HomeMy WebLinkAboutCOTTONWOOD HEIGHTS BLK 1 LT 22Onsite File
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#051 =m431 mo 13
Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP181073 PID Number: 051-431-13
Dwelling: ❑® Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: New ❑ Upgrade
Name
Jeffery & Veronica Knittle
ABSORPTION FIELD
❑ Deep Trench ❑® Wide Trench ❑ Bed ❑ Mound
Site Address
16100 Parksville Drive
❑ Other
Phone
Number of Bedrooms
Soil Rating
ITotal depth from original grade
3
1.0 GPD/SF
5.0 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
4.5 Ft.
Gravel depth beneath pipe
0.5 Ft.
Subdivision Block Lot
Cottonwood Heights 1 22
Fill added above original grade
0.0 Ft.
Gravel length
2@45 Ft.
Township Range Section
Gravel width
5.0 Ft.
Beds: Number of Lines
n/a
Distance between lines
n/a Ft.
SEPARATION DISTANCES
0
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
450 Ft2
2
61+ Ft.
Well
100'-1-
100,+
100,+TANK
0 Septic ElS.T.E.P. ElHolding F-1Other
Manufacturer
Anchorage Tank
Capacity
1000 Gal.
Surface Water
1001+
1001+
Material
Number of compartments
Lot Line
51+
10'+
NA
Steel
2
Foundation
10'+
101+
LIFT STATION
Manufacturer
Capacity
Remarks
Gal.
Alarm location
Electrical installed by
Installer
PIPE MATERIAL House to tank 3034. Tank to 3034
drainfield
Northern Contracting
Drainfield 3034 Co/MT3034
Inspector Pannone Engineering Services
BENCH MARK (Assumed elevation) 655.0 ft
Inspdeact sn 15' 10/25/18 2 10/26/18
Location and description
3rd 10/26/119 4'h 9/27/19
SW bottom trim
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
Conditional Approval: Date
,�� 0 - A/
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s'te.,F�; Y�
Septic SystemF�nrone.�
B
Approved Date
Note: this approval does not include well permit requirements.���`�`����
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PANNONE ENG SVC, LLC
P.O. BOX 1807 PALMER, AK 99645-��.
PHONE 907 745-8200 FAX 907 745-8201
�
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REVISIONS
DATE
10/24/2019
RECORD DRAWING
SCALE
COTTONWOOD HEIGHTS B1 L22
JEFFERY & VERONICA KNITTLE
16100CHUGIAKILAK DRIVE
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P.I.D. NO
051-431-13
DRAWN ACP
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NOTES: PANNONE ENG SVC LLC z����\\\\ REVISIONS DATE
RECORD DRAWING P.O. BOX 102954 ANCHORAGE, AK 99510 ��OFA�gs�� 10/24/2019
PHONE 907 272-8218 FAX 907 272-8211 ,%�P•' SCALE
COTTONWOOD HEIGHTS B1 L22 " P.I.D. NO
DRAWN ACP JEFFERY & VERONICA KNITTLE Steven ♦�.'�onniie� 051-431-13
C 81SOILS LOG �C 16100 PARKSVILAK DRIVE I�It4,A/. � 49 i SHEET
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R— DOC CO dba
BILL S& COLE
ULLIVAN WATER WELLS
AA W -
P.O. Box 670269, Chugiak, AK 99567 688-2758
OWNER OF LAND: Jeff Knittle
ADDRESS:
Bore Hole
Data
Depth
From
To
LEGAL DESCRIPTION Cottonwood Heights Block 1 Lot 22
DATE: 9-25-18
0
2
PERMIT NUMBER: OSP181073 DATE OF ISSUE: 5-7-18
TAX IDENTIFICATION NUMBER 05143113000
Is well located at approved permit location: ®Yes ❑No
Method of Drilling: ®air rotary ❑cable tool
Depth of Well: 165'
Casing Type: Steel Wall thickness .250 inches
Diameter: 6 inches, depth 165 feet
Liner type
Static Water Level: 124 feet
Recovery Rate 12 ® gpm ❑ gph
Method of Testing Air
Well Intake Opening Type: ® open end ❑open hole
❑ Screened Start feet Stopped
❑ Perforations Start feet Stopped
Grout Type: Bentonite Volume: 50 lbs
Depth: from 2 feet, to 42 feet
Well Disinfected Upon Completion: ®yes ❑ no
Method of Disinfection: Chlorine 50 PPM
Comments:
2
4
4
68
68
75
75
124
124
132
132
135
135
140
140
146
146
150
150
165
Casing Stickup
Overburden
Tight Silty Sand & Gravel
Silt & Sand
Sand & Gravel w/ Boulders
Sand & Gravel Damp
Sand & Gravel Wet
Tight Silty Sand & Gravel w/ Clay
Sand & Gravel w/ Clay 3-5 GPM
Tight Silty Sand & Gravel w/ Clay
Sand & Gravel w/ Clay & Water
Drillers Name: Cole Sullivan
ATTENTION: It is the responsibility of the property owner to submit a copy of the well log to the proper authority.
Municipality of Anchorage: Department of Health & Human Services and/or Department of Environmental Conservation.
MatSu Borough: Department of Environmental Conservation.
R -
DOC CO dba
SILL S. GQLE
® LLIVAN WATER WELL
P.O. Box 670269, Chugiak, AK 99567 688-2759
www.suilivanwaterwells.com
Pump Installati®n Log
Well Drilling Permit Number: SW OSP181073 Date of Issue 5-7-18
Parcel Identification Number: 05143113000
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
SCS Ref.#
Client Name
Project Name/#
Client Sample ID
!N4atria
Sample Remarks:
1196816001
Pannone Eng, Si -v.
16100 PARKVILLE RD
16100 PARKVILLE RD
Drinking Water
- I>RE_LIAMINAIRY -
Printed Date/Time
Collected Datc/Time
Received Date/Time
Technical Director
11/18/2019 17:11
11/13/2019 12:30
11/13/2019 13:16
Stephen C. Ede
Allowable Prep Analysis
Parameter Results LOQ Units Method Container ID Limits Date Date init
Microbiology Laboratory
E. Coli
Total Coliform
Negative 1 100mL SM219223B
Negative I 100ml- SM219223B
A 11/13/19 A.L
A 11/13/19 A.L
2
19
tmmsu
Lab, 1
6�1�
Water Quality Testiong
;Faille:
)Wailing Address:
Legal Description:
Sample Site Location:
9131 E Frontage '•
Palmer, .6,
(967)745-3005
Pannone
Lab ID"k
M191081
P.O. Box 1807
Date Sampled:
10/24/2019
Date
77me Sampled:
1200
Cottomvood Heights B1 L22
Sampled By:
ACP
---
Dale Received:
10/24/2019
Outside Hose Bib
Dine Received:
1600
Health Guard I
Parameter
�Icthod
Result
Umt.:
MRL
MCL -.
Date
Total Coliforms
Colilert
P---
---
---
10/25/2019
(SM 922313)
E. coli
Colilert
A
---
---
---
10/25/2019
(SM 9223B)
Total Nitrate - N
TNTplus 835/836
3.77
ma/L
0.200
10.0
10/25/2019
(Hach 10206)
Arsenic
Arsenic by
EPA 200.8
< MRL
µg/L
5.00
10
11/08/2019
ilfetkod Reporting Linrit (iifRL): the lowest concentration that can be reported reliably
Afavinurm Contaminant Level (MCL): highest acceptable level in public water systems as set by EPA
mgt: milligrams per liter, 1/1000" ofa gram
pg/L: micrograms per liter: 1/1,000,000`' ofa gram
Absent (A): none of this type of bacteria was detected
Present (P): one or more bacterial cells of this type were detected
Results Reported By:
Patience Lynch
Laboratory Analyst
Reviewed By:
Signature: t7g IVILII,�,wf
Email: matsutestlab.office@gmail.com
/
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Lot 8
I►
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►
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Lot 23
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BJH""""', MUNICIPALITY OF ANCHORAGE
��.� Off. ((1 G'1]C
' On-Site Water&Wastewater Program �0 6'
Sr PO Box 196650 4700 Elmore Road
Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997 ,�
�r.s "1 http://www.muni.org/onsite 11 �,�"�,�..v.� - rzX • v,
_ I)l•pa tiiiv ll
On-Site Water & Wastewater System Permit
Permit Number: OSP181073 Effective Date: 5/7/2018
Work Type: WellSeptic Initial Expiration Date: 5/7/2019
Tax Code Number: 05143113000
Site Legal Address: COTTONWOOD HEIGHTS BLK 1 LT 22 G:0756
Site Mailing Address:
Owner: KNITTLE JEFFREY TODD & Lot Size in Sq Ft: 44097
Design Engineer: PANNONE ENGINEERING SERVICES Total Bedrooms: 3
This permit is for the construction of:
0 Disposal Field 2 Septic Tank 0 Holding Tank 0 Privy II Private Well 0 Water Storage
All construction shall 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 wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Special Provisions:
1) Provide a test hole, prior to construction of the septic field to, confirm percolation rate and separations to
groundwater and impermeables. Construction may proceed at your own risk before the 7-day groundwater
reading. If the results require a design change, construction of the system shall stop pending review and
approval by On-site. Please submit stamped and signed results with the inspection report.
2) Contractor shall verify a minimum 100 foot separation between the septic system and Fire Creek, routing
across Cottonwood Heights Block 1 Lot 23 to the south.
Received B AIL/. ..,_ LI A Date: 5
Issued By: `14;CCJ2. f i/ Date: 5//
791
MUNICIPALITY OF ANCHORAGE
Community Development Department Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
On -Site Water & Wastewater Program
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 051-431-13
Property owner(s) JEFFREY & VERONICA KNITTLE Day phone
Mailing address 16408 MILLS PARK CIRCLE, EAGLE RIVER, AK 99577
Site address 16100 PARKSVILLE DRIVE
Legal description (Sub'd., Block & Lot) COTTONWOOD HEIGHTS B1 L22
Legal description (Township, Range & Section)
Lot Size 44,097 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR: APPLICATION IS AN:
TYPE OF DWELLING:
(M all that apply)
Absorption Field ❑X Initial R
Single Family (SF) ❑X
Septic Tank ❑X Upgrade E]Duplex
(w/wo ADU)
(D) ❑
Holding Tank ❑ Renewal El
Multiple Dwellings ❑
Privy ❑
(SF and/or D)
Private Well ❑X
Water Storage ❑
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
Distance: -
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: g -00
Date of Payment:
Receipt Number:
Permit No. 0S M 1013
Permit App_-'-:. ._..:c:
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP181073, Rebecca Carroll, 05/07/18
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP181073, Rebecca Carroll, 05/07/18
104.8 EXISTING ELEVATION
103.0 PROPOSED ELEVATION
SURFACE DRAINAGE
LOT COVERAGE = 4.98%
Lot 21
HOUSE DETAIL
Scale: 1" = 30'
PLOT PLAN AS BUILT X SCALE 1" = 40' GRID NW 756 Project No. 18-125/81
11500 Daryl Avenue, Anchorage, Alaska 99515-3049
Lang & Associates, inc. (907) 522-6476 Phone 4�o00p�4
(907) 522-4625 Fax Q
Professional Land Surveyors kenblongsurvey.com oo o OFA��°°o
jonathan*longsurvey.com �4;1P •.•
1 hereby certify that I have surveyed the following described property:
LOT 22, BLOCK 1, COTTONWOOD HEIGHTS (Plat No. 71-291)
Anchorage Recording District, Alaska, and that the improvements situated thereon are
within the property lines and do not encroach onto the property adjacent thereto, that
no improvements on the property lying adjacent thereto encroach on the surveyed
premises and that there are no roadways, transmission lines or other visible
easements on sold property except as indicated hereon.
Dated this the =21 Day of _ A>'+ °- at Anchorage, Alaska
It Is the responsibility of the owner to determine the existence of any easements,
covenants, or restrictions which do not appear on the recorded subdivision plat.
49TH
KENNETH G. o
..�S- 20Z... y� �
�40poo��,
AECC963
ELEVATIONS
ELEVATIONS
EXISTING
PROPOSED
EXISTING
PROPOSED
ROOF OVERHANG
�
U V
656.0
658.2
A 653.8
8 656.8
660.8
658.3
M 660.0
N 657.0
P Q
o_R
- -
��
s T vy w A
659.7
C 659.8
655.8
0 656.0
55.7'
e
�- a.o'
661.4
D 662.8
654.7
P 654.0
(
660.5
E 662.8
655.9
Q 653.8
N
660.7
F 662.8
656.6
R 653.8
661.2
G 662.8
656.3
S 653.8
M
(
661.5
H 662.8
656.2
T 653.8
C
661.3
1663.0
654.4
U 653.8
660.0
J 663.0
654.7
V 653.8
-
az.o'
H_
660.8
K 663.0
655.8
W 653.8
E x J I
F E D�
661.7
C 663.0
HOUSE DETAIL
Scale: 1" = 30'
PLOT PLAN AS BUILT X SCALE 1" = 40' GRID NW 756 Project No. 18-125/81
11500 Daryl Avenue, Anchorage, Alaska 99515-3049
Lang & Associates, inc. (907) 522-6476 Phone 4�o00p�4
(907) 522-4625 Fax Q
Professional Land Surveyors kenblongsurvey.com oo o OFA��°°o
jonathan*longsurvey.com �4;1P •.•
1 hereby certify that I have surveyed the following described property:
LOT 22, BLOCK 1, COTTONWOOD HEIGHTS (Plat No. 71-291)
Anchorage Recording District, Alaska, and that the improvements situated thereon are
within the property lines and do not encroach onto the property adjacent thereto, that
no improvements on the property lying adjacent thereto encroach on the surveyed
premises and that there are no roadways, transmission lines or other visible
easements on sold property except as indicated hereon.
Dated this the =21 Day of _ A>'+ °- at Anchorage, Alaska
It Is the responsibility of the owner to determine the existence of any easements,
covenants, or restrictions which do not appear on the recorded subdivision plat.
49TH
KENNETH G. o
..�S- 20Z... y� �
�40poo��,
AECC963
August 3, 1977
#76510
Philip Freitage
6800 ~ast 16th Street
Anchorage, Alaska 99504
Sttbject~ Permit Expiration
Dear }~. Freitage:
A permit issued by this department for well and/or on-site
sewer installation on Lot 22 Blook I Cottonwood Heights
has expired sine the issue date exceeds one (1) year.
In the event you still plan to install the well and/or on-
site sewer system, a new permit is required. The original
soil test may be used to obtain a current permit.
If the well has been drilled, a well,log should be sent
to this department to document the installation date.
If yo~ have any questions regarding the above matter, please
do not hesitate to contaot this office immediately at 279-
2511, ext~sion 224 or 225.
Sincerely,
Les N- Buchhol2, R.S.
sanitarian
~.ljh
PERH I T !'.,t0.
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FI 'I"I:;.':EI'.~CH OR F'IT IS "~ i":,T'......:.;'T~lil~',l~ BETI.,.IEEN THE :!i..:l...ll:;~:Fl:::lClii~ O1:::' "l"!...!t:
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THE:RE IS I"~O SET HI[:,TH F'L")I:;i: TREI-4CHE'S.
THE GFi:F~',,,'EL. [:,liEF'TH IS THE I"IIN~'II~~'TF~,~F GF.:~,,,EI_ E:ETHIEI.'+.':I'.,I "I"1.-I[:~
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S I G N E [:, ' ............ ~ ......................................................
FIF'F'I~:FtNT[J PHt L .12 P FREI TInG
Gte. &r ANCHORAGE AREA BO UGH
DEPARTMENT OF ENVIRONMENTAL QUALITY
3330 "C" STREET ANCHORAGE, ALASKA 99503
TELEPHONE 274-4561
SEWAGE DISPOSAL SYSTEM N APPLICATION AND PERMIT
NAME OF APPLICANT
!
SEEPAGE PIT ~ , DRAIN FIELD
INSTALLATION LOCATION
EGAL DESCR,PT,ON
INSTALLATION OF: SEPTIC TANK
TYPE AND SIZE OF FACILITY TO BE SERVED
PERMIT NO.
OTHER
FINANCED THROUGH TO BE INSTALLED BY
SOIL TEST RESULTS ~ (~ Q') '~ ~ ~r~ ~__ ~L.~ ' NOTE: TH iS PERM iT iS NOT V.~/.~,I.D.--*--V*V*V*V*V*V~,iT.,i~,~iU T $O i L TES,
COMPLETION DATE ANTICIPATED ..... it/ )
FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM ~ITHOU~I FINAL INSPECTION BY THE
MINIMUM DISTANCES, REQUIREMENTS ~ , ~DIAGRAM OF SYSTEM
FOUNDATION tO SEEPAGE PIT
SEPTIC TANK tO SEEPAGE PIT WALL i~I
SEPTIC TANK , SEEPAGE PIT
TO NEAREST LOT LINE.
DRAIN FIELD
WATER MAIN tO SEPtiC tank / 0 I
DRAIN FIELD
SEPTIC TANK, [ (~ E) ~ , SEEPAGE PIT
TO river, LAKE, STREAM.
, DRAIN FIELD-
DRAIN FIELD
a~sEPAgE Pit /~} 0 t'
CONSIDEr ARea ./~/ELLS.
~ ~EEPAGE PIt / I
,DRAIN FIELD
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF
EXCAVATION 5 FEET INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRTIGHT REMOVABLE CAPS.
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION,
~ .A .A .B.
OR
LICENSED D I~SIG N ~"R
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE
DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE.
DATE &(,, ) APPL,CANT'S S,G.AT ,.E , C. .
FORM NO. EQ-O! 6
MUNICIPALITY OF ANCHORAGE
Department of Health and Environmental Protection
SOILS LOG
Performed for
Legal Description
Phil Freitag Date Performed 7/2/76
Lot 22, Block 1, Cottonwood Heights Subdivision
4
6
8
i0
IZ
14
16
0 - 2' - Red-brown, sandy silt (ML) with organics
Perc rate = 275 ft.2/bedroom
2 - 14' - Very dense. Brown-gray, sandy gravel (GW)
with boulders to 2 feet and some silt.
Boulders are fewer below 6 feet.
Material moist at -12 feet, sand content increasing.
Perc rate = 125 ft.2/bedroom.
Total Depth = 14 feet
No water table'encoun~ered.
AVERAGE PERC RATE = 146 ft.2/bdrm.
Date Net Time Depth Net Drop
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
Parcel I.D. 051-431-13
1. GENERAL INFORMATION
Expiration Date: Imo- 6 a 5, v�y ) 0
Complete legal description Cottonwood Heights B1 L22
Location (site address) 16100 Parksville Drive
Current property owner(s) Selway Corp Day phone
Po Box 1987 Palmer, AK 99645
Mailing address
Real estate agent
2. TYPE OF DWELLING:
M Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
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:
Distance:
Received by:
Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ -r y
Date of Payment u lig 119
Receipt NumberQ b 34/(A
COSA# (35t/'A 156o
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.
In conducting an adequacy test, 1 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 fife of the system. The content of this report is for the sole
benefit of the owner listed above. Reliance on this report by another person is at their own risk. Pannone Engineering Services LLC highly
recommends buyers hire their own engineer to evaluate this report.
Name of Firm Pannone Engineering Services
Address P.O. Box 1807 Palmer, AK 99645
Engineer's Printed Name Steven R. Pannone P.E.
Phone (907) 745-8200
Date l 91//F
OF ALTs
6. DSD SIGNATURE • "' • " • • "" ...... •
f System #1 Approved for bedrooms Steven .R...Pannone
System #2 Approved for bedrooms CE 8149
S
Y pP ttt lFA' • •" ��..•
Disapproved
Conditional approval for bedrooms, with the following stipulations:
By: Y W (' S� �9J��" �X Original Certificate Date: 5 )
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
X411 -Mom
Legal Description: Cottonwood Heights 131 L22
If more than 1 septic system on lot: COSA Checklist # 1 of 1
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled 9125/18
Total depth 165 ft
Cased to 165 ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) 24 in.
Date of flow test for COSA 9/25r18 -
Static water level at beginning of test 124* ft.
Comments * Data from well log
B. TANK DATA
Age of tank(s) 101
25118 years
Tank type/material 5°P""s"
Measured operating fluid level in septic tank n/a
FO -1 Standpipes/foundation cleanout per record drawing
Date of pumping
D. ABSORPTION FIELD DATA Shallow Trench
Which system tested (date installed) 10/26/18
❑ ALL standpipes present per record drawing
Total measured depth from grade 5.0 ft (max)
Measured depth to pipe invert from grade 4.5 ft (min)
❑ N/A — pressurized field
V Monitor tubes go to bottom of effective. If not, state
depth into effective
X 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
Parcel ID: 051-431-13
Structure served by this system 1
Well production at time of test 12* Qpm
Water storage tank volume n/a gallons
Well disinfected for coliform test? ✓❑ Yes ❑ Nc
❑ Coliform bacteria is Negative
Nitrate 3.7 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by Pannone Engineering Services
Date of Sample 11/13/19
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date n/a
Results QPass For 3 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
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
Community Sewer Manhole/Cleanout > 100'
F,/ Yes
if No
ft
✓M Yes
if No
Neighboring Tank > 100' M✓ Yes
if No
ft
Private Sewer/Septic Line > 251771 Yes
if No
Absorption Field on Lot > 100' F/ Yes
if No
ft
Holding Tank > 100' P-1 Yes
if No
Neighboring Absorption Fields > 100'
Surface Water > 100'
✓0
Animal Containment > 50' Yes
if No
❑✓ Yes
if No
ft
new construction- unoccupied since
installation
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' 0 Yes
if No
ft
[✓ Yes
if No
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' ❑✓ Yes if No ft Surface Water > 100'
ft
ft
ft
ft
ft
P Yes if No ft
Property Line > 5'✓0
Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
171 Yes
if No
ft
Private Wells > 100' ✓/ Yes if No_
Water Main > 10'
n✓ Yes
if No
ft
Community Wells > 200' E] Yes if No _
Water Service Line > 10'
IZI 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'
21
Yes
if No
ft If absorption field is under driveway comment below
Property Line > 10'
✓1
Yes
if No
ft Wells on Adjacent Lots:
Water Main > TO'
✓0
Yes
if No
ft Private Wells > 100' Yes if No
Water Service Line > 10'
Z✓
Yes
if No
ft Community Wells > 200' Yes if No
Surface Water > 100'
✓0
Yes
if No
ft
F. ENGINEER'S COMMENTS
new construction- unoccupied since
installation
G. ENGINEER'S CERTIFICATION ,�� OF ALgs���l
t certify that l have determined through field inspections and review �. P
of Municipal records that the above systems are in conformance with ;
MOA COSA guidelines in effect on this date.
Steven R. Pannone
A� CE 8'1149
r
Jf \AOW
COSA Checklist yellow sheet
ft
ft
ft
ft