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HomeMy WebLinkAboutGREENLAND BLK 5 LT 2Onsite File Greenland Block 5 Lot 2 #015-171-35 (Rev 05102118) Municipality of Anchorage On-Site Water and Wastewater Section ♦ (907) 343-7904 Page 1 of 2 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP211061 PID Number: 015-171-35 Dwelling: 0 Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New F011 Upgrade Name WHITBECK ABSORPTION FIELD Q Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 4720 E 115TH AVE ❑■ other Phone Number of Bedrooms Soil Rating depth from original grade 4 0.8 GPD/SF JTotal 17 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 9 Ft. Gravel depth beneath pipe 8 Ft. Subdivision Block Lot GREENLAND BLK 5 LT 2 Fill added above original grade 1'+ Ft. Gravel length 24' SQ,see a e pit Ft. Township Range Section Gravel width 2.0 FL Beds: Number of Lines Distance between lines R. SEPARATION DISTANCES To Septic Absorption Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Lift Station Tank Line 768 Ft2 Ft. Well *501+ **100'+ 100'+ 501+ TANK ❑ Septic ❑ S.T.E.P. 0 Holding ❑ Other Manufacturer Capacity Gal. Surface Water 100'+ 100'+ 100'+ Material Number of compartments Lot Line 10'+ 10'+ 10,+ NA Foundation0 1'+ 101+ 101+ LIFT STATION Manufacturer Capacity Gal. Remarks * well is pre-1973 ** existing concrete seepage pit rebuilt w/ new drain rock Alarm location Electrical installed by PIPE MATERIAL House to tank Tank to 3034 Installer MIKE N ANDERSON, P.E. drainfield Drainfield 3034 CO/MT3034 Inspector MIKE N ANDERSON, P.E. BENCH MARK (Assumed elevation) 95.4 ft Inspeection 1# 2"d3-15-21 Lonescription description cation ad and ction SW corner of siding 3rd 4,h ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer s Stamp Conditional Approval: Date .1 p , - �r 4 912-2, r Septic Syste Appro_ Date ©^�9 C _. .by �'a `fes' • %z 1• .� Note: this approval does not include well permit requirements. '�� 4k-t•'' ' (Rev 05102118) Permit No. OSP211061 Page 2 of 2 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone: 343-4744 On—Site Wastewater Disposal System and/or Well Inspection Report Legal Description: GREENLAND BLK 5, LOT 2 PID No.- 015-171-35 - 1--- - 7 \ - MARK A B C01 70 60 ' CO2 71 fy1 PRE 1971 MT 83 171 i PID No.- 015-171-35 co, s SEPTIC \ f I )ASS SCAL'll, _1,,='S0- FINSH o co ao o 0o oo o Mm I- — T BETE SEPTIC I 1 / 1 i 0 0.0 ORO AV�.•• _ •••• y ® A 'vt: 49TH p� 0®� : MICHAEL•N. ANDERSON;_® ®®% ' No. CE 9469 ••'•..3-23-21 �AV DRY, MARCH 2021 - 1--- - 7 \ - / i I DRI AY; / WELL, PRE 1971 BENCH, BOTTOM OF SIDING1 I I WEIi� WELL B yi / NEW 24 X 24 8' SEEPAGE AROUND EXIS G 6' DIA. CON SEEPAGE NT \� � /CI'T1 TH#1-I-` \I — — — — — -1- I— — — — --f I ( � f SEPTIC I L� _ _ // I \ \I ! I 1 i I SEPTIC co, s SEPTIC \ f I )ASS SCAL'll, _1,,='S0- FINSH o co ao o 0o oo o Mm I- — T BETE SEPTIC I 1 / 1 i 0 0.0 ORO AV�.•• _ •••• y ® A 'vt: 49TH p� 0®� : MICHAEL•N. ANDERSON;_® ®®% ' No. CE 9469 ••'•..3-23-21 �AV DRY, MARCH 2021 11M� 2- 3- 4- 5- 6- 7- 8-1 1 L_ c- y -t j yr Date. WAS GROUND WATER Municipality of Anchorage Depth to Water F � Development Services Department On -Site Water and Wastewater Section 4700 Elmore St. '�j 9 : r *:'4 LHJ ej ........... P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite ri Monitoring? E 12- ............ (• 907) 343-7904 MICHAEL N. AKD.'RSr,;-,j CE 94'9 Soils Log - Percolation Test '33% Performed For: lit Z �C Date Performed: Legal Description, r A11,a1 S LLA ?-,Township, Range, a' -I Section: Slope �T7 cz� . I 1 7-1— 1 Site Plan 1 1 1 F F -T7 11M� 2- 3- 4- 5- 6- 7- 8-1 1 L_ c- y -t j yr 14-1 1 (,-t -e u 'i cT' 15- Sued , COMMENTS h-4 t Reading Date. WAS GROUND WATER 9- Depth to Water ENCOUNTERED? 10- er IF YES, AT WHAT DEPTH? L Depth to Water After 0P 11- Monitoring? E 12- Date: _.L 13- 14-1 1 (,-t -e u 'i cT' 15- Sued , COMMENTS h-4 t Reading Date. Gross Time Net Time Depth to Water Net Drop 3 L-) er -3 7/,y '33% rCJNUULM I IUINI r" 1 r- (mlnuteshnch) PERC HOLE DIAMETER _ C,0 TEST RUN BETWEENFT AND Z_' FT PERFORMED BY: I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: MUNICIPALITY OF ANCHORAGE Onsite Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 htlp:J/www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP211061 Effective Date: Work Type: Septic Upgrade Expiration Date Tax Code Number: 01517135000 Site Legal Address: GREENLAND BLK 5 LT 2 G:2636 Site Mailing Address: 4720 E 115TH AVE, Anchorage Owner: WHITBECK DEBRA A & RICHARD L Lot Size in Sq Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING Total Bedroon This permit is for the construction of: 0 Disposal Field ❑ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the S Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify th Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during fi shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing ,,ZAN Special Provisions: 1. A test hole is required prior to construction of the seepage pit to confirm minimum 6 it sepa impermeables and 4 ft separation to seasonal high groundwater, as well as to confirm percok s$ than or equal to 15 mpi. Construction may proceed at your own risk prior to 7 -day groundwat results require a design change, construction shall stop pending review and approval of a ch2 r submit results with the inspection report (or change order, if required). 2. Contractor shall stake the 100 ft well radius for the well on Greenland Block 5 Lot 3 (to the construction of the seepage pit. Received By: Date: Issued By. Date: 3 i 3/9/2021 3/9/2022 18000 ❑ Water Storage of Alaska Development weather :ion to )n rate is less monitoring. If e order. Please prior to 4 MUNICIPALITY OF ANCHORAGE Aw Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section -V Fax: 907-343-7997 Fi f ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 015-171-35 Property owner(s) Debbie and Richard Whitbeck Day phone Mailing address 4720 E 115TH AVE ANCH, AK Site address SAME Legal description (Sub'd., Block & Lot) GREENLAND BLK 5 LT 2 Legal description (Township, Range & Section) Lot Size 18,000 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field 0 Initial ❑ Single Family (SF) El Septic Tank ElUpgrade Q (w/wo ADU) ❑ Holding Tank ElRenewal ElDuplex (D) Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: $??952 (RUSH) Waiver Fees: Date of Payment: Date of Payment: Receipt Number: (9e2 C-21 �7�, Receipt Number: Permit No. OSP211061 Waiver No. G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc March 8, 2021 Municipalities of Anchorage Departments of Health and Human Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Fax 249-7847 Re: Septic Permit Legal: GREENLAND BLK 5 LT 2 To Whom it may concern: This is a request for a septic permit on the above referenced lot. The system has a concrete tank and concrete seepage pit which is plugged up and needs to be rebuilt with new drain rock. The new seepage pit will be 24’ square by 8’ deep with an application rate of 192/sqft/bedroom for a total of 750 sqft. The old trench system will be abandoned in place. Per your direction a new test hole and perc will be done to verify the soils and possible water table elevation. The lot slopes less than 2 or 3 percent to the north with no cut-banks or open water within 100 feet of the site. This revised system will not impact any of the surrounding neighbors. Sincerely Michael N. Anderson, P.E. 4661 Natrona Anch, Ak 99516 Ph 727-8864 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211061, Rebecca Carroll, 03/09/21 1"=50' PROPERTY LINE EXISTING HOUSE DRI VE W A Y 24' SQ X8' DEEP SEEPAGE PIT TO BE RE-BUILT WITH NEW DRAIN ROCK, NEW TEST HOLE REQUIRED W/ WATER MONITORING. MT CO SEPTIC AREA 100' WELL RADIUS SCALE: DJRDRAWN: DATE: GREENLAND BLK 5 LT 2 Anchorage, Alaska DEBRA & RICHARD WHITBECK 3/7/2021 100' WELL RADIUS2-3%EXISTING WELL DRILLED 1970 THEREFORE 50' RADIUS TO TANK DCO SEPTIC AREASEPTIC AREA SEPTIC AREA SEPTIC AREA WELL WELL WELL 100' WELL RADIUS 100' WELL RADIUS 100' WELL RADIUS OLD TRENCH TO BE ABANDONED IN-PLACE Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211061, Rebecca Carroll, 03/09/21 N rOW FAWRAL ►iIiar���a N8958'46" W100.00 0000�OO�O �.�49 TH D SAft 0 0ooi°NSHANE A. HOLT el �DO Qn LS -6914 C6 le��0 .la o �ofessionax ��DOOoo�� N8958'46"W10000 ALLEY NOTE NO EASEMENT5APPEAR ON THE RECORD PLATON TI -115 LOT NOTE THE BOUNDARYDATA SHOWN HEREON IS COMPUTED FROM GPS DATA; USING FOUND PROPERTY CORNERS AND BOUNDARYMONUMENTS THEBEARINGSARE NOT ADJUSTED TO THE PLAT BEARINGS NOTE THE ASPHALT DRI VEWAYIS SHOWN APPROXIMA TEL Y U51NGINTERNETIMAGING THE EXTENT OFPA VING MAYBE SOMEWHAT DIFFERENT UPON MELTING THAN SHOWN HEREON THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SHOW ANY CONFLICTS BETWEEN EXISTING STRUCTURES AND PLATTED LOT LINES AND/OR EASEMENTS; AND IS NOT TO BE USED FOR POSITIONING ADDITIONAL STRUCTURES, IMPROVEMENTS, OR FENCELINES. EASEMENTS OF RECORD, OTHER THAN THOSE APPEARING ON THE RECORD PLAT , ARE NOT SHOWN HEREON ( UNLESS INDICATED) NOTE: FENCELINES THAT MAY APPEAR ON THIS DRAWING ARE NOT TO BE USED TO DETERMNE PROPERTY LINES OR POSITION ADDITIONAL IMPROVEMENTS. ANY PAVING SHOWN HEREON MAY BE APPROXIMATE DUE TO EXCESSIVE SNOW AND/OR ICE. I THE SURVEY DATA AND MEASUREMENTS HEREON ARE PREPARED FOR THE OWNER OF RECORD AS OF THE DATE OF THIS SURVEY. ANY USE OF THIS DRAWING BY THIRD PARTIES IS PROHIBITED UNLESS WRITTEN PERMISSION IS PROVIDED. AS-BU/L T SURVEY 1" =20' NO CORNERS SET THIS DATE I HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY OF THE FOLLOWING DESCRIBED PROPERTY LOT2, BLOCK5, GREENLAND SUB ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS EXIST OTHER THAN NOTED. DATED AT ANCHORAGE,ALASKA THIS 11TH DAY OF - - - - -FEBRUARY- --------------, 2021 14938, FB 211-19 HOLT LAND SURVEYING 9309 GROVER DRIVE ANCHORAGE,AK 99507 345-5513 Gpr~TER ANCHORAGE AREA BOROI'"H HEALTH DEPARTMENT 327 EAGLE ST. ANCltORAGE, ALASKA 99501 279-2511 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL. SYSTEM MAILING ADDRESS .~7~ LEGAL DESCRIPTION SEPTIC TANK: DIS1ANCE FROM WELL ~-~'~ 7 LIQUID CAPACITY~/.~-~. ~7~ GALLONS. MATERIAL ~,,~.g/~.~_~,.,L~..,~_:._. NUMBER OF , .C~M_~RTMENTS INSIDE LENGTH INSIDE WIDTH DEPTH SEE!PAGE SYSTEM: SEEPAGE PIT: NUMBER OF PITS LINING MATERIAL NEAREST LOT LINE OUTSIDE DIAMETER ~;,~./~---;~-~:~-~ DISTANCE FROM WELl ' TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) LENGTH__'~ / , DEPTH ~' / BUILDING FOUNDATION~''~ ' ~' ,~-~ ~/ SQ. ~T. TILE DRAIN FIELD: DISTANCE FROM WELT NUMBER OF LINES ABSORPTION AREA DEPTH: TOP OF TILE TO FINISH GRADE .'/~--~'7 ~<" , FOUNDATION "'~/'~' / ''-/''- · NEAREST LOT LINE! DISTANCE BETWEEN LINES ~.-~ ~/'~2 / "/~ TRENCH WIDTH _so. FT. //U / DEPTH OF FILTER MATERIAL BENEATH TILE TOTAL L E N G TH/~'~:'~ ., OF LINES IN. TOTAL EFFECTIVE IN. ABOVE TILE / / WELL: TYPE ~-'/-~'~/~(/? ''/ DEPTH ~'~F~/~"-~;;'' LOT LINE ~ ~) / NEAREST SEPTIC ~ SEWER LINE ~ , TANK DISTANCE FROM ~ ~-- WATER , BUILDING FOUNDATION. ,//~ ~ SAMPLE .,~-..~ / SEEPAGE ,~ , SYSTEM ,,,~._~2./ , CESSPOOL · NEAREST OTHER .... , SOURCES DISTANCES: DIAGRAM OF SYSTEM DATE 'HEALTH AUTHORITY {)ROUGH c~ No._~_~ GREATEI 327 Eagle St. ANCHORAGE AREA HEALTH DEPARTMENT Anchorage, Alaska 99501 279-2511 SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT NAME OF APPLICANTT/~C/&~Je,~fl-- ~le~_Frq RESIDENCE ADDRESS LEGAL DESCRIPTION APPLICATION TO INSTALL: SEPTIC TANK TO SERVE THE FOLLOWING FACILITY FINANCED THROUGH ~' '¢ ~3 -~% PERCOLATION TEST RESULTS MAILING ADDRESS ,~'}i PT ¢~ LOCATION OF INSTALLATION_ PHONE NO TO BE ,NSTALLED BY_ Ix/ ANTICIPATED DATE OF COMPLETION ~ '~3~.v'- BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT T,~S ~S TO SERVE AS IH ~. ~ / ~ AS DESCRIBED BELOW· .. SEPTIC TANK SIZE __//~)-~'- ~) / / P o , PERMIT TO INSTALL A __ SIZE OF UNIT tO BE SERVED TYPE C~-/29Y/~/S E EPA6 E A REA DIAGRAM OF SYSTEM I certify that I am familiar with the requirements of Greater Anchorage Are] Bj?rou~.h Ordhnance No. 28-68,an~hat the/ above described system is in accordance with said code. , ,, / I.} / I,/ DATE ~ 2: ~ - ~' : (~ APPLICANTS SIGNATURE.. ?( " 3REATER ANCHORAGE AREA BOROUGH HEALTH DEPART~IF~NT 32? EAGLE STREET ANCHORAGE, ALASKA 99501 CASE # Perfommed For~.~'.~_~q~Sf[ -:: -^ Leg'al Descz, iptlon. Lot i~ Block ~.. ~uD~lvlslon__z~l~ ~,~ Th.ts Form Reports a: So~ls Log ...... Depth Feet Soil ChaPacteriszics Location Sketch Gz, oss Time Net Time Depth To H20 Net Drop ------7 ........... ZZ---7.Z Proposed Ins,allatlon: Seepage Pit ~ Drain Field , ~ ~~~~ ..... ~~~ ~ ~ ~- ~,~,_ , Test Performed REQUEST FDR APPROVAL OF ^ £/~ /~" · INDIVIDUAL SEWAGE AND WATER FACILITI~ (Fill out in Triplicate) ~i~,/Y' . ~ . ~ ~ame .of person requesting approval ~ , 5. ~ate~Analysls: a. Bacterial b. Detergent .............. Distance from well to closest existing or p~oposed: 1. Sewer line ........ 2. SeptJ. c tank 3. Seepa~fe Apea / 7~ I · 4, Cesspool' . 5. Property Line~. 6. Other sources of possible contamination, i.e., creeks, lakes, houses, barn~ drainage ditch, etc. . . Sewage disposaI system. b. Septic tank capacity in gallons e. Name of septic tank manufacturer p . e. erc~ti~ Te-st ~s~ts f. Percolation Test performed by Use the m~erse.side of this form to show 'iagram. Diagram'sho ~-~he followxng information: p~operty lines;.well location~ house location, ~ptic tank location, disposal area location~ location of percolation test, an~.direction of ground slope. 9. The '~fo~ation on this form is true and correct to the best of my knowledge. StKnature of Applicant '6~"~-- TO BE FILLED OUT BY HEALTH DEPAET!.tENT PERSONNEL he above described sanlta~y facilities are hereby approved, subject to the ............ '~$'ltowin~ conditions i Conditions: -~- The above described sanitary :facilities are disapproved for the following reasons: Date ":' . ['.[, /,.'~.,.1~ '-.App~al,. is valid, for one year following. ~, the date of approval, · .- CPJ:cw MUNICIPALITY OF ANCHORAG Development Services Department ; On -Site Water & Wastewater Section Certificate of On -Site Systems Approval Parcel I.D. 015-171-35 1. GENERAL INFORMATION Expiration Date: Complete legal description GREENLAND BLK 5 LT 2 Location (site address) 4720 E 115TH STREET, ANCH AK Current property owner(s) DEBRA & RICHARD WHITBECK Mailing address Real estate agent SAME 2. TYPE OF DWELLING: Q Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 Day phone Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER I Private Well 0 Private Septic 0 Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. $280 COSA Fee $ Waiver Fee $ — Date of Payment 2-1 Date of Payment Receipt Number 02-5- -9 Receipt Number OSC211132 COSA # Waiver # hone: 907-343-7904 Fax: 907-343-7997 POSAL: 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify thl on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this a on-site water supply and/or wastewater disposal system is (are) safe, functional and adt bedrooms and type of structure indicated herein. I further verify that based on the infon Municipality of Anchorage files and from my investigation and inspection, the on-site water disposal system is (are) in compliance with all applicable Municipal and State codes, ordin effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify th Name of Firm MIKE N ANDERSON, P.E. Phone 727 Address 4661 NATRONA AVE ANCH AK Engineer's Printed Name MIKE N ANDERSON, P.E. Date 3-15- 6. DSD SIGNATURE VSystem #1 Approved for 4 A System #2 Approved for Disapproved Conditional approval for my investigation, based Plication, shows that the uate for the number of ation obtained from the apply and/or wastewater ices, and regulations in information submitted. 1 bedrooms, with the following stipulatio S� �`�� o�TOF A A , �(, �ra s'� � o � • 1y --'r od 49 x �...•* ... .... e °. t.. .., _ _ WAST. ........ ....:. bedroomsN. ... bedrooms ��`�:r,,. CL --946 bedrooms, with the following stipulatio S� �`�� o�TOF A A , �(, Original Certificate Date: LS — — 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. T 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 .� -STTE WATER ANDm =_ _ _ WAST. Z: PRCVhAM O Original Certificate Date: LS — — 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. T 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: GREENLAND BLK 5 LT 2 If more than 1 septic system on lot: COSA Checklist # A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled UN Total depth *90 ft Cased to UN ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 10"+ in. Date of flow test for COSA 2/9/21 Static water level at beginning of test 55 Comments * FROM MOA FILE B. TANK DATA ft. r Age of tank(s) 50 years * Tank type/material Measured operating fluid level in septic tank 49" ❑ Standpipes/foundation cleanout per record drawing Date of pumping *CONCRETE -SEPTIC, 3/11/21 - of D. ABSORPTION FIELD DATA SEEPAGE PIT RE -BUILT Which system tested (date installed) 219/21 ❑ ALL standpipes present per record drawing Total measured depth from grade 17 ft (max) Measured depth to pipe invert from grade 9 ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of effective. If not, state depth into effective Parcel ID: 015-171-35 Structure served by this system Well production at time of test 1,8+ gpm Water storage tank volume 0 gallons Well disinfected for coliform test? ❑ Yes ❑ N ❑ Coliform bacteria is Negative Nitrate mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by MNA Date of Sample 2/9/21 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date NEW Results M Pass For 4 bedrooms Fluid depth prior to test in Water added gal New depth in Elapsed time min ❑ Code -required soil cover over field p Final fluid deth in ❑ System presoaked Absorption rate gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) date of test)If yes, enter date 0 Gallons introduced gallons Comments/Deficiencies. SYSTEM HAS CONCRETE SEEPAGE PIT W! NEW DRAIN ROCK INSTALLED 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' *50+ Community Sewer Manhole/Cleanout > 100' Yes if No ft M Yes if No ft Neighboring Tank > 100' F✓ Yes if No ft Private Sewer/Septic Line > 25'7/1 Yes if No ft Absorption Field on Lot > 100' ✓CI. Yes if No ft Holding Tank > 100' 21 Yes if No ft Neighboring Absorption Fields > 100' Yes if No ft Water Main > 10' Animal Containment > 50' F/ Yes if No ft MV Yes if No ft 0 Yes if No ft Water Service Line > 10' Yes if No Manure/Animal Excreta Storage > 100' If septic tank is under driveway Community Sewer Main > 75' �✓ Yes if No ftM 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' MV Yes if No ft Property Line > 5' Q Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' 0 Yes if No ft Private Wells > 100' Yes if No ft Water Main > 10' ft Yes if No ft Community Wells > 200' 0 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' 0✓ Yes if No ft Wells on Adjacent Lots: Water Main > 10'✓Q 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' Q Yes if No ft F. ENGINEER'S COMMENTS *WELL INSTALLED PRE -1973 G. ENGINEER'S CERTIFICATION 1 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 r J Ilk • • 0 MICHAEL N. AND' RSCN ; �, CE -945p D-vzmmzn -i z7u 0m D00x {mmmm�mrn D;;o z m O n z 0 -_ H -� m.-. -I W -1 O z m to m to z nHnZ 0CmD wzmr mwm-1 SJ Smrm m-Ih z wzttAM MztD - D z O m r) -nm r I� D to t -t O 0 z S Q y CP m my-100_UXM m� D O D m 30 D o m t -t z to 0 D Z< z O G) W OU Sz-4po �li �O• O mom zcMc-I VVIVI tPGG�� D�0 -1 0 H -nim ��0�✓ �Q Yo 0Dz VI-4M(A OdG Mr- m00tom �0��a 3t+x DzDO 'oDzm m;o vro m 00 D to m m o<�o w 1 r z m m Z zC-DIH- mr-q mn-iz 0 -Am 0=0� m D z m r z LA m m mtnOH ZaH2O 02A2o aZZ LA z t r -ILA >��am amQm n00 < O nxm" 111. 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