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Home My WebLink AboutMCMAHON #2 BLK 9 LT 11017 3(,,2 Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP211286 PID Number: 017-362-18 Dwelling: Q Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑■ Upgrade Name RON MCCOY ABSORPTION FIELD ❑■ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 3825 LEYDEN RD ANCH AK ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 4 0.8 GPD/SF 11 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 4.5 Ft. Gravel depth beneath pipe 6.5 Subdivision Block Lot MCMAHON #2, BLK 9, LOT 11 Ft. Fill added above original grade 2.5 Ft. Gravel length 58 Ft. Township Range Section Gravel width 2.0 Beds: Number of Lines Distance between lines SEPARATION DISTANCES Ft. R. To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line 754 Ft2 1 Well 100'+ 100'+ 50'+ TANK A Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer GREER TANK Capacity 1250 Gal. Surface Water 100'+ 100'+ Material Number of compartments Lot Line 1 U'+ 1 U'+ NA PLASTIC 2 Foundation 10'+ 10'+ LIFT STATION i Manufacturer Capacity Remarks TANK DEMO PER UPC, Gal. Alarm location Electrical installed by Installer PIPE MATERIAL House to tank 3034 Tank to 3034 drainfield MIKE N ANDERSON, P.E. Drainfield 3034 CO/MT 3034 Inspector MIKE N ANDERSON, P.E. BENCH MARK (Assumed elevation) 102.7 ft Inspdeation 1s, 8/8/21 2"tl 8/9/21 Location and description 3'° 4'h Top of Manhole ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineers Stamp Conditional Approval: Date : •. .S�ChF !:_ �s. -, .:�F c� -_= _: Septic System Approve "- - Date J0—(�-%'. Note: this approval does not include well permit requirements. io,... nunni• o Permit No. OSP211286 Page 2 of 2 Municipality of Anchorage 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 Legal Description: MCMAHON SUBD, #2 BLK 9, LOT 11 PID No.: 017-362-18 MARK A B TC01 32 17 TCO2 35 18 c01 40 25 CO2 42 26 CO3 47 68 C04 50 22 MT 51 22 �,B TOP OF MH / 1 I I I0 0 I I 1 \1250 GALLON PLASTIC TANK -—TF--�\ MLL /-- --- i —C • \ 1 • TCO2 1 \ 03/ fH#2 ---- ` 100' 1 A2WI III T. I I ® I I I 1 SCALE: 1"=50' N.T.S. DRY JULY 2021 AW j 49 H ! ............................................. \) ;MICHAEL N. ANDERSON: No. CE 9469 '•• 10/2/21 �.••' � 1 '•• 1111 Ra ��•�VA U Iva Municipality of Anchorage Development Services Department On -Site Water and Wastewater Section ,� ` i •`. y'e ,ate 4700 Elmore St. 49TH P.O. Box 196650 Anchorage, AK 99519-6650 ` ` ` • ' ' ' ° • • • • • ...... ;, �� www.muni.orglonsite �. • • . • . • . • • a r r ... • e (907) 343-7904 MICHAEL. N. ANDERSON •`� CE -9 69 Soils Log - Percolation Test Performed For:�, c �' /�/i = 2'� N Date Performed: ��`�.®�.,a`►^°"� ��2� Legal Description: ___ t-/( c M u Cyt ,ice. Z 0 -1- L I � Township, Range, Section: ,_1----4- 2- 3- C7 4- Al 5- 6- 7- 8- 9- Date WAS GROUND WATER Net Time Depth to Water ENCOUNTERED? 2 t S 10- (p IF YES, AT WHAT DEPTH? L v iG� p h eJ Depth to Water After P 11- ! t Monitoring? DV\'t �y E 12- j _ G'( %� � Date: 13- 14- 15- 16- 17- 18= 19-I I 1 0v_x. 20 - Site Plan Reading Date Gross Time Net Time Depth to Water Net Drop 2 t low (p ! t 211 j PERCOLATION RATE t -j- ((Tunutesfinch) PERC HOLE DIAMETER u ( j TEST RUN BETWEEN FT AND �� FT COMMENTS %{moi?f I�-ept ty�r ,tom, Lo 11lalr PERFORMED BY: aux ISL ( CERTIFY THAT THIS TEST W PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: Z 2 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 httpJ/w .muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP211286 Work Type: Septic Upgrade Tax Code Number: 01736218000 Site Legal Address: MCMAHON #2 BILK 9 LT 11 G:2835 Site Mailing Address: 3825 LEYDEN RD, Anchorage Owner: MCCOY RONALD & JANET TRUST Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING This permit is for the construction of: 9 Disposal Field E3 Septic Tank ❑ Holding Tank ❑ Privy Effective Date: Expiration Date: Lot Size in Sq Ft: Total Bedrooms: "Ne n Department 7/28/2021 7/28/2022 32800 ❑ 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: Date: MUNICIPALITY )r.At}. f... Development Services Department B On -Site Water & Wastewater Section Parcel I.D. 017-362-18 NCHORAGE 1Z 05)1 ON-SITE SEPTIC/WELL PERMIT APPLICATION Property owner(s) RONALD & JANET MCCOY Mailing address 3825 LEYDEN RD, ANCH AK Site address SAME Day phone Legal description (Sub'd., Block & Lot) MCMAHON #2 BLK 9 LT 11 Legal description (Township, Range & Section) Lot Size 32800 Sq. Ft. Number of Bedrooms 4 Phone: 907-343-7904 Fax: 907-343-7997 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field 0 Initial ❑ Single Family (SF) El (w/wo ADU) Septic Tank 0 Upgrade Q El (D) Holding Tank ❑ Renewal 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: 5 Date of Payment: / �0� 1 Receipt Number: DI `{ 3 Permit No. �SP21 /266 Waiver Fees: Date of Payment: Receipt Number: Waiver No. G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc July 15, 2021 Municipalities of Anchorage Departments of Health and Human Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Fax 249-7847 Re: New septic permit Legal: MCMAHON #2 BLK 9 LT 11 To Whom it may concern: This is a request for a septic permit on the above referenced lot. A test hole was excavated and found silty gravel (GM) for the entire depth and no water during or after the seven day monitoring period. The perc rate was measured at 4 minutes per inch. A new deep trench system has been designed with 8 feet of effective depth almost the same as the old system. This septic replacement will not impact any of the neighbors or encroach on any wells, septic or open water issues. The slope across the site is flat. Sincerely Michael N. Anderson, P.E. 4661 Natrona Anch, Ak 99516 Ph 727-8864 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211286, Deb Wockenfuss, 07/28/21 SEPTIC FIELD SECTION DESIGN CRITERIA: 8.0' EFFECTIVE 4 BDRM X 150 = 600 GPD SOILS = 600/0.8 = 750 SQ FT REQ'D 750/16 = 47 2.0' WIDE 47' LONG (1) TRENCH 10' DEEP -17' (TH#1) -1' GM OR 1.0'2.0' -10' -2.0 MOUND OVER FILTER FABRIC SEWER ROCK 3,3( GRADE 1"=200' PROPERTY LINE PROPOSED DRAINAGE FIELD EXISTING HOUSE -LEYDEN ROAD-8.0'EXISTING WELL 100' RADIUS SCALE: DJRDRAWN: DATE: McMAHON #2, BLOCK 9, LOT 11 Anchorage, Alaska RON & JANET McCOY 7/19/2021 -A K U L A D R I V E - -T A I G A D R I V E - -KUT C H E R D R I V E --HINCHEY PLACE-& INSULATION Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211286, Deb Wockenfuss, 07/28/21 1"=50' PROPERTY LINE EXISTING HOUSE MAINTAIN 16' BETWEEN FIELDS PROPOSED 1,250 GALLON PLASTIC SEPTIC TANK W/ 20" RISER, DECOM. EXISTING TANK PER UPC.DRIVE WAY EXISTING WELL 100' RADIUS WELL EXISTING DRAINAGE FIELD McMAHON #2 BLOCK 9, LOT 11 SCALE: DJRDRAWN: DATE: McMAHON #2, BLOCK 9, LOT 11 Anchorage, Alaska RON & JANET McCOY 7/19/2021 -LEYDEN ROAD- McMAHON #2 BLOCK 9, LOT 10 McMAHON #2 BLOCK 9, LOT 12 McMAHON #2 BLOCK 9, LOT 8 McMAHON #2 BLOCK 9, LOT 9 CO MT CO DOUBLE CO & VALVE 0 % SLOPE MAINTAIN 5' SEPARATION FROM DECK SUPPORT AND FIELD & 10' FROM BLDG FOUNDATION 2-4 % SLOPENO SLOPES > 25% OR CUT BANKS WITHIN 50' OF SITE. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211286, Deb Wockenfuss, 07/28/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211286, Deb Wockenfuss, 07/28/21 I a N 89 57'49" W18743 b M 10' UTILITYEASEMENT DECK ON 6RADE O WELL O.H. DECK SINGLE FA MIL Y HOUSE DECKON GRADE N 89 57'49" W18743 L EYDEN THE SURVEY DATA AND MEASUREMENTS HEREON ARE PREPARED FOR THE OWNER OF RECORD AS OF THE DATE OF THIS SURVEY. ANY USE OF THIS DRAWING BY THIRD PARTIES IS PROHIBITED UNLESS WRITTEN PERMISSION IS PROVIDED. STREET THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SHOW ANY CONFLICTS BETWEEN EXISTING STRUCTURES AND PLATTED LOT LINES AND/OR EASEMENTS; AND IS NOT TO BE USED FOR POSITIONING ADDITIONAL STRUCTURES, IMPROVEMENTS, OR FENCELINES. EASEMENTS OF RECORD, OTHER THAN THOSE APPEARING ON THE RECORD PLAT , ARE NOT SHOWN HEREON ( UNLESS INDICATED) NOTE: FENCELINES THAT MAY APPEAR ON THIS DRAWING ARE NOT TO BE USED TO DETERMNE PROPERTY LINES OR POSITION ADDITIONAL IMPROVEMENTS. ANY PAVING SHOWN HEREON MAY BE APPROXIMATE DUE TO EXCESSIVE SNOW AND/OR ICE. A5 -BUIL T SURVEY NO CORNERS SET THIS DATE 41.1 00000��O _o OF At��a a Woo, coG O�Oc4 SHANE A. HOLT DO LS -6914 bo4�O rofessiona\ i " =201 ��0000�� I HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY OF THE FOLLOWING DESCRIBED PROPERTY L OT 11, BL OCK 9, MCMA HON SUB 2ND ADD'N. ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS EXIST OTHER THAN NOTED. DATED AT ANCHORAGE,ALASKA THIS 18TH DAY Or MARCH 2021 14974, FB 211-73 HOLT LAND SURVEYING 9309 GROVER DRIVE ANCHORAGE,AK 99507 345-5513 O N W H H O O W 00000��O _o OF At��a a Woo, coG O�Oc4 SHANE A. HOLT DO LS -6914 bo4�O rofessiona\ i " =201 ��0000�� I HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY OF THE FOLLOWING DESCRIBED PROPERTY L OT 11, BL OCK 9, MCMA HON SUB 2ND ADD'N. ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS EXIST OTHER THAN NOTED. DATED AT ANCHORAGE,ALASKA THIS 18TH DAY Or MARCH 2021 14974, FB 211-73 HOLT LAND SURVEYING 9309 GROVER DRIVE ANCHORAGE,AK 99507 345-5513 ~' MUNICIPALITY OF ANCHORAGEs_% He/ ~:h and Environmental Proqe' ~ion Fourth Floor West 825 L Street Anchorage, Alaska 99501 279-2511, x 224, 225 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL 5¥STEM SEPTIC 'rANK: DISTANCE FROM WELL__~F~'D" ___ MANUFACTURER_ ¢'-z~."¢~' ~'42~"~" MATFRIAL INSIDE LENGTH_' INSIDE WIDTH 'LIQUID DEPTFf NUMBER OF ~ ,- ~3~:'~2', / COMPARTMENTS LIQUID CAPAC'T¥ 'L ' ALLONS. t DISTANCE [:ROM WELL ~_.~_.~-)__CFOUNDATION___.? ....... NEAREST LOf LINE._4~J ABSORPTION AREA ~ SQ. FT. LENGTH OF EACH LINE OEPIlI: TOP OF TILE TO FINIStl GRADE ~--/ DEPTIt OF FILTER ....... MAIERIAL [~[_NEATtf TtLE..~___%~. ABOVE TILE ~..IN. SEEPAGE PIT: Log Crib Rings/CRIB SIZE: BUILDING FOUNDATION____ DIAMETER ____ OR WIDTH LENGTH ., DEPTH DIAMETER ..... DEPTH_ DISTANCE FROM: WELL TOTAL EFFECTIVE NEAREST LOT LINE.__ ABSORPTION AREA (WALL AREA) SQ. FT. Well ~-~'- ..~¢, Class: Depth: Well Distance To: Lot Line Bldg: Sewer Line: Pipe Materials: 9 of Bedrooms: Installer: -- - Remarks: ~UNICIPALITY OF ANCHORAGE FOSS DRILLING OCT - 4 1336 I~ra Street SIZE OF CA~ING& II DEmH OF HOLE--S. C~m TO /~' RE~S DATE COMPLET=,.,9 ~--/~ ~ PU~ TO BE S~ AT /~--~ ~o ~o .... ,,,to to to ~t o ,,, to ..... ~o tO , __t O ..tO ~o , tO , GARY PLAYER VENTURES CONSULTING GEOLOGIST BOX 476-M, STAR ROUTE A · ANCHORAGE, ALASKA 99507 · PHONE 344-7071 SOILS LOG 16 Soil Type Water Level Remarks 18 20 Total Depth of Excavation Groundwater ~otReached Depth, if Reached__ Classification Method · ~/~sua 1 ( ) Sieve Analysis () Material at Total Depth Bedrock ~ot Reached Depth, if Reached Gary F. Player, Consulting Geologist Time Date In sp ~--~UNICIPALITY OF ANCItORAG~---~ ,DEPARTME!, ~F !!EALTH AND ENVIRONMEN-,~'-~.PI~OTECTION ~ 825 L Street, Anchorac~a, Alaska 99501 264-4720 Date Received: ~i2: Time _. ]:~P_DL%_ .... ~3: Time Insp ~/. Insp December 5, 1977 REOUIsoT FOR APPROVAL OF iNDIVIDUAL SEWER AND WATER FACILITIES Lending Institution Request: Alaska Pacific Bank Mailing Address: 601 West 5th Avenue 99501 Phone: 276-3110 Property Owner: C.E. Jackson/Mountain Enterprises Phone: 349-5200 Mailing Address: Star Route A Box 1582N 99507 3. Legal Description: Lot 11 Block 9 Mc Mahon Subdivision 4: Single Family Residence: (x Multiple Family Residence: ) Number of Bedrooms: Four Number of Bedrooms: Well System: Permit ~ Construction individual Well (x) CoP, m~unity/Public System ( ) Depth of Well 152' Well Log on File Bacterial Analysis Sewage Disposal System: Permit ~ Septic Tank Size Absorption Area On-site System (x) Public Utility ( Installed 1977 Installer Manufachurer Soils Rate Material 7. Distances: Well to Septic Tank to Sewer Line Nearest Lot line to Absorption Area Absorption Area to Nearest Lot Line , l~a~ge Two ~ Department of Health and Environmental Protection Request for Approval o£ individual Sewer and Water Facilities Legal Description: Lot 11 Block 9 Mc Mahon Subdivision Affadavit Attached: Approved: ~ Disapproved: Letter Attached: ( ) Date: Department Worksheet ¥ (ep,.~ ~l~o ~'s) --03QIAO~d 39VB3A09 30NV~OSNI ON IL6I "~dv 008£ m~°:i S~ 3009 dlZ ONV 31V15 "O'd (;;etsod snld ~0£--11¥1N 03131.LB30 BO~ ld1333B P · ~__~ ' . ,!UNICIPALITY OF ANCHORAGE ,/~ Department of Health and Environmental ProteCtion [[~~\ 825 L Street, Anchorage, Alaska 99'50i ~~ 264-4720 uest for Approval of Individual Sewer and Water Facilitle~ Property Owner: ~_~,.~_~ . ~~ ;,3 Mailing Address: ~29 ~_~' /~/ o Name of Buyer: Mailing Address: 3. Lending Institution: Mailing Address: o ° Realtor/Agent: Mailing Address: Legal Description: street Location: Phone: Phone: ,~2~ '-,~// ~ Phone: Single Family Residence: (~Number of Bedrooms: Multiple Family Residence: ( ) Number of Bedrooms: Water Supply: *Individual Well (z~~ Public/Community System If Individual_ Well, well depth /~--~,_ If Community System, name of system ( ) Sewage Disposal System: *~n-site System (m~/~ Public System ( ) If On-site System, date of installation: ~--/'- > '> *NOTE: A well log is required on ALL wells drilled since 6/75. ** If on-site sewer system is over two(2) years old, an adequacy test is required by this department. A fee of $25.00 must accompany each request before processing can be initiated° 3/77 F MUNICIPALITY OF ANCHORAGE Development Services Department �, Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 017-362-18 1. GENERAL INFORMATION Expiration Date: Complete legal description MCMAHON #2 BLK 9 LT 11 Location (site address) 3825 LEYDEN RD, ANCH AK Current property owner(s) RON & JANET MCCOY Day phone Mailing address SAME Real estate agent Day phone 2. TYPE OF DWELLING: Q Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well El Private Septic F� 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 $?,gO -+- 4160 Waiver Fee $ _ Date of Payment 44�/z / Date of Payment Receipt Number 00 6 2 SO Receipt Number COSA # __ Q.e;G Z I ) Z5 q 7 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 andlor 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 MIKE N ANDERSON, P.E. Phone 727-8864 Address 4661 NATRONA AVE ANCH AK Engineer's Printed Name MIKE N ANDERSON, P.E. 6. DSD SIGNATURE System #1 Approved for 4 bedrooms System #2 Approved for bedrooms Disapproved Conditional approval for bedrooms, Date 9-28-21 F Y 49TH �IIII MICHAEL N. ANDERSCINI �� ! . • C - 946 • ` Jp with the following stipulations: =o \A1A.qT`=v1'ATE011 =1nI -- PROGF.AM JjT( J/ By Original Certificate Date: 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: MCMAHON #2, BLK 9, LT 11 If more than 1 septic system on lot: COSA Checklist # A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 9115m Total depth 152 ft Cased to 150 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 18 in. Date of flow test for COSA 919121 Static water level at beginning of test 118 ft. Comments B. TANK DATA Age of tank(s) NEW years Tank type/material 1E1T'1P Measured operating fluid level in septic tank NEW ❑ Standpipes/foundation cleanout per record drawing Date of pumping NEW D. ABSORPTION FIELD DATA new Which system tested (date installed) 818121 ❑ ALL standpipes present per record drawing Total measured depth from grade 13.5 ft (max) Measured depth to pipe invert from grade 7 ft (min) ❑ N/A — pressurized field ❑ 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 0 gallons Comments/Deficiencies: COSA Checklist yellow sheet Parcel ID: 017-362-18 of Structure served by this system Well production at time of test 3.5+ gpm Water storage tank volume 0 gallons Well disinfected for coliform test? ❑ Yes ❑ No ❑ Coliform bacteria is Negative Nitrate 1.53 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by MNA Date of Sample 9/9121 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date new Results ❑✓ Pass For 4 bedrooms Fluid depth prior to test in Water added gal New depth in Elapsed time min Final fluid depth in Absorption rate and 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) ® Yes Septic Tank/Lift Station on Lot > 100' ft Wells on Adjacent Lots: Community Sewer Manhole/Cleanout > 100' Q Q Yes if No ft M Yes if No ft Neighboring Tank > 100' 0 Yes if No It Private Sewer/Septic Line > 25'M Yes if No ft Absorption Field on Lot > 100' Q Yes if No ft Holding Tank > 100' 0 Yes if No ft Neighboring Absorption Fields > 100' if No ft Animal Containment > 50' Q Yes if No ft Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' Yes if No ft 0 Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' U✓ Yes if No ft Surface Water > 100' ® Yes if No ft Property Line > 5' ® 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' Q Yes if No ft Community Wells > 200' Yes if No ft Water Service Line > 10' Q 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' 0 Yes if No ft If absorption field is under driveway comment below Property Line > 10' ✓[] 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' Yes if No ft Surface Water > 100'✓Q Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION I certify that I 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 owl �'.• �rir Kr' 4�9T ...:... . .... .... .. O . r j y�� MlGi3E1F� .t µAND,RSC:J f G'='946 •'. ;. • (i f a �n ®• H i O DV 3 = zw 0 'n¢z= w z w i � 2 W w W F w w V J W w -� L W W H �i Fu -i QOa LL w n O O\ Q Q H W Z O N ¢ w0E-a :D a � z Ln0 w na 3 w O W z am m h V1 Q W O z> x VI O 4j1 w 0w 00 F y W �z,a� H o v J W 2 F Hz F- t- i V) u J W11 w w x 3JN3i 7ihY GO ll _ OOSLL3„LL,Z'O00N 005_/£3„ITZOOON 993 33N21 7;VY OOOP',; �b�-�?�d•� 1 Jyhdsd 9 f` W z w o H > In i- H Ql F z wwrn opOOv�DO i F- LL- = in Li F Y O > ¢ F z ¢ 'Oda S H W>- ac w S F E Q o> W f/1 S A z 0 0 M O�'` O Q z� Q JLvw ,. 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