HomeMy WebLinkAboutT12N R2W SEC 30 S2SE4NE4NE4 PTN (2 1/2 AC)T12N R2W
ec. 30
52 SE4 NE4 NE4
PTN (2 ; AC)
#021-011-13
Municipality of Anchorage
On -Site Water and Wastewater Program • (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP121227 PID Number: 021-011-13
Dwelling: ❑■ Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project:❑ New ❑ Upgrade
Name:
Kent and Lois Miller
ABSORPTION FIELD
❑ Deep Trench 0 Shallow Trench ❑ Bed ❑ Mound
Address
10501 High Lonesome Court Anch., AK 99516
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
907-222-3044
Four (4)
1.2 GPD/SF
7.4 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
3.4 Ft.
Gravel depth beneath pipe
4 Ft.
Subdivision Block Lot
S1/2SE1/4NE1/4NE1/4PTN
Fill added above original grade
0-.5 Ft.
Gravel length
54 Ft.
Township Range Section
12N 2W 30
Gravel width
5 Ft.
Beds: Number of Lines
Distance between lines
Ft.
SEPARATION
DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
540 Ft'
1
1 Ft.
Well
>100'
>100'
N/A
N/A
>25,
TANK ❑ Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
Greer
Capacity
1,500 Gal.
Surface Water
>100'
>100'
N/A
N/A
Material
Number of compartments
Lot Line
>5'
>10'
N/A
N/A
Poly Plastic
Two
NA
Foundation
>10'
>10'
N/A
N/A
LIFT STATION
Manufacturer
Capacity
Curtain Drain
None
Noted
Gal.
Remarks
Pump on level at
in.
Pump off level at
in.
High water alarm at
in.
Pump make and model
Electrical Inspections performed by
PIPE MATERIAL House to tank D3034 Tank to D3034
drainfield
Installer
Owner Install
Drainfield D3034 CO/MTD 3034
Inspector MEA
BENCH MARK (Assumed elevation) 100 ft
Inspeectiontes: i5' 10/11/12 10/11/12
Location and description
2nd
3°' 4th
Garage Slab
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
Engineer's Stamp
law
�F' A�,�SII
Conditional Approval: Date
,� '��
*: 49 TH .*
r' '�` ' �
Michael E. Anderson
4381-E
/ale
Approved lam, j,' �stah 12/5/�g Date
.6/26/21
FD
11 pR0FE��NA
S5
`��
inspection rteport_9-i-12.aoc
Municipality of Anchorage Page 2 of 3
DEVEOPMENT SERVICES DEPARTMENT
4700 South Bragaw Street Anchorage,AK. 99519-6655-343-7904
Permit Number: OSP121227 PID No. 021-011-13
I T12N,rrR2W, SECTION 30, S.M.
rr]1��►7L1�`*1VL1�`t1VL1�`t r 11V `4#.J Lil:1C5�
S89'57'31"E 331.02
/x
/
/
109.8' 113.6 /
S2 116.0' 119.5' /
C2 181.0' 190.9' / Four Bedroom
C3 143.6' 157.1' / Horns
M1 163.8' 175.0'
Q
10
! FCO �2C0hl
,t
n tr) I BiiYsirg CO
CV I ® N
I M
a ' 2'Insulation over tine
under parking area. 1n
\ .r
.e/
Z O
N
rI
kir
.2
Alternate co 2C0 ` — —. —. .——'
Site 1
r Insulation over
line under rood.
CI
—
C2
NOTE:
/ Drawing not completed from Surveyor As
Built. Locotions are not exact and
Gravel Drive relative to the house location.
N89'46'31"W 328.91
LEGEND �",\\'
M1 — Monitor Tube . 4-E i�j ..
FCO — Foundation Clean Out .• ,
TH — Test Hole •'�P'••.....
C2 — Clean Out �?�•.�� , �
2C0 — Double Clean Out fi� :,
49th ' Of;
�0 ',MICHAEL E. ANDERSON j
PLAN A S BUILT
•��I NO. CE-4381 .:� :
SCALE 1' = 50' ••IN. w;��- •
Municipality of Anchorage Page 3 of 3
DEVEOPMENT SERVICES DEPARTMENT
4700 South Bragaw Street Anchorage, AK. 99519-6655-343-7904
On-Site Wastewater Disposal System or Well Inspection Report
Permit Number: OSP121227 PID No. 021-011-13
— o 74.8 0
U N C/3 2 to N
/ OG
rm
Grade
ri 1-1 [ U U
1,250 Gallon
Septic Tank
67.9 67.7
I
U
71.5 -
/ a 71.0
I
Finished Grade // I—
/
__.j
—
—75ngrnalround
Geotextile Fabric
67.6- Dr-infield 67.6
63.6 63.6 63.6—f
I1(Trench Length) / 57.0
{
f No Groundwater
615/12
lor.,� �`
.4,i 49th .•* ♦f
, � •
MICHAEL E. ANDERSON
PROFILE AS—BUILT '�. No. CE-4381 Ifig
No Scale ♦•.':..•••.ef-7-i ,.••''��1.
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: OSP121227
Tax Code Number: 02101113000
Work Type: Septic Initial
Permit Effective Dates: September 10, 2012 to September 10, 2013
Design Engineer: ANDERSON ENGINEERING
Subdivision: T1 2N R2W SEC 30
Site Legal Address: T12N R2W SEC 30 S2SE4NE4NE4 PTN (2 1/2 AC) G:2843
Owner/Address: COLLINS FAMILY TRUST
COLLINS RICHARD BERYL & ANNE -MARIE T / T 2553 LOVEJOY DRIVE ANCHORAGE AK 995084132
Site Mailing Address: 12975 GLEN ALPS RD, Anchorage Lot Size in Sq Ft: 108900
Total Bedrooms: 4
This permit is for the construction of:
Y Disposal Field Y Septic Tank N Holding Tank N Privy 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.
Received
Issued By.
MUNICIPALITY OF ANCHORAGE
% 1
I� �I
Community Development Department
Development Services Division —�
On -Site Water & Wastewater Program
Mayor Dan Sullivan
ON-SITE SEWERNVELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 021-011-13
Phone: 907-343-7904
Fax: 907-343-7997
Property owner(s): Kent Miller Day phone: 222-3044
Mailing address: 9121 Chipwood Circle Anchorage, AK 99507
Site address: 12975 Glen Alps Road Anchorage, AK 995116
Legal description (Sub'd., Block & Lot): T12N, R2W, Section fid, S2SE4NE4NE4 PTN
Legal description (Township, Range & Section)
Lot Size: 108,900 S.F. Number of Bedrooms: Four (4)
THIS APPLICATION IS FOR: THIS APPLICATION IS AN:
(® all that apply)
Initial X
Absorption Field X
Upgrade
Septic Tank X
❑
Holding Tank ❑
Renewal ❑
Privy ❑
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A VARIANCE 1 WAIVER REQUEST FOR:
I 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.
(Signature of property owner or authorized agent)
Permit/Rush Fees: 536 .w Waiver Fees:
Date of Payment: 8I111Q Date of Payment:
Receipt Number: QSG IL( Receipt Number:
Permit No. (36 P/ a /;J'� Waiver No.
C:\Users\AndEng\Desktop\Mike\T12N Miller\Permit Application.docC:\Users\AndEnglDesktop\Mike1T12N Miller\Permit
Application.doc
ANDERSON ENGINEERING
P.O. BOX 240773
ANGHORAGE, AK 99524
522-7773 677-7766 FAX
July 30, 2012
Municipality of Anchorage
Development Services Department
On -Site Water and Wastewater Program
4700 South Bragaw Street
Anchorage, AK 99519-6650
Subject: T12N, R2W, SECTION30, W1/2, SE1/4, SEI/4, NE1/4, NE1/4
E1/2, SW1/4, SE1/4, NE1/4, NEI/4
Septic System Design and Permit Application
Impacts to Adjacent Properties
Dear Onsite Services Engineer:
The owner of the subject lot intends to construct a new four-bedroom home on the lot.
We are therefore requesting a permit be issued for the construction of a new septic
system to accommodate the home. A well is currently in place on the lot. The attached
Site Plan and backup documentation identify the location and configuration of the
proposed septic system along with the alternate site. Also identified on the plans is the
existing well. No development exists within 1,000' of the lot and no conflicts exist
between the proposed septic system and well or septic systems and wells on adjacent
lots. Drainage arrows are shown on the site plan showing the grade and direction of
flow on the lot. The drainage pattern will not be changed as a result of this project.
Two test holes were placed on the lot in the area of the absorption trench and alternate
site. The logs indicate silty gravel (GM) in the zone specified for the absorption trench.
The percolation rate of the soil was determined to be 5 minutes per inch. No
groundwater was found during the placement of the test holes and none was noted
during the monitoring period. An application rate of 1.2 gallons per day per square foot
was used in the design of the absorption system. We are proposing to place a new
1,250 -gallon septic tank and a 50' long by 5' wide by 4' effective depth absorption
trench to treat and dispose of the effluent generated in the house. The elevation of the
distribution line in the absorption trench will be 4' below the surface and the total depth
will be 8'. A minimum of 3' of fill or 2" of insulation and 2' of fill will be placed over the
absorption trench and 4' over the septic tank.
The ground surface on the lot in the area of the septic system slopes to the northwest.
The new trench will be constructed parallel with the contours of the slope as much as
T12N, R2W, Section 30
July 30, 2012
Page Two
possible in conformance with Municipal requirements. The new septic system will be
constructed a minimum of 100' from all wells and any surface water and 10' the
proposed and existing water services in the area.
If the system is constructed in accordance with our design the following statements
apply:
1. The system, if constructed as designed, will have no adverse impact on the wells
in the area or those to be constructed in the future.
2. The system, if constructed as designed, will have no adverse impact on existing
septic systems in the area or those to be constructed in the future.
3. The system, if constructed as designed, will have no adverse impact on reserve
space, either surface or subsurface, on any lots located in the area.
4. The system, if constructed as designed, will have no adverse impact on drainage
patterns in the area. The current drainage pattern will be maintained.
Sincerely,
-�4A.L z a -..Q,
Michael E. Anderson, P.E.
Attachments
Wks•
49th ":*
MICHAEL E. ANDERSON
T12N, RM SECTION 30, S.M.
W1/2SE1/4SE1/4NE1/4NE1/4
E1/2SW1/4SE1/4NE1/4NE1/4
S89'57'31 "E 331.02
NOTE:
No Separation Distance Conflicts
Between the Well and Septic
System and Those in the Area.
No Development Within 1,000'.
LEGEND
MT — Monitor Tube
FCO — Foundation Clean Ou
TH — Test Hole
CO — Clean Out
2CO — Double Clean Out
SITE PLAN
SCALE 1' = 50'
NOTE:
No Areas of Excessive Slope or
Surface Water are Within 100of
Any Part of the New Septic
System.
k
J
_
zco
lion
SYSepyc Tank
co
m
GD
co
Four Bedroom
/
H.
/
M
ARemate /
co j
0
N
S'ito ®Z /
E Wting
®I
MT /
®t
co
sG' I.onp ct o pM
4' Ef
1
Pbsarptian Trench
Gmvel Drive `�
N89'46'31"W 328.91
NOTE:
No Separation Distance Conflicts
Between the Well and Septic
System and Those in the Area.
No Development Within 1,000'.
LEGEND
MT — Monitor Tube
FCO — Foundation Clean Ou
TH — Test Hole
CO — Clean Out
2CO — Double Clean Out
SITE PLAN
SCALE 1' = 50'
T12N, R2W, SECTION 30
W1 /2SE1 /4SE 1 /4N El /4NE1 /4
E1/2SW1MSE 1/4NE1/4NE1/4
DESIGN FACTORS: SYSTEM REQUIREMENTS:
Four Bedroom Home 5' Wide Trench System
Perc. Rate: 1-5 Min./Inch 1,250 Gallon Septic Tank
Application Rate: 1.2 GPD/SF 4' Drainfield Rock
4 Bedrooms * 150 GPD/Bedroom = 600 SF Absorption Area
600 SF/1.2 GPD/SF/5 SF (Width) *.5 (Red. Factor 50 LF Trench Length
THEREFORE: Construct a 50' Long x 5' Wide x 4' Effective Depth Absorption Trench.
Flow Line Elevation in Trench to be 4' Below Original Ground Surface. Total Depth to be
8' Below Existing Ground. Provide 3' Cover Over Absorption Trench and 4' Cover Over
Septic Tank.
5'
TYPICAL 5' WIDE TRENCH SECTION
(NO SCALE)
NOTE: Grade Area Over Trench to Drain Away.
Minimum 6' Separation From Bedrock. ..
Minimum 4' Separation From Groundwater.
�.....
Minimum 100' Separation From Private Wells in the Area. � m
Minimum 100' Separation From Surface Water or Streams.
MICHAEL E. ANDERSON
No. CE- 5 i
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT
4700 BRAGAW STREET ANCHORAGE, AK 99519-6650
DEPTH
(feet)
1-
2
3
4
5
6
7
8-
9
10-
11
12-
13-
14-
15-
16-
17-
18-
19 -
SOILS LOG - PERCOLATION TEST
LEGAL DESCRIPTION: T12N R2W Section 30
PERFORMED FOR: Kent Miller
DATE: 5/21/2012 PROJECT No.:
PARCEL ID#: TECHNICIAN: M. Anderson
TEST HOLE 1
SLOPE
ORGANIC MATERIAL
INTERMIXED WITH GM
N
0
SILTY GRAVEL
GM
SITE PLAN
SEE SITE PLAN E�
i
WAS GROUND WATER ENCOUNTERED? No
IF YES @WHAT DEPTH? 2%
DEPTH OF WATER AFTER MONITORING: None n
DATE OF MONITORING: 6/5/12 tCu
DATE
READING
GROSS TIME
(MINUTES)
NET TIME
(MINUTES)
DEPTH TO
WATER
(INCHES)
NET DROP
(INCHES)
TEST HOLE PRESOAKED PRIOR TO TESTING:
6/5
1
10:16
1.25"
2
10:46
30
8.00"
6.75"
3
10:47
1.50"
4
11:17
30
7.50"
6.00"
5
11:18
1.25"
6
11:48
30
7.25"
6.00"
PERCOLATION RATE: 5 (MIN/INCH) PERC. HOLE DIA.--L(INCHES)
TEST RUN BETWEEN: 4 FT. and 5 FT.
COMMENTS: TEST HOLE PRE SOAKED PRIOR TO TEST.
TEST PERFORMED BY ANDERSON ENGINEERING. I, MICHAEL E. ANDERSON CERTIFY THAT
THIS WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPLE GUIDELINES IN EFFECT ON THIS
DATE: 7/5/2012
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT
4700 BRAGAW STREET ANCHORAGE, AK 99519-6650
DEPTH
(feet)
I-
2-
3
4
5
6
7
8
9
10 -
II
1
I
1
1
1
1
SOILS LOG - PERCOLATION TEST
LEGAL DESCRIPTION: T12N. R2W. Section 30
PERFORMED FOR: Kent Miller
DATE: 5/21/2012 PROJECT No.:
PARCEL ID#: TECHNICIAN: M. Anderson
TEST HOLE 2
e..
SILTY GRAVEL
p.
GM
e
SLOPE
N
0
SITE PLAN
SEE SITE PLAN
WAS GROUND WATER ENCOUNTERED? No
READING
IF YES @ WHAT DEPTH?
NET TIME
(MINUTES)
DEPTH To
WATER
(INCHES)
DEPTH OF WATER AFTER MONITORING: None
0
TEST HOLE PRESOAKED PRIOR TO TESTING:
DATE OF MONITORING: 6T
P
10:31
E
DATE
READING
GROSS TIME
(MINUTES)
NET TIME
(MINUTES)
DEPTH To
WATER
(INCHES)
NET DROP
(INCHES)
TEST HOLE PRESOAKED PRIOR TO TESTING:
6/5
1
10:31
0.75"
2
11:01
30
7.25"
6.50"
3
11:02
1.00"
4
11:32
30
7.00"
6.00"
5
11:33
0.88"
6
12:03
30
6.88"
6.00"
PERCOLATION RATE: 5 (MIN/INCH) PERC. HOLE DIA. g (INCHES)
TEST RUN BETWEEN: 4 FT. and 5 FT.
COMMENTS: TEST HOLE PRE SOAKED PRIOR TO TEST.
TEST PERFORMED BY ANDERSON ENGINEERING. I, MICHAEL E. ANDERSON CERTIFY THAT
THIS WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPLE GUIDELINES IN EFFECT ON THIS
DATE: 7/5/2012
January ~, 1978
Richard Collins
Box 381
Anchorage, Alaska
99501
Su]~e(;t: ~12N R2W Section 30
A permit issued by this department for well and/or sewer
system has expired.
Permits are isstled on a calendar year basis, as stated
on the permit, by authority of Municipal ordinance.
If you have drilled the well, a well log should be sent
to this department 'to document the installation date.
/.f there are any further questions, please contact this
office at 264~4720,.
Sincerely,
Ilealth and Environmental Protection
Sewer and Water Section
i"1it*4iFiUH [:,iIiSffflI',IE:E-i E;EiiI'I4EEI",I F~ HELL. I::INIi:, l':~i",l"r'
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2: ] N~L.L Zt"4~:,Tf:'ILL THE %"r't[~;l'El'"l ZI"4 ffI(i:COI:;:'.[)I%IC:[; I.,.lI"fH "f'l'tE COl)ES.
I::1i';:'1'::'[ .. i E:I:::I N I I:,~: I E:I 'll::ff~'. [;, COLl..IN:E;
TIME
DRILL LOG
CASING
29/)'
/
ZIA ~ 1405 West 15th Ave,
Anchorage, Alaska 99501
DO7 / 344.001
START~ 27
COMPLETE
DATE
ADDRESS
CITY
JOB LOCATION
TIME WELL LOG
DRILLING
DIV.
J,'\ ~! 0 4
UOLLINS~ INC.,
STATIC LEVEl_
7 '- 3c -- 74'-'
No.
PHONE
DE-PTH WELL LOG
~D
(-',i
Millet 907-222-3044 P.?
To: On -Site Water and Waste Water Program
Phone: 343-7904
Fax: 343-7997
A—TN: Deb
From: Kent Miller
Phone: 222-3044 or 602-8055
12975 Glen Alps Road, Anchorage, AK 99516
7 August 2012
I have previously designed and installed two septic systems for homes I built in New Mexico. One was
installed in 1998 and the other in 2002. Both continue to work well.
We have our own backhoe that will be used to do the dirt work. Our location is W Yz, SE %, SE Y, NE Ye,
NE Y<, and the E'A, SW Y, SE'/, NE %, NE Y4, Section 30, Township 12 North, Range 2 West,
Seward meridian. Street Address: 12975 Glen Alps Rd, Anchorage AK.
I will be doing the work myself including equipment operation and system installation. No
workers will be compensated for any type of labor done on this project. Since I will be doing
the labor myself, I will be on site while any work is being done.
Everyone loves freedom until they benefit when someone else's freedom is taken away.
Kent 0. Miller
Property Owner
PGE BL
�• Municipality of Anchorage
On -Site Water and Wastewater Program <
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 021-011-13
1. GENERAL INFORMATION
Expiration Date: 1-2---2 V_ Z 1
Complete legal description T1 2N R2W Sec 30 S2 SE4 NE4.NE4 PTN_(2 1/2 AC
Location (site address) _ 10501 High Lonesome Ct, Anchorage AK 99516
Current Property owner(s) _Kent & Lois Miller Day phone
Mailing address
Real Estate Agent
1.050.1_ High Lonesome Ct, Anchorage_AK_99516 __ _
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS:
4
TYPE OF WASTEWATER DISPOSAL:
4. TYPE OF WATER SUPPLY:
Individual
Individual Well
®
Holding Tank
❑
Individual Water Storage
❑
Community
❑
Community Class _ Well
❑
Public Sewer
❑
Public Water System
❑
WaiverNariance request for: Distance:
Received by:
Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 55 0 Waiver Fee $
Date of Payment l a 2.24 2 j Date of Payment _ l
Receipt Number�_( �$ 5(o Receipt Number
COSA # _^0 SC ,;� f l S Jia 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.
Name of Firm ARCTERRA CONSULTING, INC.
696-6111
Address 20441_PTARMIGAN BLVD.,. EAGLE RIVER, -AK 99577
Engineer's Printed Name KENNETH M_DUFFUS Date
Engineers Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition
of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface
conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate
during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are
subject to these various and dynamic characteristics and are outside the control of the
evaluator of the well and septic system. Therefore,
ArcTerra can not give any estimate of how long a
system will function satisfactory for current or future �� \
occupants or can ArcTerra guarantee that no unseen r 01
<�,
encroachments, deficiencies or discrepancies exist. /,�c���
�* )CATH /� k
6. DSD SIGNATURE
System #1 Approved for bedrooms. hE"NNT"; M.`''"
System #2 Approved for bedrooms.
Disapproved. \�a�
Conditional approval for bedrooms, with the following stipulations:
61,S/TE
wA� - - Phone �-
VVAST AND m
O��`ATt.
-----------
- A 4o;
- RVIC��
Original Certificate Date: " 7,=1
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 blue sheet 10-10-12.dac
Legal Description: T12N R2W Sec 30 S2 SE4 NE4 NE4 PTN (2 1/2 AC) Parcel ID: 021-011-13
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
Well log is filed with Onsite (or attached)
Date drilled 7/30/78
Total depth 206 ft
Cased to 40+ ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) 14 in.
Date of flow test for COSA 8/20/21
Static water level at beginning of test 77 ft.
Comments
B. TANK DATA
Age of tank(s) 3 years
Tank type/material Septic/Steel
Measured operating fluid level in septic tank 49"
Standpipes/foundation cleanout per record drawing
Date of pumping 8/27/21
D. ABSORPTION FIELD DATA
Which system tested (date installed) 10/19/12
ALL standpipes present per record drawing
Total measured depth from grade 12 ft (max)
Measured depth to pipe invert from grade 7.25 ft (min)
❑ N/A — pressurized field
Monitor tubes go to bottom of effective. If not, state
depth into effective
Structure served by this system
Well production at time of test 3.8 gpm
Water storage tank volume gallons
Well disinfected for coliform test? Yes ❑ No
Coliform bacteria is Negative
Nitrate mg/L 11 Nitrate less than MRL (ND)
Arsenic ug/L ll Arsenic less than MRL (ND)
Collected by Areterra Consulting
Date of Sample 8/20/21 & 8/23/21
FT STATION
❑
Req-u'lesWaintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 8/20/21
Results F✓ Pass For 4 bedrooms
Fluid depth prior to test 14 in
Water added 600 gal
New depth 16 in
Elapsed time 15 min
Code -required soil cover over field Final fluid depth 14 in
❑ System presoaked Absorption rate 600+ gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) _
date of test)
Gallons introduced gallons If yes, enter date
Comments/Deficiencies:
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'
® Yes
if No
Community Sewer Manhole/Cleanout > 100'
® 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'
if No
ft
Animal Containment > 50' ® Yes
if No ft
® Yes
if No
ft
ft
If septic tank is under driveway
comment below
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:
® Yes
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
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
G. ENGINEER'S CERTIFICATION
l certify that l 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
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