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HomeMy WebLinkAboutVALLI VUE ESTATES #2 BLK 3 LT 31LL 1-A'T S OIS '.! LoT' oGREY'- iR ANCHORAGE AREA BORr- ' GH De p a r t m e .t ~3E0n~i r~ .t a I Quality Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME 'l"--~/~ ~'~-/7~:%'~//~b'd'~AILING ADDRESS /~/g' ~A,..~.r-/ PHONE SEPTIC TANK: DISTANCE ~ FROM WELl INSIDE LENGTH MANUFACTURER ~'/~/- MATERIAL NUMBER OF COMPARTMENTS INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY /.,2X72 GALLONS. TILE DRAIN DISTANCE FROM WELL ~g-rr~t?'TFOUNDATION /(~ ! 'p NEAREST LOT LINE /O /-/~OF TOTAL LINES LENGTH NUMBER OF LINES / DISTANCE BETWEEN LINES /'1').4 TRENCH WIDTH IN. TOTAL EFFECTIVE ABSORPTION AREA ~0 ~ ! SQ. FT. LENGTH OF EACH LINE D~-~14- o.r'~ ~'/ff~:~ff~14 I~,I DEPTH OF FILTER ~_tl DEPTH: TOP OF TILE TO FINISH GRADE ~ / MATERIAL BENEATH TILE ~,~ IN. ABOVE TILE IN. WELL: TYPE CONSTRUCTION BUILDING NEAREST NEAREST FOUNDATION__ LOT LINE__ SEWER LINE DEPTH SEPTIC SEEPAGE TANK __ SYSTEM CESSPOOL OTHER SOURCES APPROVED_ / DISAPPROVED REMARKS DISTANCE FROM: DISTANCES: INSTALLED BY: ZII~7~'~IPPgP~ SEWER LINE DEPTH: PIPE MATERIAL: ~'"~ ~: ~- LOT SLOPE: REMARKS: Form EQ-032 DIAGRAM OF SYSTEM GRE, ER ANCHORAGE AREA BO'~'~UGH DEPARTMENT OF ENVIRONMENTAL QUALITY 3330 "C" STREET ANCHORAGE, ALASKA 99503 PERMIT NO. SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT TYPE AND SIZE Of FACILITY TO BE SERVED FINANCED THROUGH SOIL TEST RESULTS _ //~ SEEPAGE PIT COMPLETION DATE ANTICIPATED FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. MINIMUM DI.%TANCE~', RE~:)UlREMENTS .,~ FOUNDATION TO SEPTIC TANK FOUNDATION TO SEEPAGE PIT · DRAIN FIELD SEPTIC TANK TO SEEPAGE PIT WALL SEPTIC TANK . SEEPAGE Pit DRAIN FIELD TO NEAREST LOT LINE. WELL TO SEPTIC TANK . SEEPAGE pit DRAIN FIELD / ALSO CONS[DER AREA WELLS. WATERDRAiNMA]NFiELDTO SePTICf~/~TA m SEEPAGE PIT SEPTIC TANK. ~ , SEEPAGE Pit ., DRAIN FIELD . TO RIVER. LAKe, STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UND]STURBeD SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WJTH AIRTIGHT REMOVABLE CAPS. GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. Performed Legal Uescription:_/J~-/..?/_ ~gm~ This form repor'~s: Soils log.~ GREATER ANCIIOk!\GE ARCA DOROU Department of [nvironmen[al Quality 3330 'C' Street Anchorage, Alaska 99503 SOILS I,OG PEROLATION TEST Depth Feet 2 3- 9- (~) ~ lO- tl 12- 13- ?~Jas g --~ter encountered? Reading Date Gross Time Percolation rate lainute, Percolation Eest if yes, at what depth. Net Time Depth to Wate~~ Her Drop -Proposed installation: Seepage Pit Drain Field ................ Depti of Inlet / Depth t~"-b})-~-t~-n~?"pit or trencl, E(~-040 (6174) Test Hole 7 Lot 31, Block 3 Depth in Feet From 0.0' Elevation: Existing Ground To 16.5' W.O. #17378 Soil Description NFS, Sandy Gravel, GP-GM, gray, damp, trace of silt, few large cobbles at 16', Group D. Bottom of Test Hole: 16.5' Frost Line: None Free Water Level: None Type of Sample Depth M Sample Group I 5.0'- 6.5' -- G D 2 10.0'-11.5' -- G D 3 15.0'-16.5' -- G D Remarks: 1. Type of Sample, G = Grab. 2. Group refers to similar material, this study only. RECEiVLo 9/25/81 ROBERT BREA~ER SRA BOX 28-C ANCHORAGE AK 99507 SELLER - ROBERT BREAKER SUBDIVISION-VALLEY VIEW BLOCK-3 LOT-31 ADEQUACY TEST FOR SEWER SYSTEM THE TYPE OF ABSORPTION SYSTEM IS A TRENCH WITH AN AREA OF 350 SQFT. THE SYSTEM IS CAPABLE OF ACCEPTING 600 GALLONS OF WATER PER DAY. THE SURGE CAPACITY OF THE SYSTEM IS 900 GALLONS. BASED UPON THE TEST DATA THE SYSTEM IS ACCEPTABLE FOR A 4 BEDROOM HOME. THE SEPTIC TANK WAS PUMPED ON 9/22/81 SEPTIC TANK ADEQUACY THE EXISTING SEPTIC TANK VOLUME OF THIS 4 BEDROOM HOUSE. 1250 IS ADEQUATE FOR 1220 gUest 25th Aucau¢ · Anchol'a§e, Alaska 99503 "' (907) 276-1361 82.5 "L" STREET ANCHORAGE, ALASKA 9950'1 (907) 264 4'11 I ©EPARTMENT O~: HEAL rli AND ENVII~ONMEN t A[ PROTECTION September 24, 1981 Robert Breager Star Route A Box 28-C Anchorage, Alaska 99507 Subject: Lot 31 Block 3 Valli Vue Estates Subdivision ~2 Approval for the individual sewer and water facilities cannot be granted until the following items have been completed: (1) The septic tank pumped with a receipt submitted to this office for our review. (2) An adequacy test needs to be performed on the existing leaching area. This test will determine if the system is adequate according to National Standards. A listing of private firms performing the test is enclosed. This report needs to be submitted to this office for our review. If there are any further questions, please call this office at 264-4720. Sincerely, Robert C. Pratt, R.S. Associate Specialist RCP/ljw cc: National Bank of Alaska Pouch 7-025 99510 Beverly Bowers % Century 21 - Heritage Homes 207 East Northern Lights Boulevard 99503 GREATER ANCHORAGE AREA BOROUGH Department of Environmental 3330 "C" Street, Anchorage, Alaska 99503 BE SURE TO TAKE A WATER SAMPLE AS THIS SYSTEM IS NOT BEING SAMPLED REGULARLY. Quality 274-4561 Date Received September 13, 1976 Time of Inspection REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR Cony. Date of Inspection I. Approval reouested by: Alaska Bank of Commerce Mailing Address: Pouch 7012 99510 2. Property Owner: Timber Enterprises, Inc. Mailing Address: Post Office Box 3351 Phone: 279-5641 3. Legal Description: Lot 31 Block 3 Valli Vue Estates Phone: 4. Location: 6304 Red Tree Circle 5. Type of facility to be inspected Single 6. Well Data: Contmunity System A. Type o C. Construction Sewage Disposal System: A. Installed Family No. of bedrooms B. Depth D. Bacterial Analysis On-site system B. Installer C. Septic Tank: I. Size D. Seepage Pit: 1. Absorption Area E. Disposal Field: Total length of lines Distances: A. Well to: Septic tank Nearest lot line B. Foundation to septic tank 2. Manufacturer 2. Material , Absorption area , Other contamination , Absorption area C. Absorption area to nearest lot line 349-1922/344-5931 4 , Sewer Lines , EQ-034 (1/74) Page 1 of two pages Page 2 of two pages - Re(. ~t for Approval of Individual .~-X)r & Water Facilities Legal Description Lot 31 Block 3 Valli Vue Estates Comments Approval Valid for one year from date signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM c'ertify that the information contained in this request for approval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating satisfactorily. SIGNED Date EQ-034 (1/74) MUNICIPALITY OF ANCHORAGE t~, ',!:C',t'^IITY OE ANC~C,'2A(~E DEPARTMENT OF ENVIRONMENTAL QUALITY 3. O~: I IEALTI'. ~ 3330 "C" Street, Anchorage, Alaska 99503 - 274-456~ ~;4¢' - ' ~,IENTA]- PRQ[~CrlON 19 6 REQUEST FOR APPROVAL OF INDIVIDUAL SEWER and WATER FACILITIES .': ' CE!~ED] 1. Type of Inspection: CMRO VA FHA 2. Property Owner: T±mber Enterprisesr Inc, Mailing Address: P.0. Bo× 335i, Anchorage, AK 3. Name of Buyer: Robert J. & C-heryl L. Breager Mailing Address: 4823 Bishop Way~ Anchorage~ AK 4. Name of Lending Institution: Alaska Bank o£ Commerce Mailing Address: Pouch 7012, Anchorage, AM 99510 Phone 5. Name of Realtor or Agent: Beverly Hamilton Mailing Address: 3300 C Street. Anchorage. AM Phone CONY Day Phone Day Phone 349-1922 or 344-5931 337-9521 (work) 333-7779(home) 279-5641 278-2525 Legal Description: Lot 31 Block 3 Valli Vue Estates Location: 6304 Red Tree Circle, Anchorage, AK 7. Type of Facility to be inspected: Home 8. Water Supply Type of Supply: Public Utility __ If Individual, number of dwellings presently served If Individual, depth of well 9. Sewage Disposal System Type of System: Public Utility If Individual, date of installation 1975 __ Individual Individual (on-site) No. Bdrms. 4 £0-037 (1/74) DATE RECEIVED ._ ~ INSPECTION APPOI NTM B~IT~ ~.//~/~ MUNICIPALI~ OF ANCHORAGE mUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ( ENVIRONMENTAL SANITATION DIVISION S~_P ~ 8 ]gS'l Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWE I 4. ~EALTOR/AGENT ' STREET LOCATION 6. TYPE O~ RESIDENCE NUMBER OF~BEDROOMS [] One ~~ SINGLE FAMILY ~ Two ~ Five ~ MULTIPLE FAMILY ~ ~ Six [] Other 7. WATER SUPPLY [] INDIVIDUAL~ ~ ATTACH WELL LOG. A well log is required for all wells drilled ~ COMMUNITY since June 1975. For wells drilled prior to that date, give well [] PUBLIC UTI LITY depth (attach log if available.) s. SEWAGE DISPOSAL SYSTEM ~] INDIVIDUAL/ON-SITE** ~ YEAR ON-SITE SYSTEM WAS INSTALLED. [] PUBLIC UTILITY J~ NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTI LITY Connection Verified ~G RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] INDIVIDUAL/ON -SITE ~-ATE INSTALLED []PUBLIC UTILITY 4:~ -)_~ Connection Verified ~STALLER []Septic Tank or []HoldingTank Size: /~- ~0 If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER ~.~ ~..~=~.. TOTAL ABSORPTION AREA MATERIAL 4. DISTANCESwELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5..COMMENTS /,~APPROVED FOR.'~7 BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED /~,~ DATE BY ¢( 72-010 (Rev. 6/79} MUNICIPALITY OF ANCHORAGE o� 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. 015-341-37-000 Expiration Date: Legal description VALLI VUE ESTATES #2 BLK 3 LT 31 Site address 6314 RED TREE CIR Anchorage AK 99507 Current property owner(s) UNGER LAYLA 11/10/2023 X The On-site system(s) is/are approved for 4 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: Original Certificate Date: 8/10/2023 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development 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 Absorption Field Advisory Tank Age Advisory Other X Well Flow Advisory Nitrate Advisory Arsenic Advisory COSA ApprovaLjune 2022 MV UH OpAUTY OF ANCHORAGE Development Services Department �� Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 015-341-37 Complete legal description Valli Vue Estates #2 Block 3 Lot 31 Location (site address) 6314 Red Tree Circle Anchorage, Alaska 99507 Current property owner(s) Layla Unger Day phone 2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS 3. TYPE OF WATER SUPPLY: ❑ 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 8 - 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 $ 950 Waiver Fee $ Date of Paymentt / $/ 'Z Date of Payment COSA # 05r --Z312-70 Waiver # COSA Application.doc COSA Checklist.docx COSA Checklist Legal Description: VALLI VUE ESTATES #2 B3 L31 Parcel ID: 015-341-37 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____ A. WELL DATA - PUBLIC &/OR CLASS “A” WATER Well log is filed with Onsite (or attached) Date drilled Total depth ft Cased to ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) in. Date of flow test for COSA Static water level at beginning of test ft. Well production at time of test gpm Water storage tank volume NA gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date Comments __________________________________________________________________________________ B. TANK DATA Measured operating fluid level in septic tank 50” Date of pumping 7/20/23 Required maintenance completed, if AWWTS Comments: C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) 6/16/15 ALL standpipes present per record drawing Total measured depth from grade 14.5 ft (max) Measured depth to pipe invert from grade 6.6 ft (min) N/A – pressurized field. Per record drawings, field is insulated. Monitor tubes go to bottom of effective. If not, state depth into effective Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) N If yes, enter date Adequacy test date 7/20/23 Results Pass Fluid depth prior to test 44 in Water added 600 gal New fluid depth 48 in Elapsed time 30 min Final fluid depth 44 in Absorption rate 600 gpd FIELD STATUS – POST RECOVERY Effective depth (per record drawings) 96 in Effective depth used 44 in Effective depth remaining 52 in Comments/Deficiencies: Approximate total measured depths from existing grade. ED per elevation measured shots & appears approximate. Appears the 2015 system is operating in the middle range of the field’s ED. COSA Checklist.docx E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) - NA Septic Tank/Lift Station on Lot > 100’ Yes if No ft Neighboring Tank > 100’ Yes if No ft Absorption Field on Lot > 100’ Yes if No ft Neighboring Absorption Fields > 100’ Yes if No ft Community Sewer Main > 75’ Yes if No ft Community Sewer Manhole/Cleanout > 100’ Yes if No ft Private Sewer/Septic Line > 25’ Yes if No ft Holding Tank > 100’ Yes if No ft Animal Containment > 50’ Yes if No ft Manure/Animal Excreta Storage > 100’ Yes if No ft N/A – Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundations > 10’ Yes if No * ft Tank to Property Line > 5’ Yes if No ft Field to Property Line > 10’ Yes if No ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No ft If tank or field is under driveway comment below F. ENGINEER’S COMMENTS *Met code at installation. G. CERTIFICATION & STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm FIRST WATER CONSULTING Phone 907-350-9566 Engineer’s Printed Name CURTIS HUFFMAN, PE Date 7/26/2023 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. 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 in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. 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, any or NO estimate of how long a system will function satisfactory for current or future occupants or guarantee that no unseen encroachments, deficiencies or discrepancies exist can be given by First Water Consulting & 7/26/23 0 " ' �f ` Development Services Department On -Site Water &Wastewater Section Certificate of On -Site Systems Approval Parcel I.D. 015-341-37 1. GENERAL INFORMATION Expiration Date: Complete legal description Valli Vue Estates #2 Block 3 Lot 31 Location (site address) 6314 Red Tree Circle Phone: 907-343-7904 Fax: 907-343-7997 Current property owner(s) Charles McAllen Trust Day phone Mailing address Real estate agent 6314 Red Tree Circle, Anchorage, AK 99507 Marilyn Pokupec 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 Day phone (907) 952-1229 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ❑ Private Septic Q Water Storage ❑ Holding Tank ❑ Community Well Q 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 $ 50 Date of Payment a log a 021 Receipt Number o 08� q D COSA # 05G21 f Q ui 6 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 Forge Engineering Phone (907) 522-7773 Address 1399 W. 34th Ave Suite 101, Anchorage, AK 99503 Engineer's Printed Name Benjamin Schiller Date 2/11/2021 DSD SIGNATURE System #1 Approved for —1— bedrooms System #2 Approved for bedrooms Disapproved ofgsll 1 •r•H �`.. .- -� Ben)arr nnSchiller �� �Fc • CE 12592 • �`�� Ilkl%PROFESSIONAW Conditional approval for bedrooms, with the following stipulations: \P�\�Y WATER AND M WAST" VIATER z� o_ ell By: Original Certificate Date: Z— . -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: Valli Vue Estates #2 Sub, Block 3 Lot 31 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA ❑ Well filed withOnsite (or attached) Date drilled Total depth ft Cased to ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) in. Date of flow test for COSA Static water level at beginning of test ft. Comments Community Water B. TANK DATA Age of tank(s) 6 years Tank type/material SEPTIC/STEEL Measured operating fluid level in septic tank 50 Al Standpipes/foundation cleanout per record drawing Date of pumping 02/22/21 A+ Home Services D. ABSORPTION FIELD DATA DEEP TRENCH Which system tested (date installed) 6/13/15 ❑ ALL standpipes present per record drawing Total measured depth from grade 14.7 ft (max) Measured depth to pipe invert from grade 6.9 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: COSA Checklist yellow sheet Parcel ID: 015-341-37 Structure served by this system Well production at time of test gpm Water storage tank volume gallons Well disinfected for coliform test? ❑ Yes ❑ Nc ❑ Coliform bacteria is Negative Nitrate mg/L ❑ Nitrate less than MRL (ND) Ar ug/L ❑ Arsenic less than MRL (ND) Collected by '� Date of Sample C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 2/9/21 Results Q Pass For 4 bedrooms Fluid depth prior to test 25 in Water added 626 gal New depth 45 in Elapsed time 1440 min Final fluid depth 27 in Absorption rate >450 gpd Any rejuvenation treatment (past 12 months) 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' El Yes Community Sewer Manhole/Cleanout > 100' ft QQ Yes if No ft Q Yes if No ft Neighboring Tank > 100' 0 Yes if No ft Private Sewer/Septic Line > 25' 71 Yes if No ft Absorption Field on Lot > 100' 0 Yes if No ft Holding Tank > 100' Z✓ Yes if No ft Neighboring Absorption Fields > 100' Surface Water > 100' F/1 Animal Containment > 50' Q Yes if No ft ft El Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' Q Yes if No ft rv] 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' H Yes if No ft Property Line > 5' 0 Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' 0 Yes if No ft Private Wells > 100' M✓ Yes if No ft Water Main > 10' 0 Yes if No ft Community Wells > 200' 0 Yes if No ft Water Service Line > 10' Fv� 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' El 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' F/I Yes if No ft Private Wells > 100' 0 Yes if No Water Service Line > 10' 0 Yes if No ft Community Wells > 200' 0 Yes if No Surface Water > 100' F/1 Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION I 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 OF A4 `�•'9 �¢¢ * 419TM •*>� . .. , .... Benjarri chiller >� ¢� �F� • . CE 12592 . • �`�,�� is�F •, 2/11/21 PROFESS0 ft il