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LEOS LT 5
Leos Lot 5 #051-053-39 Municipality of Anchorage On -Site Water and Wastewater Program • (907) 343-7904 Page 1 of 1 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP141285 PID Number: 05105339000 Dwelling: N Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project:❑ New ❑ Upgrade Name: Joseph A & Lynn A Roman ABSORPTION FIELD Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound Address 24236 Leo's Road, Chugiak, Alaska 99567 ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade (907)242-7151 3 0.45 GPD/SF 11.5 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 5.0 Ft. Gravel depth beneath pipe 7.0 Fl. Subdivision Block Lot Leo's Subdivision, Lot 5 Fill added above original grade 0.0 Ft. Gravel length 72.0 Ft. Township Range Section T15N R1 W 3 Gravel width 2.5 Ft. Beds: Number of Lines NA Distance between lines I NA Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches 1 From Tank Field Tank Line 1000 Fly 1 NA Ft. Well 92.5' 93.7' NA NA 50' TANK XSeptic ElS.T.E.P. LlHolding [IOther Manufacturer Anchorage Tank Capacity 1 1000 Gal. Surface Water 100'+ 1001+NA NA Material Steel - Number of compartments 2 Lot Line 30.3' 6.0' NA NA NA Foundation46.0' 47.5' NA NA LIFT STATION Manufacturer Capacity Curtain Drain NA NA NA NA Gal. Remarks Well to sewer line dist. shown above for Pump on level at n. Pump off level at in. High water alarm at in. on-site facilities. No pubic sewer line serves area. Ref. separation waiver # OSP141286 Pump make and model Electrical Inspections performed by PIPE MATERIAL House to tank D3034 d�Tank to 63034 Installer Paul Cherven, Eagle Glacier Excavating mn Drainfield 63034 Comer Inspector Rod Kinney, RPKA, Inc. BENCH MARK (Assumed elevation) 100.0 ft Inspdates: 1., 9-12-14 9-16-14 Location and description 2M 3'" 9-17-14 a Finish Floor at back door (south door) to deck COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL Engineer's Stamp OF 44%%,l Conditional Approval: Date „ g: TH 9 OF i X i..� 9�'.ROD P.IONNEYJR. 10 ( c,, : No. CE7M � Approved d -ti( Date - lit......... � %%t%% 91 Inspection RepcTl79-1-1;fPV \ \ \ N \ \ \ 1\- _ \ 10 1191 1 <\ 12 11 13 \\\ 1114 I1 / j SUQDI VIS). S).ON¢ ¢ \ \ �� \\ LEO'S ROAD /\ \ 1 /1 1 \ BUILDIN� /WEjLL / 1 I \ \ II \ Lo Lo ,\ 1 1 4 3 \,7- L Ld t DECK= A o ® //®Ll 7 6 \ / 3 SHED �i © EXISTING 100' WELL RADIUS, _ ME ® TYPICAL EXISTING i TRENCH8 ; FSEE IGURE ENLARGEMENT RGEMENT ' S89'55'10 W 70.00' _ NOTE: NO SURFACE WATER WITHIN 100' OF SEPTIC SYSTEM OF �1 i CP E•..... A<g4y TBM - DECK SURFACE AT BACK DOOR LEGEND � g� (FINISHED FLOOR OF HOUSE). //* t 9TH • • *l� ASSUMED EL.=100.00' CO SANITARY SEWER CLEANOUT �..5 .. .... / ST SEPTIC TANK CLEANOUT / .... ................ MT MONITORING TUBE s ;R A.IQNNEYJR. : —S— NEW SEWER LINE ��� No.CE79&i� r —s—FUTURE RESERVE SEWER LINE tp''`•�° %� �c�_ r GRAPHIC SCALE ¢ EXISTING WELL 40 0 20 40 OA DRAIN FIELD SEGMENT I inch = 40 feet TBM AS -BUILT 04 � Rodney l Kinney Associ" IRL L EOS SITE PLAN [.oiu.rs a s.l..r.r. PLAT P-295 1/16/2015 FIGURE 1 SWING TIE TABLE ®BLDG. COR. ®BLDG. COR. ©ST#1 53.8' 51.9' ®CO#5 61.2' 52.5' 04 � Rodney l Kinney Associ" IRL L EOS SITE PLAN [.oiu.rs a s.l..r.r. PLAT P-295 1/16/2015 FIGURE 1 GRAPHIC SCALE 10 0 5 i0% I mon - 10 feet II BUILDING I/ 3 MT#1 14' / I I ICO# OF INSTALLEDEW CLEANOUT CO#1 INSTALLED 1000' GALLON STEEL TANK i ST#1 ] ST#2 N CD#2—� CO#3—� S —� btl USE BULL RUN `��VALVE, SEE DETAIL FIGURE � 1 S, S- U DECK � 9TM ... RO ••EY P. IONNEYJ No. CE70M 1`1'%%'bft;FE` tNr 4.83' 5.2' \ CO#5 CO#6 MO 40' S \ EXISTING TRENCH TO \ REMAIN. TO BE USED \ AS FUTURE RESERVE \ AREA Il Nl TEST HOLE AS—BUILT S89.55'10"W 70.00' 0& BodmyI. Kim Amocia tiaL LOT 5, LEOS SEPTIC SYSTEM 091311Ei.l E.lh!•rt = SNFVGV.IE PLAT P-295 1/16/20151 FIGURE 2 BULL VALE (SURFACE MOUNDED TO INSURE DRAINAGE AWAY FROM DRAINFIELD GROUND „/ / �, LEVEL NATIVE. SOIL 3' (MIN.) i BACKFILL FILTER FABRIC % / EL.=90.3'— 4" PERFORATED PIPE Tj 'op•° ••°,• 6" GRAVEL) °- •� •°-•'- GRAVEL DEPTH °' ° BELOW PIPE (7') EL.=82.8' ° •' 3D- z DEEP TRENCH CROSS SECTION NTS VALVE ST RUN VALVE SEE DETAIL THIS SHEET EXISTING EL.=90.27') PERFORATED PIPE, NEW TRENCH INST, INV. EL.=89.82'- 3.5' I 1 2.3' SEPTIC TANK DETAIL 1/3 TURN 1/3 TURN NOTE: SET ON 1 (ROTATE COUNTERCLOCKWISE 1/3 TO SET ON 2) ❑� ST#2 TANK CO#3 INSTALLED BULL RUN VALVE--,, m CO#3 45' BEND .S 45' BEND ALL PIPE SHOWN IS SOLID ASTM -3034D EXCEPT AS SHOWN PERFORATED PIPE NEW TRENCH EXISTING PIPE TO OLD TRENCH BULL RUN DIVERSION VALVE DETAIL - INSTALLED TWO OPPOSING CLEANOUTS (DOUBLE OPPOSING) 8' 1 EL.=96.30' ' " TO INSTALLED 1000 GALLON SEPTIC TANK AS—BUILT LOT 5, DETAILS li& IBM P. I(i udsucimu im. LEOS su»Itlne Engineers a serrevers PLAT P-295 1 /16/2015FIGURE 3 LOT 5, PROFILES 6) Bouwey P. I( mi Associates, ilL LEOS yyyyylli.l E.ylyy.IE a yyry.yyr: PLAT P-295 1/16/2015FIGURE 4 HOUSE/TANK PROFILE 00#1 - C013 100 FINISHED 100 2 INSTALLED NEW GROUND CO#2 (CLEANOUT CO#1 ST#1ST#2 CO#3 INSTALLED BULL RUN VALVE 95 II 45' BEND I II 95 45' WYE EL.EL.--96.3'96.3' II II 415- II II EL.=92.8'2% EL.=90.7' 90 EL.=90.8' 90 46' EL.= 90.6' INSTALLED NEW 1000 EL.=89.8' GALLON SEPTIC TANK IEL.=90.3' •TM....�•iS+%11 NE G O 85 i5�P4 EXOISTNPIIPEED 85 H: 1'= V: 1"= �"'`' TRENCH PROFILE i ....... ...,..... ..........s Co#4 - CO#6 100R0 NEY P.l6NIN JR..: y, "a 100 . . CE7S6� o'•No5 :��,.•��`�" PIPE FROM DIVERSION FINISHED ,%% �' EXISTING GROUND E4.835.50' VALVE TRESERVE OFESSIOHN��� \������ FUTURE AREA CO 6 # CO#4 MT#1 CO#8 CO#5 CO#7 MT#2 95 II II II II II II II II 95 II II II II I4" PERFORATED II II II 90 PIPE 90 10 2' 14' 8.5' 17.5' 8' 2' 12 O © O 10 O II II O EL.=89.82' 85 85 II INSTALLED NEW 1000 II GALLON SEPTIC TANK BOTTOM MT u EL.=82.82, TYPICAL AS -BUILT LOT 5, PROFILES 6) Bouwey P. I( mi Associates, ilL LEOS yyyyylli.l E.ylyy.IE a yyry.yyr: PLAT P-295 1/16/2015FIGURE 4 On -Site Wastewater Disposal System Permit MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water & Wastewater Program 4700 Elmore Road, PO Box 196650 Anchorage, AK 99519-6650 Telephone: (907) 343-7904 Permit Number: OSP141285 Tax Code Number: 05105339000 Work Type: Septic Renewal Permit Effective Dates: August 18, 2014 to August 18, 2015 Design Engineer: RODNEY P KINNEY ASSOC INC Subdivision: LEOS Site Legal Address: LEOS LT 5G:1561 Owner/Address: ROMAN JOSEPH A & LYNN A PO BOX 672473 CHUGIAK AK 995672473 Site Mailing Address: 24236 LEO'S RD, Chugiak This permit is for the construction of: Y Disposal Field Y Septic Tank N Holding Tank N Privy Lot Size in Sq Ft: 10185 Total Bedrooms: 3 N Private Well N Water Storage All construction must 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 must notify the Development Services Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either: A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing. Receiv Issued ed By: 4>/zZ�f rJ Date By Date: U Municipality of Ancho P.O. Box 196650 • 4700 Elmore Road Anchorage, Alaska 99519-6650 0 (907) 343-7904 • Fax (907) 343-7997 hftp://www.muni.ora/Onsit Development Services Division On -Site Water and Wastewater Program Ment S �o F v !+ Department **** VARIANCEIWAIVER REVIEW **** Waiver#: OSP141286 COSA#: Permit#:OSP141285 PID#: 051-053-39 Legal Description: Leo's, Lot 5 Engineer: Rodney P. Kinney and Associates, Inc. Applicant: Joseph & Lynn Roman Your request for a waiver of the required 100 feet horizontal separation from the absorption field and septic tank to the private well has been approved. The approved separation distance is 92.0 feet. This waiver approval applies to the proposed absorption field and septic tank only. Any future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. Your request for a waiver of the required 10 feet horizontal separation from the absorption field to the property line has been approved. The approved separation distance is 6.0 feet. This waiver approval applies to the existing absorption field only. Any future upgrade to the on- site wastewater disposal system will require all separation distances be met or another approval from this department. ® The affected adjacent property owner(s) have been given a 7 day notice regarding this waiver. ❑ Notarized letter(s) of non -objection have been received from the owner(s) of the affected adjacent property. ❑ Adjacent properties are not affected by this waiver. ............................................................................... Waiver is Granted: X Waiver is not Granted: Date: S Approved Name of Reviewer ......................................... ................................... MUNICIPALITY OF � eak"i � Community Development Department Development Services Division On -Site Water & Wastewater Program ANCHORAGE Phone: 907-343-7904 Fax: 907-343-7997 ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 051-053-39 Property owner(s) Joseph A & Lynn A Roman Day phone (907)242-7151 Mailina address 24236 Leo's Road, Chugiak, Alaska 99567 Site address Same Legal description (Sub'd., Block & Lot) Leo's Subdivision, Lot 5 Legal description (Township, Range & Section) T15N, R1 W, Sec 3 Lot Size 10,185 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑x Initial ❑ Single Family (SF) ❑X (w/wo ADU) Septic Tank 19Upgrade Duplex ElHolding Tank ElRenewal (D) Privy ❑�� Multiple Dwellings (SF and/or D) ❑ Private Well El A, Water Storage ❑ JUL 3 0 Z0% THIS APPLICATION INCLUDES A VARIANCE / WAJYY Q T FOR: ^ � f' Absorption Trench to Lot line (6) & Well to Field/Tank (92.5') Distance: e' & 925 I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of propert)rowner or authorized agent) Permit/Rush Fees: Waiver Fees: Date of Payment: o G Date of Payment: �36 Receipt Number: iD�� d3�� Receipt Number: IOOJ� Permit No. btZ l t2� Waiver No. d Permit App__- : :_' _ c , (i) Rodney P Kinney Associates, inc. eensul[Ine Engineers s Survesers July 30, 2014 Municipality of Anchorage Development Services Department On -Site Water and Wastewater Program 4700 Elmore Road Anchorage, AK 99507 Attention: Ms. Deb Wockenfuss Subject: Leo's Subdivision, Lot 5 Septic System Replacement Dear Ms. Wockenfuss: We respectfully request your review and approval to construct the subject septic system. Attached to the application sheet are the following documents, which also includes this letter and the sizing and specifications requirements. 1. Figures 1 through 5, Septic Design Plans stamped and signed by a licensed professional engineer. 2. Design calculations stamped and signed by a licensed professional engineer. 3. Soils log and percolation results, including water table test stamped and signed by a licensed professional engineer. 4. Request for waiver for trench to property line and well to tank/field. This septic system design is for a three-bedroom home currently served by a private well. We propose the installation of a 1000 -gallon septic tank and a 7 foot deep -trench type drain field. The attached Septic Design Plans, Figures 1 through 5, respectively, include the existing adjacent and surrounding property well and septic system approximate locations, as well as the location of soil and percolation test pit used for this design application. No other wells exist within 100 feet of our proposed septic system design. The included percolation and soils identification log reflecting exploration to a depth of 17.5 feet was performed and stamped by a registered professional engineer in the State of Alaska. The test indicates silty gravelly sand with cobbles exclusively within the absorption zone. The soil percolation rate is 34 minutes per inch. No water or bedrock was encountered within the limits explored and no water was recorded in a three-week span of monitoring. 16515 Ceulerfleld Drive ■ Suite 101 ■ Eagle River, Alaska a 99517 907.694.2332 ■ Fax 901.694.1807 1 www.rpka.net Lot 2, Block 1, Roseberry Park Estates Subdivision Septic System Design Permit and Well Permit Application The topography is generally sloping variably from north to south. We did not observe any surface waters within 100 feet from the proposed and alternate septic field locations. This proposed installation does not appear to create adverse effects or limitations on existing or future adjacent wells or septic systems under current MOA Code. If you have any questions or require addition information, please do not hesitate to contact us at 907-694-2332. Sincerely, RODNEY P. KINNEY ASSOCIATES, INC. /v Rodney P inney, Jr., PE Principal Attachments RPK:djm IEY R IONNEY JR. No. CEM5 Rodney P. Kinney Associates, inc. consulting Engineers a Surveyors July 28, 2014 Municipality of Anchorage Development Service Department On -Site Water and Wastewater Program 4700 Elmore Road Anchorage, Alaska 99519-6650 Attention: Ms. Deb Wockenfuss Subject: Leo's Subdivision, Lot 5 Septic System Replacement Request for Waiver Dear Ms. Wockenfuss: The subject lot is 10,185 SF. Topography generally slopes to the south at about 5 percent. Based on the test pit completed on July 7, 2014, the surface soils consist of sandy silts and silty gravel to 17.5 feet below the ground surface. The anticipated wastewater flow should not exceed 1000 gallons per day. This is a request for a waiver for the following: 1. New and existing trench to property line: We request a waiver of 6 feet from the east and west property lines, due to location of well and minimal usable remaining area on the lot for the absorption trench. 2. Separation distance between water well to septic tank/field: A 92.5 feet from septic tank/trench to well separation distance is requested. A 7.5 feet encroachment is necessary to reserve future drain field area south of the proposed field. The proposed tank and trench are down gradient of the well; spills should flow away from the well location. The soils indicated in the well log shows clay and hardpan layers to 210 feet below the ground surface that should minimize the potential for contamination. I do not expect any adverse impacts associated with granting this waiver request. If you have any questions, please call (907) 694-2332. Sincerely, RODNEY P. KINNEY ASS IATES, INC. Rodney P. inney, Jr., P.E. Principal RPK:djm 16515 Centertiel0 Drive ■ Suite 101 907.694.2332 1 Fax 901.694.1807 Eagle River, Alaska www.rpka.net 99577 NO WELL OR SEPTIC SYSTEM 0 SEPTIC SYSTEM �V— NO WELL OR SEPTIC SYSTEM U � h \ ii Q Q WELL, TYPICAL / 2 OO. f ... RO • • EY P. KINNEY JR.•••�e j GRAPHIC SCALE 1�%. No. cE7955 too 0 so too LEGEND �9Fp •�~•-1'��� ROAD CENTERLINE x FENCE 1 inch = 100 feet PROPERTY LINE LOT 5, WELL LOCATIONS Rodney P. King Associoms, inc. LEOS consulting Engineers u Surveyors PLAT P-295 O8/08/14 1FIGURE 1 N 11 4 5 6 — — SIBS DRIVE ROBINDALE SUBDIVISION 3 2 1 21 LAKE HILL ACRES SUBDI VISION 3 9 / 10 '12 13 V4 15 16 17 I / I 4 SAMPSON ES TA TESi\ �� �\ LES ROAD y LEGS SUBDI VISION / SUBDI VISION —A 8 7 6\ 4 3 2 1 NO WELL OR SEPTIC SYSTEM 0 SEPTIC SYSTEM �V— NO WELL OR SEPTIC SYSTEM U � h \ ii Q Q WELL, TYPICAL / 2 OO. f ... RO • • EY P. KINNEY JR.•••�e j GRAPHIC SCALE 1�%. No. cE7955 too 0 so too LEGEND �9Fp •�~•-1'��� ROAD CENTERLINE x FENCE 1 inch = 100 feet PROPERTY LINE LOT 5, WELL LOCATIONS Rodney P. King Associoms, inc. LEOS consulting Engineers u Surveyors PLAT P-295 O8/08/14 1FIGURE 1 \ \ \ N \ \ \ \ \ 1 1 10 119 1 �� 12 1 l3 �� 114 �� LEOSI I / I SUQDI VISION LEO'S ROAD \ \ 1 1 I \ BUILDIN� /WELL--\/ 1 / ¢ \� 0 I � 1 h ------\� FF=10 0= _ \ O / o / O / 7 6 / 4T ic9` 3 I i SHED SEE ENLARGEMENT S FIGURE 3 s S89'55'10 5W 70.00' TBM — HOUSE FINISHED FLOOR. I F(;FNI� ��r��R ' S'F9 1) ASSUMED EL.=107.00' / 09TH */� Sc SANITARY SEWER CLEANOUT 0 k TC SEPTIC TANK CLEANOUT R' MTMONITORING TUBE %, •••••••••• ••,:•,••...•„.„j —S— PROPOSED SEWER LINE (9';RODN ,P KINNEY JH'; �Q 11 RCS :• No. CE7955 GRAPHIC SCALE s EXISTING SEWER LINE 11 �rA , {f K !Y• ' E��i 40 o so EXISTING WELL ��``E ``P„ QA DRAIN FIELD SEGMENT 1 inch = 40 feet LOT 5, SITE PLAN o& Rodney I Kinney Associates, Inc. LEOS Coeseltley Engineers a surveyors PLAT P-295 Q$/Q$/14 FIGURE 2 AS—BUILT TABLE PIPE A B C sc—x sc—x sc—x sc—x LOT 5, SITE PLAN o& Rodney I Kinney Associates, Inc. LEOS Coeseltley Engineers a surveyors PLAT P-295 Q$/Q$/14 FIGURE 2 GRAPHIC SCALE 10 0 5 IO 1 inch = 10 feet BUILDING \ / 14' / CLEANOU � NEW 1000' GALLON STEEL TANK / ST#1 ST#2 COA2� USE BULL RUN N VALVE, SEE DETAIL FIGURE 4 � 1 7„ En U) DECK DN A KINNEY A. ••c / No, CE7955 : 1�4' 5' CO#5 CO#6 M �� OD � O vn n E` 04 TEST HOLE a Sri N� DRIVEWAY —X- \ EXISTING TRENCH TO \ REMAIN. TO BE USED \ AS FUTURE RESERVE AREA \ S89'55'10"W 70.00' I LOT 5, SEPTIC SYSTEM Rodney P. Kinney Associates, k LEOS FIGURE Ceueltm, Eepineen a Eurnren PLAT P-295 08/08/14 SURFACE MOUNDED TO INSURE DRAINAGE AWAY FROM DRAINFIELD coni inin 49TH j•i ice. �/ •�../,..u.... �s........ •P. KINNEY, NATIVE SOIL ✓J C•, Ngo. CpE,7B5(/5 3 (MIN.) BAGK FILL FILTER FABRIC ` \ \ �4 ,$r1...fU,` 4" PERFORATED PIPE ` 'OROFESSIO �' N . 6" GRAVEL BULL BULL RUN VALVE GRAVEL DEPTH ° - BELOW PIPE (7') T 6" I_— 30" z2 S ►11.5' S m DEEP TRENCH CROSS SECTION NTS 1.5' BULL RUN EXISTING PIPE TO EXISTING TRENCH PERFORATED PIPE, NEW TRENCH�--�- INSTALL INV. EL. 0 0.5' BELOW z PIPE INV. TO OLD TRENCH 6' BULL RUN VALVE DETAIL 1"=5' INSTALL TWO OPPOSING CLEANOUTS (DOUBLE OPPOSING) S' 1 1.5'�, 1 1.5' in SEPTIC TANK DETAIL 1"=5' TO HOUSE , NEW 1000 GALLON SEPTIC TANK LOT 5, DETAILS Rooney P. Kinney Associates, inn. LEOS Densolling Engineers a sureevors PLAT P-295 Os/O$/ 4FIGURE LOT 5, PROFILES Rooney P. Kinney Associates, inL LEOS CAPS 110! EHIIHO r: a SITYSYM PLAT P-295 08/08/14 FIGURE 5 HOUSE/TANK PROFILE C0#1 — Co#3 2' 110 N INSTALL NEW EXISTING CLEANOUT CO#1 GROUND ST#1 GD 2 ST#2 CO#2 110 I+r o A EXISTING = I PIPE 105 II 4', TYP. BULL 105 (MIN.) II II II I RUN 2% _ VALVE 46' 2% EL.=1D0.72' 100 EL.=101.77' EL.=100.89' EL = 100 I I NEW 1000 GALLON 100.1' SEPTIC TANK(CONNECT TO EXITING PIPE 95 95 TR E OPROFILE #4#6 110 EXISTING 110 GROUND 5' CO#6 C 4 MT#1CO#8 C#5 CO#7MT#2 i Irlj 105 5 TYP. II II (MIN.) (M ii II II II II it �O 0 100 10'd 1 14 1 2 8.5' 1 17.5' 8' 00 2' 12' © 10 EL.=100.1' O NEW 1000 GALLON � O SEPTIC TANK OF • •' 9TH64 #// �/•.9 . ......y....,1.....•� �' oo` R00YP.MNNEYJR.:Q,� N CE7955 ♦I �$p'•.,�•$_ /fO,.� � ate LOT 5, PROFILES Rooney P. Kinney Associates, inL LEOS CAPS 110! EHIIHO r: a SITYSYM PLAT P-295 08/08/14 FIGURE 5 I J �RPKA Project �!`)' �� (� �u P �a€'� Page, of � ' Job No, T Date- Rodney ote- Ro_dneyP.Kin_ney_Associates inc. _ 80XSYI ' 8p61X188StSU8V8YAP5 itle ` • '• � a� l^ ���f 8 ` By. ��IV4 Soils Log - Percolation Test Performed For: osc-'-"K 1\ , i. %,at v't^ A , �..0 vn-,k Legal Description: } p' �_R®)5 Si+�,8,,/;,§p,i,KTownship Z`� z 7(0 .*-iv I5e L z A Slope 18 D-1 .'w � Depth (Feet)I—OAS /"�e#- ai� j3ra w w rJ✓�1 1z �� ; 2- 5tLa < 50111 w (s 5 f( 8 sgrNa e �° F puu 9- I�f _ ✓%''�' WAS NED?ER COUNTE NO iL s 10- --ry IF YES, AT WHAT DEPTH? `p Depth to Water After ✓-j o ASF, Monitoring? (� •'�` E 12- 't q S �S faA� Date: 13- IA 14 15 17 . 18 h t IDGr- 1'_ 9- ! !'7:C� 20-(3 CZ 5 COMMENTS (ENGIN l' F6EAL -]i;`a5 4!H F, ^y GREGOR nIAN BERT E CE 25 t cn = PERCOLATION RATE (mirwteMmh) PERC HOLE DIAMETER E TEST RUN BETWEEN FT AND FT PERFORMED BY: 6' aE%✓ *4''Ey I >S" ' % CERTIFY THAT THIS TEST W PERFORMED IN ACCORDANCIE WITH ALL STATE AND MUNICIPAL IDELINES IN EFFECT ON THIS DATE. DATE: ¢` 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 ��U/Z/�%l_�y¢--35''3 (y�NEW ❑UPGRADE MAI LING ADDRESS P, 0, /S6) x• 2/470�/ /= 57 '7 LEGAL DESCRIPTION Goy LOCATION NO. OF BEDROOMS DISTANCE TO: Well Absorption are / Dwelling !� PERMIT NO. uZQ Manufacturer .� — MateriL_ No. of compartments ~ N Liq. capacity in gallons �0 p IF HOMEMADE: Inside length --— Width Liquid depth DISTANCE TO: Well _ Dwelling PERMIT NO. �. JuZ O Z _F SQ Manufacturer _ _ Material Liquid capacity in gallons [] w= ETO DISTANC: WellFoundation /5�/ ! 47 Nearest lot line Q PERMIT NO. J LL Z F Z w No. of lines Length of each line Z! '�S Total length of lines 71 Trench width _5D inches Distance between lines ¢ Imo.. Top of tile to finish grade/ _/__T// Material beneath tile, `` Total effective absorption area o ff inches Q 723 -.�562. F Length Width Depth PERMIT NO. W 2 H Type of crib Crib diameter Crib depth Total effective absorption area a— w °• m DISTANCE TO: Well Building foundation Nearest lot line J Class Depth Driller Distance to lot line PERMIT NO. J W DISTANCE TO: Building foundation Sewer line — Septic tank Absorption area(s) OTHER O �� f PIPE MATERIALS N �,r �}/�. S E[�E/2 SOI L TEST RATI NG 2TO INSTALLER REMARKS olea°Q"�f��((��'®pp &y"0� _— Earl P. Ellis 0% 4 NO. 1745.1: (-J°�� LEGAL APPROVE DATE /2�i��� �o7- 72-013 vRev. 3/78) Tat ifirb Brining;,[�4gpA,T,''EjNTALTY OPANCHORI N` by A & L, DRILLING COMPANY JAN 41979 BOX 97, EAGLE RIVER, ALASKA 99577 a TELEPHONE 694-2588 RECEIVED OWNER OF LAND �� ;(`..` �,�'-..-';:J(! )_�. s?ti DEPTH OF WELL Ft. ADDRESS ' > + " ' STATIC LEVEL OF WATER FT LEGAL DESCRIPTION Ft. DRAW DOWN FT. _ Ft. to DATE - Started l i, ,`! ; ' ; = Ended/ " i GALS. PER FIR `7 +i = !, PERMIT NUMBER !'' ' f KIND OF CASING From , r KIND OF FORMATION From Ft. to -'- Ft. Ft. to— From —Ft. to— Ft. Ft. From Ft. to 1 (' Ft. _ =- = !' `7 +i = !, From Ft. to Ft. From , r Ft. to ( Ft. ! s : 7 d `['i - / _ 1 '� ` E rom Ft. to Ft. _Ft. From Ft. to / Ft., L-) From _Ft. to _Ft.. _ FromFt. to Ft. From. _—Ft. to— _Ft. From Ft. to i ' Ft._ „' t1 ;l %'i From Ft. to_ _Ft. From Ft. to ,1 (,y 1 Ft. c -� x_.JX) t From Ft. to Ft. From Ft. to Ft. Froin -Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. Prom Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to— Ft. From Ft. to Ft. Froin—Ft. to Ft. From Ft. to Ft.. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft.. From Ft. to— _Ft. MISCL. INFORMATION: DRILLER'S NAME 0,�, �^"P P,� B`•�R :E. 4... � F: � " F= -i1 �...-_ �. '� P ' "m-" d_'aq Via' 6=��P �`"^P A:�=; R-'16:`, A $� •". i- it A .::� �' DEPARTMENT OF HEALTH AND ENVIRONMENTAL ! •'R'O"I"F. CT I ON STREET, ANdC:HC:+E"AGE':, i' k. 's:+95i-.1.1 PERMIT NO. 'F80999 .� APPLIC:AN"r KURKA AI...ASKANd BUILDERS PO SC+; 214 F'.ffil,.E RI`v'ER 694 LOCATION LF GFIL. Lei LEC+'':5 `;/D LOT SIZE' .T.4+:t. ki TYPE OF : IL AAE:ORrw.TICN SYS -TEM IS: TRENCH t'IFf};IN11,Ih1 t'dE1NiE.EF: OF' FE:DI C1C+M= :.. ':++I I_. RFIT:EtdC (SO FT,/BR): :�C.1 THE RIFF II.1 RE_D SIZE OF THE: S.OIL ACa,!FC1F'PT I Or•.t S'7 `.TEt1I IS: THC: LE.N TH D I MUMS I ON 15 THE LENGTH 11`4 FEET) OF' T.r-IE TRENCH OR G REi:t: I'dE= :i: E:: r.. D. THE DEPTH OF A TRENCH OR PIT IS. 'THE DISTANCE BETWEEN THE SURFFICE' OF TI -IF GIRT—UNI) AND THE. E_?C+T'TOM OF 'THE E.,?.cn'vn,rTC+Nd (IN FEET). THERE IS NC.', SET WIDTH FOR TRENCHES. THE GR.AVE=L. DEPTH I:= THE MINIMUM DEPTH OF CiRAVE:L BETWEEN THE OUT"1-At.... L. PIF' - FIND THE BOTTOM OF 'THF' EXCAVFITION (IN FEET). I F=' FE V: l � ESP � . i ]C A -117 n PA 1•-=" :Ir' GF � F.m J.. ITFA�«a ar a A ::p i=ii p., __ I_. i:: w P,11 PERMIT APPLICANT HAS THEA RF.SPON S-113II_ITY TO INFORM THI.`-. DEPARTMENT Cal.lf»::T1,4+:-i ITr INSTALLATION INS-PEC:T.T.ONS OF ANY WELLS FI FICET•,IT TO THIN PROPERTY Ai',ID THE NUMBER OF RESIDENCES THAT THE: WE'L.L. WILL, SERVE. .T, W CD < :"^ I Ir -4 ° F-" l-: C:` 711` 10 Ir' -4 6=P F -`_ Iii". VE CA P.._ Y X Pr.-!_�: V:: - BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND FiPPROVAL BY THI:; DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BE:'T WIEE.Nd A WELL AND ANY OP•d" ST..TE sEmAGE rj:E F'C+•-;1;iL. .- ':=:`FF.P'i I:; :I.00 FEET FOR A PRIVATE_- f4ELL.,, OR V50 TO 200 FEET FF:C:M A PUBLIC WELL DEPENDING DING IJPONd THE TYPE OF F'!_IF;LI OTHEvR REQUIREMENTS N1E•t'T APPLY. SPECIFICATIONS AND CONSTRUCTION FIRE, FOK-1IL,ABL.E TO IP'd':.URE F='I'-OPER INSTALL..AT'IONd. It'rl 11. "1"' r : F=' 1 IrrZ F_ IC- r—__ r-1 F-1 F'a- :`- ".n. _ 1_7D -V� *,D T. CERTIFY THAT 1: 1 AN F=AMILIAR 14ITH THE REQUIREMENTS FOR C:N-•-!=3ITE; F:l.dE,k:{:: Fifff:, I'lla... l_:; R:: FORTH BY THE, MUNICIPALITY OF" ANC I-JORAGE. I WILL INSTALL "THE" SYSTEM IN ACCORDANCE WITH THE:. +'C+L EF ,. , '' I UNDERSTAND THAI' THE. ON-••W;ITE SEWER: `.-+'• STEN MAY REQUIRE' Etdl.,_ARGENEP'dT IF TTIF,: F,ES7 T DFNC F-' I r REMODELED TO I NdC:I._UDE MORE THArd Q G �• APPI.... I rF1NT F'I_ W'Fi AI...F•l:'KFINd E `,U I LDER`.: INC. ISSUED V"I".2 --)8c)CIgc't 0 Et E GEO) CHNI CAL Et ®EVELU MENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Russell Oyster Earl Ellis 694-2774 SOIL LOG 688-2280 Soils Et Foundations Land Development Performed for: Name: A'e )1eA -/ 130601--=/1s;T./c- . Tel . No. Mailing Address. fe9, ,'Fdx 7'7 Legal Description: 205- Depth 05Depth (feet) Soil Ch#rjcteristics 0 1�_ 3 —1.4 5 / u i 15 16/'7!L!.�7 �/ T _nor ii%oC%JLj fs Ground Water Encountered: Yes— No v' If yes, what depth... Proposed Installation: Seepage Pit Drain Field Comments:— Performed by: `f�/1�,'�r—" !/ ;�--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 Parcel I.D. 051-053-39-000 Legal description LEOS LT 5 Site address 24236 LEO'S RD Chugiak AK 99567 Current property owner(s) LOCASCIO EMILY Expiration Date: 8/28/2025 X The On-site system(s) is/are approved for 3 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: Original Certificate Date: 10/11/2024 Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject ystem(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services 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 work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory Other COSA ApprovaLJune 2022 MUNICIPALITY OF Development Services Department On -Site Water & Wastewater Section ANCHORAGE Phone: 907-343-7904 Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 051-053-39 Complete legal description Leos Lot 5 Location (site address) 24236 Leo's Road, Chugiak, AK 99567 Current property owner(s) Emily LOCascio Day phone 2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS 3. TYPE OF WATER SUPPLY: 0 Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units ❑ Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: ❑■ Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: ■❑ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass Age 9yrs - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ 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 $ Waiver Fee $ Date of Payment / D ZK-,ZZ! COSA # (i. 7r, 2`f 1,4 DG Date of Payment Waiver # COSA Application_ June 2022 5.09 Forge Engineering 9/4/24 8/28/24 (McDonald's) N/A N/A N/A Benjamin Schiller, P.E. (907) 522-7773 MUNICIPALITY OF -1w, Development Services Department On -Site Water & Wastewater Section ANCHORAGE Phone: 907-343-7904 Fax: 907-343-7997 Certificate of On -Site Systems Appro�_ alriF, 278061 06/221/2s I :: 40AM U. 11.;.i 27' i SSi2M fi � �fi, i'i_i Parcel I.D. 051-053-39 Expiration Date: l' 29` 22- 1. 2- 1. GENERAL INFORMATION Complete legal description Lot 5, Leos Subdivision Location (site address) 24236 Leos Road, Chugiak, Alaska 99567 Current property owner(s) Charles Renner Mailing address Real estate agent 24236 Leos Road Dan Potts 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone (907) 372-1706 iak, Alaska 99567 Day phone (907) 322-3267 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ® Private Septic 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 $ 5_9b Date of Payment Receipt Number 2780H % COSA# oS(.?_), 1 3o0 Waiver Fee $ Date of Payment Receipt Number 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 Pinard Engi;Zeerilg Phone(907) 232-1347 Address PO Box 871347, Wasilla, Alaska 99687 Engineer's Printed Name Paui E Pi Zard 6. DSD SIGNATURE System #1 Approved for 'S bedrooms System #2 Approved for bedrooms Disapproved Date ppw� y Qancocmy.° _G�r � S9� vY ....................... a PauVE Pinard ° ooCE-4 93a pRO1=E8S1��`�r, Conditional approval for bedrooms, with the following stipulations: `Z, �� ON-SITE WATER AND BT. 11. Original Certificate Date: --�z 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: Lot 5, Leos Subdivisio z Parcel ID: 051-053-39 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA ® Well log is filed with Onsite (or attached) Date drilled .10/18/18 Total depth 216 ft Cased to 216 ft ® Sanitary seal is functioning correctly ® Wires are properly protected Casing height (above ground) 18 in. Date of flow test for COSA —"./22 Static water level at beginning of test 149.0 ft. Comments B. TANK DATA Age of tank(s) 8 years Tank type/material Septic/Steel Measured operating fluid level in septic tank 4.0' ® Standpipes/foundation cleanout per record drawing Date of pumping 6/20/22 D. ABSORPTION FIELD DATA Deep Tre ich Which system tested (date installed) 9!6/14 [3J ALL standpipes present per record drawing Total measured depth from grade 13.5 ft (max) Measured depth to pipe invert from grade 6.6, 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 NA gallons Comments/Deficiencies: COSA Checklist yellow sheet Structure served by this system Well production at time of test 4.0 gpm Water storage tank volume gallons Well disinfected for coliform test? ❑ Yes [JNo ® Coliform bacteria is Negative Nitrate mg/L Nitrate less than MRL (ND) Arsenic 1 .8 ug/L ❑ Arsenic less than MRL (ND) Collected by Pi lard E zgi zeeri Zg Date of Sample 6/1/22 C. LIFT STATION NA ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 6/14/22 Results 13 Pass For 3 bedrooms Fluid depth prior to test 32 in Water added 600 gal New depth 43 in Elapsed time141 5 min Final fluid depth 34 in Absorption rate 450+gpd Any rejuvenation treatment (past 12 months) NA 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' ® Yes if No ft Community Sewer Manhole/Cleanout > 100' ❑ Yes if No 92.5 ff ® Yes if No ft Neighboring Tank > 100' ® Yes if No ft Private Sewer/Septic Line > 25'EM Yes if No ft Absorption Field on Lot > 100' ❑ Yes if No 93.7# Holding Tank > 100' ® Yes if No ft Neighboring Absorption Fields > 100' ® Yes Animal Containment > 50' ® Yes if No ft ® Yes if No ft ® Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ®Yes if No ft ® Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ® 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' ® Yes if No ft Private Wells > 100' ® Yes if No ft Water Main > 10' ® Yes if No ft Community Wells > 200' ® Yes if No ft Water Service Line > 10' ® 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' ❑ Yes if No 6.0 ft Wells on Adjacent Lots: Water Main > 10' ® 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' ® Yes if No ft F. ENGINEER'S COMMENTS See Waiver #OSP14126 for horizoltal distaice from well to absorptiol field/septic talk aid distalce from absorptioi field to property Tiie. G. ENGINEER'S CERTIFICATION I C9 certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with,, ;= ,-a!'. n " ea MOA COSA guidelines in effect on this date. e`.. �� �,,:.,�r ; % r-% P2 :9 E. Ping- rd! v � Gr-7-5,7513 COSA Checklist yellow sheet 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. 051-053-39 1. GENERAL INFORMATION Complete legal description Leos Sub, Lot 5 Location (site address) 24236 Leo's Road Expiration Date -7^r3_Z/ Current property owner(s) Aaron & Caitlin Anderson Day phone Mailing address Real estate agent 24236 Leo's Road, Anchorage, AK 99657 Mary Hutchins 2. TYPE OF DWELLING: Q Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone (907) 775-1711 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well®❑ Private Septic 0 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 $ 5 Waiver Fee $ Date of Payment 1 a Date of Payment Receipt Number ��5`� Receipt Number COSA # .05C )- 111 5S' 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 4/8/21 pF • ik,qn\ TH 6. DSD SIGNATURE System #1 Approved for bedrooms . •��een)a&hir/ System #2 Approved for bedrooms CE 12592 111P" Disapproved PROFESS0 Conditional approval for bedrooms, with the following stipulations: `g ON-SITEftTE i By: Original Certificate Date:q/ 'n _Z 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 Leos Sub, Lot 5 I1 a 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 10/18/18 Total depth 216 ft Cased to 216 ft ❑m Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 18 in. Date of flow test for COSA 3/31/21 Static water level at beginning of test 148.7 ft. Comments B. TANK DATA Age of tank(s) 7 years Tank type/material Septic/Steel Measured operating fluid level in septic tank 50.5 ❑ Standpipes/foundation cleanout per record drawing Date of pumping 4/1/21 McDonald's Pumping D. ABSORPTION FIELD DATA Deep Trench Which system tested (date installed) 9/16/14 ❑® ALL standpipes present per record drawing Total measured depth from grade 13.5 ft (max) Measured depth to pipe invert from grade 6.5 ft (min) ❑ NIA — pressurized field 0 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 1 051-0.53-3q Well production at time of test 2.7 gpm Water storage tank volume N/A gallons Well disinfected for coliform test? ❑ Yes ❑ No ❑ Coliform bacteria is Negative Nitrate mg/L ❑ Nitrate less than MRL (ND) Arsenic 5.75 ug/L ❑ Arsenic less than MRL (ND) Collected by Forge Engineering Date of Sample 4/1/21 C. LIFT STATION 7oflift maintenance completed tion years aterial Adequacy test date 4/1/21 Results 50 Pass For 3 bedrooms Fluid depth prior to test 51 in Water added 759 gal New depth 63.5 in Elapsed time 1440 min Final fluid depth 55 in Absorption rate '450 gpd Any rejuvenation treatment (past 12 months) N / A If yes, enter date N / A 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' 21 92.5* Community Sewer Manhole/Cleanout > 100' ft Yes if No ft Q Yes if No ft Neighboring Tank > 100' [D Yes if No ft Private Sewer/Septic Line > 25'0 Yes if No ft Absorption Field on Lot > 100' ❑ Yes if No 93'7* ft Holding Tank > 100' F Yes if No ft Neighboring Absorption Fields > 100' Surface Water > 100' Fv-J Animal Containment > 50' Q Yes if No ft ft Fv� Yes if No ft Waiver #OSP14126 Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' Fv� Yes if No ft Fv Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' Fl� Yes if No ft Surface Water > 100' Yes if No ft Property Line > 5' 0 Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' ❑r Yes if No ft Private Wells > 100' Yes if No ft Water Main > 10' D Yes if No ft Community Wells > 200' ✓J 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' 21 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' 0 Yes if No ft Private Wells > 100' Yes if No Water Service Line > 10' El Yes if No ft Community Wells > 200' R/1 Yes if No Surface Water > 100' Fv-J Yes if No ft F. ENGINEER'S COMMENTS Waiver #OSP14126 G. ENGINEER'S CERTIFICATION �,GOF ° I certify that 1 have determined through field inspections and review : • • H49—* of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Benjarri.18chiller CE 12592 q� �JjFA• , . 4/8/21 , • C�®,� COSA Checklist yellow sheet ft ft Municipality of Anchorage r On -Site Water and Wastewater Program^ (907)343-7904 z, Certificate of On -Site Systems Approval r Parcel I.D. 0510533900 Expiration Date: 1. GENERAL INFORMATION Complete legal description Leo's Subdivision, Lot 5 Location (site address) 24236 Leo's Road, Chugiak Alaska 99567 Current Property owner(s) Joseph A & Lynn A Roman Day phone (907)242-7151 242-36 L-eo's-Road; Cahugiak-Alaska-99567 Mailing address— rT Real Estate Agent / Audrey Mason/Remax ER Day phone (907)622-3344 2. TYPE OF DWELLING: ❑ Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well 171 Individual El Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for:// ,, Distance: W Received by: �� Date: COSA to be released to qe engineer, unless otherwise requested by the engineer. COSA Fee $ 2_Wc;o Waiver Fee $ Date of Payment Zl 15tk4 Date of Payment Receipt Number 6tfl,4 Receipt Number COSA# 05C 51652 Waiver# 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. Name of Firm Rodney P. Kinney Associates, Inc. Phone (907)694-2332 Address 16515 Centerfield Drive, Suite 101, Eagle River Alaska 99577 Engineer's Printed Name Christopher M Kinney, PE Date 2/10/15 Y 474 G �w a oec �•ssa e ; T •e..oa,S 6. DSD SIGNATURE V1���;;pe F •"s. MKinney c ChristDpher . m•�'="s% System #1 Approved for _bedrooms �{ ECE 913 System #2 Approved for bedrooms Disapproved V Conditional approval for bedrooms, with the following stipulations, fFo r / /d z -Leh N�� > )• Original Certificate Date: s 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 blue sheet .. If more than 1 septic system is on the lot: COSA Checklist # of _ Structure served by this system Certificate of On -Site Systems Approval Checklist Legal Description: Leo's Subdivision, Lot 5 A. WELL DATA Well type Individual If A, B, or C provide PWSID # Date completed 10/18/78 Sanitary seal (Y/N) Y Total depth 216 ft. Cased to 216 ft. Date of test Static water level Well production FROM WELL LOG 10/18/78 Non -legible on log ft 15 g.p.m. WATER SAMPLE RESULTS Coliform NEG colonies/100 mL Nitrate 0.102 mg/L Arsenic 5.03 ug/L Date of sample: 1/26/15 B. SEPTIC/HOLDING TANK DATA T k T /M t I Steel an ype a eria Tank size 1000 gal. Number of Compartments 2 Foundation cleanout (Y/N) Y Depression over tank (Y/N) N Date of pumping Less than 1 yr. old Pumper NA 5 Parcel ID: 051039000 Well Log (Y/N) Y Wires properly protected (Y/N) Y Casing height (above ground) 16 in. AT INSPECTION 1/24/15 137 ft. 2.5 g.p.m. Collected by: Rod Kinney, RPKA Date installed 9/12/14 Cleanouts (Y/N) Y High water alarm (Y/N) NA C. ABSORPTION FIELD DATA t Date installed 9116/,(IGI it rating (g.p.d./ft2 or ftz/bdrm) 0.45 gpd/sf System type Deep Trench Length 72 ft. Width 2.5 ft. Gravel below pipe 7.0 ft. Total depth 1 1.5 ft. Eff. absorption area 1000 ft2 Monitoring tube Y Depression over field N Date of adequacy test NA Results (Pass/Fail) NA For NA bedrooms Fluid depth in absorption field before test NA in. Water added NA gal New depth NA in. Elapsed Time: NA min. Final fluid depth NA in. Absorption rate >= NA g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NA If yes, give date D. LIFT STATION Date installed NA "Pump on" level at Datum Size in gallons in. "Pump off' level at E. SEPARATION DISTANCES WELL ON LOT TO: Cycles tested Septic tank/lift station on lot 92.5' Absorption field on lot 93.7' Public sewer main 100'+ Sewer /septic service line 50' Animal containment areas 1004 Manhole/Access (Y/N) in. High water alarm level at Meets alarm & circuit requirements? On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout 100'+ Holding tank 100'+ Manure/animal excrete storage areas 100+ SEPTIC/HOLDING TANK ON LOT TO: Building foundation 46 Property line 30.3 Absorption field 52 Water main 100'+ Water service line 65' (est.) Surface water 100'+ Wells on adjacent lots 100'+ ABSORPTION FIELD ON LOT TO: Property line 6.0' Building foundation 47.5' Water Service line 73' Surface water 100'+ Curtain drain 100'+ Wells on adjacent lots 100'+ Water main 100'+ Driveway, parking/vehicle storage 50' in. F. COMMENTS Reference Waiver # OSP141286 for horizontal distance from well to absorption field/septic tank and distance from absorption field to property line. 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. Date 2/10/15 COSA brown sheet_10-10-12.doc OF A. d- 1. Mistopher M. Kinney .msa�Rlln n.aoa - - - - - - - - - LEO'S ROAD FRaAOYI rNnea aaerfn f1E¢ (A89AAD) Ea wGaT FRONT VADNQ SEIIAfIt N S890 55'10"W 70.00' REM BWLWG SETH" w N 4 WELL cNAVEI DRNE 46.0' a EXISTING a N IT `"I v o HOUSE o _ - v 0 46.0' 11.3' a o o z z o 6 4 0 `n o d V V W 2 N �u wTpus C. .s S890 55 10"W 70.00' UNDER NO CIRCUMSTANCES SHOULD AN AS -BUILT BE USED FOR CONSTRUCTION OR FOR ESTABLISHING BOUNDARY OR FENCE LINES. THE SURVEYOR TAKES RESPONSIBILITY FOR THE INITIAL TRANSACTION ONLY AND ASSUMES FINANCIAL UABIUTY ONLY FOR THE COST OF THE SURVEY. USTED DISTANCES PREVAIL OVER SCALING. REPRODUCTION MAY CAUSE ERRORS IN SCALE. LOT SURYEY SURVEY TYPE SYMBOLS FOUNDATION AS -BUILT ❑ FINAL SMUCTURE AS-BULLT nic FRrencG ' SET REBAR M ♦ DRAINAGE ° ` ` ASPHALT ❑ PLOT PLAN ... AS-BTNLT ...LOT SURVEY ... TOPOCRMHY o FOUND REBAR 9 8 9 WOOD FENCE '` CONCRETE AS- T ... N SET RECERIIFlCARON AS -BUILT ... NO CORNERS SET j[KD ASSUMED ELEV.-X--N--N. METAL FENCE ® WOOD DECK PLOT PLANS & LOT SURVEYS NOTE: IT IS THE RESPONSIBILITY OF THE BUILDER OR OWNER, PRIOR TO ONLY THOSE IMPROVEMENTS ABOVE GROUND AND VISIBLE WALL BE CONSTRUCTION, TO VERIFY PROPOSED BUILDING GRADE RELATIVE SHOWN. FENCES, WELLS, SEPTIC CLEANOUTS, SIDEWALKS, DRIVEWAYS, TO FINISHED GRADE AND UTILITY CONNECTIONS AND TO DETERMINE ETC., ARE SHOWN IN THEIR APPROXIMATE LOCATION, ONLY. SNOW THE EXISTENCE OF ANY EASEMENTS, COVENANTS OR RESTRICTIONS MAY PREVENT SOME IMPROVEMENTS FROM BEING SEEN AND LOCATED. WHICH DO NOT APPEAR ON THE RECORDED SUBDIVISION PLAT. ALL DISTANCES ARE RECORD UNLESS OTHERWISE NOTED. SURVEY CERTIFICATION '..�r`t�%%it Prepared by " PLO I PLAN "-�.�a�l�•»�wmE.•.a... • `Q ••' ♦ Professional Land Surveyors IM b[ amRn N•nb] Nu•en. IM tlgt I ner wRw s ..error a w w iq .m y r N,wn m aw ar a aw bRR1 « FRT Nw•e••E• wr .e�u'N r aa.wlmR aaw se." r �. • _J; ••••' •• � � • •:-♦f 1700 Brink Drive. ANCHORAGE. ALASKA 99504 Scale: 1 ,e o 30, Rea. Lot S.F. Rea. Not File No. r9th FOUNDATION AS -BUILT A RRb t E bra Y. Mroy aa9ry tlw! 1 ..,.«� ARBWeevwyxny' : Nukae•n wY IM ar a,x r w � •,••, • •� �• •• % •: ..�... Dote Surveyed- " 01/29/15 Drawn b ' REJ Checked b .M K d^ •� pti r r ='/ . - ROBERTOHNIS Date Drawn: Grid: W.0 �� oew� ♦ a o - •♦y�P ••:.. 4121—S 01/30/15 NW1561 15-44 FINAL STRUCTURE AS -BUILT ARWI E AYwA r.. A br ewe i _ a6� �♦ Fe •••.... Legal Description: 1. ewWy I,aw DMnn•A a AriWl euwyM tlw .mwmw ., avR m w awe a aw - o ........., ...•'.• yoa.1 a d ♦♦i Lot AHeNNr..w Inlemwa•b > N,R., er.en Professional L� ��� • LEOS '73- MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section CIES P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # n�\ C!�I— 713 HAA # _ra Q'' 'L11 9. GENERAL INFORMATION �S Complete legal description Lot 5; Leo Subdivi,6ion Location (site address or directions) 24236 Leo'a Road Chugiak, AK _ Property owner S"an Bunq Day phone 271-4931 (w) 244-7725 (mobile) Mailing address 24235 Leo'h Road Chug�afz, AK 99567 Lending agency Day phone Mailing address_ Agent Sharron Minzch/ REMAX EAGLE RIVER Day phone 694-4200 Address 16600 CEnt?,kAieed Dkive Eagle Riven, AK 99577 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 'N 3. TYPE OF WATER SUPPLY: Individual well XXX Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site XXX Holding tank Community on-site Public sewer — NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72.025 (Rev. 1/91) Front MOA #21 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 of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is 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 in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address Engineer's signature 6. DHHS SIGNATURE Approved for Disapproved. LZ 17034 Eagle River Loop Conditional approval for Additional Comments bedrooms. Phone I' W ZI"Z �7 i Date bedrooms, with the following stipulations: Date c', - Q(t) -'� ZI The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA N21 ® Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description A. Well Data '> L.tiro 51� Parcel I.D. Well type hjZ(VA-1_6 If A, B, or C, attach ADEC letter. ADEC water system number Log preseni��J)Date completed Driller A `r L aZ/LL / N G C o Total depth - r Cased to 4d r� Casing height i4 _ Sanitary seal A) Wires properly protected FROM WELL LOG Date of test _�b�/ z� Static water level Well flow C� �% �11-1 �m Pump levell SEPARATION DISTANCES FROM WELL TO: Septic/he" tank on lot UU AT INSPECTION Z o '4/4/ ry > ai C" V N U! UJ U l i On adjacent lots _J_ r Absorption field on lot _ G U ¢� ; On adjacent lots _ �� C) � _ Public sewer main S // Public sewer manhole/cleanout Sewer service line �S / Petroleum tank LD /—E KNCx JN WATER SAMPLE RESULTS: Coliform O Nitrate d, /U �� Other bacteria i"d�ic Date of sample: r du - 9 f / 4Lz 1 / 99o ecIIC ted by: -S S G (w 6L%L! Pf_/GUC E3. SEPTIC/HOLDING TANK DATA Date installed 12 - -1 16 Tank size � 00 o Compartments Cleanouts (9)/N) J Foundation cleanout (Y/G) High water alarm (Y/ Date of pumping 4- L, - 2 _Depression (Y/&� i tested (Y/N) A _ Pumper _� , Lf-�, s r on �_ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /C>0 / On adjacent lots / �� _Foundation To property line /o JL Absorption field /6 Water main/service line /d Surface water/drainage /06 1 4- 72-026(3=)•Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent(Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) SEPARATION DISTWCE FROM LIFT STATION TO: on lot On adjacent lots D. ABSORPTION FIELD DATA tested at _VU,.GVV 11N4V1 Date installed 12 - "18 Soil rating (GPD/Ft') 20)Arse_. System type T� E Length Width if Gravel thickness -71 Total depth I1 Total absorption area /o76 Cleanout present (DN) Depression over field (Yo Date of adequacy test 4-- 7-9 t Result fail) Water level in absorption field before test 43 Peroxide treatment (past 12 months) (Y/6I /d° /l C iL^�� ✓ If SEPARATION DISTANCE FROM ABSORPTION FIELD TO: for 3 Bedrooms _After test f5 If yes, give date Well on lot /° ` On adjacent lots / ° r� Property line /a r To building foundation /a To existing or abandoned system on lot On adjacent lots -3 D ` Cutbank '`l' �, Water main/service line /a 1+ Surface water /6 Driveway, parking/vehicle storage area Curtain drain E. ENGINEER'S CERTIFICATION 1 certify that I have checked, verified, or conformed Signature Engineer's NaMY034 Eagle River Date HAA Fee $ 3 \ �) . 90 Date of Payment 5 2 L( I qL1 Receipt Number 72-026 (3/93)' Back HAA guidelines in effect on the date of this inspection. Waiver Fee $ Date of Payment Receipt Number Ax Commercial Testing &Engineering Co. Environmental Laboratory Services LABORATORY ANALYSIS REPORT CT&ERef.# 94.1932-1 Client Sample ID L5 LEO S/D Matrix WATER ClientName S & S ENGINEERING WORK Order 77898 Ordered By PrintedDate 05/03/94 @09:10 lis. Project Name Collected Date 04/29/94 @ 10:40 brs. Project# Received Date 04/29/94 @12:30 lus. PWSID UA Technical Director STEPHEN C. EDE Released By: ' r� ------------------------------------------------------------------------------------------ Sample Remarks: ROUTINE SAMPLECOLLECTED BY: S.S. QC Allowable Ext. Anal Parameter Results Qual Units Method Limits Date Date Init -------------------------------------------------- Nitrate -N 0.10 g ------------------------------------------------ U m /L EPA 353.2/300.0 10 05/02/94 MCE * See Special Instructions Above UA = Unavailable ** See Sample Remarks Above NA=Not Analyzed U =Undetected, Reported value is the practical quantification limit. LT= Less Than D =Secondary dilution. GT'= Greater Than 5633 B Street, Anchorage, AK 99518-1600 — Tel: (907) 562-2343 Fax: (907) 561-5301 ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, OHIO, UTAH, WEST VIRGINIA MUNICIPALI"IY O ANCF' = MUNICIPALITY OF ANCHORAGE DEPT. c DEPARTMENT HEALTH 'i,fa\7 OF & ENVIRONMENTAL PROTECTfgN'J CTION/(,� 825 L Street - Anchorage, Alaska 99501 I-11111 AY i 1? 0* ENVIRONMENTAL ENGINEE13ING DIVISION Telephone 264.4720 i REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND' EWERFACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten I10) days for processing. 1. PROPERTYOWNER PHONE MAILING ADDRESS <� _ PROPERTY�ESID NT (If differ ntt from above - - PHONE - INDIVIDUAL* 2. BUYER// PHONE - CJS C.?iC' ❑ PUBLIC UTILITY MAILING ADDRESS - - 3. LENDING INSTITUTION � / e -y /�S1L i5�- PHONE MAILING ADDRESS 4. REALTOR/AGENT - - PHONE 1�v � '2 s s J MAI LUIJGADDRESS NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 5. LEGAL DESCRIPTION ezSTREET LOCATION 6. TYPE OF RESIDENCE NUMBER OF BEDROOMS SINGLE FAMILY ❑ One ❑I Four ❑ Other ❑ Two ❑ Five ❑ MULTIPLE FAMILY Three ❑ Six 7. WATER SUPPLY INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1975. I -or wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available,) 8. SEWAGE DISPOSAL SYSTEM INDIVIDUAL/ON-SITE** **If individual/on-site, give installation date �� ❑ If system is over two (2) years old an adequacy test is required PUBLIC UTILITY by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. N,'-) THIS SIDE FOR OFFICIAL USE ONLY INSPECTION APPOINTMENTS DATE RECEIVED TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 1 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON -SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATE INSTALLED INSTALLER ❑Septic Tank or ❑ Holding Tank Size: 1040 D If Tank is homemade give dimensions: SOILS RATING ag 4 TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4, DISTANCES WELL T0: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS 1�1 APPROVED FOR BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE ---j BY (Title) LEGAL DESCR TI N 72-010 (Rev. 3/78)