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HomeMy WebLinkAboutHENKINS BLK 1 LT 11 Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3 ON -SITE WASTEWATER INSPECTION REPORT Permit Number: OSP251095 PID Number: 051-292-31 Dwelling: X Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ■❑ New ❑ Upgrade Name Mike Anderson ABSORPTION FIELD ❑ Deep Trench 0 Wide Trench ❑ Bed ❑ Mound Site Address 16008 Division St ❑ Other Phone Bedrooms Soil Rating Total depth from original grade (907)727-1433 [Num�le,f 1.0 GPD/SF 5.8 / 4.7 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 5.3 / 4.2 Ft. Gravel depth beneath pipe 0•5 Ft. Subdivision Block Lot Henkins 1 11 Fill added above original grade 0.0 Ft. Gravel length 120 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 2 Dist. between trenches From Tank Field Tank Line 600 Ftz >6 Ft. Well >100' >1 00' N/A N/A >25 TANK 0 Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Greer Capacity 1250 Gal. Surface Water > 100' > 100' 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 tWqTATION Manufacturer Capacity Remarks Tank rated for 10' burial Gal. Trench depths listed east / west Alarm location Electric lied by PIPE MATERIAL House to tank D3034 Tank to drainfield D3034 Installer Whitters Excavating Drainfield D3034 Co/MTD3034 Inspector Justin Earls BENCH MARK (Assumed elevation) 100 ft Inspection 15' 4/24/25 4/25/25 Location and description dates: 2nd Bottom of siding NW corner 3rd 4m ON -SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp OFF\\sk Conditional Approval: Date ����.''•''+ Benja hiller / �' •�� Septic System /��'s�� Approved Date > 6/9/25 .�,A,! l�l40 Fssio� Note: this approval does not include well permit requirements. \+PROFE\SSO�� �-�►- (Rev 05/02/18) CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FD - FLOW DIVERTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE LEGEND PERMIT # OSP251095 PID # 051-292-31 1"=30' HENKINS, BLOCK 1 LOT 11 FEET 0 30 60Benjamin Schiller CE 12592 R E GISTEREDPROFE S S I O N A L E N GINEER 4/16/26 PLAN AS-BUILT 2CO TH#1 A B FCO MH 48.6 SV 52.0 A B 2CO 54.6 CO1 59.1 MT1 61.4 CO2 71.8 3.3 26.8 30.9 33.9 45.1 47.2 55.9 FCO GILBERT ROAD 4-BDRM HOME DI V I S I O N S T R E E T (2) 60' LONG x 5' WIDE, 0.5' EFFECTIVE DEPTH ABSORPTION TRENCHES CO1 CO2 CO3 CO4 MT4 MT3 MT2 MT1 1250-GAL SEPTIC TANK EXISTING WELL APPROX LOCATION OF NEIGHBORING SEPTIC MT2 70.4 CO3 67.1 MT3 65.3 CO4 59.2 MT4 60.7 54.7 81.5 80.1 78.0 79.0 ALTERNATE SITE CAT III. 20' LONG X 5' WIDE, 0.5' EFFECTIVE DEPTH EXISTING WELL TH LOCATION CONFIRMED DURING INSTALL MH SV PROFILE AS-BUILT (NO SCALE) 93.6 88.6 94.2 98.0 FC O MH SV PERMIT # OSP251095 PID # 051-292-31 HENKINS, BLOCK 1 LOT 11 1250 GAL SEPTIC TANK 2C O 93.4 Benjamin Schiller CE 12592 R E GISTEREDPROFE S S I O N A L E N GINEER 6/6/25 60' DRAINFIELD ROCK MT 1 CO 1 CO 2 MT 2 MOA APPROVED SAND TH # 1 NO GROUNDWATER 11/21/24 87.5 88.0 77.3 87.5 88.0 93.3 ORIGINAL & FINISH GRADE 60' DRAINFIELD ROCK MT 3 CO 3 CO 4 MT 4 MOA APPROVED SAND TH # 1 NO GROUNDWATER 11/21/24 76.2 92.2 ORIGINAL & FINISH GRADE 2" INSULATION 85.585.5 87.5 88.0 87.5 88.0 85.585.5 WEST TRENCH EAST TRENCH Lot 10 HOUSE DETAIL Scale: 1 " = 30' CANT 0 22.3' ro 15.9' CI �i N , 3.8' x 7.7' 11.7' BALCONY N 2 STORY " M RESIDENCE 0 5.3' PORCH N I 29.6' I I �2.0' x 14.0' CANT 30.0' I I I�� Lot 12 / goo. I / p- I j TeCr'�e wE�c I 89'50'E 200.0' Lot 1 ZI 20,000 s.l :E I SEPTIC i km a n N O Z PSPNP6Nj : O M SEE ao "HOUSE m I —� DETAIL" SEPTIC MANHOLE \ \ N 89'50'W 200.0 GILBERT ROAD III o 11 I o o � o I / N / NOTES: GROUND LEVEL IMPROVEMENTS SHOWN ARE APPROXIMATE. DATE OF SURVEY: 06 MAY 2026 PLOT PLAN _-- AS BUILT X_ SCALE 1"= 40' GRID NW 0755 Project No. J24-2831B6-- P.O. Box 210005 Lang & Associates, inc. Anchorage, Alaska 99521-0005 Professional Land Surveyors surve y22-6g @lansu y �F q � surve��pp surve com 4=7c . • 44 I hereby certify that I have surveyed the following described property: Fi �O�Q LOT 1, BLOCK 11, HENKINS SUBDIVISION (Plat No. P-387) — Q 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 O'er ' • C. LAN. J premises and that there are no roadways, transmission lines or other visible o� easements on said property except as indicated hereon. s �'W g Z6 40�F '•.LS-9944• Dated this the �__— Day of � , _ at Anchorage, Alaska .0,oR .... • • • • • • • •.O o �p0 �FESSIONA� moo It is the responsibility of the owner to determine the existence of any easements, �OOppo�� covenants, or restrictions which do not appear on the recorded subdivision plat. State of Alaska AECC963 Date: 1-29-26 P.O. Box 670269 Chugiak, AK 99567 P: (907) 688-2759 F: (907) 688-2259 TO: Midnight Sun Construction 16006 Division Street Chugiak, AK 99567 Henkins Block 1 Lot 11 Existing Well Report Static: 69’ Well Depth: 80’ Well is fully cased to 80’ No perforations or casing breaches are present. 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 hftp://www.muni.org/onsite On -Site Water & Wastewater System Permit Permit Number: OSP251095 Work Type: WellSeptic Initial Tax Code Number: 05129231000 Site Legal Address: HENKINS BLK 1 LT 11 G:0755 Site Mailing Address: 16008 DIVISION ST, Chugiak Owner: MIDNIGHT SUN CONSTRUCTION LLC Design Engineer: FORGE ENGINEERING This permit is for the construction of: Effective Date: Expiration Date: Lot Size in Sq Ft: Total Bedrooms: 4/9/2025 4/9/2026 20038 0 Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy Q 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: Issued By: Date: c 2 6),� 4 ON -SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 051-292-31 Property owners) Mike Anderson Day phone Mailing address PO BOX 210994, Anchorage, AK 99521 Site address 16008 Division Street, Chugiak, AK 99567 Legal description Henkins Subdivision, Block 1 Lot 11 Number of Bedrooms 4 Engineering Firm Forge Engineering Building Permit Number R Z- 5- / 3 Not Applicable RN APPLICATION IS FOR: APPLICATION IS AN: (Z all that apply) Absorption Field RX Initial RX Septic Tank ID Upgrade El Holding Tank EJ Renewal EJ Privy R Well RX THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: Permit/Rush Fees: Z- O S Waiver Fees: Date of Payment: Date of Payment: Permit No. Z Waiver No. April 7, 2025 MOA Development Services, On-Site Water & Wastewater Program 4700 Elmore Rd Anchorage, AK 99507 Subject: Henkins Block 1 Lot 11 – Division Street Septic system design Dear On-Site Services Engineer: The owner of the above lot intends to build a 4-bedroom home on the property, so we are submitting this permit application for the construction of a new well and septic system. The attached site plan identifies the location of the home as well as 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 adjacent lots. The ground surface on the lot slopes toward the back of the lot away from the house, and the new septic system is located near the middle of the lot. (There are no slopes greater than 25% within 50 feet downslope of either the primary or alternate site.) Contours are shown on the site plan showing the grade and direction of flow. Stormwater 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 adjacent 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 6’ away. Please refer to the attached test hole logs, plan and profile pages 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 OSP251095, Curtis Townsend, 04/09/25 IF ANY EVIDENCE OF THE OLD SEPTIC SYSTEM IS FOUND IT MUST BE DECOMMISSIONED PER UPC. ANY PORTION WITHIN 12' OF THE PROPOSED SYSTEM MUST BE EXCAVATED AND REPLACED WITH NON-CLASSIFIED FILL. CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FD - FLOW DIVERTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE LEGEND 1"=30' HENKINS, BLOCK 1 LOT 11 FEET 0 30 60Benjamin Schiller CE 12592REGISTEREDPROFESSIONA L E N GINEER 4/7/25 SEPTIC PLAN 2CO TH#1 ≥6' FCO GILBERT ROAD 4-BDRM HOME 520 DI V I S I O N S T R E E T 530 540 ALTERNATE SITE (2) 60' LONG x 5' WIDE, 0.5' EFFECTIVE DEPTH ABSORPTION TRENCHES COCO CO CO MTMT MT MT NEW 1250-GAL SEPTIC TANK NEW WELL DV APPROX LOCATION OF NEIGHBORING SEPTIC Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP251095, Curtis Townsend, 04/09/25 HENKINS, BLOCK 1 LOT 11 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 Benjamin Schiller CE 12592REGISTEREDPROFESSION A L E N GINEER 4" PERFORATED PVC (HOLES DOWN) DRAINFIELD ROCK DESIGN FACTORS:SYSTEM REQUIREMENTS: 600 GPD PEAK FLOW PERK RATE: <1 MIN/IN APPLICATION RATE: 1 GPD/SF 5' WIDE TRENCH SYSTEM 1250-GAL SEPTIC TANK BOTTOM OF TRENCH: 5' BELOW GRADE FLOW LINE ELEVATION: 4.5' BELOW GRADE 600 GPD / 1 GPD/SF / 5' WIDE * 1 RED FACTOR [0.5 DEEP] = 120 LF TRENCH REQUIRED (120 LF SPECIFIED) GEOTEXTILE FABRIC 4/7/25 5' 2' 6" 4'-6" MOA APPROVED SAND PROVIDE ADDITIONAL FILL TO ACCOUNT FOR SETTLEMENT Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP251095, Curtis Townsend, 04/09/25 LEGAL DESCRIPTION: PERFORMED FOR: DATE: PARCEL ID#: SOILS LOG AND PERCOLATION TEST 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 DEPTH (feet) TEST HOLE 1 DATE READING START TIME NET TIME (minutes) DEPTH to WATER NET DROP PERCOLATION RATE: (MIN/INCH) (inches)(inches) DATE OF MONITORING WAS WATER ENCOUNTERED? DEPTH TO WATER AFTER MONITORING IF YES @ WHAT DEPTH? 0.2 11/11 1 2 3 4 5 6GP (POORLY GRADED GRAVEL) Professional Engineers Stamp: NO HENKINS, BLOCK 1 LOT 11 11/14/24 051-292-31 MIKE ANDERSON 10:32 1 0 16 1' OB 0:51 Benjamin Schiller CE 12592REGISTEREDPROFESSION A L E N GINEER PERC TEST LOCATION TECHNICIAN: M. JAKUBISIN 7 0 16 - DRY 11/21/24 COMMENTS: SITE PLAN 6 0 16 USCS SOIL CLASSIFICATION WAS VISUALLY DETERMINED 4/7/25 GM (SILTY SANDY GRAVEL) 10:33 1 0 161:06 7 0 16 6 0 16 10:34 1 0 161:10 7 0 16 6 0 16 10:35 1 0 161:13 7 0 16 6 0 16 10:36 1 0 161:12 7 0 16 6 0 16 10:37 1 0 161:14 7 0 16 6 0 16 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP251095, Curtis Townsend, 04/09/25 GREATEI ANCHORAGE AREA i )ROUG" Cas. No. HEALTH DEPARTMENT 327 Eagle St. Anchorage, Alaska 99501 279-2511 SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT NAME OF APPLICANT 'o%~.~)~/~/ ~, {~rr't~k~A/~~MAIklNGADDRESS -~rcx/ RESIDENCE ADDRESS ]~', 19, ~ LOCATION OF }rqSTALkATION ~t~ ~ ¢~fy_/~fl_~A~t~ LEGAL DESCRIPTION /~f'~ / [ L~'~'// '/-/~A/~'"/_.~A2~' ~..~/J_/_,~2. APPLICATION TO INSTALL: SEPTIC TANK ~ , SEEPAGE PIT. P~, DRAIN FIELD , OTHER TO SERVE THE FOLLOWING FACILITY FINANCED THROUGH PERCOLATION TEST RESULTS TO BE INSTALLED BY /Z~/'~--/~,z~.,~-z..~ ANTICIPATED DATE OF COMPLETION .""'~-/~/ BELOW TO BE FILLEO OUT BY HEALTH OEPARTMENT ~ ~ Z.~(~2~,~/__~_~ THIS IS TO SERVE AS ~'/'~'~ · (/"~~ , PERMIT TO INSTALL A AS DESCRIBED BELOW. SIZE OF UNIT TO BkSERVED . SEPTIC TANK SIZE ,,/~-2~2 TYPE (~~SEEPAGE AREA DISTANCES: /¢'~//[// ~.q-.~/~ / TYPE DIAGRAM OF SYSTEM 4 -/~uthOrit¥ - I certify that I am familiar with the requirements of Greater Anchorage Are,~,~3orough Ordinance No. 28-68 and that the above described system is in accordance with said code. / ] /'~ i.~/~ / g~ APPLicANTs SIG NATU R E '-}'~/~~ ~~.~ 5~ GJER ANCHORAGE AREA BOROU,~i,H HEALTH DEPARTMENT ~ 327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM LOCATION ~,~, /0~'~ k~ LEGAL DESCRIPT,Oi'~ SEPTIC TANK: DISTANCE FROM WELl k~--¥ L,OU,D CAPAC,TY /DOD GALLONS MATERIAL INSIDE LENGTH COMPARTMENTS INSIDEWIDTH LIQUID DEPTH SEEPAGE SYSTEM: NUMBER OF PITS LINING MATERIAL NEAREST LOT JNE SEEPAGE PIT: I. OUTSIDE DIAMETER DISTANCE FROM WELL /~7 ~ / TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) ,LENGTH J 5 .DEPTH BUILDING FOUNDATION sO. FT. TILE DRAIN FIELD: DISTANCE FROM WELl. NUMBER OF LINES ABSORPTION AREA · FOUNDATION DISTANCE BETWEEN LIN ES SQ. FT. LENGTH OF EACH LINE DEPTH: TOP OF TILE TO FINISH GRADE . NEAREST LOT LINE. TRENCH WIDTH DEPTH OF FILTER MATERIAL BENEATH TILE TOTAL .ENGTH OF LINES IN. TOTAL EFFECTIVE IN. ABOVE TILE .5~/..1~//~) DISTANCE FROM WATER WELL: TYPE ]'~l:}G DEPTH CO , BUILDING :OUNDATION. ~'~:~ / · · SAMPLE /~/"~ , NEAREST LOT LINE /~'"'~ '/ ~ NEAREST C~ / SEPTIC L~-:~ /' SEEPAGE'/~/,~ / OTHER SEWER LINE , TANK , SYSTEM ~"(fi' , CESSPOOL ' -' SOURCES DISTANCES: 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 OSC261104 Parcel ID 051-292-31 Legal description HENKINS BILK 1 LT 11 Site address 16006 DIVISION ST Expiration Date:�- Current propertyowner(s) MIDNIGHT SUN CONSTRUCTION LLC X The On -site system(s) is/are approved for 4 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or conditions: Me By: Curtis Townsend Original Certificate Date: 5/11 /2026 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 GENERAL INFORMATION Parcel I.D. 051-292-31 Complete legal description Henkinsl Block 1 Lot 11 Location (site address) 16008 Division St Current property owner(s) Midnight Sun Construction Day phone (907)727-1433 2. ON -SITE SYSTEMS SIZED FOR BEDROOMS 3. TYPE OF WATER SUPPLY: RN Private Well serving # _1 dwelling units 0 Other Non-public well as regulated by MOA M Water Storage F71 Community Well or Public 4. TYPE OF WASTEWATER DISPOSAL: X Private Septic E] Private Septic serving 2 dwelling units M Holding Tank R Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel X Plastic F-1 Concrete Fj Fiberglass Age NEW _ See advisory if steel or fiberglass older than 20 years 6. ABSORPTION FIELD: r-1 AWWTS n Bed n Deep Trench no Wide Trench n 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 $ _q S_ Waiver Fee $ Date of Payment IZ-4) Z Date of Payment COSA # Z_ (I t I Waiver # COSA Appfiration_Apr2025.doc COSA Checklist Legal Description: H2OkjnS, Block Lot11 Parcel ID: 051_292-31 Ifmore than I well and/or septic system onlot, provide separate checklist. Structure served bythis system 1 A. WELL DATA W Well log iofiled whhOnsite (or attached) [�1g69 |d80 Date drilled depth Cased80 � F*Sanitary seal iafunctioning correctly FO-1Wires are properly protected Casing height (above ground) 43 in. Date offlow test for COGA 4/1/26 Static water level at beginning of test 53 ft. Comments Well camera'd B. TANK DATA Measured operating fluid level inseptic tank NEW Oobo of pumping F-1Required maintenance completed, ifAVVVVT8 14990711712-TITM D. DISPOSAL FIELD DATA Which system tested (date installed) 2025 W ALL standpipes present [errecorddrawing Total measured depth from grade 5847ft (max) Measured depth topipe invert from grade 5.342ft (min) nNIA — pressurized field. ��-- Fl Per record dnmwinQe, field is insulated. nMonitor tubes gotobottom ofeffective. Ifnot, state depth into effective ___ FlPresoaked required if (Required ifhouse vacant orfield not used for more than 3Odays prior todate uftest) Gallons introduced _gallons date Any rejuvenationtreatment (past 12months) If yes, enter date ��3 VVaUonzducUoned�n�eoftest 6_�___gpm Water storage tank volume N/A gallons Well disinfected forco|iform test? F� Yes F011 No FWCo|iformbacteria isNegative Nitnobanng/L W Nitrate |oea than N1RL (NO) Arsenic _ug/L RArsenic less than yNRL(ND) Collected by Forge Engineering Date 4/1/26 C. LIFT STATION Required maintenance completed kof lift station — years Lift otXionmaterial _____ Adequacy test 4tE Fluid depth prior to Water added New fluid depth ____iN Elapsed time nin Final fluid depth in Absorption rategpd � FIELD STATUS — POST FKECOVE Effective depth (per record drawings) Effective depth used in Effective depth remaining in Trench depths listed east to west in E. SEPARATION DISTANCES From Well on Lot to: (Please enter distances if less than required) Septic Tank/Lift Station on Lot > 100' 9 Yes if No ft Neighboring Tank > 100' 0 Yes if No ft Disposal Field on Lot > 100' R Yes if No ft Neighboring Disposal Fields > 100' R Yes if No ft Sewer Line/Main > 100' 9 Yes if No ft Sewer Manhole/Cleanout > 100' R Yes if No ft Sewer Service/Septic Line > 25' Fff] Yes if No ft Holding Tank > 100' 0 Yes if No ft Animal Containment > 50' no Yes if No ft Manure/Animal Excreta Storage > 100' A Yes if No ft ❑ N/A - 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' FE] Yes if No ft Surface Water > 100' 0 Yes if No ft Field to Foundation > 10' R] Yes if No ft Tank to Property Line > 5' 0 Yes if No ft Field to Property Line > 10' 0 Yes if No ft Water Main/Service Line > 10' Yes if No ft F. ENGINEER'S COMMENTS Wells on Adjacent Lots: Wells > 100' Yes if No ft Community Wells > 200' © 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 Forge Engineering Phone (907) 522-7773 Engineer's Printed Name Benjamin Schiller, P.E. Date 3/6/26 COSA Checklist_May2025.docx -..- . Aw ....� °. Benja chiller ." l M ° CE 12592 •,`i Z, ���i 2,*Z?- PRoFEW01',�.►