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Home My WebLink AboutCOTTONWOOD HEIGHTS BLK 2 LT 6Cottonwood Heights Block 2 Lot 6 #051-431-06 ON-SITE WATER AND WASTEWATER SECTION APPROVAL nditional Approval: Septic Sy Approved (Rev Date a Date this approval does not include well permit requ C�• °F'`gs�1 co yk•TH 49 — •, .�� •/Z = �rHARLES G BALZARIU -/ 1 Fc�sr CE -13854 •.�� C PROFESSiO�P�.,.'" Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 1 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP191080 PID Number: 05143106000 Dwelling: R Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New 0 Upgrade Name Holden ABSORPTION FIELD ❑Deep Trench ❑Wide Trench El Bed El Mound Site Address 16241 Parksville ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 3 GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot COTTONWOOD HEIGHTS BLK 2 LT 6 Fill added above original grade Ft. Gravel length Ft. Township Range Section Gravel width Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line Ft2 Ft. Well +100 - _ _ +50 TANK IN Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer ANCHORAGE TANK Capacity 1250 Gal. Surface Water +100 _ _ _ Material Number of compartments Lot Line +10 - - - NA STEEL 2 Foundation +10 _ _ _ LIFT STATION Manufacturer Capacity Remarks Gal. Alarm location Electrical installed by PIPE MATERIAL House to tank 3034 drainfield Tank to 3034 Installer GUARANTEED SERVICES Drainfield Co/MT3034 Inspector C.BALZARINI BENCH MARK (Assumed elevation) 100 ft Inspect1�t 4/16/19 Location and description 2ion nd BOTTOM SIDING NEAR TANK 3`d 4th ON-SITE WATER AND WASTEWATER SECTION APPROVAL nditional Approval: Septic Sy Approved (Rev Date a Date this approval does not include well permit requ C�• °F'`gs�1 co yk•TH 49 — •, .�� •/Z = �rHARLES G BALZARIU -/ 1 Fc�sr CE -13854 •.�� C PROFESSiO�P�.,.'" / i\ 03 v NOTES: GROUND LEVEL IMPROVEMENTS SHOWN ARE APPROXIMATE. DATE OF SURVEY: 26 AUGUST 2025 PLOT PLAN AS BUILT —2L SCALE 1" 440' GRID NW 756 Protect No. J25 -254/A1 0005 Lang & Associates, inc P.O. urge, Alas • Anchora e, Alaska 99521-0005 (907) 522-6476 0 OF A Professional Land Surveyors survey@langsurvey.com I hereby certify that I have surveyed the following described property:"�• / 'I LOT 6, BLOCK 2, COTTONWOOD HEIGHTS SUBDIVISION (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 . / 'JONAT N ..LANG premises and that there are no roadways, transmission lines or other visible � c� . easements on said property except as Indicated hereon. Fi Dated this the ' T Da of k-UGJ S"r Z� '.LS -9944.•'' gJp Y at Anchorage, Alaska It is the responsibility of the owner to determine the existence of any easements, ��OOpppo� covenants, or restrictions which do not appear on the recorded subdivision plat. State of Alaska AECC963 49 TI- P� I CHARLES G BALZARIW CE -13854 OVERHEAD ELEC I op 1iliF,9F•% •�24_,�, \ , ROFEW( ,�� .. SUNGTIES T15N R1W SEC 29 E2NW4 A B I NO WELL OR SEPTIC I C 18.6 25 n EXISTING DRAINFIELD \ :` ., (•�' '�' TO REMAIN APPROX 100' ° •i WELL RADII �:'•.• 1 NEW AFTER I ' a TANK COs I O NEW FOUNDATION I DRIVEWAY'.''..., CLEANOUT NEW 1250 /•: •'' .'' .:e•: :� ( GAL STEEL TANK. PLAN — SCALE: 1" _ 30' BM:+100' BOTTOM SIDING AT HOUSE 9.2 92 6' COVER 1250 SEPTIC TANK 92.4 SCHEMATIC PROFILE VIEW SHOWS ELEVATIONS OF INSPECTED ELEMENTS BUT DOES NOT DEPICT SYSTEM IN ITS ENTIRETY. INSPECTION FOR GENERAL CONFORMANCE TO DESIGN AND MOA REQUIREMENTS ONLY. grHPMATIC: FI FVATI(lhl — C( AI F• NTC LEGAL COTTONWOOD ESTATES BLOCK 2 LOT 6 C&M ENGINEERING SERVICES OWNER: HOLDEN DATE:7/08/23 1 R 907-854-5558 SEPTIC RECORD DRAWING 10:49 C&M ENGINEERING SERVICES Ph: 907-8545558 Municipality of Anchorage Onsite Water & Wastewater Program 4700 Elmore Rd Anchorage, Ak 99507 RE: Septic System Modification for Cottonwood Heights Block 2 Lot 6 Dear Onsite Reviewer, We are submitting an inspection report and record drawings for the subject property. We are requesting the department approve the inspection report without receipt of an asbuilt survey: • Per 15.65.070, F, the department may determine that an asbuilt survey is unnecessary. • The tank was installed near the same location as the old tank which had previously been located by survey. • An asbuilt will be required for the property when it next needs a COSA. • There is little risk to the health and safety by accepting the inspection report and record drawings without an asbuilt survey. • There are no wells near the system and this and adjacent properties are served by community water. • Around the time this tank was installed, the MOA was accepting inspection reports for tank replacements without asbuilts in some cases. Sincerely, Charles Balzarini, PE 11/47 ocipAtir, MUNICIPALITY OF ANCHORAGE a•O ...,�: of �»r n C . \ On-Site Water& Wastewater Program \o : EPL#7A1 MUNICIPALITY OF ANCHORAGE ( fr.A.; Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section �" - Fax: 907-343-7997 Emergency Tank Replacement ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 051 431 06 Property owner(s) Waldo Holden Day phone 854-8577 Mailing address 16241 Parkview Drive Site address 16241 Parkview Drive Legal description (Sub'd., Block & Lot) Cottonwood Heights Block 2 Lot 6 Legal description (Township, Range & Section) Lot Size 47,480 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (®all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) ❑ Septic Tank ❑ Upgrade ❑ (w/wo ADU) Duplex (D) ❑ Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well n Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. C&M Engineering (Signature of property owner or authorized agent) Permit/Rush Fees: o7a.`J�I Waiver Fees: Date of Payment: I/LI6 (q Date of Payment: Receipt Number: (1210C)0 Receipt Number: Permit No. 05 P/91030 Waiver No. G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc C&M ENGINEERING SERVICES Ph: 907-854-5558 Municipality of Anchorage Onsite Water & Wastewater Program 4700 Elmore Rd Anchorage, Ak 99507 04/03/2019 RE: Proposed Septic System Modification for Cottonwood Heights Block 2 Lot 6 Dear Reviewer, The above referenced property is currently served by an older 3 bedroom septic system. The 1000 gallon tank has failed and is in need of immediate replacement. We are proposing that the existing tank be replaced with a new 1250 gallon (minimum) tank constructed and installed in accordance with MOA requirements. A polyethylene or advanced coated tank is recommended. As shown on the plan, the tank will be greater than 10’ from the house foundation. The tank shall be covered with a minimum of 2” moa approved insulation and 3’ of cover. The repair shall be performed by a moa certified installer in accordance with MOA requirements. The engineer will inspect the tank before backfilling. Repair of the proposed system will not negatively impact adjacent lots. Upon completion of the installation, a record drawing will be submitted showing the location of the new tank, leachfield, well, and other applicable features. Thank you for your time in reviewing this permit request. Please do not hesitate to contact me at 907-854- 5558 or by email cgbalzarini@gmail.com with any questions or concerns. Sincerely, Charles Balzarini, PE (04/03/19) Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191080, Deb Wockenfuss, 04/11/19 Municipality of Anchorage Page of 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: PID Number: 051 — D(O Name: ` Y ,7 ►v Wastewater System: ElNew L1Upgrade Address:�Or �JO ��G` ABSORPTION FIELD Phone: Phone: No. of Be rooms: 70 Deep Trench ❑Shallow Trench ❑Bed ❑Mound ❑Other LEGALDESCRIPTION DESCRIPTION Soil Rating: p�� 6e 6ZPD/S Total Depth from original grade: 10' -A . Ft. Lot: Block: Subdivision: // Depth to pipe bottom frorrYorigina grade: f Gravel depth beneath pipe c� Ft. Ft. Township: Range: �\ , ' Section: Fill added above original grade: Gravel length: � Ft. Ft. WELL: ❑New Upgrade Gravel width: Number of lines: I Distancebetweenlines: I Ft. Ft. Classification (Private, A,B,C): Total Depth: I Cased To: To: 1 Total absor ton area: to �O� Pipe material: a �� . OO Ft. J Ft. SQ. Ft. - ( �t Driller: M -W Date Drilled: LZ.3O Static Water Level: l3 Installer. \� 1�( � Date installed: �-r _T5 • S Ft. Yield:Pump 14,GPM Set at: Casing Height Above Ground: TANK 1 (0� Ft. Ft. SEPARATION DISTANCES Septic ❑ Holding ❑ S.T.E.P. To Septic Absorption Lift Holding Public/Private Manufacturer: ?435 7 �9�ir.�+�'� Capacity in gallons: ��O From Tank Field Station Tank Sewer Lines Well ' 5t) tav� R/A �t /l `/°�(-'`, ;IIA '4�l Material: ►n 8_V� Number of Compartments: Surface �DD�. Nlti 11 [ t LIFT STATION ►.ilk. Water C�c.t/ ` Com/ 6 Lot /JO f , /X Size in gallons: Manufacturer: Line Foundation Z"J�� 5 ,�i1V71h` 3?j,5` x N / A "Pump on" level at: "Pump off' level at: High water alarm at: Curtain r 1 IV Pump Make & Model Electrical Inspections performed by: Drain Remarks: BENCH MARK Location and Description: Assumed Elevation: Ft ENGIN)kER.'.S SEAL 4V Goo 00 or 62 ° ; ; ®8® 49 T o Inspections performed by: Dates: 1st °Ds'°°°°eeeaa-pppff°O �O B 2nd G°°� °®. o�°°°°voe°o° mo AZ ®� a J. David Norton o Department of Health and Human Services approval �o CE 6253 0 10 �B�e9op�°cppe°�"9010 �� See `tqZ C051� YZf2AIM( , 7��"W ROFESSI��, Reviewed and approved by: Date: �R 72-013 (Rev. 9/91) MOA 25 Permit No Page of Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650-0 Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Legal Description: U)T �,, BLOCK 2 C070tQ \ 00D {-I EIl�NI' ID No.: 00:51- 431 " Ola Q 4 i �4� Q i I I iw I NN L j I .J WATER Ulf e ° ITRENGN T`f PE DRla.IN FI'�L.1� I' 1500 CAL, 5EP1"1C TANK I ENC '4&rt EAL AW .�► Ey, ISTIN& MOD FRAME HOUSE000090000000 of ova RHA>`1G/ ��Se J. David Norton 3P�' ite J'�'• CE 6253'010 �® • . 0*0 AV QCs RHA, N6 ( *`,t�OFES 72-013 A (Rev. 9/91) MOA 25 I'ii�,M1T No. MAGE OF I I I I 2 i SEE Dr=TAIL"A ATC'ACHED -7 yG✓�w Asa 38' I zee\ 28 SEPTIC SITE PLAN F09 f LOT G 5LK 2., C,oT 0w\M00Q M I�HTS SUgD. LOCATF—P WITHIN SEC,29, T,ISN, F� IVI, S.M. MUWCIPkLIT"f GRIP NW 15G DATE: 12.-10-92- SCALE: 111=G0' PRAWN PAY ; J,C, WK -,W e TROWEL DRA'FTIW& ®F At ®� � C,2 e 9 �® izbootee, of •e..•a•••••s••°e •• , * tate J. David Norton CE 6253Op a• ��® A 0 Ef E GEOTECHNI CAL & DEVELOPMENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694.2774 or 688-2280 Russell ovster Earl Ellis 6942774 SOIL LOG 688-2280 Soils Et Foundations Land Development Performed for: Name: Tel . No. Mailing Address:./ -f -0-,6,=x 5;.r4d7 legal Description: La'r 6, &Y-& 2, 60; 7--cfi KIC60 Depth (feetl_ foil Characteristics 0 T 10,Al 1 2 3 4 5. 6 - "V 8 9 10 12 13 14 &0 - '7 7A9 47,4— lv6z-67 15 RECEIVED 16 DEC 10 1992 Municipality of Anchorage Ground Water Encountered: Yes No, l" If yes s what depth,_ t' Health & Human Services Proposed Installation: Seepage Pit Drain Field Comments L1117Performed by: �,/! I % ,/, �� Date: 7 M -W DRILLING, Inc. P.O. Box 10-378 • 10300 Old Seward Highway (907) 349-8535 ANCHORAGE, ALASKA 99511 DRILLING LOG Well Owner TERRY JORGENSEN Use of Well Domestic Location (address of: Township, Range, Section, if known; or distance main road_ Lot 6, Block 2 Cottonwood Hts., ChuAiak r Size of casing 6" Depth of Hole 160 feet Cased to.,. 159 feet Static water level 134 ft, ( (below) land surface. Finish of well (check one) open end ( XXX ; Screen ( ) ; Perforated Describe screen or perforation None Well pumping test at 10 gallons per (MIRL) (minute) for—1 hours with 100% , of drawdown from static level. Date of completion np r Lzmher 30 1983 WELL LOG Depth in feet from ground surface Give details of formations penetrated, size of material, color and hardness -a—TO 2 -2—TO 2 3 ?a—TO—r 77 27 TO 81 81 TO 123 123 TO 135 135 TO 141 ___L4_ _-TO 150 150 TOS TO TO TO —TO- O -TO- TO 0 0 Gravelly Clan 1 —CUSTOMER C:) F-_ r-4 0-4 �F H H_ lE_ DEPARTMENT L HEALTH HND ENVIRONMENTAL . .OTECTION - 825 'L' STREET, ANCHORAGE, HK 99501 264-472(,--1 PERMIT NO. ( 811182 ) APPLICANT JAMES TERRY JORGENSEN LOCATION ER LEGAL LT 6 BLK 2 COTTONWOOD SID PO BX 329 CHUGIFIK 19 cq ch q 1(1 688-2237 LOT SIZE 45000 SQUARE FEET MINIMUM DISTANCE BETWEEN H WELL HND ANY ON—SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR H PRIVATE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL MINIMUM DISTANCE FROM H PRIVATE WELL TO H PRIVATE SEWER LINE 15 25 FEET AND TO H COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. K K IT! lvl I -T- ��Flr4;?E="v ��PlE3EEFF_'." 'I CERTIFY THAT \`1: I HM FAMILIAR WITH THE REQUIREMENTS FOR ON—SITE SEWERS AND WELLS AS SET � FORTH BY THE MUNICIPALITY OF ANCHORAGE. � . 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. SIGNED: ........................................ CH JAMES TE � M -W DRILLING, Inc. MVN|c|p4ca(o�Awc"ge^Gc � p.o.Box ^-lc/o ° /3locInternational Airport nq9E�T. o1 x�;! u � (907)274-4611ENV! Rom';Vcx�� ' xmcnDnxsE. ALASKA 99509 DRILLING LOG Well Owner- I.ocubou <uddroxo of: Township, Range, Section, if known; or 8ixtuucc ouubn zo Depth o{ Bole foet (�uuo6to____-__-_-feot Size of cuaiug-__-L�__ ap Stotic water level -_______ft. (above) (below) land surface. Finish of well (check one) open end ( )� Screen ( Perforated ( ). Describe screen or porforuti -- .nll pumping test ut_____-guDouu per (hour) (minute) Yor-_--____'huurm with t of druvv6ovru from static level. /\ o�+ Date of completion Depth bufeet from ground surloce '___-�__-�0-------' � TO- TO- -TO- TO------ TO- WELL LOG Give details of formations penetrated, O-_----'TO__---- __-TO_----- GhedatuJanfformatiuoapeuetcate6' size of material, color and hardness � «. 0 MUNICIPALITY OF ANCHORAGE Development Services DepartmentPhone: (907)343-7904 On -Site Water & Wastewater Section Fax: (907)343-7997 Certificate of On -Site Systems Approval OSC251388 Parcel ID 051 -431-06 Expiration Date: -;�q U Legal description COTTONWOOD HEIGHTS BLK 2 LT 6 Site address 16241 PARKSVILLE DR Current property owner(s) HOLDEN WALDO C II X The On-site system(s) is/are approved for 3 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or conditions: By: Original Certificate Date: 9/5/2025 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Service Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's submittal. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory Other 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 Application 1. GENERAL INFORMATION Parcel I.D. 05143106000 Complete legal description COTTONWOOD HEIGHTS BLK 2 LT 6 Location (site address) 16241 PARKSVILLE DR Current property owner(s) HOLDEN 2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS Day phone 623-344-7344 3. TYPE OF WATER SUPPLY: *� Private Well serving # 1 dwelling units ❑ Other Non-public well as regulated by MOA ❑ Water Storage ❑ Community Well or Public 4. TYPE OF WASTEWATER DISPOSAL: 0 Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: * Steel ❑ Plastic ❑ Concrete ❑ Fiberglass Age 6 - See advisory if steel or fiberglass older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed Al Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: ❑ Distance: By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $ 50 Date of Payment 912y/1f COSA # Z(2r1 j�K Waiver Fee $ Date of Payment Waiver # COSA Application_Ap2025.doc COSA Checklist Legal Description: COTTONWOOD HEIGHTS BLK 2 LT 6 Parcel ID: 05143106000 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system _ A. WELL DATA R Well log is filed with Onsite (or attached) Date drilled 12/30/83 Total depth 160 ft Cased to 159 ft ❑■ Sanitary seal is functioning correctly FO -1 Wires are properly protected Casing height (above ground) 24 in. Date of flow test for COSA 8/21/25 Static water level at beginning of test 132 ft. Comments B. TANK DATA Measured operating fluid level in septic tank 50 Date of pumping 8/29/25 ❑ Required maintenance completed, if AWWTS Comments: D. DISPOSAL FIELD DATA Which system tested (date installed) 10/78 0 ALL standpipes present per record drawing Total measured depth from grade 10 ft (max) Measured depth to pipe invert from grade 4 ft (min) ❑ N/A — pressurized field. ❑ Per record drawings, field is insulated. On Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Comments/Deficiencies: COSA Checklist_May2025.docx Well production at time of test 6+ gpm Water storage tank volume na gallons Well disinfected for coliform test? ❑ Yes F01 Nc OR Coliform bacteria is Negative Nitrate 2.16 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L W Arsenic less than MRL (ND) Collected by NRim Eng Date 8/21/25 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 8/21/25 Results Q✓ Pass Fluid depth prior to test 5 in Water added 450 gal New fluid depth 10 in Elapsed time 20 min Final fluid depth 7 in Absorption rate 450 gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) 72 in Effective depth used 7 in Effective depth remaining 65 in E. SEPARATION DISTANCES From Well on Lot to: (Please enter distances if less than required) Septic Tank/Lift Station on Lot > 100' Z Yes if No ft Neighboring Tank > 100' Z Yes if No ft Disposal Field on Lot > 100' R]Yes if No ft Neighboring Disposal Fields _> 100' nv Yes if No ft Sewer Line/Main > 100' nV Yes if No ft Sewer Manhole/Cleanout > 100' Z Yes if No ft Sewer ServicelSeptic Line > 26'[E] Yes if No ft Holding Tank > 100' nV Yes if No ft Animal Containment > 50' ZYes &No ft Manure/Animal Excreta Storage > 100' Fv� Yes if No ft F� NFA— Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Disposal Field(s) on Lot to: (Please enter distances if less than required) Tank to Foundation > 10' nv' Yes if No ft Surface Water> 100' H Yes if No ft Field to Foundation ?� 10' R1 Yes if No ft Tank to Property Line > 5' M Yes if No ft Field to Property Line > 10' [E]Yes if No ft Water Main/Service Line > 10' [E] Yes if No It F. ENGINEER'S COMMENTS Wells on Adjacent Lots: ammom Community Wells > 200' 23 Yes if No ft M Yes if No ft If tank or field is under driveway comment below G. CERTIFICATION & 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, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm NorthRim Eng. Engineer's Printed Narne Steve Eng COSA Checklist May2025.docx Phone 694-7028 Date 8/29/25 ........ ....... Stew " . 4C Municipality of Anchorage o Development Services Department 1211110 -1 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 Parcel I.D. 051431-1)62 COSA # 0`4 OL416 Expiration Date: 3— 19-09 1. GENERAL INFORMATION Complete legal description 1^_ O 7- Mo R I kYlyd Q drS BL -O Ck, 0 L a 7-C Location (site address) 1C -2W 1 211,6 , 12—WL/ 6'1,1+k-- Current Property owner(s) _5 TF�%'/i�A) F5i21 a iC.•W Day phone 6941'4C 5"2 Mailing address Lending agency Mailing address Real Estate Agent Mailing Address Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System 1_ Day phone Dayphone Zdy—/930 TYPE OF WASTEWATER DISPOSAL: The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Onsite Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent 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 are 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 B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineers work. Individual On-site ,B ❑ Individual Holding tank ❑ ❑ Community On-site ❑ ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Onsite Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent 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 are 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 B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineers 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 Stale codes, ordinances, and regulations in effect at the time of installation. Name of Firm A/es i- 1 A %zip, z5,24 AddressE2 Sot -77 7.2y Engineer's Printed Name S%Et/E Ea_JC 5. DSD SIGNATURE _AZ Approved for _: bedrooms. Disapproved. Phone .PU- 7 ce 6 Date Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other By: 14 Original Certificate Date:--/ 7 VRw. I IM51 Municipality of Anchorage " Development Services Department ' Building Safety Division < On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 198850 Anchorage, AK 99519-8850 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description:0.6 LAnLaoJ *S 62 L,g- Parcel ID: 6_52— !A 3 /.� 0 G A. WELL DATA Well type —?— If A, B, or C provide PWSID # _ Date completed N30/�3 Sanitary seal (YM) 4 Total depth �ft. Cased to _LELft. FROM WELL LOG Date of test /Z/Jo Z d3 Static water level Well production g.p.m. WATER SAMPLE RESULTS: Coliform —0_colonies/100 mL Nitrate "M91L Arsenic: OIL", 4W Date of sample:/! 27 0 7 B. SEPTICIHOLDING TANK DATA Well Log (YM) Wires properly protected (Y/N) Casing height (above ground) _in. AT INSPECTION ! ? 07 S g.p.m. Other bacteria d colonies/100 mL Collected by:w- .t Tank TypelMaterial ANC, r axrL Irr'e Date installed o%2111) Tank size gal. Number of Compartments Z Cleanouts (Y/N) � N Foundation cleanout (Y/N)Y Depression over tan -k (YIN) � High water alarm (Y/N) Date of pumping 511,&? Pumper _.1%Z f C. ABSORPTION FIELD DATA Date installed /'0� 7- 8 Soil rating (9*A-#f2ft2/bdrm) Ps System type T%z�CH Length � 3 ft. Width y ft. Gravel below pipe 6 ft. Total depth/0 ft. Eff. absorption areas4(5 ft2 Monitoring tube ,- Depression over field N Date of adequacy lest Z 7/07 Results (Pass/Fail) ?,*" For 3 bedrooms Fluid depth in absorption field before test 0 In. Water added gal. New depth -Z_ in. Elapsed Time:, min. Final fluid depth _0 in. Absorption rate >= .SO 0 g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) _ r/^/!C If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) 'Pump on' Iev t _ in. `Pump off"X at _ in. High water alar vel at in. Datum Cycles t ed Meets a & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO:'R Septic tank/lift station on lot Absorption field on tot /00 "7' Public sewer main 64 i Sewer /septic service line lead t Animal containment areas /OD �4 On adjacent lots 1D0 /f' On adjacent lots -1-/J 6'f Public sewer manhole/cleanout AV -,4 - Holding tank 1,1414 Manure/animal excrete storage areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: / r Building foundation 'f' Property line l—rf Absorption field S ` Water main Water service line Id rt Surface water d o f Wells on adjacent lots /d d rt SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ZO v?�" Building foundation zS rr Water main Nlo'`f r Water Service line ea/ v')4 Surface water /a �i �f Driveway, parking/vehicle storage Zf � Curtain drain tiI✓K Wells on adjacent lots ed'f F. COMMENTS G. ENGINEER'S CERTIFICATION .�E•OF I certify that I have determined through held inspections and��ps�y all, review of Municipal records that the above systems are in / conformance with MOA COSA guidelines in effect on this date. are.. Engineer's Printed Name QST G C+U� d, nit: Steven W. Erg s�. PE 6:56 Date $ F9� '�•... . COSA Fee $ 3t� Waiver Fee $ Dale of Payment %? O % Date of Payment Receipt Number 103D�c1 Receipt Number (Rev. 11/05) WELL IJEcosKr�ISr�ou�Q a� / WELL ~ / JO 2.0' X 28.3' CANT 1Rl— WOOD RES] NC 7.9' X 6.7' SHED LOT 5 / WELL LOT 6 1.09 ACRES GRAVEL. DRIVE SEPTIC / OUTS-(\� 10� SERVICE 4J42 X 4.7' CANT x I 1 PATIO + I X 16.1' 1 + DECK J1 + HAINUNK I FENCE y F 0 10' UTILITY EASEMANT PLOT PLAN _ AS BUILT X SCALE 1' --50' GRID NW 756 Project No. 07-213 Lan &Associates t InC. 11500 Daryl Avenue, Anchorage. Alaska 9 (907) 522-6476 Phone Registered Land Surveyors (907) 522-4625 Fox kglanglsOalaska.net / jclonglsOalasko.net I hereby certify that 1 have surveyed the following described property: LOT 6, BLOCK 2, COTTONWOOD HEIGHTS SUBDIVISION (PLAT No.71-291) Anchorage Recording District, Alaska, and that the Improvements sifuat 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 promises and that there are no roadways, transmission lines or other visible easements on sold property except as Indicated hereon. Dated this the tR Day of DQ,m..r=,ra-- _, 704 , at Anchorage, Alaska 99515-3049 H Is the responsibility of the owner to determins the existence of any easements, 'Vppo�o ' covenants. or restrictions which do not aoaear an the rennrrleA enh,adwtnn MM Dec 19 07 08:03a axvr oa taus t eie - Jim Sullivan 907 ARCTIC PUMP & WELL INC. Jim Sullivan PO Box 770197 Eagle River, AK 99577 (907)688-2510 (907) 258-2510 arwavci net Pump Installation Log Well Drilling Permit Number: SW Parcel Identification Number: Date of Issue: Leal Description:Cotiouicood ZITS Property Owner Name R Address: Loeb Remax Of H.gIe Ricer Block:2 Pump Installation Date: 12/19/2007 Pump Intake Depth Below Top of Well Casing: Feet Pump Manufacturer's Name: Pump Model: Pump Size: hp Pitless Adapter Burial Depth: feet Pitless Adapter Ihlanufaeturer's Name: Pitless Adapter Installer: Arctic Pump & Well, Inc. Well Disinfected Upon Completion? Yes Method of Disinfection: Chlorine Comments: Well permanently decommissioned by procedure I 5.55.060L.c. Pump Installer Name: Arctic Pump & Well, Inc. Arctic Pump & Well, Inc. Pagel of P.1 Municipality of Anchorage /- Development Services Department Building Safety Division Onsite Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcell.D. bsl-y31-ur HAA# b5Q3-4G Expiration Date: I / — Is—os- 1. $—DS 1. GENERAL INFORMATION Complete legal description Lot 6, Block 2, Cottonwood Heights Subdivision Location (site address or directions) 16241 Parksville Drive, Chugiak, Alaska Current Property owner(s) James and Lynda Jorgensen Day phone 696-7037 Mailing address Lending agency Mailing address Real Estate Agent Mailing Address Day phone Audrey Mason Day phone 694-4200,242-77T7 16600 Centerfield Dr., #201. Eagle River, Alaska 99577 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well El Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ TYPE OF WASTEWATER DISPOSAL: Individual On-site El Individual Holding tank ❑ Community On-site ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority 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 HAAs upon request to homeowners. Certificates of Health Authority Approval are 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 B wells or a public water system. The Municipality of Anchorage Is not responsible for errors or omissions in the professional engineers 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 Health Authority 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 Douglas T. Kenley Phone (907) 746-1073 Address 9960 E. Puffin Dr., Palmer, Alaska 99645 Engineer's Printed Name Douglas T. Kenley Dater 1 OF i •. 1LR 9( ......... 5. DSD SIGNATURE I' CE8175 Approved for 3 bedrooms. Disapproved. ��! •• �. Conditional approval for bedrooms, with the following stipulations: Attachments: HAA Checklist X Maintenance Agreements Septic System Advisory Supplemental Engineer's Report Well Flow Advisory Other By: Original Certificate Date:S�8— o y (Rw 01102) Municipality of Anchorage • �` �, Development Services Department Building Safety Division On -Ste Water 8 Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 995196650 www.muni.orgionske (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lot 8 Block 2 Cottorevood Heights Subdivision Parcel ID: (9 s—/- y 3 / - 0& A. WELL DATA Well type P^" If A. B, or C provide PWSID # _ Date completed " Sanitary seal (Y/N) Y Total depth 190 ft. Cased to 159 ft. FROM WELL LOG Date of teat 12/30/83 Static water level 134 R. Well production 10 g.p.m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 ml. Nitrate 3.39 mg.A. Arsenic: WA mg.A. Date of sample: 7-24106 B. SEPTICIHOLDING TANK DATA Tank Type/Material SEPTIC/STEEL Tank size 1500 gal. Number of Compartments 2 Well Log (Y/N) Y Wires properly protected (Y/N) Y Casing height (above ground) 27 In. AT INSPECTION 7/24105 134.8 ft. 4.7 g.p.m. Other bacteria 0 oolonies/100 ml. Collected by: FRED KENLEY Date instaaed 10/78 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y' Depression over tank (YIN) N High water alarm (YIN) WA Date of pumping 10/16104 Pumper SANITARY PUMPERS C. ABSORPTION FIELD DATA Date installed 10178 Soil rating (g.p.d.W or fe/bdrm)SS System type TRENCH Length 456* R. Width 4 ft. Gravel below pipe 6 ft. Total depth 510 R. ER. absorption area540 R2 Monitoring tube Y«� Depression over held Date of adequacy test 724/05 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test o in. Water added525 gal. New depth In. Elapsed Time: 70 min. Final fluid depth u in. Absorption rate >= 450 g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N 8 type) N If yes, give date — D. LIFT STATION Date installed 'Pump on' level at _ In. Size in gallons Manhole/Accew (YIN) Pumpofr _a%vra r alarm level at Cycles tested Meeh alarm 8 circuit requirements? In. E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank -lift station on lot 153+ FT On adjacent lots 100+ FT Absorption field on lot 108+ FT On adjacent lots 100• FT Public sewer main N/A Pudic sewer manhole/cleanout N/A Sewer /septic service line 25+ FT Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 22+ FT Property line 104 FT Absorption field 10 FT** Water main N/A Water service line 25+ FT Surface water 100+ FT Wells on adjacent lots 100+ FT SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10 FT Building foundation 33+ FT Water main N/A Water Service line 25+ FT Surface water 100+ FT Driveway, parking/"hide smrage 35+ FT Curtain drain NOm a'O'n Io exist Wells on adjacent lots 100+ It F. COMMENTS 'Foundation dean -out Is Imide the house; ••Fran previous Inspection report & HAA; ***anew 1.1Q" MT Installed 7/12105. G. ENGINEER'S CERTIFICATION 1 cerW that I have determined through field inspections and review of Municipal records that the above systems are in oontormance with MOA HAA guidelines in effect on this date. Engineer's Printed Name Douglas T. Kenley Date 10-1-05— HAA -1-0S HAA Fee 11 Waiver Fee S _ Date of Paymentf'2��'� Date of Payment Receipt Number Receipt Number (Rev. 121(11) PERMIT No. PAGE of 40 1 I I I SEE DETA►L'P ATCAGHED % /6. /S 9•� L of U `f/t 1 %o$ �dZa SEPTIC SITE PLAN F0F% LOT Co BLK 2 GOTIONWOOD HEIGHTS SUBD. Lor- _ 0 WITHIN SEC.29,T.ISN,F.IW,S.M. MUti11CIPALMf GRID WN"15(a pATE:12-10-92 SCALE: I"*moo' DRAWN 6Yt J.E. ML KAY • TRoWEL pRAFi-1►,G &,2s 3 N F- w O W a mcaiiao N Q W W > Y > a CA 2 M0wz M •• Q N JWtn2 En RW A S <amza m U> OH 1:WX-1Li y¢ Oy w ZX co 3c us 2=00W R U N Cr in OW W_ W F.. N -O UOW W¢ WIiH OZww Q us tit J On r-) Lo N,wxLi o/ m N'-wN�o to o " x x w ur v N u-CAcc ¢ mZZZ CA Li 3 3 Z U r X O ¢ W O¢ W F- i U O J Ntu N-RHx a N WWW¢F- g CC CA M Z IN: Ui wOZwoa o co 4- a¢¢a ¢w¢a N LU m z 0 CA 0 a 0 0 3 W fn a Q- JOUh A U) N N 2x1-20> m lD N (13 F-wx00n aNIQWU041 i o X m 3 w Ln n 'z g w > m n a Q m S = N N t m J N Q ~ 3 fwd m Q w O O v = z W Q 1 MUNICIPALITY OF ANCHORAGE • '� DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I. D. # 0'r/ -L43 1 —0 �` HAA # Q-� 1r, -) `) 1. GENERAL INFORMATION Complete legal description•? �, 61 .�w �• C-te� Location (site address or directions) Property ownerJc,:Day phone 6F1� Mailing address 1",�J, 4>0x -SL`/ C, __rrlIi�fc- It< Lending agency �io,�vv<<n( 9;014.-z_ Z!& 2 Day phone ?527-34-1.31-1 Mailing address Pry. Qom 16!76zS Ahj'i 4L ` 5t-ki zs ' Agent - az� 04Day phone ?gZy Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 S. 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 of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I furtherverify 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 in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. . p �O of30 Name of Firm R'� t Phone Z(°`S Address 8 ,5� Z A, l4 0044 C, A 99 Sol Engineer's signature 6. DHHS SIGNATURE X Approved for Disapproved. Conditional approval for Additional Comments By: bedrooms. 11 ITIC Date 1 I /2. /C) z ttOF A •.� p k� ••a0 000 �4 a • 0 A,MTtu i'' gym. ji-M__ 4�i CB 453 �'$►4W bedrooms, with the following stipulations: Date Z- 11 The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their tending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA #21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: IALIJ Parcel I.D. OS/ -/ 31-G4 e,s _S/10 A. WELL DATA Well type®M�If A, B, or C, attach ADEC letter. ADEC water system number Wj,b_ ►a13e)�l3 1'I/I' Log present (Y/N) Date completed Driller v kJ Total depth Cased to 1 1 Casing height t Sanitary seal (Y/N) TCS Wires properly protected (Y/N) m FROM WELL LOG C AT INSPECTION i l z3 1 �6� - rl t!5 o z Date of test � j it M m Static water level f 0 r3 rl rQ /IM y O Well flow "( �� g.p.m. 1-11.5 9.11 �o � z Pump level z�� m r`v N o ® < SEPARATION DISTANCES FROM WELL TO:`n m 0 Septic/holding tank on lot �2 � � ; On adjacent lots Absorption field on lot On adjacent lots - Public sewer main i�!)� Public sewer manhole/cleanout Sewer service line Petroleum tank WATER SAMPLE RESULTS: Coliform Nitrate Other bacteria Date of sample: Collected by: �°�iw�s►s-�.J jMltT'fJ s GM �K4*( a v�J B. SEPTIC/HOLDING TANK DATA Date installed hL ��%8 Tank size �SQ� C4,* Compartments Z Cleanouts(Y/N) Ve-5 oundation cleanout (Y/N) Nrn S Depression (Y/N) High waier alarm (Y/N.) Alarm tested (Y/N) A16 1 Date of •pum.ping hi J Z Pumper J /2S ,� JT T SEPARATON DISTANCES FROM. SEPTIC/HOLDING TANK TO: Wells) on lot- I On adjacent lots Foundation f! To property line �d Absorption field 16 Water main/service line Surface water/drainage A0 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION f Date installed Manufacturer Size in gallons Vent (Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) Manhole/Access (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA On adjacent lots "Pump off" level at Cycles tested Date installed / Soil rating'&l#-T-( CirA hz� b Length Width y Gravgl thickness— � _ Surface water 8� System type Total depth �� r Total absorption area T1. Cleanouts present (Y/N) I Depression over field (Y/N) Mo Date of adequacy test 1 be t w_ Results (pass/fail) Auss for _'__3 bedrooms Peroxide treatment (past 12 months) (Y/N) Aho If yes, give date AJ/ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot On adjacent lots %l9 r ) �/� Property line To building foundation To existing or abandoned system on lot On adjacent lots Cutbank Water main/service line Surface water Driveway, parking/vehicle storage area Curtain drain A)t. lfa' 'E. ENGINEER'S CERTIFICATION 1 certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. OF 4�.q,�®g Signature • 'y i Engineer's Nametooled J '�• �Oo'', ®""�" •""'•*"•. Date ; J. DWA Noma+ v,® CE 623300 1000 0 • a4'� HAA Fee $ / %V ° CTV Date of Payment //— z' `~g z--- Receipt Number 71,P) 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number