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HomeMy WebLinkAboutHENKINS BLK 5 LT 7Onsite File ins G"Nbtj IF-- efir's ft o I 4m va 1 4� 14 Pump Installation Log Arctic Pump & Well Inc . Jim Sullivan PO Box 770197 Eagle River, AK 99577 (907) 688 -2510 (907) 243 -2282 jim@arcticpump.com 05129114000 Henkins 7 5 Bruce Dearinger PO BX 772833 Eagle River AK 99577 6/26/2020 39 Feet Franklin 10FRD05P4-2W230 353 TDH 13 Feet S-50 Well Drilling Permit Number: Parcel Identification Number: Date Of Issue: Legal Description Lot: Block: Property Owner Name Address: Pump Installaion Date: Pump Intake Depth Below Top of Well Casing: Pump Manufacturer's Name Pump Model: Pump Size: Pitless Adapter Burial Depth: Pitless Adapter Manufacturer's Name Pitless Adapter Installer: Well Disinfected Upon Completion? Method of Disinfection: u/k Yes Chlorine Comments:well depth 43 feet Pump Installer Name: Arctic Pump & Well, Inc. 5Y Thursday, July 31, 2025 Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 1 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP191245 PID Number: 051-291-14 Dwelling: ❑ Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑ Upgrade Name Bruce & Jennifer Dearinger ABSORPTION FIELD ❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 15840 Division St., Chugiak, AK 99567 ❑ Other Phoneber of Bedrooms Soil Rating Total depth from original grade 907-862-0217 772 0.7 GPD/SF 6.5* Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 6.0 Ft. Gravel depth beneath pipe 0.5 Ft. Subdivision Block Lot Henkins 5 7 Fill added above original grade 0 Ft. Gravel length 31 Ft. Township Range Section Gravel width 15 Ft. Beds: Number of Lines 3 Distance between lines 5 Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line 465 Ft2 Ft. Well 100+ 100+ 25+ TANK [9 Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Infiltrator Capacity 1060 Gal. Surface Water 100+ -{- 100 Material HDPE Number of compartments 2 Lot Line 5+ 10+ NA Foundation1 Q+ 1 Q+ LIFT STATION Manufacturer Capacity Remarks *does not include 2' sand filter Gal. Alarm location Electrical installed by PIPE MATERIAL House to tank 3034 Tank to drainfield 3034 Installer Homeowner Drainfield 3034 CO/MT 3034 Inspector Crewdson Engineering LLC BENCH MARK (Assumed elevation) 100 ft Inspectionoca �5 dates: 7/20/2019 2°d 7/21/2019 ion and description Bottom of siding at "BM" on Record Drawing 3`d 7/22/2019 4" 7/23/2019 ON-SITE WATER AND WASTEWATER SECTION APPROVAL .>�►`0\l OF Ac -4 t Conditional Approval: Date'`p •�dr �0 'g if' ' .,• TH Irr",, ..James A. Crewdson•: ��% '•, C11527 Septic System J°j'!S '1} Approved ' � _ Date 7/12/10 ' • • • I ...,low 1 � �QFESSIONP-® Note: this approval does not include well permit requirements.®®®®°►'^° trcev vo/UZ/1a/ BENCH MARK BOTTOM OF SIDING ASSUMED ELEV 100' ELEV ELEV EG 88.0' EG 88.0' In it n In FG 88.3' FG 88.3' C1 MH S1 DC C# M# C# M# oc SAND SEPTIC TANK ELEV TOT 84.3' DRAINFIELD ELEV INLET INV 83.7' TOR 82.8' OUTLET INV 83.5' INV 82.3' BOR 81.8' BOS 79.8' TH1 BOH 73.0' DRY PROFILE NOT TO SCALE Crewdson Engineering, LLC Nil caws IkEftwilitmina, 89howng Box 671389 Chugiak AK 99567 o cellc.1 @outic Cell/Text:907-280-9493 o Fax:907-688-2295 Henkins, Block 5, Lot 7 Septic System RECORD DRAWING Prepared for: Bruce Dearinger Date: 7-12-2021 Permit: OSP191245 Page: 1 of 1 ALL INFORMATION 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 LLI LLJ Cn O U) 0 LEGEND BM - bench mark BOH - bottom of hole BOR - bottom of rock BOS - bottom of sand BR - bedroom C# - cleanout DC - double cleanout EG - existing ground ELEV - elevation FG - finish grade INV - invert M# - monitor tube MH - 24" manhole SFH - single family home S# - septic tank cleanout TOR - top of rock TOT - top of tank AW . s,�ll ��.• :vii ..................... James A. Crewdson C11527 AN �il►��pROFESSIONP��.� � ALLC #112279 N 89°43'00" W 200.00' Shed \� Shed SWING TIES (feet) A B B FC 11.2 19.1 0 s7 C1 59.0 58.0 0 S1 MH O �\oo� °J �� C2 68.2 70.1 ct DC C3 67.4 69.8 cz C4 c5 Mt FC 1 BR SFH C4 59.0 61.3 b o Ica I I ' ' I ' C5 58.2 60.1 Gravel A, BM C6 73.7 87.1 C7 68.0 82.3 I C8 63.4 78.6 Drive CD 1 I I e DC 68.2 68.9 00 I j j o ID WELL M1 69.2 71.8 t_ - TH1IQ 77.8 Z d d do I�MH cs c7 ca Mz 7%/ � 63.2 62.2 0 SEPTIC SYSTEM �p� 01� S168.5 67.6 o Infiltrator 1060 SEPTIC TANK V �J5 o�p9 oo 15'x31' BED, 465 SIF z Lot 7 PLAN N 89°43'00" W 200.00' SCALE: 1"=30' IL BENCH MARK BOTTOM OF SIDING ASSUMED ELEV 100' ELEV ELEV EG 88.0' EG 88.0' In it n In FG 88.3' FG 88.3' C1 MH S1 DC C# M# C# M# oc SAND SEPTIC TANK ELEV TOT 84.3' DRAINFIELD ELEV INLET INV 83.7' TOR 82.8' OUTLET INV 83.5' INV 82.3' BOR 81.8' BOS 79.8' TH1 BOH 73.0' DRY PROFILE NOT TO SCALE Crewdson Engineering, LLC Nil caws IkEftwilitmina, 89howng Box 671389 Chugiak AK 99567 o cellc.1 @outic Cell/Text:907-280-9493 o Fax:907-688-2295 Henkins, Block 5, Lot 7 Septic System RECORD DRAWING Prepared for: Bruce Dearinger Date: 7-12-2021 Permit: OSP191245 Page: 1 of 1 ALL INFORMATION 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 LLI LLJ Cn O U) 0 LEGEND BM - bench mark BOH - bottom of hole BOR - bottom of rock BOS - bottom of sand BR - bedroom C# - cleanout DC - double cleanout EG - existing ground ELEV - elevation FG - finish grade INV - invert M# - monitor tube MH - 24" manhole SFH - single family home S# - septic tank cleanout TOR - top of rock TOT - top of tank AW . s,�ll ��.• :vii ..................... James A. Crewdson C11527 AN �il►��pROFESSIONP��.� � ALLC #112279 ' P n 0 CD c Basis of Bearing CD C'-' 0 -+ a N 00°08'00' W 100.00' (R&H) '� Z W yy E-- 6 a O r � T � a y W • m o — o o sv ?: o a� CLc.o Z © � v G n m wt CD UQ � 10'CD ® ®g s v Dm /� C7 o d�< ZZ c N ZZ °v' ° LJ " 00co0 0 0 0 v m ami ivi n C tD tD tD r CD n in' A� Ul WA. •A. N �0 rp O e -F 2 CE p > n. cn N CD too �} Gl �.-1n ��� oto � n DD��M cr C) tMl. n � � � d Qo c+ rp Q o -� cn a: cncoo CL - o � CD ? N p o Q = rF td D : O °c C:) 00 - - D „ Ln Z a��,, o �o oW 0 T m ST m 00 r 0 rp Ul J n W N 3 0CD 14 �ro R)� I—�_h��LO Q�Qr� U Q a A < a `< (p D to a o O -` 3 :3P N 00'08'00' W 100,00' (R) '• ,, ` Q rD o -CD0 = N 00°48'45' W Wo 98.92' (M)CD DLn �cn m oM:C+ C o - = --—DIVISION—STREET--- Vun Z0�wCn ofl v t:d s 0 D- ci p? o Ulf U w ago 5' d r n ,v o � 11' ren --------30'--------. fp ��1 /// u rru O r-: w �I �b I CD CO CD o x i `< .. i i i = d V/ •"1(D •� �• O c+ 0 <.+ j p 3 (0 rD Q C4 m f R)rD m 14' g 8, \o _ \ m 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: OSP191245 Work Type: Septic Upgrade Tax Code Number: 05129114000 Site Legal Address: HENKINS BLK 5 LT 7 G:0755 Site Mailing Address: 15840 DIVISION ST, Chugiak Owner: DEARINGER BRUCE & JENNIFER Design Engineer: CREWDSON ENGINEERING, LLC This permit is for the construction of: Q Disposal Field 2 Septic Tank ❑ Holding Tank ❑ Privy Effective Date: Expiration Date Lot Size in Sq Ft: Total Bedrooms: 6/27/2019 6/26/2020 20038 ❑ 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: _ LqZ&"A_ Date: c� Date: 7 E E-PL14NS MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 051-291-14 Property owner(s) Bruce & Jennifer Dearinger Day phone 907-862-0217 Mailing address PO Box 772833, Eagle River, AK 99577 Site address 15840 Division St., Eagle River, AK 99577 Legal description (Sub'd., Block & Lot) Henkins, Block 5, Lot 7 Legal description (Township, Range & Section) Lot Size 20,038 Sq. Ft. Number of Bedrooms 2 APPLICATION IS FOR: (® all that apply) Absorption Field 0 Septic Tank Q Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage ❑ APPLICATION IS AN: Initial ❑ Upgrade 0 Renewal ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: TYPE OF DWELLING: Single Family (SF) (w/wo ADU) Duplex (D) ❑ Multiple Dwellings ❑ (SF and/or D) Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (5lgnature of property owner or authorized agent) Permit/Rush Fees: Waiver Fees: Date of Payment: r'bl�tQ��9 Date of Payment: Receipt Number: Qt?&N67 Receipt Number: Permit No. Waiver No. GADevelopment ServicesOuilding Safety\On Site Water and Wastewater\Forms\Client FormsTermit Application.doc Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191245, Rebecca Carroll, 06/27/19 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191245, Rebecca Carroll, 06/27/19 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191245, Rebecca Carroll, 06/27/19 N Fd 3/4' IP i. El= -17 di Q_ O) o �o L o N PO FLOW 0 3 �— ul Cf o M 0° 0 0 0 Z Fd Rbr Et= 87.0' Easement An Electric Esrlt., as described in Book 752, Page 14, A.R.D. pertains to the entirety of Lot 7, Bk 5, Henkins Subdivision, N 89"24'39' W LEGEND ® Utility Ped 200.00' (R) Power Pole 12' Y 16' \o Guy Anchor ® Well Pipe ® Septic Pipe ® Perk Test Easement An Electric Esrlt., as described in Book 752, Page 14, A.R.D. pertains to the entirety of Lot 7, Bk 5, Henkins Subdivision, N 89"24'39' W 199.30' (M) Fd 3/4' IP N 89°43'00' W 200.00' (R) El= 105.5' 12' Y 16' \o I I� /— f o Shed Shed FLOW 25' FLOW 75' o 0 W a` n'$ Seer L'J + \ Detail ��" ® \ Grave 30'F- Drive z 3 Dr FL W/ v00 o in H 1 d > Vo -- S 'W'W' 1\ o / Lot 7 '�" �' o • ca \ o C3 O OA FLOW Aas NOTE. Hurried Well location per Property Owner Z Z Parole Evidence N 89°43'00' W 200.00' (R) El -1"00.0 N 89.45'09' W 200.44' (M) (Assumed) Detail (Not to Scale) i 6 Y I I " °' A I I I I I� /— 12' I hereby certify that a survey of Lot 7, Block 5, Henkins Subdivision was made on June 25, 2019 and that the improvements situated thereon are within the property lines and do not overlap or encroach on the property lying adjacent thereto, that no improvements on property lying adjacent thereto encroach on the premises in question and that there are no roadways, transmission lines or other visible easements on said property except as indicated hereon 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. Under no circumstances should any data hereon be used for construction or for establishing property boundary or fence lines. Dated at Anchorage, Alaska, this day of , APB Land Surveying zs so SCALE IN FEET 12204 East Prince of Peace Drive Eagle River, Alaska 99577 1" = 50' (907) 227-1361 Surveyed: June 25, 2019 Henkins Subdivision Lot 7, Block 5 As Depicted on: Plat No. P-387 Anchorage Recording District GRID: NW0755 / 2x2 Existing Trailer To Be Removed 16' i ao I Existing Bldg L To Be Removed 4' m I I 4' r Proposed House --- 40-------� 1' Eve All Around OF *. 49 TH . ...... ... ........ . .. ..Anti ony P. Boneta.-* ff f ted, LS -10393 _ PLOT PLAN Bruce & Jennifer Dearinger P O Box 772833 Eagle River, Alaska 99577 DRAFTED: RWR I CHECKED: I APPROVED: SHEET OAAB-HD-) GRr~.TER ANCHORAGE AREA BOROU~.H HEALTH DEPARTMENT 327 ~:~.GLE ST. ANCHORAGE, ALASKA 99501 279-2511 SEPTIC TANK: INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM MAILING ,'? ~'~ ". d .~.- ,, ~ GALLONS. MATERIAL SEEPAGE SYSTEM: SEEPAGE PIT: NUMBER OF PITS / OUTSIDE DIAMETER ~ OR WIDTH. L, N, N G M AT E R I A [ .,L ~J//,,~/'~,'~/~ /--~'~-/? . DISTANCE FROM WELL NEAREST LOT LINE ~ TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) / , BUILDING FOUNDATION so. FT. TILE DRAIN FIELD: TOTAL LENGTH DISTANCE FROM WELl ?~'"'"'~ FOUNDATION NEAREST LOT LINE .,~"'"'-~ , OE LINES NUMBER L / IN. TOTAL EFFECTIVE ABSORPTION AREA SQ. FT. LENGTH OF EACH LINE DEPTH: TOP OF TILE TO FINISH GRADE WELL: TY ' ~/~'¢~ . DEPTH ' /,~ / NEAREST ,,' /"SEPTIC LOT LINE ~"~ ~ , SEWER LINE ,./~"T''~, TANK DEPTH OF FILTER MATERIAL BENEATH TILE IN. ABOVE TILE DISTANCE FROM /.~' /'~-~-' WATER /~' ,BUILDING FOUNDATION, /~ ~f~-'. SAMPLE , NEAREST -5~/ SEEPAGE· / OTHER , , , SOU~C[S .,x~ISTANCES: J DIAGRAM OF SYSTEM . - - DATE APPROVED ~-~--~ GREATEI ~ 327 Eagle St. ANCHORAGE AREA ; ')ROUGH HEALTH DEPARTMENT Anchorage, Alaska 99501 g79-g511 SEWAGE DISPOSAL SYSTEM - APPLIC.A....T.-ION'& PERMIT .... . NAME OF APPLICANT~'~-4]'?'. -- ~ MAILING ADI~RESS ~Z/¢ 7~--~_ ....... ~r-.Ul~: l~u. lIES DENCE ADDRESS '~/ LOCATION O.~xI.~STALLAT~O.N // /. LEGAL DESCRIPTION ~ 2 ~-'~'='~ ? APPLICATION TO INSTALL: SEPTIC TANK _~ , SEEPAGE PIT. ~DRAIN FIELD ,OTHER TO SERVE THE FOLLOWING FACILITY ~ L~-..~ ~-~,-/ ,,.CO~A~O~,S~,,SU~S 8Y~'./~ mOW ~0 .~ m~.. ou~ ,~ ..A~. THIS IS TO SERVE AS ~ .~ -, PERMIT TO INSTALL A , ~~~ AS DESCRIBED BELOW· SIZE OF UNIT TO BE SERVED · SEPTIC TANK SIZE DISTANCES: Health Authority DIAGRAM OF SYSTEM I certify that I am familiar with the requirements of Greater Anchorage Area Borough Ordinance No, 28-68 and that the above described system is in accordance with said cod~..... "~ ~"~57~/~'w-'~' 2 .... ,~...-. ~ f~. / F' Y'r)~ ^,o, ,,.,,~,,-~ ~,..~,,,,-,,,~ ., .~,.-~ ~--~ '~"3REATER ANCHORAGEAREA BOROUGH HEALTH DEPARTMENT 327 EAGLE STREET ANCHORAGE, ALASKA 99501 CASE # Legal Description: fot_..z__B'lock..~. -Subdzv~slon zz/~/n ~/~.. '..____.-f ....... This Form Reports a. Soils Log z~---, . .. · -PercOl~tion Tesz___ _ ..... '._ Depth Feet 3-- ! Reading Date Gross Time Net Tim, Location Sketch Was Ground Water Encountemed?/~_.~ C°:oo~ I ~ C~ if Yes, At What DepthI.__~ ~, ~ Depth To ~20 Net Drop Pmoposed Instal~Seepage Pit · ____~.~.. Drain Field Depth Of Inlet .7~ - 'F,:., Deeth To Bottom Of Pit Or T~:mnc~: COMMENTS: ~q~ ~ ~ · ~F~.: ./~L~ - ' .... Test Performed By:~~~ _ ' Data Certified By: Date 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 OSC251317 Parcel ID 051-291-14 Legal description HENKINS BLK 5 LT 7 Site address 15840 DIVISION ST Expiration Date: Current property owner(s) DEARINGER BRUCE & JENNIFER X The On -site system(s) is/are approved for 2 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or conditions: By: Original Certificate Date: 8/12/2025 This Certif' to of On -Site Systems Approval (COSA) is intended to demonstrate the subject system are in substantial compliance with municipal code. The Municipality of Anchorage, Dev opment Service Department (DSD) issues COSAs based upon representations provided by an in ependent 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 ,r Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 051-291-14 Complete legal description Henkins, Block 5, Lot 7 Location (site address) 15840 Division St, Chugiak, AK 99567 Current property owner(s) Bruce & Jennifer Dearinger 2. ON-SITE SYSTEMS SIZED FOR 2 BEDROOMS Day phone 907-862-0217 3. TYPE OF WATER SUPPLY: 0 Private Well serving # 1 dwelling units ❑ Other Non-public well as regulated by MOA ❑ Water Storage ❑ Community Well or Public 4. TYPE OF WASTEWATER DISPOSAL: ❑■ Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 6. SEPTIC TANK: ❑ Steel n Plastic ❑ Concrete ❑ Fiberglass Age 6 years _ See advisory if steel or fiberglass older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS 100 Bed ❑ Deep Trench ❑ Wide Trench ❑ 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 $� 00 Date of Payment COSA # Waiver Fee $ Date of Payment Waiver # COSA Application_Ap2025,doc Legal Description: Henkins, Block 5, Lot 7 Parcel ID: 051-291-14 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system A. WELL DATA ❑ Well log is filed with Onsite (or attached) Well production at time of test 5+ gpm Date drilled *unknown Total depth "unknown ft Water storage tank volume none gallons Cased to "unknown ft Well disinfected for coliform test? ❑ Yes ❑Q No ❑N Sanitary seal is functioning correctly X❑ Coliform bacteria is Negative ❑ Wires are properly protected Nitrate 2.94 mg/L ❑ Nitrate less than MRL (ND) Casing height (above ground) 18+ in. Arsenic ug/L X❑ Arsenic less than MRL (ND) Date of flow test for COSA 7/29/2025 Collected by Crewdson Engineering Static water level at beginning of test 22 ft. Date 7/29/2025 Comments *Well log could not be found at MOA -Onsite or ADNR websites. Pump Log states 43' well depth. B. TANK DATA Measured operating fluid level in septic tank 4 Date of pumping 7/28/2025 ❑ Required maintenance completed, if AWWTS Comments: D. DISPOSAL FIELD DATA Which system tested (date installed) 7/23/2019 ❑E ALL standpipes present per record drawing Total measured depth from grade 6.5 ft (max) Measured depth to pipe invert from grade 6.0 ft (min) ❑ N/A — pressurized field. ❑ Per record drawings, field is insulated. ❑ Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Comments/Deficiencies: COSA Checklist_May2025,docx C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 7/29/2025 Results Z Pass Fluid depth prior to test 0 in Water added 300+ gal New fluid depth 0 in Elapsed time 60 min Final fluid depth 0 in Absorption rate 300+ gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) 6 in Effective depth used 0 in Effective depth remaining 6 in COSA Checklist_May2025.docx E. SEPARATION DISTANCES From Well on Lot to: (Please enter distances if less than required) Septic Tank/Lift Station on Lot > 100’ Yes if No ft Neighboring Tank > 100’ Yes if No ft Disposal Field on Lot > 100’ Yes if No ft Neighboring Disposal Fields > 100’ Yes if No ft Sewer Line/Main > 100’ Yes if No ft Sewer Manhole/Cleanout > 100’ Yes if No ft Sewer Service/Septic Line > 25’ Yes if No ft Holding Tank > 100’ Yes if No ft Animal Containment > 50’ Yes if No ft Manure/Animal Excreta Storage > 100’ 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’ Yes if No ft Field to Foundation > 10’ Yes if No ft Tank to Property Line > 5’ Yes if No ft Field to Property Line > 10’ Yes if No ft Water Main/Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft 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 F. ENGINEER’S COMMENTS 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 Phone Engineer’s Printed Name Date ✔✔ ✔✔ ✔✔ ✔ ✔ ✔✔ ✔✔ ✔ ✔✔ ✔✔ ✔ Crewdson Engineering, LLC 907-280-9493 James Crewdson 7/31/2025