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Home My WebLink AboutT12N R2W SEC 30 W2NW4NW4NW4SE4 Onsite File T12N R2W Section 30 W2NW4NW4 NW4SE4 #021 - 022 - 01 Municipality of Anchorage On-Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP171361 PID Number: 021-022-01 Dwelling: X Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: X New ❑ Upgrade Name MITCHELL JACOBUS ABSORPTION FIELD ❑ Deep Trench X Wide Trench ❑ Bed ❑ Mound Site Address A . ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 3 1.2 GPD/SF1 2.5 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 0.5 Ft. Gravel depth beneath pipe 2.0 Ft. Subdivision Block Lot T12N R2W SEC 30 W2 NW4 NW4 NW4 SE4 Fill added above original grade 21+ Ft. Gravel length 53 Ft. Township Range Section Gravel width 5.0 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 375 Ft2 1.0 Ft. Well 100,+ 100'+ 50'+ TANK Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer ANCH TANK Capacity 1000 Gal. Surface Water 100'+ 100'+ Material Number of compartments Lot Line 10'+ 5'+ NA STEEL 2.0 Foundation * * LIFT STATION Manufacturer Capacity Remarks * NO FOUNDATION INSTALLED Gal. Alarm location Electrical installed by PIPE MATERIAL House to tank 3034Tank to 3034 drainfield Installer MIKE N ANDERSON Drainfield 3034 CO/MT 3034 Inspector MIKE N ANDERSON, P.E. BENCH MARK (Assumed elevation) 112.6 ft /ON, Inspdates: on �s 3 23 ) �l 2nd s� Location and description TOP OF WELL CASING 3`d 4th ON-SITE WATER AND WASTEWATER SECTION APPROVAL En kwers& Stamp Conditional Approval: Date � °°k j� 4" ✓e° f `Jomo.o o r o0 0`'0 2/o ee ° e o°�•; �I• " ° MICHAEL N. ANDERSCN �� `�°°. CE-94 9 2 •:c, Septic System c Approved �%�� Date ^ .t 7�( �•. Note: this approval does not include well permit requirements. kmuv uDiuu 1 a) Permit No. OSP171361 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: T12N R2W SEC 30 W2 NW4 NW4 NW4 SE4 PID No.: 021-022-01 MARK A B C01 60 125 CO2 99 54 TC01 5 47 TCO2 11 42 CO3 11 39 C04 117 37 MT1 136 11 C05 135 13 C06 135 0 T2 1 I ",TH#1 1000 GALLON STEEL TANK DRIVEWAY 1 095,— 0 _DSUGH E EXISTING WELL RADIUS I F 001 r CO2 1/ T105.18 r C01F C04 i y/C0 /1S C05 02 t 4, ®O®®F' ®(\®oFI 101.8 C) FINISHCRAOF ® .0 ORG 4 �• ®` ®®® FlLTER FABRIC @ INSULATION ® AIF 49 TH ------------- or 1 7 U00 CALION 1 .7 sau .xn SP ............. .............. 0 S7EEL TANK 0 00.. 97 7 ®O t� '• MICHAEL N. ANDERSON. �u m �0��'. No. CE 9469 SEPTIC SECTION 81.5 l�/ ®••........(•�•� `® N.T.S. BEDROCK,TA DRY ®®®®\®®®®® / i EXISTING WELL RADIUS I F 001 r CO2 1/ T105.18 r C01F C04 i y/C0 /1S C05 02 t 4, ®O®®F' ®(\®oFI 101.8 C) FINISHCRAOF ® .0 ORG 4 �• ®` ®®® FlLTER FABRIC @ INSULATION ® AIF 49 TH ------------- or 1 7 U00 CALION 1 .7 sau .xn SP ............. .............. 0 S7EEL TANK 0 00.. 97 7 ®O t� '• MICHAEL N. ANDERSON. �u m �0��'. No. CE 9469 SEPTIC SECTION 81.5 l�/ ®••........(•�•� `® N.T.S. BEDROCK,TA DRY ®®®®\®®®®® Permit Number: #SW171361 Date of Issue: 1241-17 Parcel Identification Number: 02102201000 Date Started: 12-20-17 Date Completed: 12-23-17 Is well located at approved permit location? x Yes ❑ No Legal Description: T12N R2W Sec30 W2NW4NW4NW4SE4 Property Owner Name & Address: Mitchell& Bo Liu Jacobus iC'S5 / 1 9820 Meadows Rd IS500 � Anchorage, Alaska 1 'IC4 Borehole Data: Soil Type, Thickness & Water Strata Depth (ft) From To Method of Drilling x air rotary ❑ cable tool Casing type: steel stick-up 0 2 Wall Thickness: .025 inches gravelly silt Bedrock 2 3 3 406 Diameter: 6 inches Depth: 44 feet Liner Type: Diameter: inches Depth: feet Casing stickup above ground: 2 feet Static water level (from ground level): 167 feet Pumping level: 400 feet after 2 hours pumping 3 gpm Recovery Rate: 3 gpm Method of Testing: air li t Well Intake Opening Type: ❑ Open End x Open Hole ❑ Screened Start feet Stopped feet ❑ Perforations Start feet Stopped feet Grout Type: bentonite chips Volume: 55 hjzr Depth: Start 0 feet Stopped 41 feet Pump: Intake Depth feet Pump size hp Brand Name Well Disinfected Upon Completion? x Yes ❑ No Method of Disinfection: Comments: Appears to be a large fracture or fault at 212' 215' Area is constantly caving but may stop when air is removed. Should set pump above at 205 and test for clarity. r 6AN14-. Well Driller: Alpine Drilling & Enterprises PO Box 110496 j V Anchorage AK 99511 SGS Ref.# Printed Date/Time 12/19/2019 16:42 Collected Date/'rime 12/05/2019 13:30 Received Date/Time 12/06/2019 9:40 'rechnical Director Stephen C. Ede 1197217001 Client Name Aarow Pump & Well Service Project Name/# T12NR2WSec30 w2NW4NW4NW4SE4 Client Sample ID T12NR2WSec30 w2NW4NW4NW4SE4 Matrix Drinking Water Sample Remarks: Allowable Prep Analysis Parameter Results LOQ Units Method Container ID Limits Date Date !nit Metals by ICP/MS Arsenic ND 5.00 Up -/L EP200.8 B (<10) 12/16/19 12/18/19 BIN/I% Waters Department Total Nitrate/Nitrite-N 0.214 0.200 m&L SM21 4500NO3-P C (<10) 12/10/19 EWW Microbiology Laboratory E. Coli Negative I 100mL SM21 9223B A 12/06/19 A.L Total Coliform Negative I 100mL SM21 9223B A 12/06/19 A.1 - 2 .L 2 .trent Municipality of Anchorage .s l\� lleparunent v P.O. Box 196650 ® 4700 Elmore Road Anchorage, Alaska 99519-6650 ® (907) 343-7904 ® Fax (907) 343-7997 http://www.muni.org/Onsite ®evelopment'Services ®epaftment On -Site Water and Wastewater Section * * * * VARIANCE/WAIVER REVIEW * * * * Waiver#: OSV191102 COSA#:OSC191603 Permit#:OSP171361 PIDM 021-022-01 Legal Description: T12N RM Section 30 W2NW4NW4NW4SE4 Engineer: Mike N. Anderson Applicant: Mitchell Jacobus Your request for a waiver of the required 10 feet horizontal separation from the absorption field to the property line has been approved. The approved separation distance is 5.0 feet. See engineer's waiver request for justifications. This waiver approval applies to the existing absorption field only. Any future upgrade to the on- site wastewater disposal system will require all separation distances be met or another approval from this department. Waiver is Granted: X Waiver is not Granted: Date: �� `� f Approved by: A Name of Reviewer ..............................................................................t **** VARIAN C EMAIVE R REVIEW **** Dec. 24, 2019 Municipalities of Anchorage Departments of Health and Human Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Fax 249-7847 Re: LOT LINE WAIVER Legal: T12N R2W SEC 30 W2,NW4,NW4,NW4,SE4 To Whom it may concern: This is a request for a lot line waiver for the leach field on the above referenced lot. This new system will not impact any of the neighboring properties. The separation distance to the neighboring septic is over 500 feet and will not impact this system or waiver. Sincerely Michael N. Anderson, P.E. 4661 Natrona Anch, Ak 99516 Ph 727-8864 •ue►ogs se jdaaxa .f;aadoad Pees uo s;uauxasaa xaq;o ao souti uoxssxuxsueal 'sSeespeoa ou aim aaaq} juq; pus uot;sanb III sastuxaad aq; uo goeoaaue o}aaaq; ;uaoefpe ButSI Slaodoad aq; uo s;uouxaeoaduxx ou '4ugy •ue►ogs asuLaaq}o ssajun olaaagn -4ua3afpe BuxST S;aadoad aq; uo gosoaoua ao dulaano }ou op pus soutl Spadoad oq; utTVTA aae uoaaagl polun}ts s;uauxaeoadxm axn }uq; pus ,uot;oaatp Sux ;e ao 'aux .Sq paSaeans uaaq seq uoaaaq pagtaosap Af}aadoad aq} }aq} S;t;sao Sgaaaq I ijaxoISS t9ig-si 1 0. y�/ y�A, \7 3o 08 0-b oz 0 OZ vxsv iv `NVI(IRla 1t (lavAias ISak z aoNVZI `HIHON z T dIHSNAk0J, `os Nou'Das */T as `-V/ T AIN` -P/ T A1N WT Aw z/ T Al uoildtaasaQ jeWaZ 6GOzBSV 8-�8 oog plat a Sq uAtuaQ Tt55-05E (406) 40566 uxsvIV 'aBs xouou'V Z'IIIIH—sv CV6z MS aetaa aVetaasD Tt62: MID 119"Ag A9909 ,Ob = G 6 L03/Sz/Z [ alua,q aiva 191 00 Ln 0 m 00 U� P9'6z� :]<<9ZcL LOON •JDGA uouonjisuoo aui io L aagW@AON of aoijd UOIIID U@WIpas puri uoisoaa Iuanaad ol paziligDIS slios aq4 ao `P@;Dlabanaa ag Dogs asodind Auo aoj papnuap soajo Ild :gZON EASBIV _`a"dLmouz)uv p�eod Mopeay� O 86 :SSHZIQQV XIHHdOHd MUNICIPALITY OF ANCHORAGE mens • \ On-Site Water& Wastewater Program N0 `5(, (� ! PO Box 196650 4700 Elmore Road Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997 http://www.muni.org/onsite I)t'll;lrl•111i'lll 4'YcHOR"V' On-Site Water & Wastewater System Permit Permit Number: OSP171361 Effective Date: 12/4/2017 Work Type: WellSeptic Initial Expiration Date: 12/4/2018 Tax Code Number: 02102201000 Site Legal Address: T12N R2W SEC 30 W2NW4NW4NW4SE4 G:2943 Site Mailing Address: 9820 MEADOW RD, Anchorage Owner: JACOBUS MITCHELL & BO LIU Lot Size in Sq Ft: 54450 Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING Total Bedrooms: 3 This permit is for the construction of: 0 Disposal Field 0 Septic Tank 0 Holding Tank 0 Privy El 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: mix, Date: 174 i Issued By: Piktets, CcpjuA Date: .142 if zo I MUNICIPALITY OF ANCHORAGE --;',. Community Development Department lirli, 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. 021-022-01 Property owner(s) BRIAN MITCHELL Day phone Mailing address Site address 9 S O trY1e-ckcio W Rci Legal description (Sub'd., Block & Lot) Legal description (Township, Range & Section) T12N R2W SEC 30 W2NW4NW4NW4SE4 Lot Size 54,450 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (®all that apply) Absorption Field ❑X Initial Single Family (SF) ❑X (w/wo ADU) Septic Tank 0 Upgrade ❑ Duplex (D) ❑ Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE /WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further Certify th "'"fin accordance with applicable Municipal Codes. / w'QV a 020/, M//4"-. '-'(Signature of property owner or authorized agent) 0 �'u 68L 99n Permit/Rush Fees: Waiver Fees: Date of Payment: /1 0 Date of Payment: Receipt Number: /� � Receipt Number: (1 Permit No. � p�ITJJ(Dl Waiver No. Permit App__- :_..c Nov. 30, 2017 Municipalities of Anchorage Departments of Health and Human Services P.O. Box 196650 Anchorage,Alaska 99519-6650 Fax 249-7847 Re: New Septic & Well Permit Legal: T12N R2W SEC 30 W2,NW4,NW4,NW4,SE4 To Whom it may concern: This is a request for a septic and well permit on the above referenced lot. A single test hole was excavated and found poorly graded sand,SP,for the entire depth with bedrock at 8.5 feet.The perc rate was 2 minutes per inch therefore a shallow 5-wide trench as been designed. From the site plan all of the surrounding properties are vacant. The slope near the system is at 24 percent with no slopes over 25 percent. This permit will not impact any of the neighboring properties due to the lot layout. Please call me if you have any questions. SincerelyoA Michael N. Anderson, P.E. 4661 Natrona Anch, Ak 99516 Ph 727-8864 DESIGN CRITERIA: MOUND OVER (TH#1) o GRADE uffiglill FILTER FABRIC 3 BDRM X 150 =450 GPD 0 5 _ORO 10.5 ■•� &INSULATION SOILS =450/1.2 = 375 GPD ,"0 PIPE 375 GA/5.0 `0.70 = 52.5' SP 2.5 SEWER ROCK I 5.0' (1) TRENCH 2.5.0' DEEP 2.0' EFFECTIVE 5.0'WIDE 53' LONG 8.5 SP SEPTIC FIELD SECTION 4 L 2 I PGPN� a --__ i ` /' PROPOSED \ DRAINAGE FIELD`\ 'I j lI -MEADOW ROAD- I ,I :11 • JVELL I I I\\ I 111 I 11 / / u / \ /� PROPOSED 3 \� / // PROPOSED WELL 100' JPC'C's BEDROOOHUSE �.�� ,' RADIUS -d9t_=% \\_N__,,\,.\.\ PROPERTY LINE °:\-------- a 4 Nikic.iiiiiiiii‘ ..iiie Septic Design Prepared for .80�111kss\%41, BRIAN MITCHELL 47 C')..".* OF q��.♦♦ G'° �1, ♦♦ T12N, R2W, SEC 30,W2,NW4,NW4,NW4,SE4 : . •. 49TH /\ * ♦♦♦ Anchorage, Alaska • • 4,14)(\.. • Michael N. Anderson P.E. DATE: 11/30/2017 ♦♦♦ :MICHAEL N. ANDERSON$1- t 9 694601 NATRONA AVE DRAWN: DJR ♦%No. 1.LIQ �� ANCHORAGE,ALASKA 99516 _ ' ' • (907) 727-8864/FAX: (907) 345-1391 SCALE: 1"=100 444 `;�� • 54-P 5�P ,,, P\P P\P / • O //' .c V.- co.O'' ��//// / // / VAC TLAND / / NO CUT SLOP • 25%WITHIN 50' I / PROPERTY LINE / NEW 1000 GALLON / STEEL TANK / / CO I I-7 / PRIMARY LEACH 1---r-1`, FIELD ,' 1 .N \ 1 ' I i DTC• j // �T I i I DC �; 01,/i, PRO LL SECONDARY / I LEACH FIELD 1 1 i '9y I • 11 1 I 1 / 1 1 / 1 \ \ / 1 alliFCO\ 1 P \.-- LI 1 5 ---- 1\ P \ .� P� SLOPE TYP. \ PROPOSED • P • 5 •• • • • •• • 10 • \ \ Septic Design Prepared for .�votsmiitIlI,, BRIAN MITCHELL .��P Com, OF q4 •4. ♦. C"'�'• �1, • ♦i T12N, R2W, SEC 30,W2,NW4,NW4,NW4,SE4 : :' 49TH /\ �':'� ♦� Anchorage, Alaska • • P.E. t .. .% Michael N. Anderson, EDATE: 11/30/2017 ;MICHAEL N. ANDERSON;- ♦ NO. E 9469 ' 4601 NATRONA AVE DRAWN: DJR ♦♦♦� ; ••.(2. (3,: i ANCHORAGE,ALASKA 99516 SCALE: 1"=30' v.�� ESS� .•.• (907) 727-8864/FAX: (907) 345-1391 k'%%swiss— Municipality of Anchorage ./16424* 5 %t Development Services Department •'' •' •'• •,y T • Building Safety Division r!'i • T N i { -c.2,...e, On-Site Water and Wastewater Program / •• 9 �� •.• "r �� ._ 4700 Elmore Road 111 } . P.O.Box 196650 Anchorage,AK 99507 m••II. "f www.ci.anchorage.ak.us • MICHAEL N. ANDERSON ,ey.F4 (907)343-7904 ¢A S'-;,.. CE-9469 .','• --' Soils Log - Percolation Test �� p�''/'••.....••'•'.`°=~ Performed For: 1�t/'‘4 yy ,fit 4 r vz I/ Date Performed: `h* 'f' '- Legal Description: T-t 2 R 21,' 4 2 T 50 W L Township,Range,Section: Slope Site Plan Depth (Feet) L"- 5°M t G 4 1- 2- 3- c'tV---, c(Gtsel 41 la4- 5- 6- 7- 8- )(2,e L e•e It., WAS GROUND WATER O 9- ENCOUNTERED? J\t v fiVWi L 10- v IF YES,AT WHAT DEPTH? Depth to Water After p 11- grrd Monitoring? 0 r/�///- E 12- l Date: !['/!'hi- 13- 7// i- '/ 13- HyC42i w tns 'Pr2-sock?4, 4-//„•4t 14- Reading Date Gross Time Net Time Depth to Water Net Drop 15- 144b &U /I 5" "( tit►. C� 6 ft 16 17- Li/• 5 " 18- (OaS e/ 19- 20- PERCOLATION RATE Z/ (minutes/inch) PERC HOLE DIAMETER Go TEST RUN BETWEEN 7i FT AND Tj FT COMMENTS PERFORMED BY: f./( NJ I CERTIFY THAT THIS TEST AS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: n (.49. MUNICIPALITY OF Development Services Department On -Site Water & Wastewater Section Parcel I.D. 021-022-01 Certificate of On -Site Systems Approval 1. GENERAL INFORMATION Phone: 907-343-7904 Fax: 907-343-7997 Expiration Date: ��✓i�,h � q 2 o'1120 Complete legal description T1 2N R2W SEC 30 W2 NW4 NW4 NW4 SE4 Location (site address) 982�MEADOW RD ANCH AK Current property owner(s) MITCHELL JACOBUS Day phone Mailing address Real estate agent Day phone 2. TYPE OF DWELLING: �,� 3 4 5 6"" 0 Single Family (w/wo ADU) 90 ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) �9 3. NUMBER OF BEDROOMS: 3 8�957Z�� 4. TYPE OF WATER SUPPLY: TYPE OF WAS ATER DISPOSAL: Private Well El Private Septic Z Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Received by: iAA:: Date: 2 COSA to be released to the engineer, unless otherwise requested by the engineer. ,2ush COSA Fee $ 1 t �5� Waiver Fee $ 9 b Date of Payment r aI a3I� Gk 012)y Date of Payment L Ll Receipt Number ;t q(0 Receipt Number zn0 333 COSA # 055U611 kPo3 Waiver # 0�5N tiO� 110 a 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. Date 12-22-19 c> a °e• L�� a ° • %A 6. DSD SIGNATURE �J. ° , • . , . ° , o , , fa �1 System #1 Approved for 3 bedrooms ° ° °� ° •/ ° • ° `> 9 •° MICHAEL N. ANDERSON System #2 Approved for bedrooms '�" ` °, cE 94 Disapproved Conditional approval for bedrooms, with the following stipulatrW ,-e�,- Y• Original nOrl mal Certificate Date: 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: T12N R2W SEC 30 W2 NW4 NW4 NW4 SE4 Parcel ID: 021-022-01 If more than 1 septic system on lot: COSA Checklist # of Structure served by this system A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 12123117 Total depth 406 ft Cased to 4V ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 20"+ in. Date of flow test for COSA NEW Static water level at beginning of test 167 ft. Comments NEW WELL AND WATER SYSTEM B. TANK DATA Age of tank(s) 2018 years Tank type/material STEEL Measured operating fluid level in septic tank NEW ❑ Standpipes/foundation cleanout per record drawing Date of pumping NEW D. ABSORPTION FIELD DATA NEW SYSTEM Which system tested (date installed) NEW X ALL standpipes present per record drawing Total measured depth from grade 4.5 ft (max) 11 Measured depth to pipe invert from grade 2,4:�:ft (min) ❑ N/A — pressurized field Monitor tubes go to bottom of effective. If not, state depth into effective Well production at time of test 3+ gpm Water storage tank volume 0 gallons Well disinfected for coliform test? ❑ Yes ❑ No 0 Coliform bacteria is Negative Nitrate 0.214 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L R Arsenic less than MRL (ND) Collected by AAROW PUMP Date of Sample 1215/19 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date NEW Results [D Pass For 3 Fluid depth prior to test 0 Water added gal New depth in Elapsed time min bedrooms 1E 0 Code -required soil cover over field Final fluid depth in ❑ System presoaked Absorption rate gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) UN date of test) Gallons introduced 0 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' Q Yes Community Sewer Manhole/Cleanout > 100' If absorption field is under driveway comment below r,7/ Yes if No ft / Yes if No ft Neighboring Tank > 100' 0✓ Yes if No ft Private Sewer/Septic Line > 25' F✓ Yes if No ft Absorption Field on Lot > 100' ❑✓ Yes if No ft Holding Tank > 100' ✓0 Yes if No ft Neighboring Absorption Fields > 100' Animal Containment > 50' ❑✓ Yes if No ft r7l Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' �✓ Yes if No ft 0 Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' P(� Yes if No ft Surface Water > 100' ® Yes if No ft Property Line > 5' 0 Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' El Yes if No ft Private Wells > 100' F71 Yes if No ft Water Main > 10' 0 Yes if No ft Community Wells > 200'✓❑ Yes if No ft Water Service Line > 10' [D Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' Q Yes if No ft If absorption field is under driveway comment below Property > p y Line _ 10' ®Yes if No ft Wells on Adjacent Lots: Water Main > 10' Yes if No ft Private Wells > 100' U Yes if No ft Water Service Line > 10' Yes if No ft Community Wells > 200' El Yes if No ft Surface Water > 100' 0 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 210 Tlug 4 xe .a oaS ab;.COe aecs�aoa �4 c.e { i t L _ �