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HomeMy WebLinkAboutAUDUBON HILLS BLK 2 LT 9Onsite File Audubon Hills Block 2 Lot 9 #015-231-59 MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP241112 Work Type: SepticTank Upgrade Tax Code Number: 01523159000 Site Legal Address: AUDUBON HILLS BLK 2 LT 9 G:2739 Site Mailing Address: 12320 AUDUBON CIR, Anchorage Owner: HANSON RYAN THOMAS & Design Engineer: FORGE ENGINEERING This permit is for the construction of: Effective Date Expiration Date: �i»cnr r. r, i� t)ijmrtl>>ctit Lot Size in Sq Ft: Total Bedrooms: 6/3/2024 6/3/2025 41079 ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ 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 Received By: Issued By: Date: Date: c 3 Z 4 ON -SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 015-231-59 Property owner(s) Ryan Hanson Day phone Mailing address 12320 Audubon Cir, Anchorage, AK 99516 Site address 12320 Audubon Circle Legal description (Sub'd., Block & Lot) Audubon Hills Block 2 Lot 9 Legal description (Township, Range & Section) Lot Size 41,079 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (N all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) ❑X Septic Tank ❑X Upgrade (w/wo ADU) Holding Tank El Renewal❑ (D) ElRenewal Privy ❑ Multiple Dwellings ❑ (SF and/or D) Private Well ❑ 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. 1V `u (signature of property owner or authorized agent) Permit/Rush Fees:.-4360 Waiver Fees: Date of Payment: Date of Payment: Receipt Number: Receipt Number: Permit No. 05 P?, 2 - Waiver No. Permit App__'- : - : -.,:c ; May 30, 2024 MOA Development Services, On-Site Water & Wastewater Program 4700 Elmore Rd Anchorage, AK 99507 Subject: Audubon Hills B2 L9 – 12320 Audubon Circle Septic Tank Replacement Dear On-Site Services Engineer: The septic tank on the above lot has collapsed due to pressure from surface runoff, so we are submitting this permit application for its replacement. The attached site plan identifies the location of the home as well as the wells and septic location. No conflicts exist between this proposed system and any other wells or septic system, whether on this lot or adjacent lots. We are replacing the septic tank with the same size designed for 4 bedrooms, but a steel one that will withstand future water pressures. The new septic tank will be a minimum of 100’ from all wells and surface water. Please refer to the attached plan for the septic design. If this design is followed, there will be no adverse impacts to adjacent properties. Sincerely, Benjamin Schiller, PE Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP241112, Curtis Townsend, 06/03/24 Benjamin Schiller CE 12592REGISTEREDPROFESSION A L E N GINEER 1"=50' CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FS - FLOW SPLITTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE LEGEND FEET 0 50 100 SEPTIC PLAN 5/29/24 4-BDRM HOME TH1 PERMIT # OSP241112 PID # 015-231-59 AUDUBON HILLS, BLOCK 2, LOT 9 A U D U B O N C I R C L E AUD U B O N D R I V E 10' x 30' GUY EASEMENT 880 885 875 870 WELL EXISTING WELL EXISTING 1500 GAL GREE STEP TANK TO BE REMOVED INSTALL NEW STEEL 1500 GAL STEP TANK 50' LONG ABSORPTION TRENCH TO REMAIN IN SERVICE FCO ELEC. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP241112, Curtis Townsend, 06/03/24 Municipality of Anchorage On-Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP201473 PID Number: 015-231-59 Dwelling: 0 Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: W New ❑ Upgrade Name Alexander Homes, LLC ABSORPTION FIELD ❑ Deep Trench ■❑ Wide Trench ❑ Bed ❑ Mound Site Address 12320 Audubon Cir., Anchorage, AK 99516 ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 907-830-6211 4 1.2 GPD/SF 6.1 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 2'0 Ft. Gravel depth beneath pipe 4.0 Ft. Subdivision Block Lot Audubon Hills 2 9 Fill added above original grade 1.3 Ft. Gravel length 50 Ft. Township Range Section Gravel width 5 Ft. Beds: Number of Lines N/A Distance between lines N/A Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line 5500 Ft2 1 N/A Ft. Well >100' >1 00' N/A N/A >25' TANK ❑ Septic❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Greer Capacity 1,500 Gal. Surface Water >100, >1 00' N/A N/A Material Plastic Number of compartments 2 Lot Line >5' >10' N/A N/A NA Foundation >10' >10' N/A N/A LIFT STATION Manufacturer Greer Capacity 250 Gal. Remarks Alarm location ENTRYWAY Electrical installed by DEPENDABLE SERVICES Installer PIPE MATERIAL House to tank D3034 Tank to drainfield D3034 Northern Excavation Drainfield D3034 Co/MTD3034 Inspector L.Tidwell BENCH MARK (Assumed elevation) 100 ft Inspection 1m 12/1/20 12/1/20 Location and description nd dates: 3`d 12/2/20 4,,12/2/20 To of foundation at SE corner of home p ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional Approval: +�®+ossa � r ♦e .... Date" :qS®0♦♦ •,� • C , s f = 49th ° ♦♦ w ..... �� ..}�....}'}'.h.....® 0. /................................................ .. i♦�n ; MICHAEL E. ANDERSON Zo Septic System Appro - -� ( Date♦♦�TF,p•••.,, ♦ No. CE-43 at ;' Ar 10/12/21 ,,.• <� 4V ♦� ♦♦q '°ROSS 10�Po++o 44., FFESS\6\\ Note: this approval does not include well permit requirements. kRev uo/uu i u/ PERMIT # OSP201473 98.3 PID # 015-231-59 101.6 FINISH GRADE 100.3 ORIGINAL GRADE 2" FOAM INSULATION DRAINFIELD ROCK 98.3 94.3 94.2 50' 86.5 GROUNDWATER 10/29/20 cN N\— 85.3 ENGIN!! RING PROFILE AS -BUILT (NO SCALE) °0 49th ,% MICHAEL E. ANDERSON sT�1 NO. CE -4381 10/12121 ESS\�®\® Ea Benjamin Schiller CE 12592R E GISTEREDPROFES S I O N A L E N GINEER Jun 03, 2024 1"=50' 4-BDRM HOME CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FS - FLOW SPLITTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE LEGEND TH1 PERMIT # OSP201473 PID # 015-231-59 AUDUBON HILLS, BLOCK 2, LOT 9 A B FCO 23.7 ELEC.28.9 MH1 32.1 A B C C MH2 32.9 MT1 12.4 MT2 56.1 79.9 3.6 11.2 14.4 18.2 38.4 A U D U B O N C I R C L E FEET 0 50 100 AUD U B O N D R I V E 10' x 30' GUY EASEMENT TH2 880 885 875 870 WELL EXISTING WELL 1,500 GALLON S.T.E.P. TANK 50' LONG x 5' WIDE x 4' EFFECTIVE DEPTH ABSORPTION TRENCH ALTERNATE SITE: CATERGORY III SYSTEM w/ 25 LONG x 5' WIDE x .5' EFFECTIVE DEPTH ABSORPTION TRENCH. APP. RATE 5 GPD/SF. FCO MH2 MH1 MT1 MT2 PLAN AS-BUILT ELEC. Alpine Drilling & Enterprises Well L® Permit Number: #SW201473 Date of Issue: 11-4-20 Date Started: 12-16-20 Date Completed: 12-18-20 Legal Description: Audubon Hills Block 2 Lot 9 Property Owner Name & Address: Jeanette Tessore - Alexander Homes 2625 Arlington Drive 650 W 58th Ave Suite D Anchorage, Alaska Anchorage, Alaska 99518 Borehole Data: Depth (ft) Method of Drilling x air rotary ❑cable tool Soil Type, Thickness &Water Strata From To Casing type: steel Wall Thickness: .250 inches Diameter: 6 inches Depth: 81 feet Liner Type: Diameter: inches Depth: Casing stickup above ground: 2 feet Parcel Identification Number: 01523159000 Is well located at approved permit location? x Yes ❑ No stick up gravel fill silty peat silt silty sandy gravel H2O silt gravelly silty H2O silt bedrock 0 2 4 19 52 54 67 68 78 2 4 _ln 52 54 67 68 78 327 WATER QUALITY TESTING Coliform C01/100ml- Nitrates 4 M911 - Arsenic .D u9/L feet Static water level (from ground level): 0 feet Pumping level: 320 feet after 2 hours pumping 2 gpm Recovery Rate: 2 gpm Method of Testing: Air Li Well Intake Opening Type: ❑ Open End x Open Hole ❑ Screened Start feet Stopped feet ❑ Perforations Start feet Stopped feet Grout Type: bentonite granules Volume: 2bgs Pump: Intake Depth feet Pump size hp Brand Name Well Disinfected Upon Completion? x Yes ❑ No Method of Disinfection: Chlorine tablets Comments: Well Driller: Alpine Drilling & Enterprises PO Box 110496 Anchorage AK 99511 )i'.,/ 054 1 0i: 15 Stir -3 4 5 - ---12 [12' ALPINE DRILL.71--IG PAGE 01/01 MUNICIPALITY OF ANCHORAGE pnone: g.C)7-34.3-7904 Developmer,t_,-ervjces Departn-jent r -*ax: 907-343-7997 on-S'ite. Water & Wast6w2tel- 30cti0t! Pump Installation Log 11 �4 We ell: 201473 Date of Issue. '11 Drilling pernlitNumb 015 -231 saw. parcel Idenfificatiolt B31 ek Lot Pruperty OW"ey'Naw4�, & Address: Legal -Description leannelte Teli5or5 Audubon Hils 2 9 Alexander Hornes .PU.jl,P Installation Oate:,6 2`2 i;jg! 272 fa I purlip Intake Dept h'sellow Top of Well CPS. Myers :fumy MoLnuftichlrer-s Name' ' pra.j5jp,Mode1:2NFL102-'--P4-01 PuIrp size: 1 ---hp ritiess Adapter.Burial Depth; N/A foW 11tiess Adapter - N/A well 1110afeeted I Too, COT11pleflon! No iletlncrd Chlorine table" of .01sinfeelhOM complents. PLEASE SAVE FOR COSH. FUMP Installer N111we., Aarow Pump & Well Service, LLC company: Mailing Address" P.O. Box 110496 CRY: Anchorage P. iL)g - on-sitemitbin 30 day� of pump'installatiOR. sjj�.fll "iovidta plimp installation log to 11/4/20 PO BOX 240773 ANCHORAGE, AK 99524 522-7773 677-7766 (FAX) November 2, 2020 MOA Development Services Department On-Site Water & Wastewater Program 4700 Elmore Rd Anchorage, AK 99507 Subject: Audubon Hills, Block 2, Lot 9 – 12320 Audubon Circle Well and Septic System Design Dear On-Site Services Engineer: The owner of the above lot intends to build a 4-bedroom home on the property. We are submitting this application for a permit to construct a new well and septic system. The attached site plan identifies the location of the home and the proposed well, septic location and alternate site. No conflicts exist between this proposed system and any other well or septic system, whether on this lot or adj acent lots. The ground surface on the lot slopes to the west at grades up to 25%. There are no slopes greater than 25% within 50’ downslope of the proposed absorption trench. Ground contours are shown on the site plan showing the grade and direction of flow. Storm water drainage will not impact this septic system. The new trench will be constructed parallel to the slope as much as possible. Wells on this and adj acent lots are shown. The new system will be a minimum of 100’ from all wells and surface water, and more than 5’ away from the septic tank. The alternate site is located more than 16’ away. Please refer to the attached test hole logs and plan and profile sheets for the septic design. If this design is followed, there will be no adverse impacts to adj acent properties. Sincerely, Michael E. Anderson, P.E. 11/2/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201473, Rebecca Carroll, 11/04/20 1"=50' 4-BDRM HOME NOTE: NO SLOPES >25% WITHIN 50' OR SURFACE WATER WITHIN 100' OF THE PROPOSED SEPTIC SYSTEM ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS PROPERTY ARE SHOWN. NO CONFLICTS WITH WELLS OR SEPTIC SYSTEMS. CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FS - FLOW SPLITTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE LEGEND TH1 AUDUBON HILLS, BLOCK 2, LOT 9 A U D U B O N C I R C L E 11/2/20 FEET 0 50 100 AUD U B O N DRIV E 10' x 30' GUY EASEMENT TH2 880 885 875 870PROPOSED WELL EXISTING WELL 1,500 GALLON S.T.E.P. TANK 50' LONG x 5' WIDE x 4' EFFECTIVE DEPTH ABSORPTION TRENCH ALTERNATE SITE: CATERGORY III SYSTEM w/ 25 LONG x 5' WIDE x .5' EFFECTIVE DEPTH ABSORPTION TRENCH. APP. RATE 5 GPD/SF. FCO MH MH MT MT Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201473, Rebecca Carroll, 11/04/20 AUDUBON HILLS, BLOCK 2, LOT 9 DESIGN FACTORS: SYSTEM REQUIREMENTS: 600 GPD PEAK FLOW PERK RATE: 1-5 MIN/IN APPLICATION RATE: 1.2 GPD/SF 5' WIDE TRENCH SYSTEM 1,500 GALLON S.T.E.P. TANK TYPICAL TRENCH SECTION (NO SCALE) 1" PERFORATED PVC (HOLES DOWN) DRAINFIELD ROCK 5' 6" 6" 1'6" 4' NOTES: 1. GRADE AREA OVER TRENCH TO DRAIN AWAY 2. PROVIDE 3' OF COVER OVER TRENCHES AND 4' OVER SEPTIC TANK, OR 2' WITH 2" OF INSULATION 3. CHECK GROUNDWATER AT TIME OF CONSTRUCTION. IF LEVEL IS HIGHER THAN PREVIOUSLY OBSERVED, CALL ENGINEER IMMEDIATELY BOTTOM OF TRENCH: 6.0' BELOW GRADE FLOW LINE ELEVATION: 2.0' BELOW GRADE TOP OF TRENCH: 0.5' ABOVE GRADE 600 GPD / 1.2 GPD/SF /5' WIDE * .5 (RED. FACTOR) = 50 LF TRENCH REQUIRED (50 LF SPECIFIED) 11/2/20 2" INSULATION & GEOTEXTILE FABRIC 30 - 3 16" HOLES @ 1.7' SPACING Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201473, Rebecca Carroll, 11/04/20 LEGAL DESCRIPTION: PERFORMED FOR: DATE: PARCEL ID#: SOILS LOG AND PERCOLATION TEST TECHNICIAN: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 DEPTH (feet)✏ PROJECT No.: TEST HOLE 1 SLOPE SLOPE SITE PLAN DATE READING GROSS TIME (minutes) NET TIME (minutes) DEPTH to WATER NET DROP PERC. HOLE DIA. (INCHES)PERCOLATION RATE: (MIN/INCH) TEST RUN BETWEEN: FT. and FT. COMMENTS: (inches)(inches) A U D U B O N H I L L S B 2 L 9 ⌥ 1 0 /2 0 /2 0 L . T I D W E L L ⌥ DATE OF MONITORING: WAS GROUND WATER ENCOUNTERED? DEPTH TO WATER AFTER MONITORING: IF YES @ WHAT DEPTH? - 1 .7 6 4 5 0 1 5 -2 3 1 -5 9 T E S S O R E J E A N N E T T E ⌥ 1:55 10/22 1 2 3 4 5 6 0 0 16 / 6 0 16 2:00 2:12 2:23 2:34 2:46 1' OB Professional Engineers Stamp: 11/2/20 4:49 N O ⌥ 1 1 .0 '⌥ 1 0 /2 9 /2 0⌥ GM (SILTY SANDY GRAVEL) 7 2:57 8:51 10 10 10 10 10 0 0 16 / 6 0 16 0 0 16 / 5 15 16 0 0 16 / 5 14 16 0 0 16 / 5 14 16 0 0 16 / 5 14 16 0 0 16 / 5 14 16 6 0 16 6 0 16 5 15 16 5 14 16 5 14 16 5 14 16 5 14 16 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201473, Rebecca Carroll, 11/04/20 LEGAL DESCRIPTION: PERFORMED FOR: DATE: PARCEL ID#: SOILS LOG AND PERCOLATION TEST TECHNICIAN: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 DEPTH (feet)✏ PROJECT No.: TEST HOLE 2 SLOPE SLOPE SITE PLAN DATE READING GROSS TIME (minutes) NET TIME (minutes) DEPTH to WATER NET DROP PERC. HOLE DIA. (INCHES)PERCOLATION RATE: (MIN/INCH) TEST RUN BETWEEN: FT. and FT. COMMENTS: (inches)(inches) A U D U B O N H I L L S B 2 L 9 ⌥ 1 0 /2 0 /2 0 L . T I D W E L L ⌥ DATE OF MONITORING: WAS GROUND WATER ENCOUNTERED? DEPTH TO WATER AFTER MONITORING: IF YES @ WHAT DEPTH? - 2.9 6 4 5 0 1 5 -2 3 1 -5 9 T E S S O R E J E A N N E T T E ⌥ 1:53 10/22 1 2 3 4 5 6 0 0 16 / 6 0 16 2:04 2:15 2:27 2:39 2:50 1' OB Professional Engineers Stamp: 11/2/20 4:49 N O ⌥ 1 3 .8 '⌥ 1 0 /2 9 /2 0⌥ GM (SILTY SANDY GRAVEL) 8:51 10 10 10 10 0 0 16 / 6 0 16 0 0 16 / 5 15 16 0 0 16 / 5 14 16 0 0 16 / 5 14 16 0 0 16 / 5 14 16 6 0 16 6 0 16 5 15 16 5 14 16 5 14 16 5 14 16 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201473, Rebecca Carroll, 11/04/20 MUNICIPALITY OF ANCHORAGE ~'DI~PARTMENT OF HEALTH AhlD ENVI P, ONMENTAL PRO'IECTION f~uch ~6§O,~J~nch~r~Ue- /~laska 99502 ~76-~22 SOItS k.O~ rE RCOLAI'ION TEST SOILS LOG FE t~ERFOFIMEI):. ~~' ' " SITE PLAN 1D 11- 13- 14 15 16 18 19 PER(~OLATIO N RATE Net Time L (minutes/inch) Net Drop FT AND FT DATE: P-0\� U S N UH CC '= A L0T 7 OF '-` HC H 0R 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. 015-231-59 Expiration Date: 1. GENERAL INFORMATION Complete legal description Audubon Hills, Block 2, Lot 9 Location (site address) 12320 Audubon Cir, Anchorage, AK 99516 Current property owner(s) Alexander Homes LLC Day phone (907) 830-6211 Mailing address PO Box 110344, Anchorage, AK 99511 Real estate agent 2. TYPE OF DWELLING: M Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well®❑ Private Septic ❑® 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 $_ 75 + -0 y � Date of Payment I q -Z % Receipt Number 3 ro 7 26 Waiver Fee $ Date of Payment Receipt Number COSA # ()�2 G 21 19 1 y 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 Forge Engineering Phone (907) 522-7773 Address 1399 W. 34th Ave Suite 101, Anchorage, AK 99503 Engineer's Printed Name Michael E. Anderson, P.E. Date 10/12/21 41,R�� • OF q��sse LF' �'• 49th •' � +e. 6. DSD SIGNATURE ^ """ =a Z,t%;, System #1 Approved for bedrooms :�n ;MICHAEL E. ANDERSON _�'' NO. CE -4381 AV System #2 Approved for bedrooms ®e��FP 10/12/21 ••..••'���',� Disapproved ®® t� s0&"SS= ®®wOe Conditional approval for bedrooms, with the following stipulations: J J/JJ��MFArT SEr )))i Original Certificate Date: f d 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 s Legal Description: Audubon Hills Block 2 Lot 9 If more than 1 septic system on lot: COSA Checklist # 1 of 1 A. WELL DATA Q Well log is filed with Onsite (or attached) Date drilled 12/18/20 Total depth 327 ft Parcel ID: 015-231-59 Structure served by this system 1 Well production at time of test 2 gpm Water storage tank volume NIA gallons Well disinfected for coliform test? ❑ Yes ❑ No Cased to 81 ft 0 Coliform bacteria is Negative 0 Sanitary seal is functioning correctly Nitrate mg/L 0 Nitrate less than MRL (ND) ®❑ Wires are properly protected Arsenic ug/L R Arsenic less than MRL (ND) Casing height (above ground) '24 in. Collected by Forge Engineering Date of flow test for COSA *12/18/20 Date of Sample 10/8 & 14** Static water level at beginning of test 0 ft. Comments *New well w/ flow test *Well retested for bacteria, disinfected after initial positive test B. TANK DATA Age of tank(s) 1 years Tank type/material Plastic Measured operating fluid level in septic tank New ❑® Standpipes/foundation cleanout per record drawing Date of pumping New Construction D. ABSORPTION FIELD DATA 5' Wide Which system tested (date installed) 12/1/21 ®❑ ALL standpipes present per record drawing Total measured depth from grade 7.4 ft (max) Measured depth to pipe invert from grade N/A ft (min) ❑® N/A — pressurized field W Monitor tubes go to bottom of effective. If not, state depth into effective an Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced N/A gallons Comments/Deficiencies: Absorption Trench constructed 1212/20. COSA Checklist yellow sheet C. LIFT STATION ❑ Required maintenance completed Age of lift station 1 years Lift station material Plastic Comments: New Construction equacy test date N/A Resu ❑ Pass For bedrooms Fluid depth for 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 Community Sewer Manhole/Cleanout > 100' ✓0 Yes if No ft Q Yes if No ft Neighboring Tank > 100' Yes if No ft Private Sewer/Septic Line > 25' Yes if No ft Absorption Field on Lot > 100' Yes if No ft Holding Tank > 100' Yes if No ft Neighboring Absorption Fields > 100' Yes if No Animal Containment > 50' Yes if No ft 0✓ Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' MV Yes if No ft Q Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' 0 Yes if No ft Surface Water > 100' p Yes if No ft Property Line > 5'✓0 Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' Yes if No ft Private Wells > 100' Yes if No _ Water Main > 10' Yes if No ft Community Wells > 200'✓0 Yes if No. Water Service Line > 10' ❑✓ 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' E✓ Yes if No ft If absorption field is under driveway comment below Property Line > 10' 0 Yes if No ft Wells on Adjacent Lots: Water Main > 10'✓0 Yes if No ft Private Wells > 100' 0✓ Yes if No Water Service Line > 10' 0✓ Yes if No ft Community Wells > 200' 0 Yes if No Surface Water > 100' 0 Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION `�,0F..�C 1 certify that l have determined through field inspections and review of Municipal records that the above systems are in conformance with 49th MOA COSA guidelines in effect on this date. �. :.•.•._7....1—.... ••.•�p•�,°•..� COSA Checklist yellow sheet MICHAEL E. ANDERSON g i c �� ••. No. CE -4381 •°�� ����F�°°•e 10/12/21Man ft ft ft a�i � N �I �_ � rn v Orn c (n N co mS�m I -c N� O \ D En z ') — En - N p �cDC;a r cmAS v00 mmc Oogm-v- 0 �mm�° N�-'UM M Com ��Z�''' :r M mm001 S z 0 Ern o�Nmmm n m ca cvc��mz� m� N �pm0�c) O— N v �OGIGOMORAb o'qm�� z3: C: c�ico m oc �y ,cmn�OZZ�pCO) Zj o zorn H ;u K910 a m .�, C0 _ o r ,0 (A ;n O C) C N w N V l