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HomeMy WebLinkAboutDENALI MEADOWS LT 5A-1woo � ea Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 1 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP181298 PID Number: 015-461-46 Dwelling: F Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑■ New ❑ Upgrade Name ANDY ANGSTMAN ABSORPTION FIELD ❑ Deep Trench 9 Wide Trench ❑ Bed ❑ Mound Site Address 12121 GINAMI ST, ANCH AK ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 5 1.2 GPD/SF 6.0 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 2.0 Ft. Gravel depth beneath pipe 4.0 Ft. Subdivision Block Lot DENALI MEADOWS LT 5A-1 Fill added above original grade 2.0 Ft. Gravel length 63 Ft. Township Range Section Gravel width 5.0 Ft. Beds: Number of Lines Distance between Tines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line 625 Ft2 1.0 Ft. Well 100'-+- 100'+ 50'+ TANK ® Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Capacity ANCH TANK 1500 Gal. Surface Water 100'+ 100'+ Material Number of compartments Lot Line 10'+ 10'+ NA STEEL 2.0 Foundation 10'+ 10'+ LIFT STATION Manufacturer Capacity Remarks 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) 107.8 ft Inspection 15' 9/16/18 9/16/18 Location and description 2�d FRONT PORCH 31d 4,h ON-SITE WATER AND WASTEWATER SECTION APPROVAL :n_ 9jaekkStamp OF Conditional Approval: Dateor JL_ •... 0 • MICHAEL N. ANDERSON �••• CE 949 ."4� ".0Approved PBflc' Septic System %� , l QX,7r_ Date d /i ••, L��t '`b d Note: this approval does not include well permit requirements. ��PR ®OFE®SI.� tKev u5iuuin/ Permit No. OSP181298 Page 2 of ? 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: DENALI MEADOWS LOT 5A-1 MARK A B CO1 15 7 TC01 20 15 TCO2 28 24 CO2 35 32 CO3 36 33 4 i 38 52 C05 MT 75 66 68 63 TH1 \ C05 �kT1 / BENCH TCO2 TCO / / 07" EW Y: , 1 \\ ASS T SCALE: 1"=50' PID No.: 015-461-46 1500 GALLON STEEL TANK NEW WELL \ I I / / / CO, Tco1 rCO2 FC03 FCO4 MT2 cos ®®®®"\®®® / TCO2 I I I I r 0 ®®®� O�, ®® ` 5 FINISH CRADF Air `�P\• ���51�i® .0 ORG ® `� J '•• AV FlLTER FABRIC ♦®® — ®�® ` 491H 9 . 1.500 GALLON crtn xoc. GM/GW............................................ ,••.............................. Si 50 '� TANK 8 5 ... .................... .. ®I MICHAEL N. ANDERSON.*Q i AVslAV♦0���'•. No. E 9469 AW SEPTIC SECTION BB ®�/� `V•[}�,\'�\ �® N.T.S. WATER 0 89, OCT 2 18®®®`�'�1 E +®®®® / / / i i i TH1 \ C05 �kT1 / BENCH TCO2 TCO / / 07" EW Y: , 1 \\ ASS T SCALE: 1"=50' PID No.: 015-461-46 1500 GALLON STEEL TANK NEW WELL \ I I / / / CO, Tco1 rCO2 FC03 FCO4 MT2 cos ®®®®"\®®® / TCO2 I I I I r 0 ®®®� O�, ®® ` 5 FINISH CRADF Air `�P\• ���51�i® .0 ORG ® `� J '•• AV FlLTER FABRIC ♦®® — ®�® ` 491H 9 . 1.500 GALLON crtn xoc. GM/GW............................................ ,••.............................. Si 50 '� TANK 8 5 ... .................... .. ®I MICHAEL N. ANDERSON.*Q i AVslAV♦0���'•. No. E 9469 AW SEPTIC SECTION BB ®�/� `V•[}�,\'�\ �® N.T.S. WATER 0 89, OCT 2 18®®®`�'�1 E +®®®® Certified Drilling Log D DOC CO dba 0 IN SILL & COLE PVULUVAN WATE11WELLS - P.O. Box 670269, Chugiak, AK 99567 688-2759 OWNER OF LAND: Andy Angstman ADDRESS: Bore Hole Data Depth From To LEGAL DESCRIPTION Denali Meadows Lot 5A-1 DATE: 9-13-18 0 2 Casing Stickup PERMIT NUMBER: OSP181298 DATE OF ISSUE: 9-10-18 TAX IDENTIFICATION NUMBER 01546146000 Is well located at approved permit location: ®Yes ❑No Method of Drilling: ®air rotary ❑cable tool Depth of Well: 364 Casing Type: Steel Wall thickness .250 inches Diameter: 6 inches, depth 44 feet Liner type Static Water Level: 80 feet Recovery Rate 1.5 ❑ gpm ❑ gph Method of Testing Air Well Intake Opening Type: ❑ open end ®open hole ❑ Screened Start feet Stopped ❑ Perforations Start feet Stopped Grout Type: Bentonite Volume: 50 lbs Depth: from 2 feet, to 42 feet Well Disinfected Upon Completion: ®yes ❑ no Method of Disinfection: Chlorine 50 PPM Comments: 2 4 Overburden 4 42 Silty Sand & Gravel 42 162 Bedrock Gray 162 210 Bedrock Green 210 262 Bedrock Gray 262 301 Bedrock Gray w/ quartz 301 364 Bedrock Gray WATER QUALITY TESTING ca form N e - c Ca/100nii_ Nftmtes 0.bti2- L AnxWc tJD ug/L 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. Matsu Borough: Department of Environmental Conservation. P DOC CO dba OPM BILL & COLE :401� ULLIVAN WATE'Ro' WELLS& P.O. Box 670269, Chugiak, AK 99567 688-2759 www.suilivanwaterwells.com Pump Installation Log Well Drilling Permit Number: SW OSP181298 Date of Issue 9-10-18 Parcel Identification Number: 01546146000 Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation. W W N GINAMI HILLS SUBD. Lot 4 I ---------------------------- I Lot 1 I DENALI VIEW SUBD. Lot 2 — — — I Lot 58-1 HOUSE DETAIL Scale: 1" = 20' G� Q 2.0'x9.0' 4.0' PORCH Lot 3 2 STORY RESIDENCE 2.0'x10.3' CANT •II U i C_0 • >1 N L t N •U C 0 v � J V) as C 4d .V) V) 0 J � O Y 0o n v �t a c o m o 0 0 0 o U ^ 0 cr O _ a °0° r_ � 0 CL Do 0 00. ° V1 n v E o 0 0 s c am= N ac 00 m Ew Z_° m O „ ` L Ca, mom C +otnm a c c °<aa0,-0 3 w 00-c a o Zm�ooc � goo—_�c.00 �NQ9 cx ° n 3 ° v o O L 0 ° ° e m oc o a --M J a— c+ v D a o tZc : ° t W E MO Tc 0 0,C n 0 1 a aE c c ar°�o,om osocE—'E mU:E Eon 9 Oc f - ai 0.0 o° MUNICIPALITY OF ANCHORAGE ,111 l I7 On-Site Water&Wastewater Program ���;: •�. PO Box 196650 4700 Elmore Road Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax: (907)343-7997 http://www.muni.org/onsite _ -: Department On-Site Water & Wastewater System Permit Permit Number: OSP181298 Effective Date: 9/10/2018 Work Type: WellSeptic Initial Expiration Date: 9/10/2019 Tax Code Number: 01546146000 Site Legal Address: DENALI MEADOWS LT 5A-1 G:2741 Site Mailing Address: Owner: ANGSTMAN MYRON & SUZANNE L Lot Size in Sq Ft: 99755 Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING Total Bedrooms: 5 This permit is for the construction of: Disposal Field 0 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: a/—ff, — °t.) _q Date: q /J Issued By: Date: /L// MUNICIPALITY OF ANCHORAGE Development Services Department . j; Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 015-461-46 Property owner(s) ANDY ANGSTMAN Day phone / 3 Mailing address Site address 12121 GINAMI ST Legal description (Sub'd., Block & Lot) DENALI MEADOWS LT 5A-1 Legal description (Township, Range & Section) Lot Size 99755 Sq. Ft. Number of Bedrooms 5 5678 .9 APPLICATION IS FOR: APPLICATI• ' - '9,, TYPE OF DWELLING: (®all that apply) ,� 1► ,. le Family Absorption Field ❑ Initia a AUG l Sin(w/wo ADU)SF) ❑ Septic Tank 0 Upg =Q- m 1018 O Duplex D ❑ p Holding Tank ❑ Rene ❑ << ti Multiple Dwellings ❑ Privy ❑ oA L 9 q (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. I7AAIC (Signature of property owner or authorized agent) Permit/Rush Fees:at c 1PC}'2..1s•6°*18itWaiver Fees: '"141o.Mo Date of Payment: $ tg 0/...") Date of Payment: Receipt Number:s a Ito�1 Receipt Number: Permit No. OS plc) S Waiver No. G:1 Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc • Aug 27, 2018 Municipalities of Anchorage Departments of Health and Human Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Fax 249-7847 Re: New Well and Septic Permit Legal: DENALI MEADOWS LT 5A-1 To Whom it may concern: This is a request for a new septic and well permit on the above referenced lot. A two test holes were excavated and found GM and GW gravels with no water during the excavation. The proposed system consists of a 5 bedroom system,one bedroom for the small house and 4 bedroom for the proposed big house not shown. The lot slopes 5 to 10 percent near the test hole location for the leach field, see the site plan, then flattens out to less than 5 percent.The design consists of a simple 5-wide trench running parallel to the contours. The perc rate is 3 minutes per inch with water measured after 7 days at 13 feet. The lot is large therefore no encroachments existing for the design. No slope or cut banks existing within 100 feet of the proposed design, see the site plan. Please call me if you have any questions. Sincerer Michael N. Anderson, P.E. 4661 Natrona Anch, Ak 99516 Ph 727-8864 DESIGN CRITERIA: MOUND OVER (TH#1) Ln GRADE GRADE r 5 BDRM X 150 = 750 GPD1 0 .ORG t FILTER FABRIC SOILS = 750/1.2 = 625 GPD &INSULATION WWI625 GA/5'0.5 = 63' -2.0 "0 PIPE GM/GW (1) TRENCH SEWER ROCK 6.0' DEEP 4.0' EFFECTIVE s.o 5.0'WIDE I 5.0' I 63' LONG 14 SEPTIC FIELD SECTION \ / `- WELL .' e(141lam'" NO WELLS WITHIN 200' - PROPERTY LINE /',�, PROPOSED N // / DRAINAGE FIELD ,----%\-% ��S° / I I 'G ' � i • ff T� z' �• • I WELL• `_moi " � PROPOSED 1 I i •• ,\ r/ �� `� BEDROOM •• • / \ II WELL 6 % •` 1 SEPTIC( - ___ 1 1 ._ / • I 1 •• I // . 1 I i i \. _-tom/ /� \ / PROPOSED100' •• i/ WELL RADIUS . c' \--, IEPTIC ( 10'UTILITY Z 1._ // EASEMENT 7 _ r' WELL ,. / \`. Septic Design Prepared for �,s`•1ili� ANDY ANGSTMAN .••7E OF �',*t 4.7 DENALI MEADOWS, LOT 5A-1 :; 49TH 1\ ; * ♦♦ Anch, Alaska • - Anderson, P E Michael N. DATE: 8/24/2018 ANDERSON;' ♦ � No. E 4 9 � 4601 NATRONA AVE DRAWN: DJR ♦.� 7 i '.` ANCHORAGE,ALASKA 99516 �� �� (907) 727-8864/FAX: (907) 345-1391 SCALE: 1"=100' .4II1E;;, •• / / S' PROPERTY LINE- � 1. � TH#2 os„a ' / • I k 4 I t �• N17l /g l I e I --fie T 1'./I — '��/ % \\ \.....--1,---- TC¢TCO ONE / C SMT DC•� \ \�.� I • BEDROOM ��• 1 /��---'SCO HOUSE • \ • \ / 'D' 5-10`:J Z \ \ VFwgy / I 1500 GALLON / I \ / \ TANK 1 • / 1 / I \ r 1 r 1 r 1 r r r 1 r 1 r 1 r 1 1 / ® 1 // I / I 1 / 1 1 7/ I �� r 1 �K r \ / SEPTIC SYSTEM IS DESIGNED FOR // • • AN OTHER LARGER HOUSE IN THE // N • • FUTURE / • / Septic Design Prepared for .„��i ili%4, ANDY ANGSTMAN •••�� O� 44 DENALI MEADOWS, LOT 5A-1 49TH �� ”':k.��0 Anch, Alaska •• • edeik..\ Michael N. Anderson, P.E. DATE: 8/24/2018 : •c;MICHAEL N. ANDERSON;' 0 - No. CE 9469 ' 4601 NATRONA AVE DRAWN: DJR .1 g q/ .. ANCHORAGE, ALASKA 99516 �v l�J..... • •. (907) 727-8864/FAX: (907) 345-1391 SCALE: 1"=50' 444IE;;� 4* OF4 �0, Municipality of Anchorage -1 rCANI EPR'SS -O, r.I0 Development Services Department r '7.• •.•c1' 1, • On-Site Water and Wastewater Section :::*.:49TH* • ,r 4700 Elmore St. d P, `. •— P.O. Box 196650 Anchorage.AK 99519-6650 / r www.muni.orq/onsite �• (907)343-7904 ` v:..MICHAEL N. ANDERSCN , ' IS i • • CE-9469 •.' ,i Soils Log - Percolation Test td, `' 1 k Pf rr, v.,,��;►?. —,... Performed For: 4 h ,i 4Date Performed: M PM Legal Description: Quer a(,' dII1.J S Township. Range.Section: Map L.+ 5/4• ' Slope Site Plan Depth (Feet) 1 �JciQom►te �• 4TH Cc.. el.61 2- 3- 4- 6 /4/6 w 5- 6- 7- 8- WAS GROUND WATER 9- ENCOUNTERED? 141, S 10- IF YES,AT WHAT DEPTHS L 0 . Depth to Water After - P 1 1- Monitoring? /'77 E 12- Date. y©/V 13- © 11 9 6, / 1 AAL4• n„y y./A1/ 14, Reading Date Gross Time Net Time Depth to Water Net Drop R 11 15- P 0 th)rrt , Y t A[ii /00,,,,i to if 3 //it, 16- L 3 iib 17- 4' ' //e, 18- 60 3 7//(o 19- 20- PERCOLATION RATE 3, 7 •nvnutesnnch> PERC HOLE DIAMETER LP TEST RUN BETWEEN Z FT AND 3 FT COMMENTS PERFORMED BY: AIt / /`/t0 li, I CERTIFY THAT THIS Tel WAS/ PERFORMED IN ACCORDANCE WIT ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: Z 5�P 4I 77,l..‘w,�Ak. Municipality of Anchorage .( ripigikR.sil �l)'�q Development Services Department d r• #t On-Site Water and Wastewater Section• j y'• ?��!' •- 4700 Elmore St. / *: •4M 9TH • ,ir it, -c.k..e P.O. Box 196650 Anchorage,AK 99519-6650 Pi •/' www.munl.org/onsite (907)343 7904 A::.MICHAEL N. ANDERSON ;�/1 r c•. CE-9469 .•' -j Soils Log - Percolation Test �t�r�9'•• _ .••`�•`��: �i 11 t��PR�,r �w Performed For: H e 7 �,,, / Date Performed: �. Legal Description: D ev'1, It 1 tit 1.a J Qv Township. Range. Section: LUT— S A^t Slope Site Plan Depth (Feet) 0Jci, 1— 2- 3- 1 4- 17 t� it 5- 1,.U It-is V�✓l 6- tz /k/t A it), 7- 8- WAS GROUND WATER 9- ENCOUNTERED'? 1-l0 S 10- IF YES.AT WHAT DEPTH? L Depth to Water After 0 P 1 1- Monitoring? I ! E 12- Date y/4;0 , 13- (30g.H^ p l► t 9'/L/ice AJAi,4 • O 4 ?All 14- ReadingDate Gross Time Net Time Depth to Water Net Drop 15- W//i( ����',t I, it 3 VA, 16- ii- 'l 3 1/l,/ V 1, 17- 3 7//(i 18- (o/1 3 Vila 19- • 20- PERCOLATION RATE , .-iinutestnch) PERC HOLE DIAMETER TEST RUN BETWEEN -. FT AND 3 FT COMMENTS PERFORMED BY: I`X I I CERTIFY THAT THIS TEST AS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 7.1.67! 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 ID 015-4.61-46 Expiration Date: 8/25/2026 Legal description Denali Meadows, Lot 5A-1 Site address 12121 Ginami St Current property owner(s) Myron & Suzanne Angstman X The On-site system(s) is/are approved for 5 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or conditions: By: Original Certificate Date: 9/222025 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Service Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's submittal. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory Other 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 Application 1. GENERAL INFORMATION Parcel 1.D. 015-461-46 Complete legal description Denali Meadows, Lot 5A-1 Location (site address) 12121 Ginami St Current property owner(s) Myron & Suzanne Angstman Day phone 2. ON-SITE SYSTEMS SIZED FOR BEDROOMS 3. TYPE OF WATER SUPPLY: Rn Private Well serving 0— dwelling units R Other Non-public well as regulated by MOA R Water Storage F-1 Community Well or Public 4. TYPE OF WASTEWATER DISPOSAL: � Private Septic E] Private Septic serving 2 dwelling units ❑ Holding Tank R Community Septic or Public Sewer 5. SEPTIC TANK: A Steel n Plastic n Concrete n Fiberglass Age 7 - See advisory if steel or fiberglass older than 20 years 6. ABSORPTION FIELD: E] AWWTS FJ Bed 0 Deep Trench FW Wide Trench Fj Seepage Pit Waiver request for: Expedited review requested: Fj Distance: By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $ SAO Date of Payment V47-5 COSA# Waiver Fee $ Date of Payment Waiver # COSA Application_Apr2025.doc COSA Checklist Legal Description: Denali Meadows, Lot 5A-1 Parcel ID: 015-461-46 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system 1 A. WELL DATA R Well log is filed with Onsite (or attached) Date drilled 9/13/18 Total depth 364 ft Cased to 44 ft R Sanitary seal is functioning correctly 0 Wires are properly protected Casing height (above ground) 26 in. Date of flow test for COSA 9/2/25 Static water level at beginning of test 32 ft. Comments B. TANK DATA Measured operating fluid level in septic tank 4811 Date of pumping 8/20/25 ❑ Required maintenance completed, if AWWTS Comments: D. DISPOSAL FIELD DATA Which system tested (date installed) 2018 FE -1 ALL standpipes present per record drawing Total measured depth from grade 6.4 ft (max) Measured depth to pipe invert from grade 2.4* ft (min) ❑ N/A — pressurized field. ❑ Per record drawings, field is insulated. n Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced NSA gallons N/A date Any rejuvenation treatment (past 12 months) If yes, enter date Well production at time of test 1.5 gpm Water storage tank volume N/A gallons Well disinfected for coliform test? ❑ Yes Q No 0 Coliform bacteria is Negative Nitrate 4.93 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L 0 Arsenic less than MRL (ND) Collected by Forge Engineering Date 8/27/25 C. LTATION ❑ Required mai nce completed Age of lift station ye Lift station material Comments: Adequacy test date 9/2/25 Results II Pass Fluid depth prior to test 0 in Water added 852 gal New fluid depth 0 in Elapsed time 497 min Final fluid depth 0 in Absorption rate >750 gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) 48 in Effective depth used 0 in Effective depth remaining 48 in Comments/Deficiencies: *Grade drops right at the end where the MT is. The rest of the trench has more cover. COSA Checklist_May2025.docx E. SEPARATION DISTANCES From Well on Lot to: (Please enter distances if less than required) Septic Tank/Lift Station on Lot > 100' Yes if No Sewer Manhole/Cleanout > 100' Surface Water > 100' E Yes if No ft no Yes if No ft Neighboring Tank > 100' Yes if No ft Sewer Service/Septic Line > 25'ns Yes if No ft Disposal Field on Lot > 100' Yes if No ft Holding Tank > 100' Yes if No ft Neighboring Disposal Fields > 100' ft Community Wells > 200' Animal Containment > 50' Yes if No ft no Yes if No ft If tank or field is under driveway comment below Manure/Animal Excreta Storage > 100' Sewer Line/Main > 100' no Yes if No ft 0 Yes if No ft ❑ NIA — Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Disposal Field(s) on Lot to: (Please enter distances if less than required) Tank to Foundation > 10' Yes if No ft Surface Water > 100' Yes if No ft Field to Foundation > 10' Yes if No ft Wells on Adjacent Lots: Tank to Property Line > 5' Yes if No ft Wells > 100' n Yes if No ft Field to Property Line > 10' ❑• Yes if No ft Community Wells > 200' [E Yes if No ft Water Main/Service Line > 10' Yes if No ft If tank or field is under driveway comment below F. ENGINEER'S COMMENTS G. CERTIFICATION & STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm Forge Engineering Phone (907) 522-7773 Engineer's Printed Name Benjamin Schiller, I.E. Date 9/11/25 COSA Checklist_May2025.docx t � I BenjartnSchiller % }lslF� CE 12592 �2����,/� l��F�PROFESSI6NP�.,�