HomeMy WebLinkAboutTWOLOTS TR A2BTwo Lots
Tr A2B
#017-074-02
Municipality of Anchorage _, e
Development Services Department _
Building Safety Division
On -Site Water & Wastewater Program. 4700 Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650 Page 1 of 3
www.cl.anchorage.ek.us (907) 343-7904
Onsite Wastewater Disposal System and/or Well Inspectioo, Report
4-02
$W070029 PID Number.
Permit Number:U rade
Name: Wastewater System: ❑New ■ p9
HOLLY COX
Addfess:ABSORPTION FIELD
8051 RABBIT CREEK ROAD a ANCHORAGE, AK pother
No. of Der me: o Deep Trench O Shallow Trench Deed O Llour,d
Phone: (907) 345-1702
5•k eta": Tow 0-90Ir•m «ql.w' MAX
LEGAL DESCRIPTION 0.5 alro/ea.
o.o,,, m ek» banes, fry onll ,el sea.: cre W 4.9,h eeaee,h P': 6/6 n.
Block: Lot: Subdivision: $EE DWG. n.
TRACK A213 TWO LOTS a." ,,,,e,
section: f° e°0i0 p°°"• °�aN gra4• 50+/50+ n.
Township: Range: _ — SEE DWG. n
— Numerr of I,.re: Oirland Mwren Irne
cm'm W tl. 2.5/2.5 2 15 n.
WELL: [I New ❑ Upgrade
Tete/ Oec �"^ TO'(o•�) Te1o1 abOMPtan * so. n. Rb• D 3034/ F-810
cb.w,Kww, Rnwt.. we.c : 1200
In. R oa .
o ubc
M, pNM : s'° ` "° � E"� q+ HOMES SERVICES 4 17-19/2007
FL
„.,,, W w ae."c lwsht ^ee . rte: TANK
Ylrb: R
cvN " D Otnare
E
T■ Septic O Holding 0 S...P.
SEPARATION DISTANCES " 1250
To Septic Absorption Lift Holding �,� ,• AN
H TANK
Tank Field Station Tank. el eoapytmrhte:
From STEEL 2
Well 100'+ 100'+ —
_ 25'+
LIFT STATION
Surface Water 100'+ 100'+ — — ,oeniNe -
Sae " 9N :
Lot Line 5*+ 10,+ — — ,+ae ell � "gh wm« eke n aL
an Ierel a1:
Foundation 5'+ 10'+ — owun al ".wades. We,,,,•e py,
RieaR �•�•
Curtain Drain NONE KNOWN
BENCH MARK
Remarks: OLD TANK PUMPED, CRUSHED AND ueel»~ eha IanRu�.
COMPLETELY ABANDONED TOP OF SLAB NEAR SOUTHWEST•CORNER
100.00
ENGINEER?
GEG, Ltd. Dates: 1st 4/17/2007 ooc� A op04
Inspections performed by: 2nd 4/18/2007 0 �;.. •...... . 95 0
3rd 4/19/2007
Development Services Department Approval ...:........ .
rOV01: Date. OQ " • •. r ' .
A. arnes:s
Conditional app �AP C-7953 e[
Reviewed and approved by:gj
(RW. 4/06)
PERMR NUMBER: AS -BUILT DRAWING
SW070029
\
JEW-_ \\ i
ST1 97.81 75.69 \ \
col 153.
12 85.93 /
94 86.77
49 38.79
PARCEL ID NUMBER:
017-074-02
— — — — — _ _ _ — — }— — — — — _ _ _ — —
OUP, Ltd.
GARNESS ENGINEERING GRp;'...' 9 ...... ..
_ ---- CONSULTANTS & GENERAL CONTRACTORS
wumm
At L 11wan 1roeD. *1 . tot • ri,"" w ro ? • wmiR (•o1Wt PAGE NUMBER: • . • • •. .
PREPARED FOR: PHONE NUMBER: ••,Je A. 245;
345-1702 `
2 ODRAwN BY: OQO'o• ., I79/j3
HOLLY COX
LEGAL DESCRIPTION: K.D.M. ee. •'•S! �. +•0`T ��O
TWO LOTS SUBDIVISION: TRACT A26, DATE:
4�4Pr00�sslo"
TYPE OF WORK:5�1�2DD7
AS—BUILT DRAWING OF SEPTIC SYSTEM UPGRADE
(R". 01105)
PARCEL ID NUMBER:
PERMIT NUMBER: AS -BUILT DRAWING 017-074-02
SW070029
M. �FINAL GRADE - 98.74 do 99.18
ST2
TOP OF TANK AT
TOP OF TANK AT OUTLET . 94.77
INLET . 94.74
t;t
INVERT OF BUNG AT
INVERT OF BUNG CUTLET . 94.09
AT INLET - 94.47
SOUTH TRENCH
NORTH TRENCH
IV7
DE
RlW. CRADE Y7t7/9" C°ADE
LTFA TAMC
0A1G si.a7 �MnR IAVX
RELATIVE ELEVATION
OF HOLE BOTTOM _79.67
RELATIVE ELEVATION
OF BOTTOM OF TEST
HOLE - 78.32
G_AR_N_LSS ENGINEERING GROUP, Ltd. ,per 4;
....+.+CONSULTANTS 6 GENERAL CONTRACTORS 0
t101 t Tp011 11°'C' ate[ 101 ,ao7 •mow[ Ind PAGE NUMBER:
PREPARED FOR: PHONE NUMBER: 0i
HOLLY COX 345-1702
30 F3
oRAwN Br: Q�r,� '• ,
LEGAL DESCRIPTION: K.D.M. �� a
TWO LOTS SUBDIVISION; TRACT A2B, DATE: OC
TYPE OF WORK:5�1�2DD7
AS—BUILT DRAWING OF SEPTIC SYSTEM UPGRADE
(R". 01105)
NTRACTORS—
Ltd.
GARNLSS�o NGINEER ANG GROUP,
. _. ... , a•. per.«`
SOIL LOG — PERCOLATION TEST
LEGAL DESCRIPTION:
PERFORMED FOR: HOLLY COX
DEPTH
(feet) _�a TEST HOLE 2
1
2
3
4
1
FILL
ORGANICS
ML w/SOME
SAND AND
GRAVEL
P••
app,
.. ...
.... .......*.
ffr
y . arness.,
'
J�s� � •
d
CE/ -7953 •' FG
Nig
Sf 2.�. cj
Profess}o�-c
enu G ncSIFICATI0N5_ \
GP ML
ExlrnNa 4
GMSCLBEDROOM HOUSE fGCOL N
SWMHExIrnNG M�C
SPCH
SM OH
SC THJ14
rA
PERCOLATION RATE 10 (MIN.11NI.I-) rC
TEST RUN BETWEEN 6
FT. AND 7 FT.
A FOUR HOUR PRESOAK WAS PERFORMED: 0 YES ❑ NO
--JODY MAUS
SOILS LOGGED BY: JODY MAUS PERCOLATION TEST PERFORMED BY:
RECOMMEND A 0.5 TRENCH SOIL APPLICATION RATE
COMMENTS:
PERFORMED BY CEG, Ltd. I, JEFFREY A. GARNESS, CERTIFY THAT THIS WAS PRF RMED IN ACCORDANCE
WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE:
C.
GARNESSCONSULTANTS E 9, GENERAL GROUP. _�
FACSIMILE TRANSMITTAL F PAGES*i- NBERt
DATE: �O t
I (INCLUDING COVER
TO:
FROM: ci�o .
REF:
co,MMENTS: �-v W �-•'' 1
tee`• •� 9,�
--^" rnesseW
'`• Js r er !�
�°<r'•� . CE 7953 f�r�
f0 pROFESSt��
G a e- �--�
q_a,a, f,Dor to
3701 E. Tudor Road, Suite 101 ' Anchorage, AK 99507-1259 ca
Ph: (907) 337-6179' Far: (907) 335-3246' Website: mww'•°m
_aessengineerm�•m
Municipality of Anchorage
I!o. D)x 1("60 * ,knchomge, Alaska (Y9519-fra) • Tckphmic (!X)7) a1R-8'V)1 • rax (IMM","O
j 47(X) Ihngaw SWO • Mxhomge, Alaska IMIi1)7
U,, .munl.org
Dlagor Dark Begich Iluilding Safety Division
April 19, 2007
Jeffrey Garness, P.E.
Garness Engineering Group
3701 E. Tudor Road, Suite 101
Anchorage, AK 99507
Subject: Two Lots Tract A213
Groundwater Monitoring Testholes
Dear Jeffrey Garness, P.E.:
During a recent site inspection at the above legal description, we found testholes that did
not meet code, AMC 15.65.060B. Therefore there is no acceptable groundwater
monitoring.
If these testholes are not brought to code, any surface water intrusion into the testholes
will effect groundwater and will be used as the high groundwater reading for septic
design.
If there are any further concerns or questions regarding this letter, please call our office at
343-7904.
Sincerely,
J e oodall
ivil Engineer
On -Site Water &
Wastewater Program
Community, Security, Prosperity
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water 6 Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519.6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: Apr 04, 2007
Expiration Date: Apr 03, 2008
Permit Number: SW070029 Parcel ID: 017-074-02
Legal Description: TWOLOTS TR A213
Design Engineer: 0855 GARNESS ENGINEERING GROUF Site Address: 008051 RABBIT CREEK RD
Owner Name: HOLLY COX Lot Size: 123093 SO. FT.
Owner Address: 8051 RABBIT CREEK RD Total Bedrooms: 4 Permit Bedrooms: 4
ANCHORAGE. AK 99516-3847
This permit is for the construction of:
❑✓ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ 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 engineer must notify DSD at least 2 hours prior to each Inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, seated, and heated to prevent freezing.
Received By:
Date: S11)
Issued By. Date:
;/01
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Bragaw St.
P.O. Box 196650
Anchorage, AK 99519.6650
www.ci.enchorage.ak.us
(907)343-7904
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. _ oI'i-niQ-QO
t
°
Property owner(s) HOLLY COX Day phone 345-1702
Mailing address 8051 RARRIT CREEK ROAD * ANCHORAGE. AK
Site address
Legal description (Sub'd, Block & Lot ) TWO LOTS. TRACT A B
Zip Code 99516
Legal description (Township, Section & Range) N/A
n
Lot Size /J1:r 613 Sci.Ft. Number of Bedrooms _ 4
THIS APPLICATION IS FOR ([Dail that apply):
Absorption Field
❑
Septic Tank
Holding Tank
❑
Privy
❑
Private Well
❑
Water Storage
❑
THIS APPLICATION IS AN:
Initial
❑
Upgrade
Renewal
❑
certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal codes.
GARNESS ENGINEERING GROUP, Ltd.
Permit/Rush Fees: &0
Date of Payment: pffi)0 T
Receipt Number: r a(
(Rev. 11/05)
Waiver Fees:
Date of Payment:
Receipt Number:
GARN i SS ENGINEERING GROUP, Ltd.
- - CONSULTANTS & GENERAL CONTRACTORS --
March 21, 2007
Municipality of Anchorage
Development Service Department
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650,
Anchorage, AK 99519-6650
(907)343-7904
Ref: Proposed Septic Upgrade for Two Lots, Tract A213,
To whom it may concern:
The existing 4 bedroom house is served by a private well and septic system. The septic system is in a state
of failure and needs to be upgrade. We are proposing to install a new 1250 gallon septic tank and a dual
deep trench type drainfield. One test hole was excavated on the property. The drainfield will be designed
around the 30 foot radius of this test hole. Comments regarding the design are summarized as follows:
1. SOILS: See the attached log which shows the soil classifications, groundwater monitoring, and the
percolation test results.
2. DRAINFIELD DESIGN: See attached design drawing for drainfield specifications.
3. SURFACE WATERS: There are no surface waters within 100 feet of the proposed septic system.
4. TOPOGRAPHY: As can be seen on the attached design drawingfthe average topography around the
drainfield is generally flat. There is a 50-100% sloped cutbank on the property that will be 50 feet or more
away from the proposed septic system.
We are unaware of any adverse impacts this installation would have on adjacent wells or septic systems.
If you have any questions, please contact us at 337-6179. Thank you for your assistance.
.Sincerely,
Je re ness, .E., LS.
Pr si t
NOTE: Attached is a site plan drawing, a design drawing, one soil log, which are all part of the design package for
this septic system. (Contact G.E.C. Ltd. for 7 page construction specification letter.)
3701 E. Tudor Road, Suite 101 • Anchorage, AK 99507-1259
Ph: (907) 337-6179' Fax: (907) 338-3246' Website: www.gamessenginccring.com
KIMBERLY MANOR /2
TRACT Al
EXISTING SEPTIC
SYSTEM �
PROPOSED SEPTIC
SYSTEM �
\� CREEK
EXISTING 4 � �/
BEDROOM HOUSE -ham
KIMBERLY MANOR /2
LOT 11, BLOCK 3
KIMBERLY MANOR /2 KIMBERLY MANOR /2 KIMBERLY MANOR }2 KIMBERLY MANOR /2
LOT 3. BLOCK 3 LOT 4, BLOCK 3 LOT S, BLOCK J LOT 6, BLOCK J
(NO CONCERN) (VAS) (NO CONCERN) (NO CONCERN)
GARNESS ENGINEERING GROUP, Ltcl.
•• CONSULTANTS 6 GENERAL CONTRACTORS •-----•-.•.•-.�..,.....--...— Q....'
. c nnw ■o.o. fort 101 . u,obn.x, w "W7 nnK (mrun-ei» . FM ryoBva-u.e • ....
ZEPARED FOR: PHONE NUMBER: PACE NUMBER: ••
HOLLY COX 345-1702 1 OF 2 A � Q
Al. DESCRIPTION:
TWO LOTS; TRACT A2B
OF WORK:
SITE PLAN
B.F.M.
�. .
1y GO ess:
-E-7953 :g'
NUMBER OF BEDROOMS:4
GALLONS PER DAY (CPD): BDO
PERCOLATION RATE/S: 10 MIN./INCH
PROPOSED APPLICATION RATE: 0.5
MINIMUM DRAINFIELD SO.FT.: 1200
DRAINFIELD DESIGN:
MAXIMUM DEPTH:12 FEET
WIDTH: 2.5 FEET
LENCTH:100 (2 O 50) FEET
M.O.A. APPROVED SAND FILTER: N/A
EFFECTIVE: S FEET
REDUCTION FACTOR: N/A
ACTUAL SO.R.: 1200
CONTRACTOR MUST HAVE ALL
SURROUND WELL RADII AND 50'
SETBACK FROM CUTBANK, FLAGGED
BY A REGISTERED LAND SURVEYOR,
PRIOR TO CONSTRUCTION.
EXISTING SEPTIC SYSTEM TO
BE PUMPED, CRUSHED AND
COMPLETELY ABANDONED -
LETTER THAT PERTAINS TO THIS DESIGN.
TO OBTAIN A COPY OF THE LETTER
:ONTACT CEG. BY PROCEEDING FORWARD
WITH THIS INSTALLATION, THE ENGINEER,
WELL DRILLER, CONTRACTOR AND PROPOSED
PROPERTY OWNER AGREE THAT THEY DRAINFIELDS
HAVE READ THESE SPECIFICATIONS AND
AGREE TO ACCEPT THE TERMS AND
i
N
S E:
9
INSTALL FLOW
SPLITTER
CO I
INSTALL
FOUNDATION
/
CLEANOUT
-PROPOSED
1250 GALLON
SEPTIC TANK
— — — — — — — — — — — — — —
-
- — — — — — — — — — — — — — — —
ooaoo 4
�t 0
GARNL:SS ENGINLLRING GROUP, Ltd.
-- - CONSULTANTS & GENERAL CONTRACTORS .....,,via- .- --. �....... .. ...
... .......
fil L T00011 N1 A 5151[ 101 • M CHORCL W MSO) • NOT[ (COn{SO-01]1 . MV (,oYAM " SIC .w. apn O
PREPARED FOR: PHONE NUMBER: PAGE NUMBER: •• . . ... ....... .......
HOLLY COX 345-1702 2 OF 2 Q a t C A. ss.
LEGAL DESCRIPTION: DRAWN BY: C -7953
TWO LOTS; TRACT A213B.F.M. O'
p e '3 r /D7 (Ao
TYPE OF WORK: DATE: 40OOP, D f0 OOo�
PROPOSED SEPTIC SYSTEM 3/21/2007
GARNESS ENGINEERING GROUP, Ltd.
-- - �• CONSULTANTS 6 GENERAL CONTRACTORS o--�V.-.�•a>t•�
'01 L T1D011 PUN. SURE 101 • MC1g N 99S01 • P a W7 71179 • FA 101 - " • •EBSOL ysw�rywrin
SOIL LOG - PERCOLATION TEST
LEGAL DESCRIPTION: TWO LOTS; TRACT A2B
PERFORMED FOR: HOLLY COX DATE: 345-1702
DEPTH
(feet) F-1-flORGANICS TEST HOLE 1
2
3-
4-
5-
6-
7-
8-
9-
10-
11
4567891011
12
13
14
15
16
17
18
19
•'M SOIL
CLASSIFICATIONS
NET TIME
(MINUTES)
WATER LEVEL
READING
NET DROP
(INCHES)
3/19/2007 1
•"
—
GGWi
IIIIIIIIIML
2
16111,1GM
30
H/NH•
CL
3
2:20
—
•
—
SWMH
IIIIIIIII
30
1 3"
_
5
CH
lith
6"
•
�idB.
3:20
,q
SC
3"
ML w/ SOME
POCKETS OF
GRAVEL
DEPTH TO DATE
GROUNDWATER
DRY 3/16/2007
DRY 3/21/2007
Vey N
n � i
EXISTING 44 7v
BEDROOM HOUSE
N EXISTING SEPTIC
SYSTEM � I
I
1 �
TH11�
I
DATE READING
CLOCK
TIME
NET TIME
(MINUTES)
WATER LEVEL
READING
NET DROP
(INCHES)
3/19/2007 1
1:50
—
6"
—
2
2:20
30
3"
3-
3
2:20
—
6"
—
4
2:50
30
1 3"
3"
5
2:50
—
6"
—
6
3:20
30
3"
3"
PERCOLATION RATE 10 (MIN./INCH) PERC. HOLE DIA. 6 (INCHES)
TEST RUN BETWEEN 4.0 FT. AND 4.5 FT.
20 A FOUR HOUR PRESOAK WAS PERFORMED: N YES ❑ NO
SOILS LOGGED BY: JODY MAUS PERCOLATION TEST PERFORMED BY: KYLE MAUS
COMMENTS: RECOMMEND A 0.5 TRENCH SOIL APPLICATION RATE
PERFORMED BY GEG, Ltd. I, JEFFREY A. GARNESS, CERTIFY THAT THIS WA PE FORMED IN ACCORDANCE
WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE: 3 Z/
�^) MUNICIPALITY OF ANCHORAGE
j
® 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
'3y
❑ NEW
�kTIPGRADE
MAILING ADD ESS
ei3 t q qS-o
LEGAL DESCRIPTION
2 l tN i f L^ 11A(L
LOCATION
C f �
NO. OF BEDROOMS
Uy
DISTANCE TO:
Well
-{- �Gr
Absorption area
5
Dwelling
�.- 30
PERMIyV� O. n
Tib �j I? Z. "
I -Z
Manufacturer
Material
No. ofsyompartments
rn
Lie. capaisn j Ions
ty
4i
Inside length
IF HOMEMADE:
Width
Liquid depth
❑
Jt2Z
DISTANCE TO:
Well
O.
2 z Fa-
Manufacturer
Material
Liquid capacity in gallons
❑
m=
DISTANCE TO:
Well r
Foundation r
Nearest lot line
PERMIT NO. �1
J LL zNo.
PZ w
of lines
�+
Length of each line
Total length of lines
Trench width
, inches
Dist an FS b ween lines
<I..
❑
Top of the to finish grade a
Material beneath tile ��-yy
) -ineffes
Total eff ctive or tion area
w
L7
Length Width
Depth
PERMIT NO.
Q F
Type of crib rib diam
Cr
th
effective absorpti ea
ti
� ell
{i(STANCE TO:
Building ou ion
Near e
J
J
.Bfa Depth
Driller
Distance to lot line
PERMIT NO.
w
�
DISTANCE TO: Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATERJALS f`
SOI L TEST RATI NG
INSTALLER
REMARKS
10
A tax
APPROVED DATE LEGAL
l° A ` t -Tr A-2- 6A RPrL, a -n
72-013 (Rev.3 )
PERMIT
I
TO INFORM
THIS DEPARTMENT E:'URING THE
INSTALLATION INSPECTIONS
OF ANY WELLS ADJACENT TO
THI=; PROPERTY AND THE
10 F__
�4QLt,
•` DEPARTMEya1
HEALTH
AND EtdVItit NMEFIEHL t-•t!OTEC:T10PJ
g�
¢� 82
I STREET,
ANCHORAG
> AK. 9-9501
26,.3r.'4; 20
Aas LL
t CH 04
__ EE 1,L°.l L- 9=—_
—
�' �._ `sem° � °� .� -T—
PERMIT NO. r: 8I0927
APPLICANT JAMES W. CO.'.-,,
LOCATION RABBIT CREEK
LEGAL TR A-•2
SH;Ih7EEF'.''.LY MANOR #2
TYPE OF SOIL.. ABSORPTION SYSTEM IS:
MAXIMUM NUMBER OF BEDROOMS = 4
2-
:SRA BOX 40 ANC:H. 99507 344-25891.1 30
LOT SIDE 1!'?�!_I!_lt=0 _;QUARE. FEET
DRA I NF I ELD 71s)l
SOIL RATING ,:: a- h7r.E:F:
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM I •
.-.i a._ 5o CA F- Y C %A E= II.__ E fl E- tl ^ —Y 1 Y "._ -I-
THE LENGTH DIMENSION IS THE LENGTH .,::IN FEET) OF THE TRENCH OR DRAINFIELD
THE DEPTH OF H TRENCH OR: PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION 0N FEET).
T ._ 0s. A=cv RI AD d'" K E_. `.E' ..
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL. PIPE
AND THE BOTTOM OF TETE: EXCAVATION (IN FEET).
PERMIT APPL.IC:ANT HAS THE.
- -- -
RESPONSIBILITY
TO INFORM
THIS DEPARTMENT E:'URING THE
INSTALLATION INSPECTIONS
OF ANY WELLS ADJACENT TO
THI=; PROPERTY AND THE
NUMBER OF RESIDENCES THAT
THE WELL WILL
SERVE.
I4 C9 < _A' ti I r -^N F� E_ PC:- T- :I: 13 F-°! No f=l FO E= F1 !E� a a R_� a � �= I.: • _. —. �.
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THI'-
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN A WELL AND AP'd''f ON --SITE SEWAGE DISPOSAL SYSTEM I`=
100 FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC: WELL DEPENDING
UPON THE TYPE OF PUBLIC: WELL.
MINIMUM DISTANCE FROM A PRI'V'ATE HELL Ti_: A PRIVATE SEWER LINE I. 25 FEET AND
TO A COMMUNITY SEWER LINE IS 75 FEET.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTlON DIAGRAM'' ARE
AVAILABLE. TO INSURE PROPER INSTALLATION. -
Fo"Fo0notwl I E071,010, "f mo=o E" EA E= e Eo Pl E7 IE= FV? 000_1 "I _Y K00
I CERTIFY THAT
1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS, AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
__: I WILL INSTALL. THE SYSTEM IN ACCORDANCE WITH THE: CODE_.
3: I. UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS R ._ ;, 'r, TO it. L,_iDE. MORE: THAN 4 BEDROOi!_;:
__(�LCC(�
=1: 1Tt/g
SIGNE_D:.___........_---------.._...._____._._.__..__.__.._....___. WD� �
AF`F'L --ANT JAMES t.d. I :OX
ISSUED B'r'_. _.__C_4_e�'�/
/ InNZ f
s5vya
I
SOILS LOG
MUNICIPALITY OF ANCHORAGE
+� .. DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION A PERCOLATION
• TEST
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST
Boring #1
PERFORMED FOR: JIM COX DATE PERFORMED: 7/1/81
LEGAL DESCRIPTION: Tract A-21 Kimberly Manor Subdivision, Addition #2
I.T, SLOPE. SITE PLAN
Brown JHIVUT 3iLI, PIL
w/organics
Brown SILTY SANDY GRAVEL, GM
moist
Brown SANDY SILT, ML
moist
tu, ASA
„I■'94®_■_FFIXra■
111.■E��1�101��1�
WAS GROUND WATER NO L
ENCOUNTERED?
O
P TIt
IF YES, AT WHAT E
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
13.50
7/1/81
10:33
-
8.25*
-
12.53
7/1/81
10:34
30
min.
7.28
0.97
12.65
7/1/81
11:04
30
min.
7.40
0.12
12.75
7/1/81
11:34
30
min.
7.50
0.10
12.83
7/1/81
12:04
30
min.
7.58
0.08
12.92
7/1/81
12:34
30
min.
7.67
0.09
WAS GROUND WATER NO L
ENCOUNTERED?
O
P TIt
IF YES, AT WHAT E
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
13.50
7/1/81
10:33
-
8.25*
-
12.53
7/1/81
10:34
30
min.
7.28
0.97
12.65
7/1/81
11:04
30
min.
7.40
0.12
12.75
7/1/81
11:34
30
min.
7.50
0.10
12.83
7/1/81
12:04
30
min.
7.58
0.08
12.92
7/1/81
12:34
30
min.
7.67
0.09
13.25
7/7/81
10:34
8.0
TOTAL DEPTH OF BORING - 20.0' _V
PERCOLATION RATE ?� minutes/inch)
TEST RUN BETWEEN '71 V FT AND -7 �L FT
*Hole was drv, added 0.97" of water.
PERFORMED BY: 8111 Queitzsch CERTIFIED
72-008 (6/79)
PERFORMED
i "'� ■ SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ■ PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST Boring #2
JIM COX DATEPERFORMED: 7/7/81
LEGAL DESCRIPTION: Tract A-2, Kimberly Manor Subdivision, Addition #2
I WNW SLOPE SITE PLAN
1 a 4 Brown SILTY SANDY GRAVEL, GM
2
3
4
5
6
8
9
10
11
12
13
14
15
16
17
18
19
20
Dark Brown ORGANIC SILT, ML
moist
Brown SILTY SANDY GRAVEL, GM
moist
Brown GRAVELLY SANDY SILT, ML
moist
lq1. Lombe
4254-E
TOTAL DEPTH OF
BORING - 20.0' PERCOLATION RATE 60 (minutes/inch)
TEST RUN BETWEEN 4.0 FT AND 4-9 FT
*Hole was dry, added 12-1/4" of water.
WAS GROUND WATER NO L
ENCOUNTERED?
O
P
E
IF YES, AT WHAT _
DEPTH?
Reading
Date
GrossNet
Time
Time
Depth to
Water
Net
Drop
61-1/4"
7/7/81
ONEEMENNIEN
-
54-3/4"*
mom
■
INNEEMMONEN
NEENJOINOUR®
I..■■■0■L010I00
EEMENE1
NOMINEE
1100
9:19
■■MEEMEN1_J■■
O
�,�
..NIIIIIIIIIEW
mEWINIMMWEEZURNARMONEENNONEE
51.0
7/7/81
9:49
30
min.
44-1/2"
2.0"
52.0"
Reading
Date
GrossNet
Time
Time
Depth to
Water
Net
Drop
61-1/4"
7/7/81
9:18
-
54-3/4"*
49.0"
7/7/81
9:19
-
42-1/211
51.0
7/7/81
9:49
30
min.
44-1/2"
2.0"
52.0"
7/7/81
10:19
30
min.
45-1/2"
1.0"
52-7/8"
7/7/81
10:49
30
min.
46-3/811
7/8"
53-1 2"
7/7/81
11:19
30
min.
47.0"
5/8 "
54.0"
7/7/81
11:49
30
min.
47-1 2"
1 2"
54-3/8"
7/7/81
7 81
12:19
30
min.
7-7 "
"
55.0"
7/7/81
12:49
30
m:in.
48-1 2"
"
55-1 2"
7 7 81
1:19
30
min.
49.0"
1 2"
PERFORMED BY:. Mark Hall CERTIFIED BY: „�/f� �`' ` _ DATE:
72-008 (6/79)
r,
�� ■ SOILS LOG
MUNICIPALITY OF ANCHORAGE
■ PERCOLATION
• �e DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION TEST
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST
Boring #3
PERFORMED FOR: JIM COX DATE PERFORMED: 7/7/81
LEGAL DESCRIPTION: Tract A-2, Kimberly Manor Subdivision, Addition #2
fl SILTY Topsoil w/ORGANICS, OL
SLOPE
T� SITE PLAN
`�
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
1s
19
20
1010 TIu
Brown SILTY SANDY GRAVEL, GM
moist
Brown GRAVELLY SANDY SILT, ML
moist
>1SR hL txm5i
No. 4254-C
WASGROUND WATER NO L
ENCOUNTERED?
O
P
E
IF YES, AT WHAT
DEPTH? ------
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
31-1/211
7/7/81
9:13
-
21.0"
-
31-1/2"
7/7/81
9:43
30
min.
21.0"
0
31-5/8"
7/7/81
10:13
30
min.
21-3/8"
1/8"
32.0
_77
10:43
30
min.
21-1/2"
3/8"
32-1/8"
7/7/81
11:13
30
min.
21-5/8"
1/8"
32-1/4"
7 7 81
11:43
30
min.
21-3
32-1/2"
7/7/81
12:13
30
min.
22.0"
1/4"
32-5/8"
7/7/81
12:43
30
min.
22-1/2"
1/8"
32-3/4"
7/7/81
1:13
30
min.
22-1/4"
1/8"
TOTAL DEPTH OF BORING - 20.0'
PERCOLATION RATE Z46;, (minutes/inch)
TEST RUN BETWEEN Z FT AND LFT
PERFORMED BY: Mark Hall CERTIFIED BY:
72-008 (6/79)
JMLAMBE AND ASL'CIATES
4101 ARCTIC BLVD., SUITE 205
276-0007
WATER TABLE
LEVEL OF WATER BELOW GROUND TIME
TOTAL DEPTH OF PIPE BELOW GROUND
,_1
(;.TENT Jim Cox
JOB #
TECH. mwer //4z -
DATE /0-7-B/
PERC. HOLE
LEVEL OF WAVER FROM TOP OF PIPE Dky TOTAL DEPTH OF PIPE Cod
PIPE IS 60 ABOVE/BELOW GROUND.
TIME
8=3CD
9=06
9=36
wolf
iv:3(o
/ • OCo
/2: 3(o
CHANGE IN TIME WATER LEVEL CHANGE IN
TO TOP PIPE DEPTH
30 miN
n
5) %/r
-7i N
J5cJ ,/n
25/s
1 7/-1(
57 3/S it
I /5"
Sg
SI y2�i
—
53%4"
3�cf a
,5 4 3/4,
) %2"
PERL. I wra 2UMIN Prfoz. 1NLt1
12.1"
HOLE � 4
WATER IN HOLE WATER ADDEDI
7 '/R
9
7
�v %
_yam.»eas
��.OF
44. �s s�
X. Lambe
4254•E
/o17/si
MUNICIPALITY OF ANCHORAGE
Development Services Department\' -' _`, Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 017-074-02
1. GENERAL INFORMATION
Complete legal description
Location (site address)
TWO LOTS TR A2 B
8051 Rabbit Creek Rd
Expiration Date:1g ZwZ0
Current property owner(s) FEDERAL NATIONAL MORTGAGE ASS. Day phone 522-5220
Mailing address
Real estate agent
Bob Brock
2. TYPE OF DWELLING:
El Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
Day phone 522-5220
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
0
Private Septic
Fx_1
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 $
Waiver Fee $
Date of Payment
Date of Payment
Receipt Number
Receipt Number
COSA #
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 NorthRim Eng. Phone 694-7028
Address PO Box 770724, Eagle River
Engineer's Printed Name Steve Eng Date 4/13/20
By: Original Certificate Date: JZZ13
The Municipality of Anporage 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
6. DSD SIGNATURE
l/ System #1 Approved for bedrooms�/�
System #2 Approved for bedrooms
Disapproved
Conditional approval for bedrooms, with the
following stipulatioris� f'u ..,
By: Original Certificate Date: JZZ13
The Municipality of Anporage 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: TWOLOTS TR A213
If more than 1 septic system on lot: COSA Checklist #
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled unk
Total depth unk ft
Cased to unk ft
❑ Sanitary seal is functioning correctly
OR Wires are properly protected
Casing height (above ground) 18 in.
Date of flow test for COSA 10/23/19
Static water level at beginning of test 86.4 ft.
Comments Well casing extended- new well cap
B. TANK DATA
Age of tank(S) 4/18(07 years
Tank type/material steel
Measured operating fluid level in septic tank 46
❑ Standpipes/foundation cleanout per record drawing
Date of pumping 10/21/19
D. ABSORPTION FIELD DATA 4/18/07
Which system tested (date installed) 4/18/07
❑ ALL standpipes present per record drawing
Total measured depth from grade 13 ft (max)
Measured depth to pipe invert from grade 7 ft (min)
❑ N/A — pressurized field
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective
❑ Code -required soil cover over field
❑ System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced gallons
Comments/Deficiencies: ALL STANDPIPES PRESENT
COSA Checklist yellow sheet
Parcel ID: 017-074-02
of Structure served by this system
Well production at time of test 5+ gpm
Water storage tank volume 0 gallons
Well disinfected for coliform test? ❑ Yes ❑ N
❑ Coliform bacteria is Negative
Nitrate 1.5 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by NRimEng
Date of Sample 4/1/20
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments: 2nd Measurement Proves Tank OK
Adequacy test date 10/23/19
Results E✓ Pass For 4 bedrooms
Fluid depth prior to test 18 in
Water added 600 gal
New depth 29 in
Elapsed time 30 min
Final fluid depth 20 in
Absorption rate 600 gpd
Any rejuvenation treatment (past 12 months) no
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'
✓0
Yes
Community Sewer Manhole/Cleanout > 100'
❑✓ Yes
if No
ft
M Yes
if No ft
Neighboring Tank > 100' p✓ Yes
if No
ft
Private Sewer/Septic Line > 25' F✓ Yes
if No ft
Absorption Field on Lot > 100' P Yes
if No
ft
Holding Tank > 100' ❑✓ Yes
if No ft
Neighboring Absorption Fields > 100'
Yes if No ft
Water Main > 10'
Animal Containment > 50' P/ Yes
if No ft
F/ Yes
if No
ft
0 Yes if No ft
Water Service Line > 10'
E✓
Yes
if No
Manure/Animal Excreta Storage > 100'
If septic tank is under driveway comment below
Community Sewer Main > 75' Q✓ Yes
if No
ft
F/I Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
✓0
Yes
if No
ft
Surface Water > 100'
Yes if No ft
Property Line > 5'
Q7
Yes
if No
ft
Wells on Adjacent Lots:
0
Absorption Field > 5'
F/
Yes
if No
ft
Private Wells > 100'✓0
Yes if No ft
Water Main > 10'
✓Q
Yes
if No
ft
Community Wells > 200'
0 Yes if No ft
Water Service Line > 10'
E✓
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' Q✓ 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'✓1
Yes
if No
ft
Private Wells > 100'
Water Service Line > 10'
0
Yes
if No
ft
Community Wells > 200'
Surface Water > 100'
0
Yes
if No
ft
F. ENGINEER'S COMMENTS
Outhouse Located On Survey Is Removed
G. ENGINEER'S CERTIFICATION
I certify that 1 have determined through field inspections and review
of Municipal records that the above systems are in conformance with
MOA COSA guidelines in effect on this date.
COSA Checklist yellow sheet
U✓ Yes if No ft
F/ Yes if No ft
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 1. D. 017-074-02
1. GENERAL INFORMATION
Complete legal description TWOLOTS TR A2B
Location (site address) 8051 Rabbit Creek Rd
Expiration Date: 3
Current property owner(s) FEDERAL NATIONAL MORTGAGE ASS. Day phone 522-5220
Mailing address
Real estate agent
Bob Brock
2. TYPE OF DWELLING:
Fx_1 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
4. TYPE OF WATER SUPPLY:
Private Weil
Q
Water Storage
❑
Community'Well
❑
Public Water System
❑
Waiver request for:.
Received by� i — ,2`� -
COSA to be relised-td-a engineer, unless otherwise
COSA Fee $ 57,5-b
Date of Payment 11/1,5 jig
Receipt Number NA54L)
COSA # OfKM542
M
by the engineer
Day phone 522-5220
�6 7 8 g �0
>>
ti
ITV 2 2019 b
6 g � 9
TYPE OF WASTEWATER DISPOSAL:
Private Septic
0
Holding Tank
❑
Community
❑
Public Sewer
❑
Distance:
Date: la L1.3 Ll d
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 NorthRim Eng. Phone 694-7028
Address PO Box 770724, Eagle River
Engineer's Printed Name Steve Eng
6. DSD SIGNATURE
Date 11/12/19
�17,
System #1 Approved for Lj bedrooms
., -p. • c rte. E.a
•o Stever'r:..`: i,.J
4P 6°•,°
System #2 Approved for bedrooms
> J PF 62564,0
Disapproved
4., "80FESSI���Q
Conditional approval for bedrooms, with the following stipulations:
,kal,l(1(l( i"-
By:kz Original Certificate Date: /3 /
The Municipality of Ancho ge 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
Septic System Advisory
Well Flow Advisory
COSA Checklist blue sheet
X Nitrate Advisory...;
Arsenic Advisory:
Other
COSA Checklist
Legal Description: TWOLOTS TR A213
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled unk
Total depth unk ft
Cased to unk ft
❑■ Sanitary seal is functioning correctly
❑■ Wires are properly protected
Casing height (above ground) 18 in.
Date of flow test for COSA 10/23/19
Static water level at beginning of test 86.4 ft.
Comments Well casing extended- new well cap
B. TANK DATA
Age of tank(s) 4/18107 years
Tank type/material steel
Measured operating fluid level in septic tank 46
❑■ Standpipes/foundation cl , anou per record drawing
Date of pumping G 2
a
D. ABSORPTION FIELD DATA 4/18/07
Parcel ID: 017-074-02
Structure served by this system
Well production at time of test 5+ gpm
Water storage tank volume 0 gallons
Well disinfected for coliform test? ❑ Yes ❑■ N
❑N Coliform bacteria is Negative
Nitrate 1.6 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by NRimEng
Date of Sample 10/281
19
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments: 'S C- C-0 N
IA T— PleovF _ T `7;;v\ nk
Which system tested (date installed) 4/18/07
Adequacy test date 10/23/19
❑■ ALL standpipes present per record drawing
Results ❑✓ Pass For 4 bedrooms
Total measured depth from grade 13 ft (max)
Fluid depth prior to test 18 in
Measured depth to pipe invert from grade 7 ft (min)
Water added 600 gal
❑ N/A - pressurized field
New depth 29 in
■❑ Monitor tubes go to bottom of effective. If not, state
Elapsed time 30 min
depth into effective
FEWCode-requiredsoil cover over field
Final fluid depth 20 in
F-1 System presoaked
Absorption rate 600 gpd
(Required if vacant for greater than 30 days prior to
Any rejuvenation treatment (past 12 months) no
date of test)
Gallons introduced gallons
If yes, enter date
Comments/Deficiencies: 6 LL
_S
COSA Checklist yellow sheet
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
71
Yes
Community Sewer Manhole/Cleanout > 100'
✓0 Yes
if No
ft
❑✓ Yes
if No ft
Neighboring Tank > 100' ❑✓ Yes
if No
ft
Private Sewer/Septic Line > 25' ❑✓ Yes
if No ft
Absorption Field on Lot > 100'✓❑ Yes
if No
ft
Holding Tank > 100' ✓❑ Yes
if No ft
Neighboring Absorption Fields > 100'
Yes
if No
Animal Containment > 50' ✓❑ Yes
if No ft
0✓ Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ❑✓ Yes
if No
ft
R] 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'
71
Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
❑✓
Yes
if No
ft
Private Wells > 100'✓Q Yes if No.
Water Main > 10'
✓l
Yes
if No
ft
Community Wells > 200'✓0 Yes if No.
Water Service Line > 10'
Q✓
Yes
if No
ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10' Q✓ Yes if No ft If absorption field is under driveway comment below
Property Line > 10'✓❑
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'✓❑
Yes
if No
ft
Private Wells > 100' Yes if No
Water Service Line > 10'✓❑
Yes
if No
ft
Community Wells > 200' ❑✓ Yes if No
Surface Water > 100'✓Q
Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that / have determined through field inspections and review
of Municipal records that the above systems are in conformance with
MOA COSA guidelines in effect on this date.
COSA Checklist yellow sheet
C Phi wEEIR'S "
SUFESS •�`� r::
u'1
ft
ft
ft
ft�
I•