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HomeMy WebLinkAboutT13N R3W SEC 26 LT 7Onsite File T13N R3W Sec 26 Lot 7 #007-022-26 Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 4 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP201190 PID Number: 007-022-26 Dwelling: 9 Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New 0 Upgrade Name Colette Muller ABSORPTION FIELD ❑ Deep Trench 0 Wide Trench ❑ Bed ❑ Mound Site Address 3310 Campbell Airstrip Rd. Anch., AK 99504 ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 518-779-3574 5 1.2 GPD/SF 7.0 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 2.8 Ft. Gravel depth beneath pipe 4.2 Ft. Subdivision Block Lot 7 Fill added above original grade 1.7 Ft. Gravel length 63 Ft. Township Range Section 13N 3W 26 Gravel width 5 p 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 630 FF 1 Ft. Well >100' >100' N/A N/A >25 TANK DJ Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Greer Capacity 1,500 Gal. Surface Water >1 >1 00' N/A N/A Material Number of compartments Lot Line >5' >10' N/A N/A NA Plastic 2 Foundation i >1 0'1 >10' N/A N/A LIFT STATION Manufacturer Capacity Remarks Landscaping over tank to provide Gal. additional cover. Alarm location Electrical installed by PIPE MATERIAL House to tank D3034 Tank to drainfield D3034 Installer Wilco Contractors Drainfield D3034 CO/MT D3034 Inspector L.TidWell/J. Millette BENCH MARK (Assumed elevation) 100 ft Inspection 15` 8/20/20 nd 8/21/20 dates: Location and description 2 Back Door Threshold aro 4th ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp "•••:QS� ®®��®OF q� ��+s#®®�® Conditional Approval: Date ���P,.•••""' ® °••'049 th ;.MICHAEL E. ANDERSON ��®® Septic System �' ®®',r�'F:, NO. CE -4381 ca �' Date Approve q_-I_w2� �'•a,•• 10/22/20 .•.••''�t�r ��, Note: this approval does not include well permit requirements. ®®��®®S®�� ®® �+® kmev vo/UL/10) BLK3LT5 GLENN -DON BILK 3LT4 I BLK3LT1 Tl 3N R3W SEC26, LOT 7 PERMIT # OSP201190 PID # 007-022-26 GLENN -DON #1 I LOT 1OB// >T 8 I BILK 3 LT 9 I , / NORTON LOT 10A PLAN AS -BUILT 50 0 Em FEET FCO 39.9 8.9 MH1 42.0 18.1 SV1 43.85 21.8 2C0 50.9 34.4 C01 104.0 88.9 MT1 105.6 90.6 CO2 91.1 106.5 MT2 1 89.6 105.0 LEGEND CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT PP - POWER POLE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE Tl 3N RM SEC26, LOT 7 LEM"- 95.6 FINISH GRADE 93.9 ORIGINAL GRADE :E 0 0 in 91.1-- DRAINFIELD ROCK 86.9 86.9 63' 81.9 TO BOH & GROUNDWATER 6/16/20 M ttt 77.9 6/16/20 PROFILE AS -BUILT E H 0 1 N E 9 R I NG (NO SCALE) 91.1 DEPTH (feet) 1 - 3 — 4- 5- 6- 7- 8- 9- 10- 11- 12- 13- 14- 15- 16- 17- 18- 19 - SOILS LOG AND PERCOLATION TEST E N G I N E E R I N G LEGAL DESCRIPTION: T13N R3W SEC26 LOT 7 PERFORMED FOR: COLETTE MULLER DATE: 8/20/20 PROJECT No.: PARCEL ID#: 007-022-26 TECHNICIAN: L. TIDWELL SP TEST HOLE' OF ••'•49th '••�� MICHAEL E. ANDERSON J No. CE -4381 'f,'•.,� oc OFESS%Ct'k®S WAS GROUND WATER ENCOUNTERED? YES IF YES Q WHAT DEPTH? 12' L DEPTH TO WATER AFTER MONITORING: NIA 0 DATE OF MONITORING: N/A P E DATE READING GROSS TIME NET TIME WATER NET DROP (MINUTES) (MINUTES) (INCHES) (INCHES) PERCOLATION RATE: (MIN/INCH) PERC. HOLE DIA_INCHES) TEST RUN BETWEEN: FT. and FT. COMMENTS: TEST HOLE TO MEET PERMIT SPECIAL PROVISIONS. O ,0000-- C14 XDMPD08 LO --f- I N') 4, 4� 4- 0 0 0 i?o 0 00 C14 C14 1 (0 0 �i >- C'4 Ld 1-1 CL C) W U) M 0 -6 tz W C 0) C TJ a) L) m mQ> D 0 -0 u o > u cL cn 0 0a) -i Q) LL- LL Ste.U) 0 LL. Gj- V) U) C;) CNJ m 0 C FD -C g, 0 Q) i (n 0 c: c: 0 z, 4) N 0 C:) re) U) C: (n Q) � a M Ll - c5 V Q) (n E 0- a>)' L rM�II ul 0 E Qn) rr a) of < i� C) r- 0) io C, C 0 3: V) 110 c u"t c — . 0 0 0 Q) Z� -, Q) O C 0 0) >14, q)-.0.,oos-- -,z -) 11 q) > p)�.U) Oz :1 - 0 x C, —. z T- U) U) CO 12 (n (n Lo CrI a) -14 -Z-) 2: a) m E 0) 0 > a < ml? < 0— to (n 0 a) A 0 .>,t= 1- 0 cn -a -0 -0 (n ujc C: C: �Q C: "t 0 M :3 0 C4 C tC -i _3 U) 0 ,-4....E 0 (1) a :E II a- .2- (P ZO 10, 0 V) 10 E ("D 42 0 (n U) I-- oC � — ONTO MO z U) C;) CNJ m 0 C FD -C g, 0 Q) i (n 0 c: c: 0 z, 4) N 0 C:) re) U) C: (n Q) � a M Ll - c5 V Q) (n E 0- a>)' L rM�II ul 0 E Qn) rr a) of < i� C) r- 0) io C, C 0 3: V) 110 c u"t c — . 0 0 0 Q) Z� -, Q) O C 0 0) >14, q)-.0.,oos-- -,z -) 11 q) > p)�.U) Oz :1 - 0 x C, —. z T- U) U) CO 12 (n (n Lo CrI a) -14 -Z-) 2: a) m E 0) 0 > a < ml? < 0— to (n 0 a) A 0 .>,t= 1- 0 cn -a -0 -0 (n ujc C: C: �Q C: "t 0 M :3 0 C4 C tC -i _3 U) 0 ,-4....E 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: OSP201190 Work Type: Septic Upgrade Tax Code Number: 00702226000 Site Legal Address: T13N R3W SEC 26 LT 7 G:1638 Site Mailing Address: 3310 CAMPBELL AIRSTRIP RD, Anchorage Owner: BLAHUT MICHAEL 50% & Design Engineer: FORGE ENGINEERING This permit is for the construction of: Effective Date: Expiration Date: �Ll enr n Department Lot Size in Sq Ft: Total Bedrooms: 7/14/2020 7/14/2021 83635 Q 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 3 Special Provisions: Proposed system too deep for soils information submitted. The Engineer shall do an additional test hole prior to the construction of the septic field. Please submit stamped and signed results with the As -built Inspection Report. If the results require a design change, construction of the system will stop pending On -Site review and approval. Received B} Issued By: Date: J_� Date: 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. 007-022-26 Property owner(s) Colette Muller Mailing address 3631 Reflection Drive, Anchorage, AK 99504 Site address 3310 Campbell Airstrip Road Anchorage, AK Day phone (518) 779-3574 Legal description (Sub'd., Block & Lot) LOT 7 I Legal description (Township, Range & Section) T1 3N R3W SECTION 26 Lt % Lot Size Sq. Ft. Number of Bedrooms 5 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (M all that apply) Absorption Field ❑R Initial ❑ Single Family (SF) ❑X (w/wo ADU) Septic Tank ❑X Upgrade ❑x Duplex (D) ❑ Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑ Privy ❑ (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. (Signature of property owner or authorized agent), Permit/Rush Fees: '7 4lO, Z 5 Date of Payment: Receipt Number: 019 rJ� Permit No. 0S f wll q0 Permit App__- : - Waiver Fees: Date of Payment: Receipt Number: Waiver No. PO BOX 240773 ANCHORAGE, AK 99524 522-7773 677-7766 (FAX) July 10, 2020 MOA Development Services Department On-Site Water & Wastewater Program 4700 Elmore Rd Anchorage, AK 99507 Subject: T13N R3W Section 26 Lot 7 – 3310 Campbell Airstrip Road Septic System Design Dear On-Site Services Engineer: The existing septic system on the subject lot has failed and must be replaced. We are submitting this design and permit application for the construction of a new septic system. The system will be designed for five-bedrooms. The attached site plan identifies the location of existing wells in the area, the existing septic system and the proposed septic location. No conflicts existing between the proposed septic system and all private wells in the area. The ground surface on the lot slopes to the west at grades less than 25% in the area of the absorption trench placement. Drainage arrows are shown on the site plan indicating 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. The test hole will be deepened to at least 13’ prior to construction to verify the lack of impermeable soils or bedrock. Results will be forwarded with the Inspection Report. The existing septic tank will be decommissioned in accordance with the Uniform Plumbing Code. The existing absorption pit will be pumped, demolished and backfilled. The new tank will be a minimum of 10’ from the house foundation and 5’ from the proposed absorption trench. Please refer to the attached test hole log and plan and profile sheet for the septic design. If this design is followed no adverse impacts will occur to adjacent properties. Sincerely, Michael E. Anderson, PE 7/10/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201190, Deb Wockenfuss, 07/14/20 // // // // // // // // // // // // // // // // // // // // // // // // // // // // // // // // // // // // // // // // // // ALTERNATE SITE FCO 10050 0 FEET 1"=50' 63' LONG x 5' WIDE x 4' EFFECTIVE DEPTH ABSORPTION TRENCH 3-BDRM HOME 1500-GALLON SEPTIC TANK W/ 20" MANWAY 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 PP - POWER POLE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE LEGEND TH1 T13N R3W SEC26, LOT 7 CAMPBELL AIRSTRIP ROAD7/14/20 5' T&E EASEMENT 33' ROADWAY & PUBLIC UTILITIES EASEMENT SHED SHED SHED GREENHOUSE TH2 25% 25% 25% 25% 25% MH SV 2CO CO MT MT CO EXISTING WELL DECOMMISSION EXISTING CONCRETE SEPTIC TANK PER U.P.C. EXISTING ABSORPTION PIT. LOCATION AND DIMENSIONS UNKNOWN. PUMP, DEMOLISH & BACKFILL. SHED TO BE REMOVED PP PP PP Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201190, Deb Wockenfuss, 07/14/20 T13N R3W SECTION 26 LOT 7 DESIGN FACTORS: SYSTEM REQUIREMENTS: 750 GPD PEAK FLOW PERK RATE: <1 MIN/IN APPLICATION RATE: 1.2 GPD/SF 5' WIDE TRENCH SYSTEM 1,500-GALLON SEPTIC TANK TYPICAL TRENCH SECTION (NO SCALE) 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: 7.0' BELOW GRADE FLOW LINE ELEVATION: 3.0' BELOW GRADE TOP OF TRENCH: .5' ABOVE GRADE 750 GPD /1.2 GPD/SF /5' WIDE * .5 (RED. FACTOR) = 62.5 LF TRENCH REQUIRED (63 LF SPECIFIED) 7/10/20 4" PERFORATED PVC (HOLES DOWN) DRAINFIELD ROCK 5' 6" 2.5' 4' 6" GEOTEXTILE FABRIC Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201190, Deb Wockenfuss, 07/14/20 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) T13N R3W SEC26 LOT7 6/9/20 L. Tidwell DATE OF MONITORING: WAS GROUND WATER ENCOUNTERED? DEPTH TO WATER AFTER MONITORING: IF YES @ WHAT DEPTH? 12' 0.2 6 6 7 007-022-26 Colette Muller 11:54 6/9/20 1 2 3 4 5 6 3" - 9" 11:55 11:57 11:59 12:03 12:07 2' OB Professional Engineers Stamp: 7/10/20 0:38 yes 12' 6/16/20 SP 6" 3" - 9"1:01 6" 7 12:10 3" - 9"1:15 6" 3" - 9"1:16 6" 3" - 9"1:18 6" 3" - 9"1:02 6" 3" - 9"1:12 6" Walls of test hole collapsing, reason for 12' test holes Material appears to meet gradation for sand. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201190, Deb Wockenfuss, 07/14/20 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) T13N R3W SEC26 LOT 7 6/9/20 L. Tidwell DATE OF MONITORING: WAS GROUND WATER ENCOUNTERED? DEPTH TO WATER AFTER MONITORING: IF YES @ WHAT DEPTH? 12' 0.06 6 4 5 007-022-26 Colette Muller 12:20 6/9/20 1 2 3 4 5 6 3" - 9" 2' OB Professional Engineers Stamp: 7/10/20 0:26 yes 12' 6/16/20 SP 6" 3" - 9" 6" 3" - 9" 6" 3" - 9" 6" 3" - 9" 6" 3" - 9" 6" Walls collapsing caused 12' test hole BOT 12:21 0:23 12:22 0:20 12:23 0:21 12:27 0:21 12:28 0:20 Material appears to meet gradation for sand. 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GENERAL INFORMATION Complete legal description T1 3N R3W SEC 26 LOT 7 Location (site address) 3310 Campbell Airstrip Road Current property owner(s) Mailing address Real estate agent Colette Muller Day phone (518) 779-3574 3310 Campbell Airstrip Road, Anchorage, AK 99504 2. TYPE OF DWELLING: ❑ Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 5 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well Private Septic ❑i 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 $ ZfJ Waiver Fee $ Date of Payment Z /I (o/ 2 Z_ Date of Payment Receipt Number C-122 1 7& P Receipt Number COSA # OSc— ZZ I o '�-rJ 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 Benjamin Schiller Date 2/15/22 TH 6. DSD SIGNATURE ' ...� ... . .�. i System #1 Approved for bedrooms �� �.. Benjarrt.iSc.hiller System #2 Approved for bedrooms CE 12592 Disapproved �l�ll pROFESS1oN1 Conditional approval for bedrooms, with the following stipulations: «ctctr OF ON—SITE �� WATER AND By: _ Original Certificate Date: —,7 Zd 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 Legal Description: TI 3N R3W Sec 26 Lot 7 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 11/12/81 Total depth 145 ft Cased to 145 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 30 in. Date of flow test for COSA 7/8/20 Static water level at beginning of test 97.8 ft. Comments B. TANK DATA Age of tank(s) <2 years Tank type/material Septic/Plastic Measured operating fluid level in septic tank New ❑® Stand pipes/foundation_cleanout per record drawing Date of pumping Installed on 8/21/20 D. ABSORPTION FIELD DATA 5 -WIDE TRENCH Which system tested (date installed) 8/21/20 0 ALL standpipes present per record drawing Total measured depth from grade 8.7 ft (max) Measured depth to pipe invert from grade 4.5 ft (min) ❑ N/A — pressurized field R Monitor tubes go to bottom of effective. If not, state depth into effective ❑® Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced N/A gallons Comments/Deficiencies: COSA Checklist yellow sheet Parcel ID: Structure served by this system 1 007-022-20 Well production at time of test 3.2 gpm Water storage tank volume N/A gallons Well disinfected for coliform test? ❑ Yes ❑ No ®❑ Coliform bacteria is Negative Nitrate ND mg/L ❑ Nitrate less than MRL (ND) Arsenic ND ug/L ❑ Arsenic less than MRL (ND) Collected by Forge Engineering Date of Sample 12/10/21 C. LIFT STATION URS . ed maintenance completed Age of lift station ears Lift station material Comments: Adequacy test date *New System Results ❑ Pass For bedrooms F,Lid depth prior to test in Water a -tided gal New depth 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' 0 Yes Community Sewer Manhole/Cleanout > 100' F✓ Yes if No ft M Yes if No ft Neighboring Tank > 100' ✓M Yes if No ft Private Sewer/Septic Line > 25' [D Yes if No ft Absorption Field on Lot > 100' Fv Yes if No ft Holding Tank > 100' M✓ Yes if No ft Neighboring Absorption- Fields > 100' Yes if No Animal Containment > 50' - El Yes if No ft 0✓ Yes if No ft if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' �✓ Yes if No ft rVJ Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' P( Yes if No ft Surface Water > 100' Q✓ Yes if No ft Property Line > 5' 0 Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' Q✓ Yes if No ft Private Wells > 100' Yes if No ft Water Main >. 10.'_.� . _EV] Yes if No ft Community Wells > ?00'f 1 Yes if No ft Water Service Line > 10' F71 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' 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' Yes _ if No ft Private Wells > 100' Yes if No ft Water Service Line > 10' F,71 Yes if No ft Community Wells > 200' ❑✓ Yes if No ft Surface Water > 100' 0 Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION 1 certify that l have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. COSA Checklist yellow sheet 49 TH Benja5chiller 2/15522 ���1�,®•� ��� PROFESSI©Nt' -�