HomeMy WebLinkAboutPROSPECT HEIGHTS BLK 2 LT 8
.. Municipality of Anchorage Page
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: ,~JffS'ol;~z. 'PID Number:
Name: ~'o H'~ 6bo~'4 ~ ,~o Wastewater System: ~ New D Upgrade
Address:
~ ~. ~ A~. ~,~os A~,.;A~.~o~ ABSORPTION FIELD
Phone: ~ ~ ~C C No. of B~rooms: ~ Deep Trench ~ Shallow Trench ~ Bed ~ Mound ~ Other
LEGAL DESCRIPTION Soil Rating: / - Z GPD/Sq. Ft. Total Depth from j°riginaIo ' grade:
Lot; Block: Subdiv~ion: Depth to pipe bottom from original grade: Gravel depth beneath pipe
Township: Range: Section: Fill added above original grade: Gravel length:
Number of lines: Distance be~een lines:
WELL: ~ New ~ Upgrade Graveiwidth: ~' ~ Ft. I ~ Ft.
Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material:
Driller: Date Drilled: Static Water Level: Installer: ~C~GE Date installed:
Yield: Pump Set at: Casing Height Above Ground:
SEPARATION DISTANCES ~ se,t,c ~ Ho~,n~ ~ S.T.~.P.
To Septic Absorption Lift Holding =ublic/Private Manufacturer: Cap~cityin gallons:
From Tank Field Station Tank Sewer Lines ~ ~ ~ ~
Material: Number of Compa~ments:
su..c~ , LIFT STATION
Water Joe + Joe ~ ~ ~
Lot ~ ~O/ Size in gall°ns: I Manufacturer: ~ "~ :
Line ~ ~
"Pump on" eve at~ff" level at: High water alarm at:
Foundation ~ ~ ~ ~ ~+ ....~ i "
Cu~ain Pump Ma~l Electrical Inspections pedormed by:
Drain ~ h d~E ~ ~
Remarks: ~T~47E ~K~c~ ~~0. BENCH MARK
Location and Description:
,J ~sumed Elevation: .,
Inspections performed by: s & s ENGINEERING
Eagle River, AlasEa ~5~ 2nd. ~ - zs- ~
Department of Health and Human Se~ices approval
Reviewed and approved by: ~~ ~ Date: 7-fl/-~
Pea'mit No,
SW950132 Page 2 of 2
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
LegalDescription: LOT 8, BLOCK 2, PROSPECT HEIGHTS S/D PIDNo.: 015-135-17
FCO 3-.5' 11.5'
ST1 3, ' 15'
ST2 2; .5' 23.5
DBL1 2' .5' 25' ._,3~¢ ~/[ SPRINGS
DBL2 2' .5' 26' /// /I MAIl rAINED MINIMUM
DV $,~' 51.5' '~' 'l SETB,~CK TO SURFACE
C01 $,~' 51.5'
CO3 6 .5' 42.5'
(;04 ~: bo- .
MT1 4 .5' 63'
C05 4'" 74.5' ,
MT2 4'" 75' ~ ~50' SETBA
C06 1 ,5' 55' / ' ~ / SLOPE
'5 Inous
INSUreD U DER BEWE 1 NSTALLEO (INST~EB 6-25-9
D FLOW D R R
~99.5' II
o 8E US RE
I LNEW 12 ~0 GAL
~ X~WSSO GAL __~ ~ , ~PTIC TANK
9 ' ~95
LT. ,
A 85.6'
100'
WATER.
72-O13 A (Rev. 9/91) MOA 25
K FROM
JUN-20-19gG 12:27 FROM THE BLOMFIELD CO TO 6g41211 P.02
~ ~ - ~'~ ~,.
~ATE OF A~8~ "
DEPA~M~T OF NATU~L R~OURC~
D~ION OF ~J~fNO · WAT~ MGM~
~O~TION O~ ~ WATER W~L R~ORD
LOCATIONISK~CH: ~L O~:
~.~ . .,'.>
............ '" .......... Depth of
Martial ~pe a~d Co~r From To
~ - / M~HOD OF DRILLING: ~-air
W~ INTAKE O~ING TY~
....... ~ perforated ,~ open
Depth; 0f 0~o~ngs:
$CRE~ ~PE: DEem:
GROUT TYPE: Voice:
~ f '
Municipality o~ Ar ;~orage D~ELOPM~T M~U~Dt ~,4 ,
PUMPING L~ AND YIE~
~MP I~AKE D~Ht ~ .
CONTRACTOR INFORMATIOht: REMARK;:
PLEASE MAlL WHITE COPY OF LO0 TO:
DNmDIVlSlON OF MININO& WATER MGMT
PO BOX 10700E
ANGHORAGE AK
TOTRL P. 02
Rick Mystrom.
Mayor
Municipality of Anchorage
Department of Health and Human Services
625 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
June 27, 1996
Sandra Ilene Blomfield
7610 Wildwood Circle
Anchorage, Alaska 99516 1015
Subject: Lot 8 Block 2 Prospect Heights Subdivision
Permit #SW950132, PID ~015-133-17
The subject permit, issued June 27, 1995 by this office for a
single family well and/or on-site wastewater system, has
expired as of June 27, 1996.
A new permit must be obtained from this office for a well
and/or on-site wastewater system NOT installed by the
expiration date.
If you have drilled the well, a well log must be sent to
this office for documentation of the installation and to
close the permit.
If a licensed Professional Engineer has inspected the
installation of the on-site wastewater system, the original
as-built inspection report must be sent to this office for
review, approval and documentation. All inspection reports
must be submitted within 30 days of construction completion°
When applying for a new permit, the fees are: $320.00 for an
on-site wastewater permit; $120.00 for a well permit and
$440.00 for a combined on-site wastewater and well permit.
If you have any questions, please call this office at 343-4744.
/~.7~rely'
Program Manager
On-site Services
enc:
Copy of Permit
cc: S & S Engineering
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NLrMBER:SW950132
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:BLOMFIELD SANDRA ILENE
OWNER ADDRESS:10200 PROSPECT DR
ANCHORAGE, AK 99516
DATE ISSUED: 6/27/95
EXPIRATION DATE: 6/27/96
PARCEL ID:01513317
LEGAL DESCRIPTION:
PROSPECT HEIGHTS BLK
2 LT 8
LOT SIZE: 82500 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM
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 DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
ROBERT C. COWAN, P.E.
ROBERTA. SHAFER, P.E.
June 2, 1995
CIVIL ENGINEERS
HEALTH AUTHORflY
APPROVALS
SEWER&WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOILTEST
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ON SITE
WASTEWATER
DISPOSAL SYSTEM
DESIGN
(907) 694-2979
FAX (907) 694-1211
MUNICIPALITY OF ANCHORAGE
Department of H~alth and Human Services
P.O. Box 196650
Anchora9e, AK 99519
REFERENCE: Lot 8; Block 2; Prospect. H~ights
/~ec~cre~t 9'0- issu-e ape. rm,~ ta ~ a tue,~ a. nd Z. n6~ a se~ptie, sb'stem
to ~se~ue the p~po,sed ~oruc bed,'mora kou~e on ~ ne~e~eneed pc. opera.
A test hole was excavated and a percolation test performed. The
approximate location of the t~st hole is located on the attached site
plan.
At the time of excavation, water was encountered at 15 fe~t and after
seven day ground water monitoring ~ter was found at 15 fe~t.
This property has cnough ar~a for a future septic upgrade which can be
seen on the attached site plan.
We do not anti,pate any adverse effects on n~ighboring properties by
the i~tallation of the proposed septic system. There are no point~
of co~[mi~on within the proposed w~llradius which can be seen on
the attached site plan.
The proposed 1250 gallon septic tank is to be placed outside the w~ll
protective radius. Attached is a site plan which depicts the location
of the proposed tank.
If you requ~e additional information, please contact us.
Sincerely,
Robert C. Cowan, P.E.
RCC/gk
Enclosure
17034 NORTH EAGLE RIVER LOOP · SUITE 204 * EAGLE RIVER. ALASKA 99577
Z
ZO
m~.~
~2o
a__O
too_
,,, <
~°~
N91S3CI ['
NYqd 3.LIS ,0~ = ,,~
.'1" = 50'
8GALE
0
O0
lc/)
Fq
(il
EDZ
DESIGN
ISITE PLAN
--i00
--I
0
>z
tOC.)
.TiT
-<
1
I~" (DO--I--
I--'t ou) O
I' z..-4 ~ 02
m~.m<
>~ 0
/
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L' Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
LEGAL D E S C R I PT I O N .'~O~c.i-~
1
2 /~L
3
8
9
10
11
12
13
14
5
16
17
18
19
2O
COMMENTS '-~/~'~ c F,)('~.~, ~/,cl-"~/~.:.~P
DATE
/ ~ownship, Range, Section:
WAS GROUND WATER
ENCOUNTERED?
SLOPE SITE PLAN
S
IF YES, AT WHAT (~ C',lr~' ~
DEPTH? ~/"T p
Depth to Water After ~
Monitoring? l.~ Date: ~!-~L[q~
Gross Net Depth to Net
Reading ' Date Time Time Water Drop
P.: ~o ~ ~%" -
:~% ~,~ ~ ~ /,/~"
~ s~ ~ ~ V~" _
· ~o ~,~ ~ s/~" I'/~"
: ~ ~ ~ 5~/~'' l Yy"
PERCOLATION RATE
TEST RUN BET~/EEN
(minutes/inch) PERC HOLE DIAMETER
FT AND ~ FT
$ & $ ENGINEERING
PERFORMED BY: '~ ~'~'~ ~'u~- R;v~r i.~p Rea~i No. 'JO~, CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE W~TH AF~I~it~e~I~41(~9~[L;'Z~U~DEU NES ~N EFFECT ON THiS DATE. .
72-008 (Rev. 4/85)
ROBERT C. COWAN, P.E.
ROBERTA. SHAFER, RE.
CIVIL ENGINEERS
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION PRACTICES
and
MATERIAL SPECIFICATIONS
(907) 694-2979
FAX (907) 694-1211
HEALTH AUTHORITY
APPROVALS
SEWER&WATER
MAIN EXTENSIONS
SEWER&WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOWTEST
SITE pLANS
ROAD DESIGN
SOILTEST
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
ON SITE
WASTEWATER
DISPOSAL SYSTEM
DESIGN
REFERENCE:
Lot 8, Block 2, Prospect Heights S/D
June 2, 1995
GENERAL:
The scope of this project includes the installation of
a 1250 gallon septic tank and a leachfield trench to
serve the proposed four bedroom residence for the
referenced property.
2e
Construction shall be in accordance with the approved
site plan and design drawings, Municipal permit with
any special provisions or conditions, and all
applicable State and Municipal Wastewater Disposal
Regulations.
The contractor shall be responsible for obtaining any
necessary underground utility locates.
e
Unless specifically agreed otherwise, the property
owner shall be responsible for final grading areas
subsequently depressed from soil settling. On all
leachfield mound systems, the property owner shall be
responsible for ensuring a satisfactory vegetation
growth over the mounded area.
Se
Contractors installing wastewater disposal systems
must be certified by the Municipal Health Department
for system installations. Owners installing their own
systems must also receive prior approval from the
Municipal Health Department.
SEPTIC TANK INSTALLATION:
A septic tank is to be constructed by a certified
septic tank manufacturer. Construction shall include
two 4" cleanouts for pumping access.
The septic tank shall be sufficiently bedded to
prevent settling or shifting of the tank.
3e
Ail standpipes on the septic tank shall extend a
minimum of 12 inches above final grade.
17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577
Page Two
Lot 8, Block 2, Prospect Heights S/D
June 2, 1995
Se
Se
Septic tanks installed with less than 4 ft. of cover shall
be insulated.
A foundation cleanout shall be installed one to four feet
from the building foundation. In the line between the tank
and the leachfield there shall be two adjacent cleanouts
(unless an effluent pumping system exists within the septic
tank). These cleanouts shall be located on undisturbed
soil not more than 10 ft. from the tank. The first
cleanout, in line, shall be to clean toward the leachfield.
The second cleanout shall be to clean toward the septic
tank.
Final grading over the septic tank shall be such that a
positive slope exists away from the septic tank.
ABSORPTION TRENCH/DRAINFIELD INSTALLATION:
Excavate the proposed trench to the dimensions shown on the
design. The bottom of the excavation shall be within 2
inches of level. If the sidewalls of the excavation become
smeared, they must be raked or scratched (ruffed-up) before
gravel (sewer rock) placement.
Once the gravel is installed, the distribution pipe is to
be installed level with the perforations faced downward.
Gravel is then to be placed over the distribution pipe to
provide a minimum of 2 inches of cover over the pipe.
A silt barrier must be installed between the final gravel
layer and the native soil backfill. Ensure the silt
barrier covers the entire gravel surface before placing
backfill.
e
Monitor tubes shall be of four (4) inch diameter,
installed approximately in the locations shown on the
design, and extend a minimum of 12 inches above final
grade. The portion of the monitoring tube extending
through the gravel shall be perforated from the bottom of
the trench to the invert of the distribution pipe. This is
equivalent to the effective depth of the gravel as noted on
the design.
So
Backfill over the final gravel layer must not be less than
twenty-four (24) inches. Insulation must be installed when
the backfill depth is less than thirty-six (36) inches.
The finish grade over the trench must be mounded to prevent
the formation of a depression after settling.
Page Three
Lot 8, Block 2, Prospect Heights S/D
MINIMUM MATERIAL SPECIFICATIONS:
Any septic tank proposed for installation must be
constructed by a Municipally approved septic tank
manufacturer.
The following pipe materials are approved for use in septic
system installations in the Municipality of Anchorage:
Type of Pipe
Perforated Solid
Cast Iron
ASTM D3034 (PVC)
ASTM F810 (HDPE)
ASTM D2662 (ABS)
Yes Yes
Yes Yes
Yes No
Yes Yes
Use of a type of pipe other than listed above must be
approved by the inspecting engineer.
Insulation shall be at least 2" thick extruded direct
burial polystyrene (Dow Chemical Company Styrofoam HI or
equal).
Septic tank inlets and outlets shall be fitted with
watertight couplings (Caulder, Fernco, or equal).
A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N,
or equal) must be installed between the final leachfield
gravel layer and the native soil backfill.
Ail leachfield gravel (sewer rock) shall be 0.5"-2.5"
screened gravel with less than 3% passing the ~200 sieve.
When sand is being used as a filter material, its gradation
specifications must conform to current M.0oA. or D.E.C.
requirements°
Page Four
Lot 8, Block 2, Prospect Heights S/D
June 2, 1995
INSPECTIONS:
Typically there will be a minimum of three (3) inspections
required during the installation of the wastewater disposal
system. These inspections will occur as follows:
The first inspection must be conducted after the
excavation of ditches, pits, trenches, or beds and
before the installation of any gravel. A septic tank
may be set in place, but may not be backfilled before
this inspection.
e
The second inspection must be conducted after the
placement of the silt barrier, gravel, distribution
lines, standpipes, cleanouts, and insulation, but
before the placement of any other backfill.
The final inspection is to occur upon final grading of
the property.
Often there will be more than these 3 inspections required.
Especially with the installation of multiple trenches, sand
filters, pressurized distribution systems, etc. Thus, the
inspecting engineer is to be contacted at least 24 hours prior
to the start of construction. If necessary, a pre-construction
meeting will take place on-site. The inspecting engineer will
not coordinate, direct or control in any way the contractors
activities.
The owner shall contract with the contractor to perform the work
outlined in these specifications and plans and in accordance
with the attached M.O.A. permit. There will be no contractual
arrangement existing between the contractor and
S & S Engineering. S & S Engineering shall be the owner's
representative and will inspect the work as stated above to
document the contractors activities. Final acceptance of the
contractors work rests with the owner and the M.O.A.
S & S Engineering shall have no liability to the owner or to
others for acts or omissions of the contractor or any other
persons performing work on this project or the failure of the
contractor to carry out the work in accordance with these
construction documents. S & S Engineering's inspecting engineer
will not be responsible for the construction means, methods,
techniques, sequence, procedures or the safety precautions
incident to this project.
CONTRACTOR/OWNER
qp 0-0
•
rye ;`i'i>'lw: A
-
•
C„•r:�
• Municipality of Anchorage I °1V1&y L `a1018 3
On-Site Water and Wastewater Program
(907) 343-7904 s a F ET ti
w
•fe
. C'31\otss �9
Certificate of On-Site Systems Approval
Parcel I.D. 015-133-17 Expiration Date: a-
1. GENERAL INFORMATION
Complete legal description Prospect Heights Block 2 Lot 8
Location (site address) 10200 Prospect Drive
Current Property owner(s) Charles & Sandra Blomfield Day phone
Mailing address 10200 Prospect Drive Anchorage, AK 99507
Real Estate Agent Day phone
2. TYPE OF DWELLING:
0 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 Q Individual
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: Distance:
Received bc: ) X f7l� Date: KtJi
,
COSA to be released to the engineer,unless otherwise request�d by the ngineer.
COSA Fee $ 6-161 Waiver Fee $
Date of Payment 6f 9 /C$ Date of Payment
Receipt Number O d 0716 Receipt Number
COSA# O X 1'S 133 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.
In conducting an adequacy test,I attempt to provide a thorough,conscientious engineering analysis of the system in accordance with MoA COSA
guidelines and regulations.The reported results describe the performance of the system under the conditions encountered at the time of the test,
and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil
condition,ground water levels that may fluctuate during the year,and the water usage of the family being served by the system.These conditions
are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future
performance of the system,nor do they guarantee that there are no hidden defects or encroachments.Therefore we cannot provide any warranty
for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed
above.
Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218
Address P.O. Box 100217, Anchorage Ak. 99510
Engineer's Printed Name Steven R Pannone Date 5/23/2018
*: ' • II i •*%
6. DSD SIGNATURE � ��'P
�
X System #1 Approved for 4( bedrooms O Sieven i. F56nnone: f
t♦ ,•. CE-8149.
System #2 Approved for bedrooms s•. r
Disapproved ll '40FESSIONA�`4
Conditional approval for bedrooms, with the following stipulations:
,S-.kt
C-i- LS 42 cac -Q 0-Qei
A v o I. _0 U� c, Ste(. .Q- --� -c v K t� 2_0 yv, 01...,,b
�= c, , ,c__o i`t_e) otxX �-4.r t reS 6-u2,49,v4, -elm e.
o •N p,S GRP�� •
pRO c
c
Ii p
By: / Original Certificate Date: �� F���`
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 blue sheet • ,.
If more than 1 septic system is on the lot:
COSA Checklist# 1 of 1
Structure served by this system 1
Certificate of On-Site Systems Approval Checklist
Legal Description: Prospect Heights Block 2 Lot 8 Parcel ID:015-133-17
A. WELL DATA
Well type Private If A, B, or C provide PWSID# Well Log (Y/N) Y
Date completed 7/25/1995 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y
Total depth 225 ft. Cased to 40+ ft. Casing height(above ground) 12+ in.
FROM WELL LOG AT INSPECTION
Date of test 7/25/1995 5/9/2018
Static water level 37 ft. 42.5 ft.
Well production 3 g.p.m. 2.4 g.p.m.
WATER SAMPLE RESULTS:
Coliform NEG colonies/100 mL Nitrate 2.26 mg/L
Arsenic ND ug/L Date of sample: 5/9/2018 Collected by: PES
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel Date installed 7/25/1996
Tank size 1250gal. Number of Compartments 2 Cleanouts(Y/N) Y
Foundation cleanout(Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N/A
Date of pumping 11/5/2017Pumper Isaac's Pumping Service
C. ABSORPTION FIELD DATA
Date installed 7/25/1996 Soil rating (g.p.d./ft2 or ft2/bdrm) 1.2 GPD/SF System type Deep Trench
Length 50/50 ft. Width 2.5 ft. Gravel below pipe 5 ft.
Total depth 10 ft. Eff. absorption area 500/500 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 5/9/2018 Results (Pass/Fail) PASS For 4 bedrooms
Fluid depth in absorption field before test 5 in. Water added 600 gal. New depth 8 in.
Elapsed Time: 225 min. Final fluid depth 5 in. Absorption rate >= 600+ g.p.d.
N
Any rejuvenation treatment(past 12 mo.) (Y/N &type) If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at in. "Pump off' level at in. High water alarm level at in.
Datum Cycles tested Meets alarm&circuit requirements?
E. SEPARATION DISTANCES
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 100+
Animal containment areas 50+ Manure/animal excrete storage areas 100+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 10+ Property line 5+ Absorption field 5+
Water main 10+ Water service line 10+ Surface water 100+
Wells on adjacent lots 100+
ABSORPTION FIELD ON LOT TO:
Property line 10+ Building foundation 0+ Water main 10+
Water Service line 10+ Surface water 100+ Driveway, parking/vehicle storage 10+
Curtain drain 50+ Wells on adjacent lots 100+
F. COMMENTS
G. ENGINEER'S CERTIFICATION �� 4 i
� OFA�q`ts,,
I certify that I have determined through field inspections and rie0)..Airy Aseoct1 ...t..";$#1,
review of Municipal records that the above systems are in 0*: - TH /\ -.*7
conformance with MOA COSA guidelines in effect on this date. %•• �1047# r•••• 0
Steven Pannone ••
Engineer's Printed Name -1,1:-..
• Sleveri 'annone
Date 5/23/2018 1,19f,. CE-8149 �;
r
COSA canary sheet_2-6-15.doc