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HomeMy WebLinkAboutBIRCHWOOD LOOP LT 3 Onsite File Birchwood Loop Lot 3 #051-243-17 Municipality of Anchorage Community Development Department 2019 Page 1 of 2 On -Site Water and Wastewater Program 4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 • http://www.muni.org/onsite • (907) 343-7904 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP181292 PID Number: 051-243-17 New ❑ El Upgrade Name: JASON & RYAN MATHIAS NHN S BIRCHWOOD LOOP Phone Number of Bedrooms 4 LEGAL DESCRIPTION Subdivision Block Lot BIRCHWOOD LOOP 3 Township Range Section SEPARATION DISTANCES To From Septic Tank Absorption Field Lift Station Holding Tank Sewer Line Well 100+ 100+ N/A I N/A 50+ Surface Water 100+ 100+ N/A N/A Lot Line 5+ 10+ N/A N/A NA Foundation 10+ 10+ N/A N/A Curtain Drain 50+ 50+ N/AN/A Remarks ABSORPTION FIELD 0 Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound ❑ Other Soil Rating Total depth from original grade 0.6 GPD/SF 7.0 Ft. Depth to pipe invert from original grade Gravel depth beneath pipe 1.0 Ft. 6.0 Ft. Fill added above original grade Gravel length +/- 5.0 Ft. 2@42.0 Ft. Gravel width Beds: Number of Lines Distance between lines 2.5 Ft. N/A N/A FL Total absorption area Number of trenches Dist. between trenches 1008 Ft2 2 12.0 Ft. TANK [Z] Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Capacity ANCHORAGE TANK 1250G,1. Material lNumber of compartments FT STATION STEEL 1 2 ty Pump on level at IPump off level at IHigh water alarm at in. Pump make and model Gall in.I Inspections performed by PIPE MATERIAL House to tank Tank to Installer 3034 drainfield 3034 GROUND BREAKERS Drainfield 3034 CO/MT 3034 Inspector Pannone Engineering Services BENCH MARK (Assumed elevation) 165.0 ft Inspection5; Location and description dates: 10/16/18 2nd 10/19/18 3`d 10/19/18 4 1 3/6/19 GARAGE FF COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL Engineer's Stamp �k OF A Conditional Approval: Date ,® "<<G • . fq.1 k� • Steven Pannone CE 8149 Approved - Date mspecuon Keport_1-1-12.doc i•Y tom` � i I t l�% i .! �t ! ~i ��r r � .��1 pr, ;a; r t i �:f �,y t�'f (� \ , i t_. gam; '') Steven R. Pannone, Principal Registered Professional Engineer E-mail: steve@panenaak.com June 24, 2019 Municipality of Anchorage Development Services Department On -Site Water & Wastewater Program 4700 Elmore Road P. 0. Box 196650 Anchorage, Alaska 99519 Subject: BIRCHWOOD LOOP L3 Drainfield Configuration Modification Ladies and Gentlemen: I am writing to request a modification to the normal configuration of monitoring tubes and cleanouts for the subject property. Currently the absorption area is a gravity fed field with a monitoring tube at the ends of both fields and a cleanout at the far end of both fields. Prior to the fields is both a double cleanout and a flow -splitter that was intended by the installer to act as the near end cleanout for the fields. This double cleanout is within the applicable distance from the upper field. The double cleanout is on the outer bounds of the appropriate distance from the lower field however, it will function as required. We are requesting approval for this configuration for this installation only. Granting this modification will not pose a threat to the safety of this lot or the surrounding lots. Please contact me if you have any comments or concerns. Sincerely, Steven R. Pannone, P.E. Owner/Civil Engineer June 24, 2019 Pa li=ne: !/lailinc7P 0. Box i 07, PaInner, AK a964 Te l•^'Ph()r e: '(90 7"!5-U2`00 X: (9=071 i:- 5 --IS 2)0 i N D � Z� n M D Z O mO zj Z -j C1 OF m 0 O �5 -nn-11nm'o -I D ( -'is nava nv iz �7 -i^C �_(l) D(!� D- Z O --S Ocn cn <om�0 mD0 N Q v Q m z n� om-�z Pl O n < ;u0 mD0 X) DO.. CCDrC7 T.Q Cn --+f� m ZLn m - :O Z. FT -1 ci >x z����n�_no m >> r�>F- COy(I7 -i m m CO m _0 -{ I ( A r_n O m O o =# ai N A "� m -< �> m Lt% m x -< O P O r- x A m M M O = .. Z .. z rn Ej 0 C D N C-7) -'u< 0 -D,, D - 0 -< n -*zD� o Vx W>L',0L, m -.. .. Z m 10tnZ v P.�0'7�,7�OGz0 � 0 � �' o0 oo�y�0g:0 D DN NIo K -,O "0 :j mA lO --i o m O I m S*, m� m y D o (n O (�,+ fel O. 0 (Il n -I El: Z o z o_0 0 00 5 O� D Orn �0+' ii I FOUNDATION m 20 n O � _ `' i, N D� z 00 x -i (n 0 010 O) .� 3y CLEAN OUT Z m m m y a� m y a Ln P) r X 'TT -u O Ui Z �m OD x z �� mZ' O m -+ 0 OCLEAN OUT v o z 0 o a C7 _E m 0- r O F 71 C m C 0 CLEAN OUT -1 I o �n DOUBLE F' O `a------�"�- woar�s cows° �• fc �' -� CLEAN OUT !- M FLOW SPLITIR !2' F 4• _� Z D Z �' y.::,:�`.I b Z mn n is r cOh'� E o m/ �l azo I,iONITOR TUB f� / f`' m m O X 0 A �• �.' E <t �$V D N O Ln D < �. m !J D O m .. n. moi_... J3 le m - no0- zm �/ � -� \ �U czp�� a�mJ" >QB.. \ nim yr M�n D �z A. '+l Cli_m m _- 1 \.\\z ODOR_ QvO-r:\°'- / \ --�• \ mzoz z _ \ r \ \ .'0 0 i a \�• \ r m \ ,\ y 6 C1 D \ \ f < Z n a \ � A m � � � \ -rl 07 O a 4 / - � \Q NOTES: RECORD DRAWING DRAWN JRL SITE PLAN K n K K n ca n 0 -1 SCALE = 60' BIRCHWOOD LOOP L3 SITE: 17790 S BIRCHWOOD LOOP RD JASON & RYAN MATHIAS PO BOX 110818.......OSP181292 ANCHORAGE, AK 99511 "A CW CA N N ± \> xyy. N i -. Z \ LO v V O \ MONITOR TUBE - - � �� \ � � + i / D m \ \ .,.., X \ CLEAN OUT D 00 A N \ A K n K K n K n 0 -1 SCALE = 60' BIRCHWOOD LOOP L3 SITE: 17790 S BIRCHWOOD LOOP RD JASON & RYAN MATHIAS PO BOX 110818.......OSP181292 ANCHORAGE, AK 99511 "A CW CA N N PERMIT NO. 0 N i -. D� A N \ A D 0 _ > Oz r V A > A z` 0 \ 0 <m =.DO \ a\\ ` \ o O -\ z V M \ . O o z z \ m o O cn m n CO \ \ 0 K n K K n K n 0 -1 SCALE = 60' BIRCHWOOD LOOP L3 SITE: 17790 S BIRCHWOOD LOOP RD JASON & RYAN MATHIAS PO BOX 110818.......OSP181292 ANCHORAGE, AK 99511 "A CW CA N N PERMIT NO. 0 N i -. D 0 0 0 0 0 0 0 0 0 0 O O O V M O cn O CO N r K m D (n C m m K m Z N I+ O PANNONE ENG SVC LLC P.O. BOX 1807 PALMER, AK b9645 PHONE 907) 745-8200 FAX 907)'745-8201 p *`49R1" aeren R. ch We CE 8149 {st� REVISIONS DATE 03/08/2019 REV1:20190624 SCALE = 60' BIRCHWOOD LOOP L3 SITE: 17790 S BIRCHWOOD LOOP RD JASON & RYAN MATHIAS PO BOX 110818.......OSP181292 ANCHORAGE, AK 99511 P.I.D. NO 051-243-17 PERMIT NO. SHEET 2 OF 2 , `"PAI./ MUNICIPALITY OF ANCHORAGE mens On-Site Water&Wastewater Program moo' 'Jo y.� PO Box 196650 4700 Elmore Road Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax: (907)343-7997 httpa/www.muni.org/onsite iH is I) 'parttncnt 4NCN UP P4� On-Site Wastewater Disposal System Permit Permit Number: OSP181292 Effective Date: 9/6/2018 Work Type: Septic Initial Expiration Date: 9/6/2019 Tax Code Number: 05124317000 Site Legal Address: BIRCHWOOD LOOP LT 3 G:0954 Site Mailing Address: Owner: MATHIAS JASON 50% & Lot Size in Sq Ft: 116724 Design Engineer: PANNONE ENGINEERING SERVICES Total Bedrooms: 4 This permit is for the construction of: 2 Disposal Field El Septic Tank ❑ Holding Tank 0 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 lJ r Received By. 1 � Date: 9(-70 ' Issued By: Date: 9/67/g eelj414.5 MUNICIPALITY OF ANCHORAGE ( "?. Community Development DepartmentPhone: 907-343-7904 Development Services Division Fax: 907-343-7997 On-Site Water& Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 051-243-17 Property owner(s) RYAN & JASON MATHIAS Day phone Mailing address PO BOX 110818 Site address NHN BIRCHWOOD LOOP Legal description (Sub'd., Block & Lot) BIRCHWOOD LOOP L3 Legal description (Township, Range& Section) Lot Size 116,724 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (®all that apply) Absorption Field ❑X Initial 0 Single Family (SF) ❑X (w/wo ADU) Septic Tank ❑X 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 that this is in accordance with applicable Municipal Codes. N \ 2 4.4146, (Signature of property owner or authorized agent) Permit/Rush Fees: Waiver Fees: Date of Payment: ' ,.i >ti Date of Payment: Receipt Number: 0 [6 Receipt Number: Permit No. 03P17/ 61 Waiver No. Permit App_'•: ::....c Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP181292, Deb Wockenfuss, 09/06/18 ENSTAR ENSTAR Natural Gas Company A DIVISION OF SEMCO ENERGY Engineering Department,Right of Way Section Natural Gas Company 401 E.International Airport Road P.O.Box 190288 Anchorage,Alaska 99519-0288 (907)277-5551 FAX(907)334-7798 September 5,2018 Subject: Letter of Non-Objection: Septic Lots 2,3,and 4,Birchwood loop Subdivision To whom it may concern: ENSTAR Natural Gas Company has no objection to the proposed septic system,which will cross a portion of the ten foot wide natural gas easement,within Lots 2,3,and 4,Birchwood Loop Subdivision, as described in"Note 12"of Plat No.2018-46,located within the Anchorage Recording District,Third Judicial District, State of Alaska. Acceptance and use of this letter of non-objection by yourself,your heirs,your assigns,or your successors,will constitute agreement to the following stipulations: • Landowner/Contractor working near ENSTAR gas facilities shall contact the Alaska Digline, Inc., (907)278-3121 or 811 for line locating two(2)business days prior to any related excavation. This service is free of charge. • ENSTAR will be held harmless,now and forever for any damages or injury to any person or property as a result of this encroachment. • Any ENSTAR facility damaged or destroyed,as a result of this encroachment will be repaired at no cost to ENSTAR. • Any costs incurred by ENSTAR for special construction necessitated by this encroachment will be borne by the land owner. • All applicable safety code regulations will be observed and maintained. • This letter of non-objection will in no way preclude ENSTAR from full use and enjoyment of its rights within any portion of its right-of-way. Sincerely, Cassie Acres Right of Way and Compliance Technician ENSTAR Natural Gas Company Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP181292, Deb Wockenfuss, 09/06/18 Hideo documentation of well is as follows: Pitless —10' 6"Casing-- 0' plus with no perforations Total Depth — 340' i2&1(tl� Brian R. Wille President Wheaten Water Well Inc. 10/10/2017 Wheaton Water Well, Inc. 907-376-2041 - Fax: 907-376-2030 - email: brianw@wheatonwells.com 1190 N. Wasilla-Fishhook Road Wasilla, AK 99654 To Whom It May Concern: On October 10, 2017 a 24 hour flow test was performed at the following property: 17620 S. Birchwood Loop Road TI 8N, R1W, 519, Lot 4REM Anchorage Parcel #: 051-243-09 The well is approximately 340 feet deep with 90 feet of casing. A pump was installed and encountered an obstruction at 188 feet. The pump intake was set at 170 feet. The test was performed using low water protection. A total of 1,426.09 gallons of water was pumped in the 24 hour period. It was determined that the well is producing .99 gpm. Municipality of Anchorage ® Development SeMces Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 ON-SITE SEWER/WELL SUBMITTAL COMMENT SHEET To: lieff Garness Legal description: T15N R1W Section 19 Lot 4 The attached paperwork has been reviewed and is being returned for the follow! ❑ Original signature or stamp missing on ❑ calculation error in design. ❑ Additional soils information needed. ❑ Water monitoring results inadequate. ❑ Discrepancy in information submitted. ❑ Topographic information missing or inadequate. ❑ Incomplete; missing ❑ Incomplete; missing ❑ Additional adequacy test information needed. ❑ Water sample unacceptable. ❑ Measured/proposed distances/dimensions missing. ❑ Locations of all soils, percolation and water monitoring tests not shown. ❑ Proposed system too deep for soils information submitted. ❑ Well log required. ❑ Omission in narrative. ❑ Insufficient fill over tank or field. ® Other. Need to determine if there is 4 feet ground water separation. Name of reviewer: Eoe goodall ns: Date: 8/26/02 Please supply the necessary information and re -submit your request. LEAVE THIS FORM ATTACHED TO THE PAPERWORK ALASKA WATER & WASTEWATER CONSULTANTS, INC. August 12, 2002 Municipality of Anchorage Development Service Department On -Site Water & Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, Ak 99519-6650 (907) 343-7904 Ref: Septic System Documentation for Lot 4, T15N, RI W, Section 19 A permit (# SW920128) was issued on June 9, 1992 for a well and septic system for the referenced property. A well and septic system has been installed on the property. No well log was found for the existing well. It appears that no inspections were performed during the installation of the septic system. The new owner has retained our services in order to document the septic system and obtain a land use permit. The following as -built package is our findings from the site visits we have performed. I am unaware of any adverse impacts this installation has on adjacent wells or septic systems. If you have any questions, please contact us at 337-6179. Thank you for your assistance. P.E., M.S. 6901 Debarr Road, Suite 2B * Anchorage, AK 99504 Ph: (907) 337-6179 0 Fax: (907) 338-3246 • Website: akwwc.conn Municipality of Anchorage 01 .ti. Development Services Department - Building Safety Division — ' On -Site Water 8 Wastewater Program, 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519.6650 www.ci.anchorage.ek.us (907) 343-7904 Page 1 of 3 Onsite Wastewater Disposal System and/or Well Inspection Report Permit Number. SW920128 PID Number. 051-243-09 Name: DAN COLEMAN Wastewater System: ■ News p Upgrade Address: P.O. BOX 772094 a EAGLE RIVER. AK 99577 ABSORPTION FIELD Phone: No. of Bedrooms: (907) 830-7602 3 0Deep Trench ■Shallow Trench 0Bad 0Mound 13 Other LEGAL DESCRIPTION SoS RWYq: 0.60 Tocol D.Wh ban onpinW po0•: **7.42-8.25 GPD/54. In. Ft Block: Lot. Subdivision: Depth to pipe betton, bone D69" ped.: Crow depth lewwath pqc - 4 - **4.0-4.83 In. **3.42 n. Township: T15N Range: R1W section: 19 s• omed above "Inas podw crow tmph: R **86 R WELL: O New (] Upgrade Crow want **5.0 NUMv W en..: 1 Dwuwe b.t..«r lines — R n. GwMrcau-- Pdwle. X9.0 : Totd fa.d To: Tdut ob.wptbn ante: PWe awt dat D 3034/F-810 PRIVATE R R 796 so. FLI Drew: N Doc piled: v'g \ Statia water tow: swt~. UNKNOWN Det* lr a 1992 R n.la:Nang W At: CoWN Height Move cwlab: TANK ,� R FL SEPARATION DISTANCES ■Septic 0Holding 0S.T.E.P. 0Other To Septic Absorption Utt Holding 0e/Prhal. Ypntoo`t"" UNKNOWN capaelry in /aearw: 1500 From Tank Field Station Tank s.e.r Un.. Well 100'+ 100'+ — — 25'+ Mat.rw. STEEL r*.nbe, of ownportrneeft 2 Surface water 100'+ 100'+ — — — LIFT STATION Lot Una 5'+ 10'+ — — — 4n In gorarw: tOmW«bwW: Foundation 5'+ 10'+ — — — en W. aL v W: .dqh .Nave Warm ab Nara tOaE, awbea bwp.clww w nned Sr Curtain Drain NONE KNOW Remarks: *THIS IS A DOCUMENTATION OF A SEPTIC BENCH MARK tnaaaan Wed wwrauan: SYSTEM THAT DID NOT HAVE INSPECTIONS PERFORMED BOTTOM OF DOOR THRESHOLD DURING THE INSTALLATION. **THESE ITEMS ARE FROM ELEVATION SHOTS AND A.wnW a.vWlan: 100.00 rt ENWNEEWS SEAL FIELD MEASUREMENTS TAKEN ON 7/29/2002. 04 o F, OF gsp0 ***CAPACITY OF TANK DETERMINED BY PUMPING (PUMPED BY JR's PUMPING). v.�... Inspections performed by: AKWWC, INC. Dates: 1st 7/29/2002 ..4.. ..I. ........ 2nd - ..A .. p 3rd — O '•, ff or ess: Development Services Department Approval 13 �p0 ' •., �v� ��0p0�oressto^= Reviewed by: Date: and approved O0000� INUMBER: AS -BUILT DRAWING PARCEL ID NUMBER:I SW9 SW920128 051-243-09 01 \ \\ \ \� F11 �a \ 1 EXISTING DLD. DOCUMENTED TED OON ` 7/29/02. \ EXISTING 1500 GALLON I // 1 SEPTIC ON TANK. DOCUMENTED (�y / \ IDBL2 j� 1 BL7� / CREEK APPROX. LOCATION ' Z. er, C I 101, /to 1 EXISTING I Q — TEST HOLE BY DAVID DAYTON, P; E. t.1 yo 6 11. o' 100 FROM 11Lo C o S/jo Iq L ST1 22.5 29.7 ST2 31.0 32.8 DBL1 33.5 34.2 DBL2 39.1 38.1 C01 123.4 114.7 MT1 121.8 112.6 CO2 39.3 45.9 2' MT 122.8 113.9 8/12/200 DRAWN BY: ALASRA «'AFI'LR & `N'AS 1,1'NVXrER SCALE J.L.M. CONSULTANTS. INC. 1 • = 50' 6001 DFRAPR ROAD. SUITE ?R • ANr KORAGF. AK OOSOL • PHONF (007)3174170 • FAX (907)SIS-37L6 PREPARED FOR: PHONE NUMBER: PACE NUMBER: DAN COLEMAN 694-2348/727-2348 2 OF 3 LEGAL DESCRIPTION: LOT 4, SECTION 19, T15N, R1W (BIRCHWOOD GYMNASTICS) TYPE OF WORK: AS -BUILT DRAWING OF UNDOCUMENTED SEPTIC SYSTEM I AS -BUILT DRAWING I LIQUID LEVEL IN TANK IN STI - 96.51 1= INVERT OF BUNG IN »96.43 STI rFINAL GRADE 100.22-100.49 ST2 i LEVEL IN TANK ST2 - 96.56 =\ `INVERT OF BUNG OUT - »96.58 BOTTOM OF TANK IN STI — 92.14 BOTTOM OF TANK IN ST2 - 92.45 APP -1 DISIING GRADE - 99.69-100.72 VEL ON 1002 (AVG.) .... •f:Y 3 jrINVERT y:yf: yfjff�f;.•• iii• jr!f • • .rryyYr'� f•�95.89 a . ��•. •:�f!•�lyfj� BOTTOM OF Yyjyf ��jY1+ j• TRENCH 8/12/2002 oa u 112!1 *� i DRAWN JBY:.L.M. F'. �F... ALASKA «'A1 LR & WASTEAWrE'R 4 y� CONSULTANTS. INC -.._.._..__.. _ _ SCALE: a e e00, DFAeoq peep. SNTF 7!i * eNf HO•eGf. ea 00504 * PwOHF (007US).e179 • Fpa (90)1Ra-074e N.T.S. IEPARED FOR: PHONE NUMBER: PACE NUMBER: DAN COLEMAN (907) 727-2348 3 OF 3 eft A. Garne s... :CAL DESCRIPTION: QA E-79 it T15N, RiW, SECTION 19, LOT 4, ok, ��!/ PE OF WORK: PROFILE rofsestoo AS—BUILT DRAWING OF UNDOCUMENTED SEPTIC SYSTEM Op000 40poo GALLONNK z z j rEzz i LEVEL IN TANK ST2 - 96.56 =\ `INVERT OF BUNG OUT - »96.58 BOTTOM OF TANK IN STI — 92.14 BOTTOM OF TANK IN ST2 - 92.45 APP -1 DISIING GRADE - 99.69-100.72 VEL ON 1002 (AVG.) .... •f:Y 3 jrINVERT y:yf: yfjff�f;.•• iii• jr!f • • .rryyYr'� f•�95.89 a . ��•. •:�f!•�lyfj� BOTTOM OF Yyjyf ��jY1+ j• TRENCH 8/12/2002 oa u 112!1 *� i DRAWN JBY:.L.M. F'. �F... ALASKA «'A1 LR & WASTEAWrE'R 4 y� CONSULTANTS. INC -.._.._..__.. _ _ SCALE: a e e00, DFAeoq peep. SNTF 7!i * eNf HO•eGf. ea 00504 * PwOHF (007US).e179 • Fpa (90)1Ra-074e N.T.S. IEPARED FOR: PHONE NUMBER: PACE NUMBER: DAN COLEMAN (907) 727-2348 3 OF 3 eft A. Garne s... :CAL DESCRIPTION: QA E-79 it T15N, RiW, SECTION 19, LOT 4, ok, ��!/ PE OF WORK: PROFILE rofsestoo AS—BUILT DRAWING OF UNDOCUMENTED SEPTIC SYSTEM Op000 40poo ALASKA WATER & WASTEWATI✓R CONSULTANTS. INC. LEGAL DESCRIPTION: LOT 4: SECTION 19, T15N, RiW PERFORMED FOR: DAN COLEMAN DATE: 10/4/2000 DEPTH __�- (feet) ORGANICS TEST HOLE 1 1 11r ,?I 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 GM/SM/ML (LOAMY) 3OM �T•P.6 � •. I =`41aT•L•� � 3:11 - 111111111 2 3:41 30 5-1/2" 1-1/2- -1 2"3 VY/P 3:41 - MINWFIR • 4 4:11 30 II1111111 1-1/2- 5 4:11 - % �l11111f 4:41 30 5-1/2* �.de • DEPTH TO GROUNDWATER DATE DRY 10/4/00 DRY 10/11/00 3:11 - 6- + / 1 I SITE PLAN I 10-100' DATE READING CLOCK TIME NET TIME (MINUTES) WATER LEVEL READING NET DROP (INCHES) 10/4/2000 1 3:11 - 6- 2 3:41 30 5-1/2" 1-1/2- -1 2"3 3 3:41 - 6" - 4 4:11 30 5-1/2* 1-1/2- 5 4:11 - 6- 6 4:41 30 5-1/2* 1-1/2- 19� PERCOLATION RATE 20 (MIN./INCH) PERC. HOLE DIA. 6 (INCHES) TEST RUN BETWEEN 4.5 FT. AND 5.0 FT. 20 A FOUR HOUR PRESOAK WAS PERFORMED: N YES ❑ NO SOILS LOGGED BY: JODY MAUS PERCOLATION TEST PERFORMED BY: JODY MAUS COMMENTS: PERFORMED BY AKWWC, INC. I, JEFFREY A. GARNESS, CERTIFY THAT THIS WA P RFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE: g rL Ztv2 ALASKA «'ATER & WASTENVATER CONSULTANTS, INC. 901 DOOM RW. SUrTE 20•ANOMMW. AVL 99504 PHDNL, (907W7-4170 • FAX. 90 • ek..c.eom SOIL LOG - PERCOLATION TEST �......... LEGAL DESCRIPTION: LOT 4; SECTION 19, T15N, R1w �Q a '•, s' PERFORMED FOR: DAN COLEMAN pgTE; 10/4/2000 01 7953 `FOp (feet ORGANICS TEST HOLE 2 oo�660 SOIL CLASSIFICATIONS 3 .�°•c GP ML GM CL 4 GC OL °.2% SW MH 5 •.:•. t SP CH \ \ SM OH 6 Sc I +�7 /rr .4q r/ / GM/SM/ML 6 (LOAMY) / 1 1 I SITE PLAN ♦ I 1'100' 10 DATE READING CLOCK NET TIME WATER LEVEL NET DROP 11 t� 1 12 f+{ 13 3 3:40 } 14 B.O.fI. 15 16 17 18 19 PERCOLATION RATE 26 (MIN./INCH) PERC. HOLE DIA. 6 (INCHES) TEST RUN BETWEEN 4.5 FT. AND 5.0 FT. 20 A FOUR HOUR PRESOAK WAS PERFORMED: N YES [—]NO SOILS LOGGED BY: JODY MAUS PERCOLATION TEST PERFORMED BY: JODY MAUS COMMENTS: PERFORMED BY AKWWC, INC. I, JEFFREY A. GARNESS, CERTIFY THAT THIS WAS/PE FORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE: L OL GROUNDWATER DEPTH TO DATE DRY 10/4 00 12.5' 10/11/00 9 TIME (MINUTES) READING (INCHES) 10/4/2000 1 3:10 — 6" — 2 3:40 30 5-7 B" 1-1 8" — 6" — 4 4:10 30 5-7 8" 1-1 8" 5 4:10 — 6" — 6 4:40 30 5-7 6" 1-1 8" PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW920128 DATE ISSUED: 6/09/92 DESIGN ENGINEER:DAVID R. DAYTON, P.E. EXPIRATION DATE: 6/09/93 OWNER NAME:DREBERT RICHARD A & CAROL V OWNER ADDRESS:HC 78 BOX 2532 CHUGIAK, AK 99567 PARCEL ID:05124309 LEGAL DESCRIPTION: T15N R1W SEC 19 LT 4 PTN LESSS RR ROW . LOT SIZE: 666648 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD / WELL SYSTEM 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 FOLLOWING SPECIAL PROVISIONS. SPECIAL PR()VT9T0M9• RECEIVED B ISSUED BY: DATE:DATE: ���j D. R. DAYTON, P.E., R.L.S. HC 78 Box 1026 Chugiak, Alaska 99567 (907) 666-2417 May 19, 1992 DESIGN NARRATIVE Gov=t Lot 4, Sec. 19, T15N, R1W, S.M. Gavernment Lot 4, which borders on South Birchwood Road is a large tract (approximately 14 acres). Ivan Creek runs through the property, creating a swamp of considerable size. The building site is on higher, well drained ground, along South Birchwood Road North of the creek. The higher ground (2 to 3 acres) is grown up with Birch and occasional Spruce trees. The area drains Northwesterly from the road at a. slope of approximately 8 to 10%. The proposed system will have no measurable impact on existing or future wells on adjacent properties. There will be no impact on reserve space/surface or subsurface or on drainage. R ectfully,- David R. Dayton i �G o r� na 8 x D�� w 00� c �m nN m N N N1p� r' tIK _ a p og i �G o r� na 8 x D�� w 00� c �m m N N tC SY STC`rA t c516> rJ (�T4, 5�--c-. 19 1 oco �M-`-�Ni 2 c PA2T'/KE'>ti3T 1��2e I�4T� 44-M, /n c H LoaOv 75 : 0.45 9a��/prrY TPi y`{ • EFF�c..rru� Din Ty 300. Olt bob 29 F : David R. Dayton W NO. 2205-2 G/s 2• 7-2��vc ins 8� ' 4 aOFES$I oe,�„qac 2_`” Mr lr,ZAlw M,N VC4rV0c. CZ wx�.ao PILMNL �..% RAA 4- if x w Qezg O O - .. _ .—�,.' I, �orrvti. o2 T OLW"JCN S r3�c w OR.G. foftmU�JO SEw� hoc M�jaW4i J�uLP• P, P6 2" S��e. eoaw- ov en, Peer - 4a � ro rFic ren FABh,c �„� A` )000Ugt �. F` T'c-�r� 1-q FJ2rc. civ 3•C+-�sw�ic. Z Corn&. i M iLOtAL _. - 6L, 8Ss <r wa-r�4- 7. I Nsv�o�� -lR •3+}cic.w..� rrirj,..¢ LESS rrW.J NLint.mwM Pj �F�SGCL/LTL.T 1.�1JC`5 UND�T�L. 7ruu�5 �-APA.e.tanA A+t3+t's David R. Dayton P.E. HC 78 Box 1026 Chugiak, Alaska 99567 / ” ' Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST PERFORMED FOR: )�1CJfy}-,¢Q A T,- DATE PERFORI LEGAL DESCRIPTION: Z43 r- SZ' Township, Range, Section: y DEPTH SLOPE SIT (FEET) 1 '1 ® 1h%vz�s 2 3 4 5 6 7 8 9 10 12 / 3--13 14 15 16 18 19 Ix D David R. Doyroa NO. 2205-E .. WAS GROUND WATER _.-. . ENCOUNTERED? / L� s q's�y��jZ IF YES, AT WHAT i L DEPTH? P E gepth to Water After WA�t'4. Monitoring? /�o gate: al= Reading Date Gross Time Net Time Depth to Water Net Drop N a .. WAS GROUND WATER _.-. . ENCOUNTERED? / L� s q's�y��jZ IF YES, AT WHAT i L DEPTH? P E gepth to Water After WA�t'4. Monitoring? /�o gate: al= Reading Date Gross Time Net Time Depth to Water Net Drop 20 PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN FT AND FT COMMENTSy`LL"V �7TAM JI�J/GL' IA; lo' 13,2G / /% ? y0' 2t S,G. u1 %j7r L PERFORMED BY: ➢, k— k�'Z) 1• it-�'-� � CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) ' Municipality of Anchorage rVo DEPARTMENT OF HEALTH & HUMAN SERVICES pqa 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST �B�F PERFORMED FOR:��Clt//,l'-/J fy"✓rZ:%�2Ty 2d DATE PERFORMED: 4 LEGAL DESCRIPTION:C70JT- le) 7- ¢ Township, Range, Section: c /9� 7-1- DEPTH /DEPTH SLOPE SITE PLAN (FEET) '7'TY'f%SJ/L Q/rG„j /}sVJ43 1 2 3 4- 5 6 7 �7t L7 K CiGhUt?Cr 8 .... 10 WAS GROUNDWATER. ENCOUNTERED? IF YES, AT WHAT 12 .. - .DEPTH? IE3 - - Depth to Water After 13 c - - _ Monitoring? Dale: d 15 w Ta/t sn 16 P'csvrav1 OF- 18 19 gGINEER'S'SEAL)� _•. r aar'i �. a E, S �oae�Xa... aeea a: David R. Dayton i WQ NO. 2205-t .' ol�t l9 a�..........' WO (4 �I ■ ENEENNEENE MEMENEEMEN Reading Date Gross Time Net Time Depth to Water Net Drop Sll,,,l2 /2; ydZ 10 7AI 1312- 30 &j &" 1311i4 O 7 /v /3"If4 3o B 8 a " /`�•/rf SJ 8 // n /G // 20 PERCOLATION RATE �v (minutes/inch) PERC HOLE DIAMETER -� TEST RUN BETWEEN S FT AND FT COMMENTS - �� 9(< 7e 57` . LLL ,r�'2e'S4'tiez-w 0//G2'tI14 />1'T J` Id/L 7Yl /75%— PERFORMED BY: _ �%��� `'�j"' !"'� CERTIFY THAT /THIS TEST WAS PERFORMED.IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: L !� 72-008 (Rev. 4/85) MUHMPAUTY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Parcel I.D. 051-243-17 1 Certificate of On -Site Systems Approval Expiration Date: S' 10 ` Z. GENERAL INFORMATION Complete legal description BIRCHWOOD LOOP LT 3 Location (site address) 17790 S Birchwood Loop Rd Current property owner(s) STEVENSON MICHAEL Mailing address Real estate agent 2. TYPE OF DWELLING: R Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 Day phone 267.9647 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well D Private Septic ED Water Storage ❑ Holding Tank ❑ Community Well ❑ 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 $ Waiver Fee $ Date of Payment "�— -3 — Z oZ Z Receipt Number 67 Y 01 6y COSA # 05C2_21 IS 1 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 NorthRim Eng. Phone 694-7028 Address PO Box 770724, Eagle River Engineer's Printed Name Steve Eng Date 4/30/22 6. DSD SIGNATURE ♦�f fl�.p•f stw. .l System #1 Approved for bedrooms �;i'.° Ar System #2 Approved for bedrooms Disapproved Conditional approval for bedrooms, with the following stipulations: By: Original 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 engineers work. 7. ATTACHMENTS: COSA Checklist Septic System Advisory Well Flow Advisory COSA Ct ecxlist blue sheet X Nitrate Advisory Arsenic Advisory Other `g ON-SITE �y '- p q) WAST': v''ATP0 rn-77 PROGRAM J O,. � By: Original 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 engineers work. 7. ATTACHMENTS: COSA Checklist Septic System Advisory Well Flow Advisory COSA Ct ecxlist blue sheet X Nitrate Advisory Arsenic Advisory Other Legal Description: BIRCHWOOD LOOP LT 3 If more than 1 septic system on lot: COSA Checklist # A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled Total depth 340 ft Cased to 90+ ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 18+ in. Date of flow test for COSA 4/21/22 Static water level at beginning of test 65.8 ft. Comments B. TANK DATA Age of tank(s) 4 years Tank type/material Sptcstl Measured operating fluid level in septic tank 50 ❑ Standpipes/foundation cleanout per record drawing Date of pumping 5/9/22 D. ABSORPTION FIELD DATA 10/19/18 Which system tested (date installed) same NO ALL standpipes present per record drawing Total measured depth from grade 11 ft (max) Measured depth to pipe invert from grade 5 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: 51-243-17 of Structure served by this system Well production at time of test 2 gpm Water storage tank volumeo --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 NRim Eng. Date of Sample 4/25/22 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 4/21/22 Results Q✓ Pass For 4 bedrooms Fluid depth prior to test 18 in Water added 600 gal New depth 24 in Elapsed time 30 min Final fluid depth 18 in Absorption rate 600 gpd Any rejuvenation treatment (past 12 months) n0 If yes, enter date E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) El Yes Septic Tank/Lift Station on Lot > 100' ft Wells on Adjacent Lots: Community Sewer Manhole/Cleanout > 100* Q [-,,-1 Yes if No ft 0 Yes if No ft Neighboring Tank > 100' P11 Yes if No ft Private Sewer/Septic Line > 25' M Yes if No ft Absorption Field on Lot > 100' [E] Yes if No ft Holding Tank > 100' El Yes if No ft Neighboring Absorption Fields > 100' if No ft Animal Containment > 50' El Yes if No ft [D Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' (E] Yes if No ft P1 Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' S Yes if No ft Surface Water> 100' Yes if No ft Property Line > 5' El Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' Q Yes if No ft Private Wells > 100' Yes if No ft Water Main > 10' 0 Yes if No ft Community Wells > 200' Yes if No ft Water Service Line > 10' Q 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 / certify that I 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. COSI Checklist yellow sheet R� MUNICIPALITY OF ANCHORAGE 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. 051-243-17 1. GENERAL INFORMATION Complete legal description Birchwood Loop L3 Location (site address) 17790 S Birchwood Lp Current property owner(s) Jason & Ryan Mathias Mailing address Real estate agent 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 Expiration Date: —< Day phone Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ❑ Private Septic 0 Water Storage ❑ Holding Tank ❑ Community Well 0 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 $ 15- DD Date of Payment 13 0 �) Receipt Number COSA # 0 SC Waiver Fee $ Date of Payment Receipt Number Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER 6. 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. In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA COSA guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed above. Reliance on this report by another person is at their own risk. Pannone Engineering Services LLC highly recommends buyers hire their own engineer to evaluate this report. Name of Firm Pannone Engineering Services Address P.O. Box 1807 Palmer, AK 99645 Engineer's Printed Name Steven R. Pannone P.E. DSD SIGNATURE System #1 Approved for bedrooms System #2 Approved for Phone (907) 745-8200 Date 07/03/19 Conditional approval for bedrooms, with the following stipulation k OF (( �4�j J ON -SIT E ATER z^ PROGZANI By: Original 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: Birchwood Lp L3 Parcel ID: 051-243-17 If more than 1 septic system on lot: COSA Checklist # of Structure served by this system A. WELL DATA ( I Well log is filed with Onsite (or attached) Date drilled unknown Total depth 340' ft Cased to 90' + ft ® Sanitary seal is functioning correctly ® Wires are properly protected Casing height (above ground) 24" in. Date of flow test for COSA 7/8/19 Static water level at beginning of test 43.9 ft. Comments See Inspection Report on File B. TANK DATA Age of tank(s) years Tank type/material Steel Measured operating fluid level in septic tank ❑ Standpipes/foundation cleanout per record drawing Date of pumping D. ABSORPTION FIELD DATA Deep Trench Which system tested (date installed) 10/17118 © ALL standpipes present per record drawing Total measured depth from grade 7.0 ft (max) Measured depth to pipe invert from grade 6.0 ft (min) ❑ N/A — pressurized field Q Monitor tubes go to bottom of effective. If not, state depth into effective Q 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 Well production at time of test 1.0 gpm Water storage tank volume N/A gallons Well disinfected for coliform test? ❑ Yes M Nc A Coliform bacteria is Negative Nitrate mg/L Nitrate less than MRL (ND) Arsenic ug/L © Arsenic less than MRL (ND) Collected by Pannone Date of Sample 06125119 and 06127119 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date n/a Results Q Pass For 4 bedrooms Fluid depth prior to test in Water added gal New depth in Elapsed time min Final fluid depth in Absorption rate 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' 0 Yes Community Sewer Manhole/Cleanout > 100' ✓v Yes if No ft 0 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' Q Yes if No ft Neighboring Absorption Fields > 100' 0 Yes if No ft Water Main > 10' Animal Containment > 50' Yes if No ft [Z] Yes if No ft [D Yes if No ft Water Service Line > 10' El Yes if No Manure/Animal Excreta Storage > 100' If septic tank is under driveway Community Sewer Main > 75' Yes if No ft P/1 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' ®✓ Yes if No ft Property Line > 5' Q Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' Q Yes if No ft Private Wells > 100' 0 Yes if No ft Water Main > 10' F/� Yes if No ft Community Wells > 200' [D Yes if No ft Water Service Line > 10' El 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' ✓� Yes if No ft Private Wells > 100' Yes if No ft Water Service Line > 10' F-71 Yes if No ft Community Wells > 200' Yes if No ft Surface Water > 10 0'F/-1 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. Z COSA Checklist yellow sheet R14 -Of 'A!