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HomeMy WebLinkAboutT15N R2W SEC 25 LT 129AOnsite File T15N R2W Section 25 Lot 129A #051-312-33 Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page of ON-SITE WASTEWATER INSPECTION REPORT Permit Number: 0SP221111 PID Number: 051-312-33 Dwelling: ❑■ Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New [N Upgrade Name Merrill Bruce A Trust ABSORPTION FIELD ❑ Dee Trench ❑ Bed ❑ Mound p ❑Wide Trench Site Address 15411 Husky St., Eagle River ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 907-863-4713 3 GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe Subdivision Block Lot 129A Ft. Ft. Fill added above original grade Ft. Gravel length Township Range Section T1 5N 2W 25 Ft. Gravel width Beds: Number of Lines Distance between lines SEPARATION DISTANCES Ft. Ft. To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line Ftz Ft. Well 100+ 25+, TANK X Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Capacity Surface Water 100+ Greer 1000 Gal. Material Number of compartments Lot Line 5+ NA ILIFT Polyethylene 2 Foundation 10+ STATION Manufacturer Capacity Remarks Gal. Alarm location Electrical installed by Installer PIPE MATERIAL House to tank 3034 Tank to 3034 drainfield Martin Construction Company Drainfield CO/MT3034 Inspector Crewdson Engineering LLC BENCH MARK (Assumed elevation) 100 ft Inspeection 15' 5/23/22 2�a 5/23/22 Location and description 3'd 5/24/22 4"' Bottom of siding at "BM" on record drawing. ON-SITE WATER AND WASTEWATER SECTION APPROVAL _-X':E OF ALq Conditional Approval: DateAwy,�4; • �+f, r TH*J. ' •�,� lr '6.0`:. ' A �•JamesA.0rewdson :,,2F% �/ Septic System Appro �--�( �`� -ZZ 011527 .•&'�� 1 's'F•' ,.� Date ,.:" Note: this approval does not include well permit requirements. rrao,, ng/roti PN SWING TIES (feet) A I B FC 20.2 22.1 MH 29.2 31.1 S1 32.5 35.0 DC 34.5 36.9 SUMP 20.9 57.9 •A PROPERTY LINE I SUMP I Q ( I A I \ I 3BR SFH \� I FC MH S1 J1 A \\ 51+ �o a BM 0 0 DC 1 I� e (Ij rrn• I I SEPTIC TANK I DRIVEWAY- B GREER POLY 1000 50' SECTION UNE EASMENT BENCH MARK ELEV BOTTOM OF SIDING EG 95.8 ELEV 100' FG 96.1 FC MH S1 DC SEPTIC TANK ELEV TOT 91.7 INLET 91.1 OUTLET INV 90.9' PROFILE NOT TO SCALE 10' UTILITY EASMENT T1 5N, R2W, SEC 25, Lot 129A Septic Tank Upgrade RECORD DRAWING -w Prepared for: CMI &ftft""'wtal H gh im'"g Bruce Merrill Date: 6-2-2022 PO Box 671389 Chuglak AK 99567 a cellc.l@oudook.com Permit: OSP221111 Page: 1 of 1 CelUText:907-280-9493 • Fax: 907-688-2295 ALL LNIFORMATION SHOWN ON THIS DOCUMENT IS THE PROPERTY OF CREWDSON ENGINEERING. LLC AND SHALL NOT BE USED FOR ENGINEERING OR CONSTRUCTION PURPOSES WITHOUT WRITTEN PERMISSION FROM CREWDSON ENGINEERING, LLC 00 N 0 U7 W Q0 o W Oa �0n Cf) PLAN SCALE: 1 "=20' LEGEND BM - benchmark BR - bedroom DC - double cleanout EG - existing ground ELEV - elevation FG - finish grade INV - invert MH# - 24"0 manhole S# - standpipe SFH - single family home TOT - top of tank 49 �r me . Crewdson �F • . C11527 �A PROFESSIONP� ALLC #112279 Lot 1288 I 50 BLM ROAD RESERVATION 30,0' 30.0' I W ILLJ X Lot 129B \ \ S 89'50'30"E 299.05' to I 9.6'x14.8' DECK V) N 100RO p rfC Y � w o I V ( O Z TIE --® o L=28.32' - o R=20.00' M — -I Lot 141 I \ 10' UTILITY \ EASEMENT \ SEPTIC PIPE ' 45.0' trVC RADIUS Ry N SHED v� DA l/ Lot 1 2 A 20.3'STO G ES/PENCE• NT BSMT. 30,807 S.F. WELL f2.0' ff CN CONC' 1 10.0'x10.0' GREENHOUSE --,o44'2' GRAVEL DRIVEWAY C j —II7E-Y,0%E . 0Ia--�Bt�—= p/E �U E 0/E N 89'51'10"W 279.08' L -OVERHEAD POWER LINES — — —q— SEE SAW AVENUE Lot 140 -SEPTIC f PIPES 0 t� MANHOLE 10' UTILITY / EASEMENT Lot 130 0/E 0/E — 50' BLM ROAD b ( RESERVATION N i Lot 139 0 10 25 50 100 SCALE: 1"=40' PLOT PLAN _— AS BUILT _x_ SCALE 1" = 40_ GRID _ NW 0653 Project No. _� 22-333 Al _ 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Associatesinc. (907) 522-6476 Phone 9(907) 522-4625 Fax �����C1ODD40 Professional Land Surveyors kenAlongsurvey.com o C) F A �tOp jonathon0langsurvey.com ©P I hereby certify that I have surveyed the following described property: LOT 129A, SECTION 25, T15N, R2W, SEWARD MERIDIAN, ALASKA (PLAT No. 72-131) 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 said property except as indicated hereon. Dated this the �M_ Day of _ hn�� , �''? 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. '** �t '-.'7- 49TH( KENNETH G. LANG o c Ljv-& J�J ��Fo'••.LS-5202.•'• 5 4 4QRR�FeSS10NAL AECC963 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: OSP221111 Work Type: SepticTank Upgrade Tax Code Number: 05131233000 Site Legal Address: T1 5N R2W SEC 25 LT 129A G:0653 Site Mailing Address: 15411 HUSKY ST, Eagle River Owner: MERRILL BRUCE A TRUST Design Engineer: CREWDSON ENGINEERING, LLC This permit is for the construction of: ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy Effective Date Expiration Date Lot Size in Sq Ft: Total Bedrooms: �snent Depal'ttriellt 5/17/2022 5/17/2023 26125 ❑ 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: I_ Date: 5 ( .2022 3 MUNICIPALITY OF ANCHORAGE thip, ji_AT` Development Services Department ��,7 Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 051-312-33 Property owner(s) Bruce Merrill Day phone 907-86-4713 Mailing address 15411 Husky Dr., Eagle River, AK 99577 Site address same Legal description (Sub'd., Block & Lot) Legal description (Township, Range & Section) T1 5N, R2W, Section 25, Lot 129A Lot Size 26,125 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (N all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) (w/wo AD U) Septic Tank El Upgrade F-1 (D) ❑ Holding Tank ElRenewal ElDuplex Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ 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. (Signature of property owner or authorized agent) Permit/Rush Fees: 2 2 S Waiver Fees: Date of Payment: Date Date of Payment: Receipt Number: Receipt Number: Permit No. OS I9 2 Z 1 1I I Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc James “Jay” Crewdson, P.E. Email: CELLC.1@outlook.com Cell/Text: (907) 280‐9493 Fax: (907) 688‐2295 PO Box 671389 ● 18368 Amonson Road ● Chugiak, Alaska 99567 May 4, 2022 Onsite Reviewer Municipality of Anchorage On‐site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99519‐6650 Reference: T15N, R2W, Section 25, LOT 129A Septic Tank Upgrade Design Narrative The owner of the 3‐bedroom home would like to replace the existing septic tank. The existing septic tank will be removed in accordance with the code and replaced with a 1000‐gallon or larger new septic tank in accordance with the code.  The existing foundation cleanout will be inspected and reused if found to be in good working condition.  If not, they will be replaced in accordance with the code. A new double cleanout will be installed within 10 feet of the septic tank outlet in accordance with the code. There are no anticipated probable adverse impacts to adjacent properties if the septic tank upgrade is constructed as designed. Please feel free to contact me if you have any questions. James “Jay” Crewdson, P.E. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221111, Rebecca Carroll, 05/17/22 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221111, Rebecca Carroll, 05/17/22 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE NEW ^Lae sor �, q -a 30 0 UPGRADE MAI LING ADDRESS 41 F & c2 LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS 3 U Y DISTANCE TO: Well Absorption area g Dwelling y t I / �� PERMIT NO. Ha70;" — ~a Q Manufacturer ��� Material�£L No. of compartments LU N Liq. capacity in gallons vo CD I IF HOMEMADE: Inside length Width Liquid depth DISTANCE TO: Well Dwelling PERMIT NO. 2 z FQ- Manufacturer Material Liquid capacity in gallons w = DISTANCE TO: Well / //34- Foundation :33// /— Nearest lot line PERMIT N J LL z No. of lines Length of each line Total length of lines Trench width Distance between lines F- z = ' /o Z t G inches F Top of tile to finish grade Material beneath tile Total effective absorpti n area 0 ".2 8//,z inches '5 Length Width Depth PERMIT NO. w oQ ~ LU a Type of crib Crib diameter Crib depth Total effective absorption area W DISTANCE TO: Well Building foundation Nearest lot line Clas Depth Driller Distance to lot line PERMIT NO. J W DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS 03� SOI L TEST RATING a INSTALLERQ ii, / Al e_W, C 0M ES REMARKS d Ib �r APPROVED DATE LEGAL �G i[ -U d (Hev.✓.i F'O E;O:*: 59,:$ E. LF T :5 'J' ZE '- ' ~- F'E'ET ...... J. .... THE Fi£-%:!UZF:E[:, L=.;IZE E¢:' ............ THE: CFiTi :iE::qr-[F:'F"'i -I'.1 =,'-" '""'Tf=' *.~ =:. ~ ~ ..¥'='..,. ]"HE LENGTH DIP1EF,!SZON IS TI,-IE LE:N~3-f'H (IN FEET) OF THE 'TRENCFI ElK: DF:F'IZ[NFIELD. THE DEPTH OF I.:! '!'FtENCI,-! OF: PiT !'_'5 THE DiE;TRi'.~C[i[ BETHEEN THE: E;UJ:4:FRC:E OF= THE GROUB!D RND THE BCFFTO!"t OF' THE E;:--';CF!VRTZON <If.s, FEET). THERE !:'2: h!O SE:T HID'TI,-! FOR TRENCHES. THE GRFI'v'Et_ DEI,:"i'H IS THE i"!II'.,!ZPiUH, DE:PT,~4 E,'F EiRW,,,'EL E~EI"HEEN 'THE OUTF'!=ILL FiND !'HE E~OTTO!-I 01.: TI--IE E:qCFIVRTZOI"~ <IN FEET>. . [. E., , t,-..T[ Il_h! [:,lJf~: I NG THE "~'" THE ' ,-'-,-i --F:T ' ' IHJ .... F'EF;:piI~T RF'PLIC:FIi",!! HF,.:, . I*.E :,r- ...~.: ......... L.[] r 'l"O INF'C~RPI IF,!S'T'F!LI,..FYf'ZOh! ZNSF'EC:T]:ONS OF F!BI? [ c'l ' ,:' c-. ¢':4-'~" T -. ....... [ ......... ~ ~t 'FEi HLMED?~ OF ~:ESZE:,EBICES THF!T "I-I4E: HELL FiZL. L .:,L,"--P'""..', c. Hr,l'¢ HY. F'Ii',!RL. c,~pF, n, '¢i EW" "';:' E:FiCI,:::F :!: L L '? I",!G OF '- * S'T'"=';'TEPi THOUT l NSF'ECT i ES! F:Ll"6.r.:' I'",F~P'Tr'l:=l~'I'l* PiTI~ -.,E .:,!.Jb._!,_L.] TFI PIq:(:I:E;E(.':IJTICIN. ,-..]. ,I',~.=. !.'.I[.=.L!.-TE! R ........... FrEE'T 'Z . ?..7 . .- - Z C:EF?.'TZF? THRT ;t.: I FLt'! FFJH:[L.ZRR .L!_TTH Ti-iE F?.E6!LJIREFIENTS FOR [)N--.S;[TE SEi4ERS FORTFi E?¢ THE P!UH:[E:ZPF!L:E'TY' OF' Rh!CFIO?.F~GEZ. 2: i HILL INSTRLL THE S'¢STEI'i ]:f.,! F~CCE~RDRNC:E !.,!ITH THE CODE:E;. ii:: I I_I?.,iDER:STF!N[:, THRT 'I'HE CIBI--.:SZ~E SEi,.!ER S~'S"FEPI P!Fi? ~ESZDENC:E IS ?EP'!C~[:,F~N]~/E:,E HCIF:E 'I"Hi~N L~: BEDF~OCIHS. :Fi; :[ GNED: ......~] ............ ISSUED E?'¢ .._ .,.~ ...... E ................ b.r, L.P ,,aE. "Ir:.[ ,: !' r F 'I"I.-IE ","';i', O & E EN'~.iNEERING & DEVELC .'MENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Ruesell Oyster 694-2774 Performed for: Name' Mailing Address: Legal Description: ~/~/--~/~ /~ / Earl Elli~ SOIL LOG 688-2280 Depth (feet) Soil Characteristics 0 1__ 2__ 3 9__ 10__ 11__ PLOT PLAN 12__ 13__ 14__ 15__ 16 __ ~rTz~// ~z.: Ground Water Encountered: Yes No ~ Proposed Installation: Seepage Pit If yes, what depth Drain Field ~"/" PERC. TES¥ Comments: Performed by: ~¢~'~ ~-~)~ *'7~"'-~ DOC Co, dba P.O. BOX272, CHUGIAK, ALASKA 99567 · TELEPHONE688-2759 OWNER OF LAND /,~A"td < £,:' /~d~/4~;~(/,d C ADDRESS '~,'<:c' o ~;,Czt ;? ~/~ ~'~ ~L ~ LEGALDESCRI~ION/ /~c~/~ ~'~ :~6~' ~?~ A~,)''~ ~RAW DOWN FT. DATE- Started :¢ / .;'/~.k Ended ,5 : ~ GA~. PER HR / / · PERMIT NUMBER ~-c;~ O ~)~ ~7-' KIND OF CASING DEPTH OF WELL STATIC LEVEL OF WATER FT. KIND OF FORMATION: From Ft. to <",~ Ft. ~ -- · From From ') Ft. to /()' Ft. .c' :/'// d7 "' , ~ / ' . ('> '",%':'%~/~"'~ From.__ I ,;' ,5~:'/"°~:2 '> ',~,'"','f/cz~d Fro]n From / J Ft. to ';"*~!. Ft. ~' , -, __ From Ft. to.__Ft. ,i~?' (:z/;t)' From From~ Z Ft. to </¢.. Ft, )~q,q/~] ? /;4/?~d'd From From Ft. to.~Ft. ~5// d:'dz9)~ '~ ~3~ From From". t, Ft. to d~/ Ft. (~Z,///~ - ~,~;4~,,k: c, From Frmn '~ / Ft. to tc~,~' t ,~ /-~ ~c"c From From., ? ~ _Ft. to From From~Ft. to Ft. ':) ')] 'e:"/&>'} From From ,; - Ft. to ,; ~ o Ft. ,~)~:: ,~{?/9< ': From From Ft. to Ft. From From Ft. to _Ft. From From Ft. to Ft. From From. Ft. to Ft From Ft. to Ft. Ft. to Ft.. Ft. to__Ft Ft. to _Ft .... °age Ft. to Ft. Ft. to Ft Ft. to__ Ft. Ft. to_ Ft. Ft. to__Ft. Ft. to Ft. Ft. to Ft. Ft. to __Ft MISCL. INFORMATION: DRILLER'S NAME APPLI( 'NT FILLS OUT UPPER HA? ONLY t pro~ertyOwner~n~.c.. /Z~.,~. ~/~: j~ Phone Address Zip Code ~ - ~ ~ ~ ~- Really Co. & A~nt Address Zip Code Street Locali~ Type of Resi~nce ~ Multiple Family NO. of Bedroo~ Water Supply ~ Individual A~ACH WELL LOG. A w~l Icg is required for all wells drilled since June 1975. ~ Community For wells drilled prior to that date, give well depth (attach Icg if available), ~ Public Utility Sewer Disposal ~ Year Indiv~ual Installed: Individual ~ Public Utility When Connected to Public Utility: ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED. Time Date Inspector Time Date Inspector ( '~ ) APPROVED BEDROOMS -~//~/ ( L-).--~ISAPPROV E D · ( ) CONDITIONAL APPROVAL DATE I ~ -- ~. ~".'.'.'.'.'.'.'.~ ~el-~ Date Inspector MUNICII ANCHORAGE RECEIVED Soils Rating 72-023 (3182) Date Sewer Installed Well To Absorption Area JWell Log Received Septic Tank Size / Ig ~ ~:~ • Y �g .. .. .. Jam._..,,....._ .. ... .: . Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section - Fax. 907-343-7997 Parcel I.D. 051-312-33 Certificate of On -Site Systems Approval Expiration Date: qr� ZZ 1. GENERAL INFORMATION Complete legal description T1 5N, R2W, Section 25, Lot 129A Location (site address) 15411 Husky St., Eagle River Current property owner(s) Merrill Bruce A Trust Mailing address same Real estate agent 2. TYPE OF DWELLING: Fxj Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone 907-863-4713 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well 171 Private Septic F-1 Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. Date: COSA Fee $ ��� Waiver Fee $ Date of Payment 5/°������a Date of Payment Receipt Number 0 `� S' 1C, Receipt Number COSA # 05C, 22 l 2'A 1 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 Crewdson Engineering LLC Phone 907-280-9493 Address PO Box 671389, Chugiak, AK 99567 Engineer's Printed Name James Crewdson Date 5/26/2022 OF A/qs11 1 TH* �r 6. DSQ SIGNATURE �'�' System #1 Approved for bedrooms James A. Crewdson.. System #2 Approved for bedrooms 011527 i Disapproved 1\\�`R�FES�`��� Conditional approval for bedrooms, with the following stipulations: �sv��G\PA r O C' rj 0 0G6 TFR ►'� J 1 1 Original Certificate Date: & _1q_26 ?12 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: T1 5N, R2W, Section 25, Lot 129A If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 5-6-82 Total depth 300 ft Cased to 56 ft FOR Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 12+ in. Date of flow test for COSA 4-28-22 Static water level at beginning of test 54 ft. Comments B. TANK DATA Age of tank(s) 0 years Tank type/material �',P" Measured operating fluid level in septic tank OR Standpipes/foundation cleanout per record drawing Date of pumping not required D. ABSORPTION FIELD DATA Which system tested (date installed) ❑ ALL standpipes present per record drawing Total measured depth from grade 11.3 ft (max) Measured depth to pipe invert from grade 2-8 ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of effective. If not, state depth into effective Parcel ID: 051-312-33 Structure served by this system Well production at time of test 5+ gpm Water storage tank volume gallons Well disinfected for coliform test? ❑ Yes ❑ No ® Coliform bacteria is Negative Nitrate mg/L ® Nitrate less than MRL (ND) Arsenic ug/L ® Arsenic less than MRL (ND) Collected by Crewdson Engineering Date of Sample 5-26-22 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 4-28-22 Results Q Pass For 3 bedrooms Fluid depth prior to test 17 in Water added 480 gal New depth 33 in Elapsed time 120 min ❑ Code -required soil cover over field Final fluid depth 17 in ❑ System presoaked Absorption rate 450+ gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) no date of test) If yes, enter date Gallons introduced gallons Comments/Deficiencies: `2' soil cover approved on 1982 Inspection Report COSA Checklist yellow sheet 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' W Yes Community Sewer Manhole/Cleanout > 100' E✓ Yes if No ft M Yes if No ft Neighboring Tank > 100' Q✓ Yes if No ft Private Sewer/Septic Line > 25'r--71 Yes if No ft Absorption Field on Lot > 100' 0 Yes if No ft Holding Tank > 100' Yes if No ft Neighboring Absorption Fields > 100' Yes if No Animal Containment > 50' 0 Yes if No ft Q Yes if No ft if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ❑✓ Yes if No ft P/1 Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' [V Yes if No ft Surface Water > 100' Yes if No ft Property Line > 5' W Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' [Z] Yes if No ft Private Wells > 100'✓0 Yes if No ft Water Main > 10' 0 Yes if No ft Community Wells > 200' 0✓ Yes if No ft Water Service Line > 10' 0 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' [Z] Yes if No ft If absorption field is under driveway comment below Property Line > 10' M Yes if No ft Wells on Adjacent Lots: Water Main > 10' 0 Yes if No ft Private Wells > 100' Yes if No ft Water Service Line > 10' ❑✓ Yes if No ft Community Wells > 200' Q✓ Yes if No ft Surface Water> 100' 0 Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION I 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 OF •�TH .. . ...... ,James A. Crewdson •• C11527 v { 1t AROFEss����=