HomeMy WebLinkAboutT12N R3W SEC 22 LT 25 S396' Onsite File
T12N R3W Sec 22
Lot 25 5396 '
#015 - 521 - 40
Rol!"
Municipality. of Anchorage NOV113 2019
On -Site Water and Wastewater Section - (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP191091 PID Number: 015-521-40
Dwelling: N Single Family (SF) F1 with ADU F Duplex (D) F-1 Two Single Family Project: 171 New FIB] Upgrade
Name
Ben & Eleanor Parrish
ABSORPTION FIELD
R Deep Trench IMM Wide Trench F-1 Bed F-1 Mound
Site Address
11135 Our Rd, Anchorage, AK 99516,
El Other
Phone
Number of Bedrooms
Soil Rating
depth from original grade
306-2768 —1
4
1.2 GPD/SF
ITotal
7.1 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
3.1 Ft.
Gravel depth beneath pipe
4.0 Ft.
Subdivision Block Lot
25 S 396'
Fill added above original grade
0.0 Ft.
Gravel length
50 Ft.
Township Range Section
12N 3W 22
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
500 Ft2
1
Ft.
Well
>100'
>100'
N/A
N/A
>25
TANK M Septic [I S.T.E.P. El Holding C1 Other
Manufacturer
Anchorage Tank
Capacity
1,250 Gal.
Surface Water
>100'
>100'
N/A
N/A
Material
Number of compartments
Lot Line
>5'
N/A
N/A
NA
Steel
2
Foundation
>10'
>10'
N/A
N/A
LIFT STATION
Manufacturer
Capacity
I
—
Remarks 2" Insulation over trench.
Gal.
Alarm location
Electrical installed by
Installer
PIPE MATERIAL House to tank D3034 drainfielcITankto D3034
John's Excavating
Drainfield D3034 COIMT D3034
Inspector J. Millette
BENCH MARK (Assumed elevation) 100 ft
Inspdates: 2nd ection is, 4/24/19 5/29/19
Location and description
31d 4(h
Garage slab.
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
Conditional Approval: Date
�,� ............F ...... . q(�,
..94 th
r . ...... .... ....... 10
0 0
..............
MICHAEL E. ANDERSON tgf
Septic Syst em
Approved Date 717,lZmo
No CE -4381
4101'••..,,1114119 40ZY
Fo.............
Note: this approval does not include well permit requirements.
*�
4110 PROFE'ZS�01'b
Municipality of Anchorage
P.O. Box 196650 e 4700 Elmore Road
Anchorage, Alaska 99519-6650 a (907) 343-7904 0 Fax (907) 343-7997
http://www.muni.org/Onsite
Development ices Department
On -Site Water and Wastewater Section
Waiver#: OSV201037 COSA#: Permit#-. OSP191091
PID#: 015-521-40
Legal Description: T12N RM Section 22 Lot 25 S396'
Engineer: Forge Engineering
Applicant: Ben & Eleanor Parrish
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 9.5 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.
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Waiver is Granted: X Waiver is not Granted:
Date: Zb Zy Approved by: /"Y C r
Name of Reviewer
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PO BOX 240773
ANCHORAGE, AK 99524
522-7773 677-7766 (FAX)
July 8, 2020
Municipality of Anchorage
Development Services Department
On-Site Water and Wastewater Program
P.O. Box 196650
Anchorage, AK 99519-6650
Subject: T12N R3W SEC22 L25 S396 - 11135 Our Road
Separation Distance Waiver
Absorption Trench to Lot Line
Dear On Site Services Engineer:
The northwest corner of the new absorption trench is 9.5’ from the northern property line. The
vast majority of the trench is more than 10’ from the line. A waiver is required to allow the
trench to remain in its current location.
The percolation rate of the underlying soil is 2 minutes per inch. Effluent absorption is expected
to be downward with little or no migration in a horizontal direction. The trench is located more
than 100’ from all wells in the area. The trench is also more than 50’ from the septic system on
the property to the north. Placement of the system at the location described above will have no
adverse impact on the well or septic system on this or adjacent lots. We hereby request a lot line
waiver be issued.
Sincerely,
Michael E. Anderson, P.E.
T12N R3W SEC 22, LOT 25 S396'
PER IT # OSP191091 PID # 015-521-40
I
I i MT1 50' LONG x 5' WIDE x 4' EFFECTIVE
Col DEPTH ABSORPTION TRENCH.
EXISTING CRIB FILLED & ABANDONED
eco IN PLACE PER MOA CODE.
O7H1 SV2 OLD TANK REMOVED &
CO2MT2 SV DISPOSED OF PER MOA CODE.
NEW 1,250 GALLON
\ I SEPTIC TANK
I 1
I
IN
la00
ID ALTERNATE SITE' -
00 \
IY
m
I�
co
IW
W
IW
IW
co
IW
ry
13:
10
IM
I co
A B
C
SV1
- 87.2
86.1
SV2
- 95.2
94.0
2CO
- 98.6
96.1
C01
- 126.3
124.5
MTI
- 128.9
126.5
CO2
118.1 135.9
-
MT2
115.4 133.4
-
L
GE
ENGINEERING
0/1
jl , it
B co^o
9�
EXISTING WELL
4 -BEDROOM HOME
1 00'WELL RADIUS
11 "09KM1001-01
33' Patent Roadway Reserve Patent 1134664
-----------------
EAST 112TH AVE
PLAN AS -BUILT
0 50 100
FEET
1 "=50'
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEANOUT
FS - FLOW SPLITTER VALVE
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
Tl 2N R3W SEC 22, LOT 25 S396'
PERMIT # OSP 191091 PID # 015-521-40
O F -
U:5
ENGIN EE N I NC
92.9 ORIGINAL/FINISH GRADE � O
2" INSULATION n n
DRAINFIELD ROCK
85.8
50'
78.9
NO GROUNDWATER 4/23/19
PROFILE AS -BUILT
(NO SCALE)
85.8
:•
MICHAEL J. HORNE
LS-5318FARPOINT ASBUILT SURVEY OF:
SCALE:
GRID No:
WORK ORDER No.
DRAWN: CHECKED:
DATE:
FB BOOK/PAGE:
Jan. 6, 2020 50'
MEJD SW2637 147/09
Lot 25, T12N R3W SEC 22, S. 396'
Anchorage, AlaskaSERVINGALASKASIN
C
E1982EXCLUSION NOTES: It is the owners responsibility to determine
the existence of any easements, covenants, or restrictions which
do not appear on the Plat used for this survey. NOTE: Under no
circumstances should any data hereon be used for construction
or for the establishing of property lines.
SURVEY CERTIFICATION: FARPOINT has conducted a physical
survey of the subject property, the improvements situated
thereon are within the property lines as shown.
Recovered Rebar
Septic Vent
Well
PREPARED FOR:
Ben Parrish
11135 Our Road
Anchorage, AK 99516
1. Bearings and distances are record per referenced plat unless otherwise noted.
2. Sufficient boundary evidence was recovered to establish the subject parcel on the ground. Not all
controlling evidence is shown hereon.
ZONING:
R6
MUNICIPALITY OF ANCHORAGE ,,,enc
\,, On-Site Water& Wastewater Program \° .'
/ aftse PO Box 196650 4700 Elmore Road •
Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997 yz { v
http://www.muni.orgionsite
.�-
Department
QNcHoppGE On-Site Wastewater Disposal System Permit
Permit Number: OSP191091 Effective Date: 4/15/2019
Work Type: Septic Upgrade Expiration Date: 4/14/2020
Tax Code Number: 01552140000 •
Site Legal Address: T12N R3W SEC 22 LT 25 S396' G:2637
Site Mailing Address: 11135 OUR RD, Anchorage
Owner: PARRISH BEN F & ELEANOR Lot Size in Sq Ft: 130482
Design Engineer: FORGE ENGINEERING Total Bedrooms: 4
This permit is for the construction of:
Disposal Field Q Septic Tank 0 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
Special Provisions:
**The Engineer is required to do an additional percolation test for the alternate site prior to construction of the
septic field. Please submit stamped and signed results with the As-built Inspection Report. If the results require a
design change, construction of the system will stop pending On-Site review and approval.
5/019 co ! /Edd S i e1G1 .vert:'r .
f� ) Date:Received B : (II(Miei)1'/L / 7
Y ,,
Issued By: /A i� Date: 5-//001
Epaivs
MUNICIPALITY OF A NCHORAGERose/.-....._
•
r11_ �
Community Development Department Phone: 907-343-7904
Development Services Division
Fax: 907-343-7997
On-Site Water & Wastewater Program
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 015-521-40
Property owner(s) Ben & Eleanor Parrish 306-2768
Day phone
Mailing address 11135 Our Rd, Anchorage, AK 99516
Site address 11135 Our Rd
Legal description (Sub'd., Block & Lot) T12N R3W SEC22 Lot 25 S 396'
Legal description (Township, Range & Section)
Lot Size 130,482 Sq. Ft. Number of Bedrooms 4
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(®all that apply)
Absorption Field Ej LO #\ Initial 1 1 Single Family (SF) ❑X
Septic Tank ❑X U (w/wo ADU)
pgrade IXI Duplex (D)
Holding Tank ❑ Renewal n
Multiple Dwellings ❑
Privy (SF and/or D)
Private Well Li
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.
Y"31----i
(Signature of property owner or authorized agent)
Permit/Rush Fees: c9Z- 370 Waiver Fees:
Date of Payment: L q / 5N cIDate of Payment:
Receipt Number: dub / D 063' Qceipt Number:
Permit No. (10,01e IV / Waiver No.
Permit App__-:• :;.,c
PO BOX 2411773
♦omw ANCHORAGE.AX 114224
r GE 577-7771
677-7766(FAX)
• ENGINEER ! NG FORGECIVIL.COM
May 9, 2019
MOA Development Services, On-Site Water& Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
Subject: T12N R3W SEC22 L25 S396 - 11135 Our Rd
Septic System Design
Dear On-Site Services Engineer:
The existing septic system on the above lot has failed and must be replaced. The existing home
has 4-bedrooms. We are submitting this permit application for the placement of a new septic tank
and absorption trench. The attached site plan identifies the location of the existing home, well
and septic system and the location of the proposed septic tank and absorption trench. The
drainage pattern in general will not be changed by the construction.
The existing septic tank will be decommissioned in accordance with MOA code. The abandoned
absorption crib on the lot will be pumped dry, collapsed and backfilled. The ground surface on
the lot in the area of the absorption trench slopes as shown on the Site Plan.. Stormwater
drainage will not impact this septic system. The new trench will be constructed parallel to the
slope as much as possible.
Wells on this and adjacent lots are shown. The new system will be a minimum of 100' from all
wells and surface water, and more than 5' away from the septic tank.
Please refer to the attached test hole log and plan and profile sheets for the septic design. If this
design is followed,there will be no adverse impacts to adjacent properties.
Sincerely.
-144"--.-Lit 04"--c9-----1
.� q �a•
Michael E. Anderson, P.E. �E, ,,hC,�s••
d 49thi�. ..` ••i
•
11. MICHAEL E. ANDERSON j
•• •. N0. CE-4381 :•��i
N'<ep"%.,, 5-9-19 N•.••'c
•,
T12N R3W SEC 22, LOT 25 S396'
—
I50'LONG x 5'WIDE x 4' COLLAPSE,BACKFILL AND
:S.
EFFECTIVE DEPTH Co ABANDON EXISTING SEPTIC
ABSORPTION TRENCH N ` ABSORPTION PIT.
2DECOMMISSION EXISTING
� Mi CO.� SEPTIC TANK PER MOA CODE.
CO 2C• — — — _
•444
/ 1 \ 1,250 GALLON/ S Ci- \N
\ c\I SEPTIC TANK
\ a / oy \
I 1 ots ALTERNATE SITE \
CO
/ III 64z, III. \
VcD
/ 1
I / w I I*Ili 1
// > 1
I / ))) 1\ EXISTING WELL
/ L
// (Y \ 4-BEDROOM HOME //
I 0 0 \ /
/ Iy fY \ /
1Y cc) \ /
0 N7
- - - - -
LOT 25 S396'
33' Patent RoadwayReserve Patent 1134664
_J L -
GE EAST 112TH AVE
[Na1N[t RING NOTE:
.••'�OF qNI_ NO SLOPES>25%WITHIN 50'OR SURFACE WATER WITHIN 100'OF THE LEGEND
••-7E. „.......Cq e• PROPOSED SEPTIC SYSTEM
4!, \);.••••" ••••. • CO-CLEANOUT
!,1 -% 2C0-DOUBLE CLEANOUT
'•>}♦ ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS
JL 49th ,,,♦ FCO-FOUNDATION CLEANOUT
NIA, •"•• • PROPERTY ARE SHOWN.NO CONFLICTS WITH WELLS OR SEPTIC
•7 _.i,r. ��• FS-FLOW SPLITTER VALVE
♦ --- r. .• SYSTEMS.
♦ MICHAEL E. ANDERSON •• = MH-MANHOLE
♦♦•-�J t No. CE-4381r' � 0 50 100 MT-MONITORING TUBE
♦i fc�''..,• 5/9/19 r••' I♦ OM MI FEET
♦6 4*�ROF;S;� ::? 1"=50' TH-TESTI HOLE VENT
T12N R3W SECTION 22 LOT 25 S396'
DESIGN FACTORS: SYSTEM REQUIREMENTS:
600 GPD PEAK FLOW 5' WIDE TRENCH SYSTEM
PERK RATE: 1-5 MIN/IN 1,250-GAL SEPTIC TANK
APPLICATION RATE: 1.2 GPD/SF
600 GPD/ 1.2 GPD/SF/5' WIDE *.5 RED. FACTOR = 50 LF TRENCH REQUIRED 50 LF SPECIFIED)
BOTTOM OF TRENCH: 7.5' BELOW GRADE
FLOW LINE ELEVATION: 3.5' BELOW GRADE
TOP OF TRENCH: .5'ABOVE GRADE
6"
IIII1 X11
q�I��Io�u�n�u�i
3' ��11�11 1�11 �.0I
loll 11* 0 *11*1
6"
''=`•'=•'='='='='= ='= 4" PERFORATED PVC (HOLES DOWN)
DRAINFIELD ROCK
4' .:.:.:.:.:.:.:.:.:.:.:.:.:.:..
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
5'
I'
's.�ENGIN
GE
EERING
TYPICAL TRENCH SECTION .•••��••��
.••�E OFq(�+i•
(NO SCALE) r�K ..' •...i.4q�, .�..
NOTES: a�•_49th •= 0,
1. GRADE AREA OVER TRENCH TO DRAIN AWAY
2. PROVIDE 3' OF COVER OVER TRENCHES AND 4' OVER SEPTIC TANK, OR 2' `,,rMICHAEL E. ANDERSON t•
WITH 2" OF INSULATION �v.v.s No. CE-4381 ,.�_:
3. CHECK GROUNDWATER AT TIME OF CONSTRUCTION. IF LEVEL IS HIGHER jFp'•• 516119 +,;F '•+
THAN PREVIOUSLY OBSERVED, CALL ENGINEER IMMEDIATELY ��h. r;;S;; :•••
illiii?GE 11,, tztlartz
SOILS LOG AND PERCOLATION TEST . •` 49th ,` `' -♦.
ENGINEERING /1.s iAt
;
MICHAEL E. ANDERSON J
,c .: N o. CE-4381 _-
♦ l ". k, •
LEGAL DESCRIPTION: T 12N R3W SECTION 22 LOT 25 ♦v,,pe6;.....---0 .*•
PERFORMED FOR: JOHN PARR ISH
v., il e6
W.
DATE: 4/15/19 PROJECT No.:
PARCEL ID#: TECHNICIAN:
J. WILLIAMS Professional Engineers Stamp:
DEPTH TEST HOLE 1
(feet)
1 1' OG/OL SLOPE SITE PLAN
2 � f
4 • .
5 , f' ., ; SEE S'TE P.AN
6 . • a._
7 ' • • • : SANDY SILTY GRAVEL
8 ••• ••ti:• '. ` GM
E
9
WAS GROUND WATER ENCOUNTERED? NO
1I.t. IF YES 1 WHAT DEPTH? - S
' DEPTH OF WATER AFTER MONITORING NONE
11 .‘:.;1:... DATE OF MONITORING L/23/'9
E
12 , :.•• : -
GROSS TIME NET TIME DEPTH TO NET DROP
13 DATE READING (MINUTES) (MINUTES) NCHES (INCHES)
14 . ' ` 4/17 TEST HOLE PRESOAKED PRIOR TO TESTING:
15 1 11:32/11:42 10 0/5 5
2 11:53/12:03 10 0/5 5
16
3 12:06/12:16 10 0/5 5
17
4 12:17/12:27 10 0/5-1/16 5-1/16
18 5 12:28/12:38 10 0/5 5
19 6 12:39/12:49 10 0/5 5
20
PERCOLATION RATE: 2 (MIN/INCH) PERC. HOLE DIA. 6 (INCHES)
TEST RUN BETWEEN: 3 FT. and 4 FT.
COMMENTS: Depth measurements taken to 1/16".
MICHAEL J. HORNE
LS-5318FARPOINT ASBUILT SURVEY OF:
SCALE:
GRID No:
WORK ORDER No.
DRAWN: CHECKED:
DATE:
FB BOOK/PAGE:
April 22, 2019 50'
MEJD SW2637 147/09
Lot 25, T12N R3W SEC 22 S396',
Anchorage, AlaskaSERVINGALASKASIN
C
E1982EXCLUSION NOTES: It is the owners responsibility to determine
the existence of any easements, covenants, or restrictions which
do not appear on the Plat used for this survey. NOTE: Under no
circumstances should any data hereon be used for construction
or for the establishing of property lines.
SURVEY CERTIFICATION: FARPOINT has conducted a physical
survey of the subject property, the improvements situated
thereon are within the property lines as shown.
Recovered Rebar
Septic Vent
Well
PREPARED FOR:
Ben Parrish
11135 Our Road
Anchorage, AK 99516
1. Bearings and distances are record per referenced plat unless otherwise noted.
2. Sufficient boundary evidence was recovered to establish the subject parcel on the ground. Not all
controlling evidence is shown hereon.
ZONING:
R6
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: (907)343-7904
On -Site Water & Wastewater Section Fax: (907)343-7997
Parcel ID 015 -521-40
Certificate of On -Site Systems Approval
OSC251423
Expiration Date: 8/11/2026
Legal description T1 2N R3W SEC 22 LT 25 S396'
site address 11135 OUR RD
Current property owner(s) PARRISH BEN F& ELEANOR
X The On-site system(s) is/are approved for 4 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or conditions:
(No comments
By: .�`— �T"? Original Certificate Date: 9/23/2025
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 X
Tank Age Advisory Arsenic Advisory
Other
MUNICIPALITY 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 I.D. 015-521-40
Complete legal description T12,R3W SEC 22 Lot 25 S396
Location (site address) 11 135 Our Rd
Current property owner(s) Ben & Elenor Parrish
2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS
Day phone
3. TYPE OF WATER SUPPLY: [k Private Well serving #_1_ dwelling units
❑ Other Non-public well as regulated by MOA ❑ Water Storage
❑ Community Well or Public
4. TYPE OF WASTEWATER DISPOSAL: A Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: ❑O Steel ❑ Plastic ❑ Concrete ❑ Fiberglass
Age 6 - See advisory if steel or fiberglass older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench ❑N Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested: ❑
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 $ 5S0 Waiver Fee $
Date of Payment q M115 Date of Payment
COSA # G SC 2� 1 q2_1 Waiver #
COSA Application_Apr2025.doc
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT 907-343-7904
On -Site water and wastewater Section Fax: 343-7997
www.muni.org/onsite
Nitrate Advisory
Certificate of On -Site Systems Approval # OSC251423
Subdivision: T12N R3W SEC 22, Block: , Lot: 25 S396'
A water sample revealed a nitrate concentration of 7.04 milligrams per liter (mg/Q.
The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. Since nitrates are known to slowly increase, we recommend
you monitor the water quality. Please see the attached "Nitrate Fact Sheet" for
important information regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
Mailing Address P :O Box, -19
6650 * Anchorage, Alaska 99519 6650 *www muni org
/a�NpRgG
YOUR NO.
SHIP VIA
p
ANCHORAGE WELL & PUMP SERVICE, INC.
ti
DATE
PG.
7640 KING STREET
ANCHORAGE,
40608
AK 99518
\4pf j
PH. 907-243-0740
Invoice
Bill To:
John Parrish
Estate of Eleanor Parrish
5125 E 112th Ave
Anchorage, AK 99516
Ship To:
20254844
John Parrish
JOB: Estate of Eleanor Parrish
11135 Our Rd
Anchorage, AK 99516
SALESPERSON
YOUR NO.
SHIP VIA
COLPPD
SHIP DATE
TERMS
DATE
PG.
40608
Net 30
9/23/2025
1
TY.
ITEM NO.
DESCRIPTION
PRICE
DISC %
EXTENDED
PRICE
TX.
1
Service Call
CAMERA WELL FOR ALL DATA FOR COSA
1
FIELD SERVICES
09/22/25 - Check system. Camera well.
WELL CAMERA RESULTS:
Pitless adapter depth - 9'-6"
Static water level - 84'-4"
Pump set -134'
Bottom of well -140'-2"
Cased to bottom of well
1
ST2-Mark
Service Tech
1
CAMERA
WELL CAMERA
$400.00
$400.00
SALE AMT.
$400.00
FREIGHT
$0.00
SALES TAX
$0.00
TOTAL AMT.
$400.00
PAID TODAY
$0.00
BALANCE DUE
$400.00
Legal Description:
COSA Checklist
T1 2N R3W SEC 22 Lot 25 S396
Parcel ID: 015-521-40
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system 1
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled C. 1960 Total depth 140.2* ft
Cased to 140.2* ft
W Sanitary seal is functioning correctly
9 Wires are properly protected
Casing height (above ground) 24 in.
Date of flow test for COSA 8/11/25
Static water level at beginning of test 80 ft.
Comments *Well camera'd
B. TANK DATA
Measured operating fluid level in septic tank
Date of pumping 9/17/25
❑ Required maintenance completed, if AWWTS
Comments:
D. DISPOSAL FIELD DATA
Which system tested (date installed) 2019
0 ALL standpipes present per record drawing
Total measured depth from grade 6.3/7.4 ft (max)
Measured depth to pipe invert from grade 2.3/3.6 ft (min)
❑ N/A — pressurized field.
❑o Per record drawings, field is insulated.
❑ Monitor tubes go to bottom of effective.
If not, state depth into effective 473.8'
❑ Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced 2000 gallons 8/11/25 date
Any rejuvenation treatment (past 12 months) N/A
If yes, enter date NIA
Comments/Deficiencies:
COSA Checklist_May2025.docx
Well production at time of test 0.6 gpm
Water storage tank volume N/A gallons
Well disinfected for coliform test? ❑ Yes ❑N No
0 Coliform bacteria is Negative
Nitrate 7.04 mg/L ❑ Nitrate less than MRL (ND)
Arsenic 7.70 ug/L ❑ Arsenic less than MRL (ND)
Collected by Forge Engineering
Date 8/11/25
C. STATION
❑ Required m nance completed
Age of lift station
Lift station material
Comments:
Adequacy test date 8/11/25
Results F Pass
Fluid depth prior to test 9/9 in
Water added 603 gal
New fluid depth 2/2 in
Elapsed time 1440 min
Final fluid depth 0/0 in
Absorption rate >600 gpd
FIELD STATUS — POST RECOVERY
Effective depth (per record drawings) 48 in
Effective depth used 0/3 in
Effective depth remaining 48/45 in
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'
Yes if No _
0 Yes
if No
ft
0 Yes
if No
Neighboring Tank > 100' E Yes
if No
ft
Sewer Service/Septic Line > 25' 0 Yes
if No
Disposal Field on Lot > 100' Q Yes
if No
ft
Holding Tank > 100' ❑• Yes
if No
Neighboring Disposal Fields > 100'
lE Yes
if No
Animal Containment > 50' 0 Yes
if No
R] Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Sewer Line/Main > 100' Yes
if No
ft
❑m Yes
if No
❑ N/A — 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 _
Field to Foundation > 10'
Yes
if No
ft Wells on Adjacent Lots:
Tank to Property Line > 5'
no Yes
if No
ft Wells > 100'
FEI Yes if No _
Field to Property Line > 10'
❑ Yes
if No 9.5*
ft Community Wells > 200'
❑• Yes if No _
Water Main/Service Line > 10'
lE Yes
if No
ft If tank or field is under driveway comment below
F. ENGINEER'S COMMENTS
*Waiver #OSV201037
ft
ft
ft
ft
ft
ft
ft
ft
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
Engineer's Printed Name Benjamin Schiller, P.E.
COSA Checklist_May2025.docx
Phone (907) 522-7773
Date 9/11 /25
.' . ,
BenjarninSchiller
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