5 21.4 Ti 43.5 31 .0 T2 51.3 38.8 DC 53.7 41.2 FS 56.0 43.7 Cl 35.2 31.6 M1 36.6 32.8 _ C2 45.8 43.3 M2 47.8 45.0 C3 72.6 62.0 M3 71.6 60.8 .. C4 - 67.5 55.6 M4 66.7 53.7 C D WELL 29.2 46.1 NOTES: RECORD DRAWING DRAWN BY: NJC PLAN (T17f NEW 4BR HOUSE FC FC B M1 c' ICS A 1 I /M w Z2 1 W w > w• I o ~ U- Z w I�U 1 NEW WELL � 0✓11/'� I Z� -�� W- 5 WELL (E) PANNONE ENG SVC, LLC P.O. BOX 100217 ANCHORAGE, AK 99510 PHONE (907) 272-8218 FAX (907) 272-8211 WILKEN, LOT 2 KURT WILKEN C.O. MICHAEL ANDERSON SCENIC DRIVE CHUGIAK, AK 99567 �. OF Date 7/28/2016. . - I Scale - iSAP'' C *� 1"=50' ' • • • P.I.D.- NO 051-082-46 Steven R. Pannone CE 81-19 - .'<„�/� PERMIT N0. OSP161039 ('�liF4�OfES510i��'� Sh2e0F 3 w 91.9 91.7 12508 SEPTIC TANK NEW DESIGN PARAMETERS PRIMARY/RESERVE SEPTIC SYSTEM NO. BEDROOM: 4 (600 gpd) TANK SIZE: t868Ej. PERC RATE: 0.8 MPI SOIL RATING: 1 GPD/SF AREA ROD: 600 SF SYS. TYPE: WIDE TRENCH 2.0'ED RE: 0.70 MIN LENGTH: 84 LF USED: (2EA) 42 LFx5'Wx2.0' E.D., 5.0'TD TOTAL AREA: 600 SF CU - COPPER m MINIMUM O O w0 3� w FILTER FABRIC N Z w r `2S o� 0' � \ INSULATION p 91.9 91.7 12508 SEPTIC TANK NEW DESIGN PARAMETERS PRIMARY/RESERVE SEPTIC SYSTEM NO. BEDROOM: 4 (600 gpd) TANK SIZE: t868Ej. PERC RATE: 0.8 MPI SOIL RATING: 1 GPD/SF AREA ROD: 600 SF SYS. TYPE: WIDE TRENCH 2.0'ED RE: 0.70 MIN LENGTH: 84 LF USED: (2EA) 42 LFx5'Wx2.0' E.D., 5.0'TD TOTAL AREA: 600 SF 87 PROFILE LEGEND W WATER LINE/ WELL RADIUS — SS — NEW SEPTIC NOTES: PANNONE ENG SVC, LLC RECORD DRAWING P.O. BOX 100217 ANCHORAGE, AK 99510 PHONE (907) 272-8218 FAX (907) 272-8211 DRAWN BY: NJC WILKEN, LOT 2 KURT WILKEN C.O. MICHAEL ANDERSON 21300 SCENIC DRIVE DESIGN DETAILS CHUGIAK, AK 99567 TH-2 OR _10 S61 89.9 -2.5 87.9 I , SP/ 5.0 SM 82.9't 80.9 -12.0 ABBREVIATIONS CU - COPPER m MINIMUM TH FILL WITH TS&V r FOUNDATION CLEAN OUT w FILTER FABRIC � � o 0 ~ CLEAN OUT N0, r MONITOR TUBE NO. R.I. 0 DCO 4" 0 URAIN PIPE p 0 FS FLOW SPLITTER BFG z OG ROCK 6" AROVE PIPE INV fl 0, FINISH GRADE TS&V- �URAIN NIC NOT IN CONTRACT OFA./ i Date 7/29/2016 87 PROFILE LEGEND W WATER LINE/ WELL RADIUS — SS — NEW SEPTIC NOTES: PANNONE ENG SVC, LLC RECORD DRAWING P.O. BOX 100217 ANCHORAGE, AK 99510 PHONE (907) 272-8218 FAX (907) 272-8211 DRAWN BY: NJC WILKEN, LOT 2 KURT WILKEN C.O. MICHAEL ANDERSON 21300 SCENIC DRIVE DESIGN DETAILS CHUGIAK, AK 99567 TH-2 OR _10 S61 89.9 -2.5 87.9 I , SP/ 5.0 SM 82.9't 80.9 -12.0 ABBREVIATIONS CU - COPPER MIN MINIMUM TH TEST HOLE - - FC FOUNDATION CLEAN OUT T# TANK CLEAN OUT NO.. C# CLEAN OUT N0, M# MONITOR TUBE NO. R.I. RIGID INSULATION DCO DOUBLE CLEAN OUT DV DIVERTER VALVE FS FLOW SPLITTER BFG BELOW FINISH GRADE OG ORIGINAL GRADE FG FINISH GRADE TS&V- TOPSOIL AND VEGETATE NIC NOT IN CONTRACT OFA./ i Date 7/29/2016 -,j � vro Scole NTS ....... . ... ... �j P.I.D. NO 1-082-46 Steven R. Pannone PERMIT CE 8149 k- NO. OSP161039 �I. FRS_•••'.:, `v Sheet 3 O 3 1 d: TH-2 W SEPTIC -AR (E)- •10.0 \PRIMARY/ RESERVE DRAIN FIELD (P) MSEPTI �REA (E) JI ---l" (2EA) 42LF x 5'W x 2.0'ED x 5.0'TD y \ z / M\ w � iy a q 4BR W HOUSE w 0.0� h o 77 .70.a 7! (P) I- I c� P. 9. _10.0 / ' z ! w 1250g SEPT C TANK (P) WITH DOUBLE CLEAN OUT AND FOUNDATION CLEAN OUT IA$'C/fLL- FLpW �PNTTa� j i i NOTES: CHANGE ORDER PLAN '1 n 0u 10.9 I U' WELL (P)n DRIVEWAY J WELL (E) / PANNONE ENG SVC, LLC P.O. BOX 100217 ANCHORAGE, AK 99510 PHONE (907) 272-8218 FAX (907) 272-8211 WILKEN, LOT 2 KURT WILKEN C.O. MICHAEL ANDERSON SCENIC DRIVE CHUCIAK. AK 99567 M _lvk S\FP OF) l J -AA - I I�AREA (E) 4/2016 P.I.D. NO 051-082-46 •Steven R. Pannone / PERMIT NO. P CE 8149 ,•e OFES5101dP�".Ghee SPI 61039 �� QSS 1 OF 3 12509 SEPTIC TANK (P) DESIGN PARAMETERS PRIMARY/RESERVE SEPTIC SYSTEM NO. BEDROOM: 4 (600 gpd) TANK SIZE: i$ABg 1,.d So Gc,/ PERC RATE: 0.8 MPI SOIL RATING: 1 GPD/SF AREA ROD: 600 SF SYS. TYPE: WIDE TRENCH 2.0'ED RF: 0.70 MIN LENGTH: 84 LF USE: (2EA) 42 LFx5'Wx2.0' E.D., 5.0' TO TOTAL AREA: 600 SF PROFILE LEGEND W WATER LINE/ WELL RADIUS — SS — NEW SEPTIC ABBREVIATIONS CU COPPER MIN MINIMUM TH TH-2 MIN 0.5' FILL FILTER FABRIC 4" 0 DRAIN PIPE DRAIN ROCK 6" ABOVE PIPE INV FOUNDATION CLEAN OUT T# TANK CLEAN OUT NO. C# -1.0 OR I �- 3.0 Tai a l` R. 1. RIGID INSULATION DCO DOUBLE CLEAN OUT DV S ice.. FLOW SPUTTER BFG BELOW FINISH GRADE OG ORIGINAL GRADE FG 2.01_ TS&V TOPSOIL AND VEGETATE NIC NOT IN CONTRACT SP 1 [-5.0-I 10.0--s.O-i SM 5.0 9 -10,0 --1 87.3 —-11.0 86.3 SECTION -12.0 rr w z w MIN 0.5' FILL w "'0 Qo �n j FILTER FABRIC j z a w w O4U mw J z 4" 0 DRAIN PIPE z w U U O UU w Q Z Z O O J 4 OR MIN. R.I. o DRAIN ROCK 6" ABOVE PIPE INV 12509 SEPTIC TANK (P) DESIGN PARAMETERS PRIMARY/RESERVE SEPTIC SYSTEM NO. BEDROOM: 4 (600 gpd) TANK SIZE: i$ABg 1,.d So Gc,/ PERC RATE: 0.8 MPI SOIL RATING: 1 GPD/SF AREA ROD: 600 SF SYS. TYPE: WIDE TRENCH 2.0'ED RF: 0.70 MIN LENGTH: 84 LF USE: (2EA) 42 LFx5'Wx2.0' E.D., 5.0' TO TOTAL AREA: 600 SF PROFILE LEGEND W WATER LINE/ WELL RADIUS — SS — NEW SEPTIC ABBREVIATIONS CU COPPER MIN MINIMUM TH TEST HOLE FC FOUNDATION CLEAN OUT T# TANK CLEAN OUT NO. C# CLEAN OUT NO. M# MONITOR TUBE NO. R. 1. RIGID INSULATION DCO DOUBLE CLEAN OUT DV DIVERTER VALVE FS FLOW SPUTTER BFG BELOW FINISH GRADE OG ORIGINAL GRADE FG FINISH GRADE TS&V TOPSOIL AND VEGETATE NIC NOT IN CONTRACT NOTES: `��\� Date CHANGE ORDER P aN o 0aNE7 ENG CK 995L0 'C OF A�'gs��'1 4/14/2016 r. '� ( Scale PHONE (907) 272-8218 FAX (907) 272-8211 * . TH *'� NTS WILKEN, LOT 2 1 P.I.D. NO KURT WILKEN / 051-082-46 Steven R. ne / PERMIT N0. C.O. MICHAEL ANDERSON �t c. CE 8149 OSP161039 SCENDESIGN DETAILS CHU AKICADR199567 tIFQFppROF SSONP1& Sheet l\\\ `_W— 2 OF 4 SPECIAL PROVISIONS TO SPECIFICATIONS 1. ALL CONSTRUCTION SHALL BE INSTALLED AS SPECIFIED IN THE MOST CURRENT EDITION OF THE MUNICIPALITY OF ANCHORAGE STANDARD SPECIFICATIONS (MASS) FOR COMPONENT PARTS AND MATERIALS USED IN CONSTRUCTION OF ON—SITE WASTEWATER DISPOSAL SYSTEMS AND AND IN ACCORDANCE WITH AMC 15.65 AND 15.55. 2. SCOPE OF WORK: INSTALL NEW SEPTIC TANK AND SOIL ABSORPTION SYSTEM. INSTALL WELL. 3. GROUNDWATER WAS NOT ENCOUNTERED TO A DEPTH OF 10 FEET BELOW EXISTING GRADE AS EVIDENCED BY THE SOIL TEST HOLE. IF AN APPARENT WATER TABLE IS OBSERVED IN ANY OF THE EXCAVATIONS LESS THAN 10 FEET BELOW EXISTING GRADE NOTIFY THE ENGINEER IMMEDIATELY. 4. THE CONTRACTOR (BOTH WELL AND SEPTIC SYSTEM CONTRACTORS) SHALL HAVE ANY WELL LOCATION AND SEPTIC LOCATION STAKED AND ANY LOT LINE AND WELL RADIUS SHOWN ON THE PLAN WITHIN 30 FEET OF THE PROPOSED SYSTEM STAKED BY A REGISTERED LAND SURVEYOR BEFORE STARTING THE WORK. 5. THE CONTRACTOR IS RESPONSIBLE FOR ALL R.O.W. AND OTHER REQUIRED PERMITS, OTHER THAN THE ATTACHED, 6. THE CONTRACTOR SHALL CALL FOR LOCATING OF ALL BURIED UTILITIES. 7. THE CONTRACTOR SHALL PROVIDE 24 HOUR NOTICE TO THE ENGINEER PRIOR TO START OF WORK. ALL SURVEYING AND LOCATES SHALL BE IN PLACE PRIOR TO NOTIFYING THE ENGINEER. 8. THE CONTRACTOR SHALL NOTIFY THE ENGINEER OF ANY DISCREPANCY BETWEEN THE APPROVED DRAWINGS AND SITE CONDITIONS/LIMITATIONS POTENTIALLY CAUSING THE NEED TO MODIFY THE DESIGN. 9. AT THE COMPLETION OF THE WORK, THE CONTRACTOR SHALL SUBMIT RED—LINE AS—BUILT DRAWINGS TO THE ENGINEER. THE RED—LINES SHALL INCLUDE PIPE LENGTHS, ORIGINAL GROUND ELEVATIONS, PIPE ELEVATIONS, AND TANK ELEVATIONS. 10. THE CONTRACTOR SHALL PROVIDE PHOTOGRAPHS OF THE SYSTEM INSTALLATION TO INCLUDE BOTTOM OF EXCAVATION, TOP OF PIPE. WITH CLEAN—OUTS AND MONITOR TUBES INSTALLED, INSTALLED TANK AND FINAL GRADING. 11. THE CONTRACTOR PROVIDED DATA (UPON WHICH THIS RECORD DRAWING IS BASED) APPEARS TO REPRESENT THE PROJECT AS CONSTRUCTED, THIS DATA IN CONJUNCTION WITH THE PERIODIC FIELD OBSERVATIONS BY -THE ENGINEER (OR HIS DESIGNEE) AS REQUIRED BY AMC 15.65 DOES NOT GUARANTEE THAT THERE ARE NO HIDDEN DEFECTS BY THE CONTRACTOR. 12. THE CONTRACTOR SHALL SIGN THE FOLLOWING: I CERTIFY THAT ALL WORK WAS PERFORMED IN ACCORDANCE WITH THE APPEND PERMIT, AND ANY AND ALL CHANGE ORDERS, AND THAT THE AS—BUILT REDLINES ARE TRUE AND ACCURATE REPRESENTATION OF THE PROJECT AS CONSTRUCTED. - CONTRACTOR: BY: - - TITLE: NOTES: PANNONE ENG SVC, LLC— _Ny 101e OFA / CHANGE ORDER P.O. BOX 100217 ANCHORAGE, AK 99510 PCS "" qS��) 4 14 2016 Sca le PHONE (907) 272-8218 FAX (907) 272-8211 � * ,• TH '9 f`I NTS WILKEN, LOT 2 % "" ..."" P.LD. NO 051-0K- 6 KURT WILKEN / Steven'2" no / PERMIT NO. C.O. MICHAEL ANDERSON j�P/. CE 8149 .�� OSP161039 SCENIC DRIVE Sheet (s `'� CHUCIAK, AK 99567 + ligF�Pp njpNP DESIGN DETAILS �� 3 OF 4 SOILS LOG - PERCOLATION TEST TEST HOLE 2 OR ORGANICS 2 SM SILTY SAND 3 4-id yv 6 fet'7' SILTY SAND A SM ROUND ROCK 7 8 9 10 3/25115 411/15 11 5/28/15 12 BOH 13 14 15 16 7 18 DATE. 411115 19 DEPTH TO WATER AFTER MONITORING? -11.0' DATE: 5128/15 DATE PERFORMED: 2120115 PEROLATION RATE 0.8 (min/inch) PERC HOLE DIAMETER 6 inches TEST RUN BETWEEN 3 FT AND 4 FT COMMENTS: Test hole excavated by WHITTERS EXCAVATING. Prec hole was presoaked. Test run for at least one hour. Last 3 readings reported - - PERFORMED BY: Steven R. Pannone, P.E. I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDLINES IN EFFECT ON THE DATE OF THIS TEST. NOTES: 7��7�77�� 7�7�I �� `��\� Date CHANGE ORDER P,Q �NOBOX j9N 4 ENG SVAGE,C, 99 LO r �� OFA�,, lk � 4/14/2016 PHONE (907) 272-8218 FAX (907) 272-8211 /roj�P �y+r Scale 4 TH Nis WILKEN, LOT 2 % ""' "' / P.i.o. NO -46 KURT WILKEN }"'.'even R. ' non / PERMIT NO. C.O. MICHAEL ANDERSON IPF. CE 8149 OSP161039 SOILS LOG SCENIC DRIVE +,t�jFHfppR,'I".. Sheet CHUGIAK, AK 99567 �1l� 4 OF 4 SLOPE F SITE PL7�1 a I /� I SEPLIC AR (E) E) �\ rR—z AND S DATE CLOCK TIME NET TIME WATER LEVEL READING NET DROP 1 2/20!15 11:35 --- 2.50 -- z 11:39 4 MIN 8.50 6.00 a 11:45 --- 2.50 --- a 11:55 4.9 MIN 8.50 6.D0 s 11:55 -- 2.50 --- s X TH 11:40 aeR HOUSE rc 6.00 1 r \ 11 (P'E/ I N / IF `11' II ORIVEWPY I �Pnc 1 nREn (El WAS GROUND WATER SLOPE ENCOUNTERED? Y IF YES, AT WHAT TN X DEPTH? -10.0' DEPTH TO WATER AFTER MONITORING? -10.0' READING DATE CLOCK TIME NET TIME WATER LEVEL READING NET DROP 1 2/20!15 11:35 --- 2.50 -- z 11:39 4 MIN 8.50 6.00 a 11:45 --- 2.50 --- a 11:55 4.9 MIN 8.50 6.D0 s 11:55 -- 2.50 --- s 11:40 5.0 MIN 8.50 6.00 MUNICIPALITY OF ANCHORAGE Development Services Department 1' Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 051-082-46 1. GENERAL INFORMATION Complete legal description WILKEN LT 2 Location (site address) 21300 Scenic Dr Current property owner(s) Mailing address Real estate agent Expiration Date: l — f `1 —z I BANNAN LINDSEY S & DEBORAH G same 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 Day phone (907) 274-0170 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well Private Septic El Water Storage ❑ Holding Tank ❑ Community Well ❑ 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 $ 550 Date of Payment 7 0.2 1 Receipt Number 4-tS COSA# 05C �2 11 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. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm NorthRim Eng. Phone 694-7028 Address PO Box 770724, Eagle River Engineer's Printed Name Steve Eng Date 5/12/21 0A, jrAr Ar 6. DSD SIGNATURE _ Ce� * : 49__ * t System #1 Approved for bedrooms 0- - ' f, X System #2 Approved for bedrooms tc Steve Eng Disapproved♦CE-6256" N4, �:/�2/2Y* Conditional approval for bedrooms, with the following S ipulla ions: At -S Ww �T� `' 'AST NO rn �0-o GA,gM oz J J \ y: _ Original Certificate Date: The Municipality of Anchorage Development Semices 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 tvlunicipality 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 COSA Checklist Legal Description: WILKEN LT 2 Parcel ID: 051-082-46 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 3/31/16 Total depth 126 ft Cased to 118 ft ❑ Sanitary seal is functioning correctly Al Wires are properly protected Casing height (above ground) 18+ in. Date of flow test for COSA 5/20/21 Static water level at beginning of test 24 ft. Comments B. TANK DATA Age of tank(s) 5 years Tank type/material SPtcstl Measured operating fluid level in septic tank ❑ Standpipes/foundation cleanout per record drawing Date of pumping D. ABSORPTION FIELD DATA 6/29/16 Which system tested (date installed) same Al ALL standpipes present per record drawing Total measured depth from grade 8.5 ft (max) Measured depth to pipe invert from grade 6.5 ft (min) ❑ N/A – pressurized field OR 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 Comments/Deficiencies: COSA Checklist yellow sheet Well production at time of test 6+ 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 7.22 ug/L F–, Arsenic less than MRL (ND) Collected by NRimEng Date of Sample 5/21121 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 5/20'21 Results Q✓ Pass For 4 bedrooms Fluid depth prior to test 2 in Water added 600 gal New depth 5 in Elapsed time 30 min Final fluid depth 3 in Absorption rate 600 gpd Any rejuvenation treatment (past 12 months) no If yes, enter date E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if cornmunity,,vell Septic Tank/Lift Station onLot 1OD F/1 Yes Community Sewer Manhole/Cleanout 1O0' Yes JNoft, Property Line >1(/ F�1Yes if No Neighboring Tank >�100^ F�Yeo ifNoft Wells on Adjacent Lots-, Private Sewer/Septic Line >25'[�lYes if No AtmVrphonField nnLot >1OQ' F�Yen i[NnO Yes �� Holding Tank >�1O0' ��Yoo if No Neighboring Absorption Fields >�1O0' ��YeV ifNoft VVa\mrService Line >10' Animal Containment ?:SO' Yee if No F/�Yes ifNoft |fseptic tank isunder driveway comment below Manure/Animal Excreta Storage 1O0' Community Sewer Main >7S' F-11Yes|fNoM [JYes if No M ft ft D ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 1U S Yes if No ft Surface Water > 100' 21 Yes if No ft Property Line >5' F/1 Yes ifNoft Wells onAdjacent Lots: Property Line >1(/ Absorption Field > 5' Yes ifNoh Wells on Adjacent Lots-, Private Wells >1OO' Yes ifNoft Water Main >1O` ifNoh Yes ifNoft Water Service Line >10' Community Wells >2Q0' ��YeV ifNoft VVa\mrService Line >10' [� �^Ynn Community Wells >200' Yeo ifNo# i[Noft DYoe |fseptic tank isunder driveway comment below From Absorption Field onLot to: (Please enter distances if loss. than required) Building Foundation >10' Yes ifNn0 If absorption field hsunder driveway comment below Property Line >1(/ ��Yen KNoM Wells on Adjacent Lots-, Water Main >1J F/1 Yes ifNoh Private Wells >10O` Yes ifNuft Water Service Line >10' 21 Yes ifNoft Community Wells >200' Yeo ifNo# Surface Water >1UO DYoe ifNoft / certify that //sevmdetermined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA emireffect onthis date.