HomeMy WebLinkAboutT12N R3W SEC 27 LT 32Onsite File
#018-092-13
Municipality of Anchorage
On -Site Water and Wastewater Program • (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP191068 PID Number: 018-092-13
Dwelling: ❑■ Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑ New Q Upgrade
Name:
Carr Family Trust
ABSORPTION FIELD
X Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound
Address
4905 DeArmoun Rd. Anchorage, AK 99516
❑ Other
Phone
(907) 240-8581
Number of Bedrooms
3
Soil Rating
Total depth from original grade
0.6 GPD/SFJ
10.7 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
3.7 Ft.
Gravel depth beneath pipe
7.0
Subdivision Block Lot
32
Ft.
Fill added above original grade
Gravel length
Township Range Section
12N 3W 27
0.3 Ft.
56
Gravel width
3 Ft.
Beds: Number of Lines
Distance between lines
SEPARATION DISTANCES
To Septic Absorption Holding Sewer
Lift Station
Total absorption area
Numerbof trenches
Ft.
Dist. between trenches
From Tank Field Tank Line784
Ftz
1
Ft.
Well
>100'
>100'
N/A
N/A
>25'
TANK 9 Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
Greer
Capacity
11,000 Gal.
Surface Water
>100'
>100'
N/A
N/A
Material
Number of compartments
Lot Line
>5'
>10,
N/A
N/A
Plastic
2
NA
Foundation
>10'
>10'
N/A
N/A
LIFT STATION
Manufacturer
Capacity
Curtain Drain
None
Noted
Gal.
RemarksThe tank and a portion of the line going
Pump on level at
Pump off level at
High water alarm at
to the trench are covered with 2" of
in.
in.
in.
Insulation. Garage connected to septic. tank.
Pump make and model
Electrical Inspections performed by
Half bathroom, but no bedroom in garage.
Installer
PIPE MATERIAL House to tank D3034 Tank to
drainfield D3034
Owner Installation
Drainfield D3034 CO/MT
Inspector J. Millette
BENCH MARK (Assumed elevation) 100 ft
Inspees:ection 151 5/13/19 2�d 5/16/19
Location and description
aro 4'h
Threshold of lower level door to garage.
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
Engineer's Stamp
Conditional Approval:
OF
Date
/�•
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49th �
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MICHAEL E. ANDERSON .'AV
No. CE -4381 ,•' _��
����p••..,,12/27/19 •�`����
*F
Approved Date �2 7
......•••
m®
Inspection Report 9-1-17 rinr
HOUSE DETAIL
Scale: 1" = 30'
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6.0'x14.0'
COVERED DECK
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GARAGE
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2 STORY
RESIDENCE
DECK
Lx-„
DECK of
50' ROAD & UTILITY
RESERVATION
LOT 9A
SCHUMACHER SUBD.
0' C.E.A. EASEMENTS
X
N 89.50'01"E 330.01
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-4
PLOT PLAN ___ AS BUILT _x_ SCALE _�� =60__ GRID _ SW 2936__ Project No.
11500 Daryl Avenue, Anchorage, Alaska 99515-3049
Lang & Associates inc. (907) 522-6476 Phone 0000ppp
(907) 522-4625 Fax o� Q
Professional Land Surveyors ken®langsurvey.com o of
jonathanOlongsurvey.com
I hereby certify that I have surveyed the following described property:
BLM LOT 32, SECTION 27, T12N, R3W, S.M., ALASKA
Anchorage Recording District, Alaska, and that the Improvements situated thereon are
within the property lines and do not encroach onto the property adjacent thereto, that
no Improvements on the property lying adjacent thereto encroach on the surveyed
premises and that there are no roadways, transmission lines or other visible
easements on said property except as indicated hereon.
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Dated this the �Z5Day of -Lo�9 at Anchorage, Alaska
It is the responsibility of the owner to determine the existence of any easements,
covenants, or restrictions which do not appear on the recorded subdivision plat.
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BLM LOT 32
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108,900 s.f.
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50' ROAD & UTILITY
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RESERVATION
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BLM LOT 418
PLOT PLAN ___ AS BUILT _x_ SCALE _�� =60__ GRID _ SW 2936__ Project No.
11500 Daryl Avenue, Anchorage, Alaska 99515-3049
Lang & Associates inc. (907) 522-6476 Phone 0000ppp
(907) 522-4625 Fax o� Q
Professional Land Surveyors ken®langsurvey.com o of
jonathanOlongsurvey.com
I hereby certify that I have surveyed the following described property:
BLM LOT 32, SECTION 27, T12N, R3W, S.M., ALASKA
Anchorage Recording District, Alaska, and that the Improvements situated thereon are
within the property lines and do not encroach onto the property adjacent thereto, that
no Improvements on the property lying adjacent thereto encroach on the surveyed
premises and that there are no roadways, transmission lines or other visible
easements on said property except as indicated hereon.
t^
Dated this the �Z5Day of -Lo�9 at Anchorage, Alaska
It is the responsibility of the owner to determine the existence of any easements,
covenants, or restrictions which do not appear on the recorded subdivision plat.
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N,"-—"""'� MUNICIPALITY OF ANCHORAGE
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On-Site Water& Wastewater Program c - �;,
PO Box 196650 4700 Elmore Road
Anchorage,Alaska 99519-6650 Phone: (907)343-7904 Fax:(907)343-7997 ,�
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On-Site Wastewater Disposal System Permit
Permit Number: OSP191068 Effective Date: 4/4/2019
Work Type: Septic Upgrade Expiration Date: 4/3/2020
Tax Code Number: 01809213000
Site Legal Address: T12N R3W SEC 27 LT 32 G:2936
Site Mailing Address: 4905 DE ARMOUN RD. Anchorage
Owner: CARR FAMILY TRUST Lot Size in Sq Ft: 108900
Design Engineer: FORGE ENGINEERING Total Bedrooms: 3
This permit is for the construction of:
0 Disposal Field El 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
5/2/N - G k a,n AAk. 1-1owu kn.!. 2 6edroon45 . beuble C,o as it b-e ovcid1 z
4, 4 ht_ Lw2- he'hoc en a- nec..) 1-i im' lie a rf a FCo_.
Received By: abg.itteig9144, Date: -//1//9
Issued By: i)j,�,- l� Date: / ..
MUNICIPALITY OF ANCHORAGE
Community Development Department Phone: 9.7_ 1
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Development Services Division Fa
On-Site Water& Wastewater Program zA
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ON-SITE SEWER/WELL PERMIT APPLICATION a MAR 2 6 2019
Parcel I.D. 018-092-13 c hw
Property owner(s) Mark Carr Day phone (907) 2409:!
Mailing address 4905 De Armoun Rd. Anchorage, AK 99516
Site address 4905 De Armoun Rd.
Legal description (Sub'd., Block & Lot)
Legal description (Township, Range & Section) T12N R3W SEC27 L32
Lot Size 108,900 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(® all that apply)
Absorption Field I X( Initial ❑ Single Family (SF) (Xi
(w/wo ADU)
Septic Tank X Upgrade n Duplex (D)
Holding Tank _ Renewal n Multiple Dwellings n
Privy n (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.
(Signature of property owner or authorized agent)
Permit/Rush Fees: SSS Waiver Fees:
Date of Payment: 3 Ig-7411 9 Date of Payment:
Receipt Number: 01-'344P-b. Receipt Number:
Permit No. 05 P) 1 IOUS Waiver No.
Permit .App__- • : .,:c
) " GE
ENGINEERING
PO BOX 240773
ANCHORAGE,AK 99524
522-7773 677-7766(FAX)
March 26,2019
MOA Development Services Dept,On-Site Water&Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
Subject: T12N R3W SEC27 L32-4905 De Amnon Road
Septic System Design and Permit Application
Dear On-Site Services Engineer:
The above lot has an undocumented septic system. The owner intends to upgrade to an approved
3-bedroom system. We are submitting this design and permit application for the construction of a
new septic system. The attached site plan identifies the location of the home and the existing well
along with the existing and proposed septic locations. No conflicts exist between the proposed
system and any other well or septic system on this or adjacent lots.
The ground surface on the lot slopes gently northwestwardly toward the NW corner of the property.
It is in that flatter area that the new septic system location is located. There are no slopes greater
than 25% within 50 feet downslope of the proposed site. Contours are shown on the site plan
showing the grade and direction of flow. 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 logs, soils lab analysis, plan and profile pages for the septic
design. If this design is followed, there will be no adverse impacts to adjacent properties.
Sincerely,
s` : 49•th J,f
tZ
0 .q. N...M.1......Mr.,,...0
fin;MICHAEL £ ANDERSON 77 t�yC`K s
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No. CE-4187 ,� �i
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Michael E. Anderson, PE
T12N R3W SEC27 Lot 32
S\ ��\ ~« E / T LOT H` `. ' /1 E.A. A EMN S
/ / 7 z'7 /—I__. _)1
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/ ) AB BQN EXISTING _ — I
/ / ABSORP1 N FEED NEW 10 - L \ \ �� / J
IN PACE SEPTIC \ \\ illI / 1 f
54'LONG x 3'WIDE x 7'EFFETIVE • \ �\ \
DEPTH ABSORPTION TR NCH. t %1119_ \I
1 MAINTAIN 14'SEPARATION 'ROM �, 2C0i �I /re 1)/
OLD ABSORPTION SY EM. o CO'_ _ t
1 TH 1. 1 o \ > JIrrI
I ARCTERRA // 1 0 � \ \ '.o. I I I / III 1
n ALTERNATE SITE 0/ ` �'r, ,� 1 ���e' c( \ / 1 I / /
LO / DE •MM.SSIO `` ••••� \ I / ) r I
NO iLL / EXI' ING S PTIA \ \\\\\ I /
ON 1T 31 TANK R MO ODE \\\\\ \\ �1!� / III
1 / ./ ) \ \ \\ (( J_?
\ / _ _I- EXIS/ING WELL �\ \ \ I /
1 1 1 I
�,O(WELL RADIUS ARN 1 I I
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iWGE \\BLM LOT 41B / d LOT 40
/ [NOIN![RING I NOTE: / / /I
•.�E OF 47 •♦♦ PROPOSED SEP4 NO SLOPES oTIC SYSTEM WITHIN 50'OR SURFACE WATER WITHIN 100'OF THE LEGEND
.• P,..•••• •••••.,\i CO-CLEANOUT
• � •
1, ♦ 2C0 DOUBLE CLEANOUT
:,"' 49th i� `. ♦i ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS
�. 4 •• .•_. FCO FOUNDATION CLEANOUT
I PROPERTY ARE SHOWN.NO CONFLICTS WITH WELLS OR SEPTIC
i�� •� SYSTEMS. MH-MANHOLE
•camas j1,MICHAEL E. ANDERSON F J. MT-MONITORING TUBE
♦i Jf's,.. NO. CE-4381 — 0 50 100 SV-SEPTIC VENT
400.......3122/19 ..•• l''• = I= I♦ = FEET
LE
♦♦drI. •**kc-••• 1"=50' CONTOUR INTERVALO1'
• I.Ess�
T12N R3W SEC27 Lot 32
DESIGN FACTORS: SYSTEM REQUIREMENTS:
450 GPD PEAK FLOW 7' DEEP TRENCH SYSTEM
PERK RATE: 16- 30 MIN/IN • 1000-GAL SEPTIC TANK
APPLICATION RATE: 0.6 GPD/SF
450 GPD /0.6 GPD/SF/ 7' EFFECTIVE / 2 SIDES = 53.6 LF TRENCH REQUIRED (54 LF SPECIFIED)
BOTTOM OF TRENCH: 10' 6" BELOW GRADE
FLOW LINE ELEVATION: 3' 6" BELOW GRADE
TOP OF TRENCH: 6" ABOVE GRADE
6"
t-- II —
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4" PERFORATED PVC (HOLES DOWN)
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Allow
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N G I N
TYPICAL TRENCH SECTION .•••''crk 440
aSi4_
(NO SCALE) X46') ".' ,-\ ••
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NOTES: L�' 49�th ri.,�.Y+ ,�
&
1. GRADE AREA OVER TRENCH TO DRAIN AWAY � G j. »:
,cTERR ARCA. '$ OFA dam '
¢ CONSULTING, INC /T<S• ' y
. 212 E.51s`Ave,Anchorage,AK.99503 i .�
Office(907)868-3791,Fax(907)868-3793 * ''
41
`'i,q-tiLrlNG.� ikc• ' # KENNETH M8 �
Ott.sgsT7-
SOILS PERCOLATION TEST + AO
<5' 6 3 �ro�.+'
ssto - Alr
Performed for: Mark Carr Date Performed: 09/21/2106 \ 1'\`•••
Project: T12N R3W SEC 27 LOT 32 TEST HOLE# TH 16-1
Depth
(Feet) SEE ATTACHED SITE PLAN
-, :'tlfg FOR HOLE LOCATION
•
1=
1- art Org/OL
_ 5} Was Ground water encountered? NO What depth? NA
3 Depth to water after monitoring? DRY Date? 10/3/16
s-
SM/GM Reading Date Gross Net Depth of Net
5 J Akft 7:1 Time Time Water Drop
tar
6-= Y'_ 1 1013/16 1:00 - 6" -
7-+ .' 2 1:30 30 min 4 5/16" 1 11/16"
r,
1:31 6„
8-W' 0.:, 3 * -
':::A2
9 =; 4 2:01 30 min 4 4/16" 1 12/16"
10- - 5 * 2:02 - 6" -
11- F=� 6 2:32 30 thin 4 5/16" 1 11116"
12- ;4; `. 7
13—• --14_,...,
4- _
t.
175 9
15-ki.:0 ;i; 10
r
16 .� 11
17- 12
B.O.H.
18- * Water Added
19- Percolation Rate 18 (min/in)Pero Hole Diameter 6"
HOLE PRESOAKED
20- PRIOR TO TEST Test Run Between 5 feet and 6 feet
I, Kenneth M. Duffus, certify that this test was performed in accordance with all State
and Municipal guidelines in effect on this date.
MUNICIPALITY OF ANCHORAGE
n
miummimmilmillmommummormeaviolion
Detieiot,zment Sersiices Department Phone: C-07.343-7904
Dn.:9,1e Water&Wastewater Section Fax: 907-543-7997
Se .tic stern Owner-installer A reement
The On,stba,Water and Wastewater SiWion (On-site) may issue ar approval fo a !-ornewner
perfonm work on art ort-filte wastewater disi.nosal srstern-to sere that individuars owner.
occupied, singl*OrYtify ør ducn home if the homeowner meets and agrees tc the ftkOArettg
geoutrerneris:
I. The property owner and excavation eouiprinent operator tray perform work on no more
than one owneirmtnstalation project in a12-rnortth period.
2. Owner's projactecl. active involvement with he installation:
r It_
alitglitr_btallisLALAxgavoittpri_r. Vairig::
3 The :ram* Of the tion equipme—t r
4, 1 .awee tat there will be no monetary wrrpensalion for installation ,services nertitrod
5 The home of the iftspeomq engineer: Forge Engineering
6.. I agree Zo discuss This follOwin9 A*MS With The i:r.3pectin,engirkette
a. Permit desin criteria and speciricaticns.
inspection require:merits set forth in AMC 1$.65.070.
c. AdvanCe notes 9rven titot On-Site Weer& wastewater Sactori for all rectwad
municipal iriapeclikorts (AMC 15.55,0704
agree to have the proteCt-speCifT Ort-sile Wastewater Disposal System Pem '. avagaVe
at the construction s':10 for the duration of au related work.,
I agree that tf the system is an advanced wastewater treatment system AW`ittiTS), will
ottain aorPtionat installation instrusztorts and &poemsfrom the equipment distributor
As owne- of (legal description: .
agree that the rkforrnation above is true and aocurate.
Owner's printed name: /111 ark-, care-
14.)wner's svaturra: 71.11, 2ier .-----"--' Dabs.: 3 - 11- /1
m rig dri . P. 0. Box 116650 A,VAI ' WV 4/9'rutin; flag
LOCATIO
TYPE F E
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BOX 1713, STAR ROUTE
SPENARDo ALASKA
SUBSURFACE
EXPLORATION
-T n4r"e "Ai -n)l ) "-'0
%, AHOLE MO.13 #L,
CONTRACT rvo_ _ � NUMBER
� 3. SURFACE ELEVATION WEATHER
DEPTH- g15GIN SHIFT -DEPTH-END SHIFT I ��r"
- QEPTH DRiLLED-��-�
4. PERMAFROST ENCO�ITERED:, FROM TO
'. WATER LEVE � rel c �GATE & SHIFT c
- I
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TIME DISTRIBUTION HOURS
DRILLER FISHING �DRILLING
- REPAIRS BULL CAS! NG—
HELPIER STANDBY MovING.
7. GASOLINE
0. OIL - --
.
CASING LOG
dft
9
TOTAL
LENGTH LENGTH
ter• '
,!57
6.37
CEO"
dr
eP'7 �Pl dAP
SUPPLIES AND REPAIRS (ITEMIZE)
s. SOILS LAG
SAMPLE DEPTHS
Na- FROM TO
f
TYPE
SAMPLE
SUMMARY COLUMN
MATERIALS AND REMARKS
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MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: (907)343-7904
On -Site Water & Wastewater Section Fax: (907)343-7997
Parcel ID 018 -092-13
Certificate of On -Site Systems Approval
OSC261057
Expiration Date: 9/4/2026
Legal description T1 2N R3W SEC 27 LT 32
Site address 4905 DE ARMOUN RD
Current property owner(s) CARR FAMILY TRUST
X The On-site system(s) is/are approved for 3 bedrooms
M
Conditional approval for bedrooms, with the following stipulations:
Comments or conditions:
No comments
Original Certificate Date:
3/17/2026
This Gi rtificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
�evelopment
em(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage,
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 I. D. 018-092-13
Complete legal description T1 2N R3W Section 27, Lot 32
Location (site address) 4905 De Armoun Rd, Anchorage, AK, 99516
Current property owner(s)
Carr Family Trust
2. ON-SITE SYSTEMS SIZED FOR BEDROOMS
Day phone 907) 240-8581
3. TYPE OF WATER SUPPLY: M Private Well serving #2 dwelling units
El Other Non-public well as regulated by MOA R Water Storage
F] Community Well or Public
4. TYPE OF WASTEWATER DISPOSAL: RE Private Septic R Private Septic serving 2 dwelling units
17-1 Holding Tank r_1 Community Septic or Public Sewer
5. SEPTIC TANK: M Steel RE Plastic R Concrete R Fiberglass
Age 7 - See advisory if steel or fiberglass older than 20 years
6. ABSORPTION FIELD: [] AWWTS n Bed n Deep Trench E] Wide Trench n Seepage Pit
Waiver request for:
Expedited review requested: F-1
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$ Waiver Fee $
Date of Payment Date of Payment
COSA# 65C-9 C 1 0 �i Waiver #
COSA Applicaflor�_Apr2025.doc
COSA Checklist_May2025.docx
COSA Checklist
Legal Description: Parcel ID:
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____
A. WELL DATA
Well log is filed with Onsite (or attached)
Date drilled Total depth ft
Cased to ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) in.
Date of flow test for COSA
Static water level at beginning of test ft.
Well production at time of test gpm
Water storage tank volume 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
Date
Comments __________________________________________________________________________________
B. TANK DATA
Measured operating fluid level in septic tank
Date of pumping
Required maintenance completed, if AWWTS
Comments:
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. DISPOSAL FIELD DATA
Which system tested (date installed)
ALL standpipes present per record drawing
Total measured depth from grade ft (max)
Measured depth to pipe invert from grade ft (min)
N/A – pressurized field.
Per record drawings, field is insulated.
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 gallons date
Any rejuvenation treatment (past 12 months)
If yes, enter date
Adequacy test date
Results Pass
Fluid depth prior to test in
Water added gal
New fluid depth in
Elapsed time min
Final fluid depth in
Absorption rate gpd
FIELD STATUS – POST RECOVERY
Effective depth (per record drawings) in
Effective depth used in
Effective depth remaining in
Comments/Deficiencies:
C.LIF
d mainte
years
Presoak
difhous
to date
gallons
)
T12N R3W Section 27, Lot 32 018-092-13
■5.1
7/15/61 108 N/A
108 ■
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3.20
>18 ■
3/4/26 Forge Engineering
80 3/5/26
49"
9/4/25
5/16/19
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11.0
4.0
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3/4/26
71
X
478
80
1440
71
>450
84
71
13
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 ft
Neighboring Tank > 100’Yes if No ft
Disposal Field on Lot > 100’Yes if No ft
Neighboring Disposal Fields > 100’
Yes if No ft
Sewer Line/Main > 100’ Yes if No ft
Sewer Manhole/Cleanout > 100’
Yes if No ft
Sewer Service/Septic Line > 25’Yes if No ft
Holding Tank > 100’ Yes if No ft
Animal Containment > 50’Yes if No ft
Manure/Animal Excreta Storage > 100’
Yes if No ft
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
Field to Foundation > 10’ Yes if No ft
Tank to Property Line > 5’ Yes if No ft
Field to Property Line > 10’ Yes if No ft
Water Main/Service Line > 10’Yes if No ft
Surface Water > 100’Yes if No ft
Wells on Adjacent Lots:
Wells > 100’Yes if No ft
Community Wells > 200’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 Phone
Engineer’s Printed Name Date
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