HomeMy WebLinkAboutTIMBER TRAIL TR 1C-1 Onsite File
Timber Trail
Tract iC - i
#017 - 101 - 64
• Municip:;ity of Anchorage
On-Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP171372 PID Number: 017-101-57
Dwelling: II] Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ■❑ New ❑ Upgrade
Name
MGJ BLDG GROUP ABSORPTION FIELD
Site Address ❑] Deep Trench ❑Wide Trench [' Bed ❑ Mound
❑ Other
Phone Number of Bedrooms Soil Rating Total depth from original grade
4 0.8 GPD/SF 9.0 Ft.
LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe
Subdivision Block Lot 2.0 Ft. 7.0 Ft.
TIMBER TRAIL TR 1C-1 Fill added above original grade Gravel length
Township Range Section 1.5 Ft. 63 Ft.
Gravel width Beds: Number of Lines Distance between lines
SEPARATION DISTANCES 2 Ft. Ft.
To
Septic Absorption Holding Sewer Total absorption area Number of trenches Dist. between trenches
Tank Field Lift Station Tank Line 882 Ft2
FromFt.
Well 1 00'+ 100'+ 501+ TANK 0 Septic 0 S.T.E.P. 0 Holding ❑Other
Manufacturer Capacity
ANCH TANK 1250 Gal.
Surface Water 100'+ 1001+ Material Number of compartments
Lot Line 10'+ 10'+ NA STEEL 2.0
Foundation 1 0'+ 10'+ LIFT STATION
Manufacturer Capacity
Gal.
Remarks
Alarm location Electrical installed by
PIPE MATERIAL House to tank 3034Tank to 3034
drainfield
Installer
MIKE N ANDERSON, P.E. Drainfield 3034 CO/MT3034
Inspector MIKE N ANDERSON, P.E. BENCH MARK (Assumed elevation) 118.4 ft
Inspection 15, 0_20 'I� Location and description
dates: 2 30 m GARAGE SLAB
ON-SITE WATER AND WASTEWATER SECTION APPROVAL . ks'L "'p
..�e OF Ai'lta
Conditional Approval: Date 0,9-4.)\�� • • , .. X
11
49TH *err
i
PI
7a! MICHAEL N. ANDERSON• -e
Septic Syste it+'�rF..,. i" r�9�(9 •••�:.r.:
A rove j t'A„ t` Date 3/ I a 49. •, . •' E�..
Approve Note: this approval does not include well permit requirements. ``t�V0x��-~�`~
p
(Rev 05/02/18)
Permit No. 0SP171372 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: TIMBER TRAIL TR 1C-1 PID No.: 017-101-57
/' , I Nl
MARK A B / I/ \
CO1 I 1 35 40 —-- —N // \\
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TCC011 75 73 \\ /
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C03021 82 813 SEPTIC / ,/
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C05 I 90 95 I I
NT1 1 85 131\— / r
MT2 90 95 _—'
BENCI4 rgELL
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NEW 1250 TANK /
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FF n R C9Me F ��. .�
FUER MK a �'' A 9TH 2.? •,
1250 GALLON \_mils �� / 't• ,`%�I��I !!��VV /
992 / 250 TAP* ma.x. gillSP
•7 r /
94.9 / s \A_5 94 / ..�..MICHAEL N. ANDERSON/,�
�.%i, No. C 469 .�z
SEPTIC SECTION • 62, — 44}4,..- C��\L 4�
N.T.S. -rt 3 DRY.OCT 2017 ,',-i1��
Certified Drilling Log
DOC CO dba
B,« 8. COLE
WELLS
I ULUVAN WATER
leP.O. Box 670269,Chugiak,AK 99567 688-2759
OWNER OF LAND: MGJ Building Group Inc. Bore Hole Data
ADDRESS: Depth
LEGAL DESCRIPTION Timber Trail Tr 1C1 From To
DATE: 5-31-18 0 2 Casing Stickup
PERMIT NUMBER: OSP171372 DATE OF ISSUE: 3/9/18
2 4 Overburden
TAX IDENTIFICATION NUMBER 01710157000
Is well located at approved permit location: NYes ]No 4 29 Silty Sand &Gravel
Method of Drilling: Nair rotary ncable tool 29 42 Tight Silty Sand & Gravel w/Clay
Depth of Well: 205' 42 57 Silt& Sand
Casing Type: Steel Wall thickness .250 inches 57 101 Tight Silty Sand & Gravel w/Clay
Diameter: 6 inches, depth 204 feet
101 163 Hardpan w/Cobbles
Liner type
Static Water Level: 130 feet 163 191 Silty Sand & Gravel w/Clay
Recovery Rate 8 gpm n gph 191 199 Silty Sand & Gravel Water
Method of Testing Air 199 205 Tight Yellow Clay & Gravel
Well Intake Opening Type: open end open hole
D 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: Flyes ri no
Method of Disinfection: Chlorine 50 PPM
Comments:
WATER QUALITY TESTIN c
ColiforRIM comont
-Nitrates N
MN at tk.t, „n.finigiL
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.
DOC CO dba
1hLL111AN Ilk WATER WELLS
P.O.Box 670269,Chugiak,AK 99567 688-2759
www.sullivanwaterwells.com
Pump Installation Log
Well Drilling Permit Number:SW OSP171372 Date of Issue 3-9-18
Parcel Identification Number: 01710157000
Legal Description Property Owner Name &Address
Timber Trail Tr 1C1 MGJ
Pump Installation Date: 9-26-18
Pump Intake Depth Below Top of Well Casing: 170 feet
Pump manufacturer's Name: F&W
Pump Model: 4F07P05301S
Pump Size: 1/2 hp
Pitless Adapter Burial Depth: 10 feet
Pitless Adapter Installer: Mike Anderson—Anderson Engineering
Disinfected Upon Completion? ® yes ❑ no
Method of Disinfection: Chlorine 50 PPM
Comments: Pitless Manufacturer: Martinson
Pump Installers Name: Sullivan Water Wells
Attention:The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
�o,,"°""tr_o MUNICIPALITY OF ANCHORAGE
t�• On-Site Water&Wastewater Program \O `'f;
PO Box 196650 4700 Elmore Road `�
' ij )ry Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997 �Y`
4\\ �,.5 7Y"' 1 http://www.muni.org/onsite ,- �;
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1�eparUmen t
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On-Site Water & Wastewater System Permit
Permit Number: OSP171372 Effective Date: 3/9/2018
Work Type: WellSeptic Initial Expiration Date: 3/9/2019
Tax Code Number: 01710157000
Site Legal Address: TIMBER TRAIL TR ICI G:3037
Site Mailing Address:
Owner: MGJ BUILDING GROUP INC Lot Size in Sq Ft: 90169
Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING Total Bedrooms: 4
This permit is for the construction of:
El Disposal Field El Septic Tank 0 Holding Tank 0 Privy Q 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: ,rkit'' Date: 3 23 /V-
Issued By: j2QJJ(JOJ\C. EccQ Date: 3 • r '
MUNICIPALITY OF ANCHORAGE
Community Development Department -414-x t? 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. 017-101-57
Property owner(s) MGJ Day phone
Mailing address V911 Toto.c SI-ree-I., f\nc\norcle_, AK 9q'SO '1
Site address
Legal description (Sub'd., Block & Lot) Timber Trail Tr 1 C 1
Legal description (Township, Range & Section)
Lot Size 90169 Sq. Ft. Number of Bedrooms 4
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(®all that apply)
Absorption Field ❑x Initial 2 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 lig-
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 ac or - i h
,ieetapplicable Municipal Codes. �`��
\'<, ij
/1111Ars \\,q _. .y.'//
(Signature of property owner or authorized agent) \!77-9;.!%-
Permit/Rush Fees: '$ 15101 .00 Waiver Fees:
Date of Payment: /210/I? Date of Payment:
Receipt Number: Pi alti3a? Receipt Number:
Permit No. DSPO' W Waiver No.
Permit App__•:• : c
MIMI lb.
March 7, 2018
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: Proposed Timber Trial S/D Tract 1C1, (S-12377)
To Whom it may concern:
This is a request for a septic and well permit on the above referenced lot. A two test hole was
excavated and found silty gravels GM,for the entire depth with no bedrock or water observed.The
perc rate was 12 minutes per for each of the four test holes. From the site plan the slopes are fairly
flat (less than 5-10 percent) at the test hole locations. The lots are large (one acre plus) and the
soils are good with no ground water or bedrock.
This permit will not impact any of the neighboring properties due to the lot layout.
Please call me if you have any questions.
Sincerely
Michael N. Anderson, P.E.
4661 Natrona
Anch, Ak 99516
Ph 727-8864
DESIGN CRITERIA: MOUND OVER
(TH#3) (TH#4) o GRADE
4 BDRM X 150 =600 GPD
SOILS = 600/0.8 = 750 GPD 1.0 _ORG 1 0 _ORG FILTER FABRIC
750 GA/12 =63' -4"0 PIPE
GM GM -3.0
(1)TRENCH `SEWER ROCK
9.0' DEEP
6.0' EFFECTIVE -90
2.0' WIDE 2.0'
63' LONG 18.0 18.0 _ 1
SEPTIC FIELD SECTION
N. H
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\ PROPOSED HOUSE /'� I
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�'\\� `PRO�EFjtY LINE I S TI I WELL I w�
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PROPOSED t: / • ( /
DRAINAGE FIELD I I I( • 1 /1.,__,�'
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PROPERTY LINE i Z --I-'I // �,`
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Septic Design Prepared for ���sSwiliiti1
:� P� •OF q�,qs�.♦♦
MGJ BUIDLING GROUP ••••••.
TIMBER TRAIL TRACT 101, (S-12377) ;. f 49TH /\ \'� -: .14A, : t•
Anchorage, Alaska •
•
Michael N. Anderson, P.E. DATE: 3/7/2018 •
♦j�•;MICHAEL N. ANDERSON.
♦ � No. C 9469 r,Z
4601 NATRONA AVE ♦0. �,, °• '
DRAWN: DJR %••1/• •� .�:
ANCHORAGE,ALASKA 99516 .1� ••. �.
(907) 727-8864/FAX: (907) 345-1391 SCALE: 1"=200' .i : ���4
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RAPTORS KNOLL 1 �• 1 I
LOT \ \ I •
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HOUSE
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PROPOSED 1i3 \ \\\� •
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RESERVE FIELD , \\ DIRECTION OF �� I I �/ •v
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` I / PROPOSED WELL
PROPSOED f4.iBERTRAIL l / I
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RAPTORS KNOLL I \ _\ �/ f 11 1
LOT 2 PROPOSED TIMBER TRAIL t
TRACT 1C2 PROPERTY LINE \ \I\\ I I
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Septic Design Prepared for ..0,76�,��q 111,
MGJ BUIDLING GROUP •�-PSE OF 4�S-**
TIMBER TRAIL TRACT 1C1, (S-12377) ;' 49TH %\ �:' ���
Anchorage, Alaska I ` `7,. 0
Oe .�
Michael N. Anderson, P.E. o :MICHAEL N. ANDERSON
E DATE: 3/7/2018 ��C" No. C 9 69 ;'
4601 NATRONA AVE DRAWN: DJR ..j 3 � ' :
ANCHORAGE,ALASKA 99516 - SCALE: 1"=50' •���11ESS;��i��•
(907) 727-8864/FAX: (907) 345-1391 ■iiw�
....7, 7i,1 T.
Municipality of Anchorage �{>r1961NEgg'S$EAL);�), �
A� Lam-�.e• n
Development Services Department ,�.fir.•
• Building Safety Division 0. �j•• l'`y .
N •
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� � On-Site Water and Wastewater Program �.s �-. 49.7!-! N~r'( "•
4700 Elmore Road P'�
P.O.Box 196650 Anchorage,AK 99507
www.ci.anchorage.ak.us �/' °••
(907)343-7904 fp%'=',••MICHAEL N. ANCrij0h ,".0
(I°7'-•
• CE 9461
• •
Soils Log - Percolation Test " ''^;•.,
Performed For: rCPAE0,/4 t? -r rOA:V- Date Performed: YA'rc�'E`,' ZJ 2t) (
Legal Description: T) rn b L,, ' YAC ( 4L I C7 Township.Range.Section:
Slope Site Plan
(-tr/ -5j)
Depth
(Feet)
c.1•-)Cr4,1I2 2-7
1
2- Gi "6'7 9(D✓(
3-
4-
5- ,
6-
7-
8- & >>'l
WAS GROUND WATER
9- ENCOUNTERED' 0
10- IF YES.AT WHAT DEPTH? L
0
Depth to Water After p
1 1- Monitoring? 0 P l] E
12- Date (tom
13- 0 /i Sue kt '
14- Reading Date Gross Time Net Time Depth to Water Net Drop
15- /t$f I?- 3c414) n t.e -2 1 S„
16 f0 I' 2
I5 ,r
if
17- Go '
).
Z' 5-
18�
19-
20-
PERCOLATION RATE (7J (minuteslinch) PERC HOLE DIAMETER 67 '
TEST RUN BETWEEN L. FT AND 0.3 FT
COMMENTS
PERFORMED BY: / 7( C A I CERTIFY THAT THIS TEST WAS
PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ( Z-! /S(/7---
Municipality of Anchorage ,.— (ENGINEER'SSEAL).
Development Services Department .. . •,
Building Safety Division i''.0
On-Site Water and Wastewater Program r 9 T!4 �4
4700 Elmore Road ""•••• •••••••• ..•.�. ..
• - P.O.Box 196650 Anchorage.AK 99507 4
www.ci.anchorage.ak.us i' 4• <
^- • MICHAEL N. ANDERSON :, -:'P
's.,..., (907)343-7904 f -� .
l, CE-9469 ';:"::;.;"
Soils Log - Percolation Test 1,/e-,�•. •..
r °g ,. .:•
Performed For: r�� r� S Date Performed: �FiV'�, � �
t16-
Legal Description: 'T, ,. 1 cJ f\fm‘ ( T2- ` c Township. Range.Section:
Slope Site Plan
Depth
(Feet) 0vsoi /
-
1-- +
2- 4 -T.& P (o r
3-
4-
5-
6-
7- C,7 t _
8-
WAS GROUND WATER f
9- ENCOUNTERED? ` D
S
10- IF YES,AT WHAT DEPTH? L
0
Depth to Water After P
1 1- Monitoring? Qt t. E
12- D.,:e hi/AO 7-
13- Pu•GSc9NIti.
14- Reading Date Gross Time Net Time Depth to Water Net Drop
15- lc/77-1/7— 3•0 r,n,h (i i( 7, i,---
16-
l16- (P/t 7,S
17- (a" -2, --
18- - (g �l 2.
19- (�ct 2.
20-
PERCOLATION RATE ( )____. (minutes/inch) PERC HOLE DIAMETER Le
TEST RUN BETWEEN "l FT AND -,--- FT
COMMENTS
PERFORMED BY: 1--)\"bA I CERTIFY THAT THIS TEST AS
PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 2 2
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70. 09 30 /\ / �A� `,_ 1~ 1
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♦ L3-5484 /
GRAPHIC SCALE: 1 Inch = 30 Feet ,` ''o5 /�"f/ /
\SSIoNM- " /'
15-0 ''E15 30 60 ‘Ith.:1‘.70-41P.
Date Scale Legal Description
5/7/2018 1" = 30' LOt 1 C-1 I hereby certify that the property described hereon has been surveyed
BOBBY F. B URNETT Grid by me, or at my direction, and that the improvements situated thereon
2941 Carriage Drive SW 3037 AS-BUILT are within the property lines and do not overlap or encroach on the
TIMBER TRAIL SUBDIVISION property lying adjacent thereto unless otherwise shown. That no
Anchorage, Alaska 99507 improvements on the property lying adjacent thereto encroach on the
(907) 350-5541 Drawn by Field Book Plat # 2018— premises in question and that there are no roadways, transmission
BFB ASB2018 lines or other easements on said property except as shown.
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. 017-101� 6�-� Expiration Date:
1. GENERAL INFORMATION
Complete legal description TIMBER TRAIL TR 1C-1
Location (site address)
Current property owner(s) MGJ BLDG. Day phone
Mailing address
Real estate agent Day phone
2. TYPE OF DWELLING:
Li Single Family (w/wo ADU)
❑ Duplex
E Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4.0
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Private Well [] Private Septic
Water Storage ❑ Holding Tank ❑
Community Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
Waiver request for: Distance:
Received by: Ar/A" ' . Date: , 2
� q'
COSA to be released to the engineer,unless otherwise requested by the engineer. Date: ,//
COSA Fee $ 120. 06 Waiver Fee $
Date of Payment 63/111)61 Date of Payment
Receipt Number Cl\ L 4J O92( Receipt Number
COSA# OSC I q I Qn 1 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 MIKE N ANDERSON, P.E. Phone 727-8864
Address 4661 NATRONA AVE. ANCH AK 99516
Engineer's Printed Name MIKE N ANDERSON, P.E. Date 3-10-19
OOOJO° 00 Ce4 a`4D 00 4°.0
6. DSD SIGNATURE
,C- System #1 Approved for t-I bedrooms r),;-1:„4 MICHAEL'N. ANE SC.,; -
.'i,°, CE 9-^.59
System #2 Approved for bedrooms 4>J,�,•, rn�,
a t
Disapproved 0 ` ' ' -`-'
Conditional approval for bedrooms, with the following stipulations:
"'v‘,/
ON-SITE ,-N,
WATER AN
D
z:
PROGRA
ATER
C) WA�TEW Q
M O .
9' \ri SECO\GAS
f��
B • C ��� lrG`-�"'u Original Certificate Date: l ^`
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: TIMBER TRAIL TR 1C-1 Parcel ID: 017-101-57
If more than 1 septic system on lot: COSA Checklist# of Structure served by this system
A. WELL DATA
0 Well log is filed with Onsite (or attached) Well production at time of test 8/NEW gpm
Date drilled 5-13-18 Water storage tank volume 0 gallons
Total depth 205 ft Well disinfected for coliform test? Yes ❑ No
Cased to 205 ft 0 Coliform bacteria is Negative
0 Sanitary seal is functioning correctly Nitrate ND mg/L ❑ Nitrate less than MRL (ND)
['Wires are properly protected Arsenic ND ug/L ❑ Arsenic less than MRL (ND)
Casing height(above ground) 24 in. Collected by MNA
Date of flow test for COSA NEW Date of Sample 2-25-19
Static water level at beginning of test 130 ft.
Comments
B. TANK DATA C. LIFT STATION
Age of tank(s) NEW years ❑ Required maintenance completed
Tank type/material STEEL/jet 6%c- Age of lift station years
Measured operating fluid level in septic tank NEW Lift station material
El Standpipes/foundation cleanout per record drawing Comments:
Date of pumping NEW
D. ABSORPTION FIELD DATA NEW
Which system tested (date installed) NEW 64-2 "." Ig Adequacy test date NEW
❑■ ALL standpipes present per record drawing Results ID Pass For 4 bedrooms
Total measured depth from grade 11 ft(max) Fluid depth prior to test NEW in
Measured depth to pipe invert from grade 4 ft(min) Water added gal
❑ N/A—pressurized field
New depth in
❑■ Monitor tubes go to bottom of effective. If not, state Elapsed time min
depth into effective
❑■ 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)
date of test)
Gallons introduced NEW 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' Community Sewer Manhole/Cleanout > 100'
0✓ Yes if No ft 0 Yes if No ft
Neighboring Tank > 100' 0 Yes if No ft Private Sewer/Septic Line > 25' E Yes if No ft
Absorption Field on Lot > 100' 0 Yes if No ft Holding Tank > 100' 0 Yes if No ft
Neighboring Absorption Fields > 100' Animal Containment> 50' 0 Yes if No ft
0 Yes if No ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ❑✓ Yes if No ft -LI 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' I Yes if No ft
Property Line > 5' 0 Yes if No ft Wells on Adjacent Lots:
Absorption Field > 5' 0 Yes if No ft Private Wells > 100' 0 Yes if No ft
Water Main > 10' 0 Yes if No ft Community Wells > 200' ✓0 Yes if No ft
Water Service Line > 10' 0 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' 0 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' 0 Yes if No ft Private Wells > 100' C✓ Yes if No ft
Water Service Line > 10' 0 Yes if No ft Community Wells > 200' 0 Yes if No ft
Surface Water > 100' 0 Yes if No ft
F. ENGINEER'S COMMENTS
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G. ENGINEER'S CERTIFICATION 7<?:**• • .8,,rl'd
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I certify that I have determined through field inspections and review %IT e 49TH . z;��'�
of Municipal records that the above systems are in conformance with •
MOA COSA guidelines in effect on this date. l..? ..�'F. §s os
/ r:P „,,MICHAEL N. ANDERSON ;('Q'/4
f:.� CE-9 69 •�`''�%
COSA Checklist yellow sheet