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HomeMy WebLinkAboutFOREST VIEW HEIGHTS LT 14F y �; orest � y U •o a y' APR 2 7 2018 Municipality of Anchorage On -Site Water and Wastewater Program • (907) 343-7904 Page 1 of 2 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP171230PID Number: 014-141-21 Dwelling: 9 Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: Q New ❑ Upgrade Name: JOHN MATTHEWS ABSORPTION FIELD 0 Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound Address ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 3 1.2 GPD/SF 11.4 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 5.4 Ft. Gravel depth beneath pipe 6.0 Ft. Subdivision Block Lot FOREST VIEW HEIGHTS, LOT 14 Fill added above original grade 0.5 Ft. Gravel length 35 Ft. Township Range Section Gravel width 2.0 Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Lift Station Tank Line 420 Ft2 1 Ft. Well 100'+ 100'+ 50'+ TANK 9 Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer ANCH TANK Capacity 11000 Gal. Surface Water 100'+ 100'+ Material STEEL Number of compartments 2 Lot Line p'+ 2'* NA Foundation 51"+" 10'+ LIFT STATION Manufacturer Capacity Curtain Drain U N U N Gal. Remarks * LOT LINE WAIVER REQUESTED Pump on level at in. Pump off level at in. High water alarm at in. Pump make and model Electrical Inspections performed by Tank to PIPE MATERIAL House to tank 3034 drainfield 3034 Installer MIKE ANDERSON Draintield 3034 CO/MT 3034 Inspector MIKE ANDERSON, P.E. BENCH MARK (Assumed elevation) 96.4 ft Inspeection �" 9-9-17 9-9-17 Location and description 2nd 3'd 4'h GARAGE SLAB COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL �Flginee�s Sdamp Conditional Approval: Date.°r a - r, p� J • qZ v < o o e.• e e s. e• e•° •f# •o .n :• ........... o•MICHAEL N. ANDERSCiJ� r .� CE .0,4 119 o. Approved fukx/,,U, (�UUA Date 541.0 h$ inspecuon Keport_a-­i-iz.aoc Permit No. OSP171230 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: FOREST VIEW HEIGHTS, LOT 14 PID No.: 014-141-21 MAR A B C01 E 35 11 TCO 1-1 38 14 CO2 38 23 CO3 35 Y5-- _.CQ4 21 52 MT 22 51 A I z� I I!, DRIVEWAY i I \ \ \/' - --- -------- F_'v3;U1 IN MT1 rr i� v 03 �7 CO2 0 0 c c 0 1, TP Z_ I ti NEW 100 STEEL TANK rGG' _TCQ1 CO2 r C114 W&ML'"TATAII trio rco, r�T f 0 99,5 ............... RN'5fl GRAO' -,17 # 49— •Q Ti 0 ......... ..... 0 914.5 1.000 CALLOW{ SW 0 0 STEEL TANK 00 0........ ................................. N. ANDERSONIT" tNo. :E 9469 SEPTIC SECTION . . Lj U.S. DRY AUG. 2017FE it It % 11 �p \ �' t pay p ,01 N00008'00"W 62.50 o 0 10' T & E EASEMENT . Joe ° ° ° ° ym h�°�ytdtE p'' ------------------------------------ ---- ' 6' / c7 P ,� a� cd a Air J -d 07 a o o�°per a� Vpmm�a A3110 .P'�b u "-, OR P'ck) sol9 - - coal wmam7��.�mgp C7 aOj ° 00 ma, �a i � . Q� c Q�'►�i o �°�..m � �' a m c ami a`�i qq 3 L_L_J �i F �A ° M o o (L) L� O O ~.c�aap 00 00 o L r 0 L 8 5'S L) z (D-) \i (7)0 00 rn 00 N > z o cn „ 0 o N c o a U) 072 5 C o a� w W o A a =� Cd Lli > > LoLij o LL Ln 6 2.5 0 Lnm L LEWIS LANE �, ��to C ° � �co �,�� N 00°08'00" Wco co w v Q°q�0v o m U')� N cd N .Lj it OWNER 0FLAND: Bird Treatment& Learning ADDRESS: LEGAL DESCRIPTION Forest View Heights Lot 14 DATE: 9-6-17 PERMIT NUMBER: [8p171230 DATE opISSUE: 8-22-17 TAX IDENTIFICATION NUMBER 01414121000 is well located at approved permit location: L/NYes [_]No F71 �� Method of Drilling: 1/Nair rotary �_|cab|etoo| Depth ofWell: 125' [asingType: Steel Wall thickness .lSO inches Diameter: 6 inches, depth 124 feet Liner type Static Water Level: 52 feet Recovery Rate 20 [X] gpm El Qph Method ofTesting Air Well Intake Opening Type: IN open end Mopen hole F-1 Screened Start feet Stopped �� __- �� Perforations Start feet Stopped Grout Type: Bentonite Volume: 50lbs Depth: from 2 feet'to 42 feet Well Disinfected Upon Completion: Nyes [_]no Method of Disinfection: Chlorine 50 PPM Comments: Bore Hole Data Depth From To Casing Stickup l 4 Overburden 4 68 Silty Sand &Gravel 68 91 Silty Sand & Gravel w/Clay 91 106 Silty Sand & Gravel w/Cobbles 106 108 Tight Sand & Gravel Water 3GPM 108 112 Yellow Clay &Gravel 112 122 Silt QSand w/Gravel 122 | I25 | Sand&Grave| Water Drillers Name: Cole Sullivan ATTENTION: It is the responsibility of the property owner to submit a copy of the well log to the proper authority. Municipality of Anchorage: Department of Health & Human Services and/or Department of Environmental Conservation. MatSuBorough: Department ofEnvironmental Conservation. Well Drilling Permit Number: SW OSPI71230 Date of Issue 8-22-17 Parcel Identification Number: 01414121000 Legal Description FOREST VIEW HEIGHTS LT 14 Pump Installation Date: 12,17'17 Pump Intake Depth Below Top ofWell Casing: Pump manufacturer's Name: F&VV Pump Model: 4FI1PO5301S Pump Size: 1/2 Pit|essAdapter Burial Depth: 10 Pit|essAdapter Installer: ANDERSON Disinfected Upon Completion? N yes Method ofDisinfection: Chlorine SQPPM U UComments: PNess MonufacturenMART|NSEN 11 Pump installers Name: Sullivan Water Wells Property Owner Name &Address JOHNN1ATTHEWS 7917LEWIS PLACE ANCHORAGE 90 feet feet Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation. MI Mun*dpafity of Anchorage A110"k, P.O. Box 196650 ® 4700 Elmore Road Anchorage, Alaska 99519-6650 ® (907) 343-7904 © Fax (907) 343-7997 http://www.muni.org/Onsite Development Services Division On -Site Water and Wastewater Program * * * * VARIANCE/WAIVER REVIEW * * * * Waiver#: OSV171087 COSA#: Permit#:OSP171230 PID#: 014-141-21 Legal Description: Forest View Heights Lot 14 Engineer: Mike N. Anderson Applicant: John Matthews �E l�c9Ci�v�1� re�J �seci -00r u�S1�Iled ooS -V-01C Your request for a waiver of the required 10 feet horizontal separation from the absorption field to the' has been approved. The approved separation distance is 5< Q. 0 feet. See engineer's letter for justification. This waiver approval applies to the absorption field only. Any other future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. ❑ The affected adjacent property owner(s) have been given a 7 day notice regarding this waiver. ❑ Notarized letter(s) of nonobjection have been received from the owner(s) of the affected adjacent property. ® Adjacent properties are not affected by this waiver. Waiver is Granted: x Waiver is not Granted: Date: S %� �O% Approved by: daaat& Name of Reviewer .............................................................................. I **** VARIAN C E/WAIVER REVIEW **** April 25,20l7 Municipalities of Anchorage Departments u[8c khandBmnam8crvios P.O. Box 196650 Anchorage, Alaska 995lV-665O Fax 249-7847 Ke: Lot line Waiver Leou: Forest View Heights Lot 14 To YVhom kmay concern: This is u request for lot |bu waiver u|the north end oftbc leach field. 9leoyc seed the attached site p|uo and inspection report for the location. . This lot line wiavcrwill not impact any nfthe neiohboho� propertiesductodlot Please call mcifyou have any questions. Sincerely 04 Michael N. Anderson, P.E. 4661 Natrona &nuh,/\k995[6 Ph 727-8864 MUNICIPALITY OF ANCHORAGE „r On-Site Water&Wastewater Program PO Box 196650 4700 Elmore Road 1 4 Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997 �rr. '!, j httpalwww.muni.org/onsite i1.1 i• u n.fft On-Site Water & Wastewater System Permit Permit Number: OSP171230 Effective Date: 8/22/2017 Work Type: WellSeptic Initial Expiration Date: 8/22/2018 Tax Code Number: 01414121000 Site Legal Address: FOREST VIEW HEIGHTS LT 14 G:2134 Site Mailing Address: 7317 Lewis PL, Anchorage Owner: BIRD TREATMENT & LEARNING Lot Size in Sq Ft: 8349 Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING Total Bedrooms: 3 This permit is for the construction of: 0 Disposal Field El Septic Tank ❑ Holding Tank ❑ Privy 0 Private Well 0 Water Storage 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 State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development 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 freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By: Date: Issued By: Date: af20 / 7 MUNICIPALITY OF ANCHORAGE r Community Development Department • ` Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On-Site Water & Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 014-141-21 Property owner(s) JOHN MATTHEWS Day phone Mailing address Site address LEWIS PLACE Legal description (Sub'd., Block & Lot) FOREST VIEW HEIGHTS LOT 14 Legal description (Township. Range & Section) Lot Size 8349 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (®all that apply) Absorption Field ❑X Initial ❑x Single Family (SF) ❑x (w/wo ADU) Septic Tank ❑X Upgrade I- Du ❑ Holding Tank ❑ Renewal ❑ ~` ple DwelTlrts ❑ Privy ❑ F acid/or D) `'6, O Private Well Nrn .0 Water Storage ❑ 4- THIS APPLICATION INCLUDES A VARIANCE /WAIVER REQUEST FOR: _ . .4 • BETWEEN THE FOUNDATION AND SECONDARY TRENCH Distance: g 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: St 916 1- 7 V4 -- Waiver Fees: .91 Date of Payment: o ( �11 Date of Payment: ? Ito hi Receipt Number: d1 6 �2I Receipt Number: .I 5 52) Permit No. OSQ)1 'i30 Waiver No. OSV I 1 1" -1 Permit App__-.. ::_.,.c V Aug 15, 2017 Municipalities of Anchorage Departments of Health and Human Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Fax 249-7847 Re: New well/septic system and Waiver Legal: Forest View Heights Lot 14 To Whom it may concern: This is a request for a septic and well permit on the above referenced lot, plus a waiver between the foundation and leach field. A new test hole was excavated in the backyard and found a very clean sand, SW. Water was not observed during the excavation or after the 7 day monitoring period. The perc rate was 2 minutes per inch at 4 feet below grade. A deep trench has been designed with 6 feet of effective. The tank will be a STEP due to the elevation. Due to the size of the lot we are also requesting a waiver of 5 feet between the foundation and the secondary trench. The foundation is a crawlspace and will not impact the septic trench due to the depth of the trench and footing location. The lot sloped about 5 to 6 percent and has no cut banks with slope greater than 25 percent, see the drawing. This new system will not impact any of the neighboring properties due to the lot layout. Please call me if you have any questions. Sincerely ` tt V Michael N. Anderson, P.E. 4661 Natrona Anch, Ak 99516 Ph 727-8864 Carroll, Rebecca M. From: Randy Hamilton <randy@taxsolutions.net> Sent: Saturday, August 19, 2017 5:02 PM To: Mike Anderson Cc: Carroll, Rebecca M.; Noffsinger, Ross D. Subject: Re: FOREST VIEW HEIGHTS LT 14 Mike: Thank you for your assistance in helping my wife Carolee and I get our well moved onto lot 13, which I purchased only 45 days ago, from Lot 9 where it currently exists. We think this move is required if we are ever to be able to develop lot 9 or 10. Randy Hamilton 907-243-1040 office 907-230-9105 cell randy@taxsolutions.net On Aug 18, 2017, at 2:15 PM, Mike Anderson <mnandersonS8@gmail.com>wrote: Randy, the MOA needs you to give them an email for the file stating you intend to move your well to your new lot 13... per the attached plan..just as we discussed last week...so we don't impact any neighbors...please tell them you recently purchased the lot ...its not showing up on the MOA records too.. I have copied the MOA reviewers so just respond...all.. Mike 727-8864 From: Carroll, Rebecca M. [mailto:CarrollRM@ci.anchorage.ak.us] Sent: Friday, August 18, 2017 9:45 AM To: Mike N. Anderson (MNAnderson58(agmail.com) Subject: FOREST VIEW HEIGHTS LT 14 Just a reminder that this is all that is needed for approval of this permit. <Onsite Review Comments.pdf> <Septic]-Layout 1.pdff DESIGN CRITERIA: I MOUND OVER (TH#1) o r- GRADE 3 BDRM X 150 = 450 GPDoRc SOILS = 450/1.2 = 375 GPD 1.0 - mill• m FILTER FABRIC 375 GA/12 = 31 ' 1.25.0 PIPE (1) TRENCH I S , SEWER ROCK 10.0' DEEP !0 6.0' EFFECTIVE -$1.0 2.0' WIDE 2.0' 31' LONG 19 SEPTIC FIELD SECTION .` VA 1 v . • I I / II`. I PROPOSED NEW VACANT ` � ' - -- .--- 3 BEDROOM VACANT HOME I - r�. J . . ,','• PROPERTY UNE rf �`* , f r . . '//' , WELL /,/, . I g' pin // II l If 1 II I } 1 I1 I \\, 401 ill ; 7 L iJI1 I f 1 1 1 11SEP'[IC`1 1_ 1 I 1 `N. CIEI!f 1 1 PROPOSED PROPOSED NEW WELL �.'''r4 \.` PRIMARY SEPTIC t /7. ' p SYSTEM j1 PROPOSED •ff rb 1250 GALLON `� `11 FUTURE WELL / ii STEP TANK `� 10 BY CURRENT 1� sir VA S .'y�`- ____-- --- 0 �IAv+"" �I I ' I ,\\,. 1, /i,1 I /' 11 LY \♦ 1 / i 1 W „5S , , / 1 w APPROX �XISTINIG WALL ' `-' LOCATION OF �, / I a HOUSE rr --- --- iI I rr 111 rr , \ r 1 1 , ,�\_-, SEPTIC „'. `. \ 1 I, / ii Septic Design Prepared for �1� JOHN MATTHEWS + ~...................... �F 4�q• �. FOREST VIEW HEIGTHS, LOT 14 a., _ �I .• q •• Anchorage, Alaska �9 H �� • Michael N. Anderson, r.E. DATE: 8/12/2017 #. .;MICHAEL N. ANDERSON. j 4661 NATRONA DRIVE •• No. 469 \z ANCHORAGE, ALASKA 99516 DRAWN: DJ 1• .,. . ,. + + ` i (907) 727-8864/ FAX: (907) 345-1391 SCALE: 1"=50' ++i� ,+.• i• / r r 1 / I 1 / 1 VAST // 1I'► / 1 ff / I / 1 / 11 ij I I\ /' I ' VACANT ' I I ' \„, , _____I------ ___.� I I -- r PROPOSED WELL I I / 100' RADIUS I I \� I I I PROPOSED WELL I I •/ \ \ �` 100' RADIUS • PROPERTY UNE `•`\•\\ 5-6% ' I 5' WANER REQUESTED TO HOUSE � \ \ v 1\ \ 1....2„.„-----. � I % TI 11 \\\ [El tf., I _,T/ j r� \\\ � I � II PROPOSED 3 �� • '--Z //- \L BEDROOM HOUSE \\ 1 �, � \ 5-6X \� I \ SEPTIC \I I / 1 \ 1 — ''''. Co EllE -.,-", - ok . \,... A -__ ... ____ PROPERTY LINE11 5-6% \ PROPOSED 1250' 11 \ GALLON STEP 'I I PROPOSED DRAINFIELD TANK rnr 11 I •• H • / r/ / ,`/' I ' r r rI I VACANT r / VACANT % / I I .- / ' / I I / / / / / I I , / /', r r I I /- 1 / I I /' r / / / r11 , / / ' / II , �/ I - i i Septic Design Prepared for ' �, iliikiit, JOHN MATTHEWS •'•+� Gr �I`,�*+ FOREST VIEW HEIGTHS, LOT 14 ♦♦ p .49TH ♦ Anchorage, Alaska • • • r• i • Michael N. Anderson, P.E. r DATE: 8;12;2017 ♦♦�'.MCHAEL N. ANDERSGN.\ s ♦ No. Y 9469 • 4661 NATRONA DRIVE • DRAWN: DJR ANCHORAGE, ALASKA 99516 U '••�• ••''� • (907) 727-8864/FAX: (907) 345-1391 SCALE: 1"=30' +4j� F=�, is• 4 Municipality of Anchorage ��pVtG IR4144. ,} �+ - -- Development Services Department .maP. y r. \ Building Safety Division /-k T H �r,� 0 vir,........) On-Site Water and Wastewater Program r ; 49_ L 1-. 4700 Elmore crag �G� 11 i P.O. Box 196650 Anchorage,AK 99507 r• • •- www.ci.anchorage.ak.us : MICHAEL N. ANDERSEN ;4r (907)343.7904 v./ - ie+? CE-9469 ••�``•A Soils LogPercolation Test l�•ff ••••,.•••E`.`°„r Performed For: S� 40 ,..1 ,v1,, 7�'c+cw �j Date Performed: k op ^•••Legal Description: Pry T Lit- 11, #G 14.k 5 Township.Range,Section cr 4-- r I-{ Slope Site Plan fL1 Depth (Feet) toady 1 - - ,,++�� 2- `>�e_-, go.,, 3- 4- 5 ' .lam 6 G(.rG� Orn L. 7- 8- WAS GROUND WATER 9- ENCOUNTERED? l�-0 S , 10- IF YES.AT WHAT DEPTH? L Depth to Water After 0 1 p 1 1- Monitoring? 6.),/4 E 12- Date 1INi _ 13- ` 14- Reading Date Gross Time Net Time Depth to Water Net Drop ip-- !r15- '4l /0»„., g �r 16- to it ,S 1r 17- �/� S N 18- tit S li 19- 0% 64,14,,,, Cl" S r r 20- PERCOLATION RATE 7/ minutes/inch 1 PERC HOLE DIAMETER M TEST RUN BETWEEN i•-t FT AND FT COMMENTS PERFORMED BY: Intl ic,-e_AviLr,►Awl I CERTIFY THAT THIS TEST AS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 15.5"tf MUNICIPALITY OF ANCHORAGE Development Services Department t4 Phone: 907-343-7904 On -Site Water & Wastewater Section '� Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 014-141-21 1. GENERAL INFORMATION Expiration Date: Complete legal description FOREST VIEW HEIGHTS LT 14 Location (site address) 7339 LEWIS PL Current property owner(s) MATTH EWS Mailing address Real estate agent SAME 2. TYPE OF DWELLING: El Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone Day phone 2345 4. TYPE OF WATER SUPPLY: TYPE OFf'WA-5-T Private Well 0 Private Septic Water Storage ❑ Holding Tank Community Well ❑ Community Public Water System ❑ Public Sewer Waiver request for: Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. Date: COSA Fee $ 660 Waiver Fee $ Date of Payment W19 Date of Payment Receipt Number (10,3 9C/ Receipt Number COSA # Q5Qq 1S&3 Waiver # h--) ER DISPOSAL: El Distance: 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 MIKE N ANDERSON, P.E. Phone 727-8864 Address 4661 NATRONA AVE ANCH AK Engineer's Printed Name MIKE N ANDERSON, P.E. 6. DSD SIGNATURE System #1 Approved for 3 System #2 Approved for _ Disapproved Conditional approval for _ bedrooms bedrooms Date 4Q r A 1k 000 .49TH • -�� �, MICHAEL N. ANDERSON r CE- 4 9 •4``•� SSIQe`�� bedrooms, with the following stipulations: r 0" tri O A- BOriginal Certificate Date: — —7-19 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 COSA Checklist Legal Description: FOREST VIEW HEIGHTS LT 14 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 916117 Total depth 125 ft Cased to 2 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 24+ in. Date of flow test for COSA 7/27/19 Static water level at beginning of test 52 ft. Comments B. TANK DATA Age of tank(s) 2018 years Tank type/material STEEL Measured operating fluid level in septic tank NEW Al Standpipes/foundation cleanout per record drawing Date of pumping NEW 3 BEDROOM, 2017 D. ABSORPTION FIELD DATA NEW SYSTEM 9/9/17 Parcel ID: 014-141-21 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 ❑ No X Coliform bacteria is Negative Nitrate 6ZO mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L Al Arsenic less than MRL (ND) Collected by MNA Date of Sample 7/30(19 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Which system tested (date installed) 9/9/17 Adequacy test date NEW ❑ ALL standpipes present per record drawing Results ❑✓ Pass For 3 bedrooms Total measured depth from grade 11.4 ft (max) Fluid depth prior to test 0 in Measured depth to pipe invert from grade 5.4 ft (min) Water added NEW gal ❑ N/A — pressurized field 0 New depth in 01 Monitor tubes go to bottom of effective. If not, state Elapsed time NEW min depth into effective ❑® Code -required soil cover over field Final fluid depth 0 in ❑ System presoaked Absorption rate NEW 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: NEW SYSTEM, LESS THAN 2 YEARD OLD THEREFORE NO TESTING REQUIRED COSA Checklist yellow sheet UN 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 Community Sewer Manhole/Cleanout > 100' 7 Yes if No ft 2✓ Yes if No Neighboring Tank > 100' ❑✓ Yes if No ft Private Sewer/Septic Line > 25' M Yes if No Absorption Field on Lot > 100' 7 Yes if No ft Holding Tank > 100' E✓ Yes if No Neighboring Absorption Fields > 100' Yes if No Animal Containment > 50' ✓❑ Yes if No ❑✓ Yes if No ft if No ft F. ENGINEER'S COMMENTS Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' Q✓ Yes if No ft 2 Yes if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' Q✓ Yes if No ft Surface Water > 100' ft ft ft ft ft Q✓ Yes if No ft Property Line > 5' ❑✓ Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' ❑✓ Yes if No ft Private Wells > 100' ❑✓ Yes if No. Water Main > 10' E✓ Yes if No ft Community Wells > 200' Yes if No. 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 2 ft Wells on Adjacent Lots: Water Main > 10'✓Q ®J 0 MICHAEL N. ANDERSON ; � CE Yes if No ft Private Wells > 100' ❑✓ Yes if No Water Service Line > 10' ❑✓ Yes if No ft Community Wells > 200' Q✓ Yes if No Surface Water > 100' ✓❑ Yes if No ft F. ENGINEER'S COMMENTS ft ft ft ft �•'' G. ENGINEER'S CERTIFICATION p- . ' • 5�a$ p �j�. -J7 Q 1 certify that 1 have determined through field inspections and review•'49TN� Municipal that of records the above systems are in conformance with MOA COSA guidelines in effect on this date. �. .......... . ..... : . . �+ ®J 0 MICHAEL N. ANDERSON ; � CE � P�pfESS10�'�g`` v COSA Checklist yellow sheet ft ft ft ft