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HomeMy WebLinkAboutHINSON LT 1Onsite File may;" .luN i n<�n�4 Municipality of Anchorage Community Development Department Page 1 of 3 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: OSP191012 PID Number: 011-$61-56 ❑ New El Upgrade Name: Sherlyn Shears ABSORPTION FIELD ❑✓ Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound Address 4915 W. 87th Avenue ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 3 1.2 GPD/SF 12.0 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 5.O Ft. Gravel depth beneath pipe 7.0 Ft. Subdivision Block Lot Hinson 1,2,3 Fill added above original grade O Ft. Gravel length 30.0 Ft. Township Range Section Gravel width 2.5 Ft. Beds: Number of Lines N/A Distance between lines N/A Ft. SEPARATION DISTANCES To Septic Absorption Lift Station I Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line 420 Ftz 1 N/A Ft. well 101.0 116.5 N/A N/A 25+ TANK El Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Infiltrator Capacity 1060G,1. Surface water 100+ 100+ N/A N/A Material Number of compartments Lot Line 5.0 7.2 N/A N/A Plastic 2 NA Foundation 7.4 7.6 N/A I N/A LIFT STATION Manufacturer Capacity Curtain Drain 50+ 50+ N/A N/A Gal. Remarks See waiver modification Pump on level at in. Pump off level at in. High water alarm at in. Pump make and model Electrical Inspections performed by Installer PIPE MATERIAL House to tank 3034 Tank to drainrield 3034 Pomraining Construction Drainfield 3034 CO/MT 3034 Inspector Pannone Engineering Services BENCHMARK (Assumed elevation) 1 00f Inspection s, dates: 1 3/14/19 2^d 3/16/19 Location and description 3rd 3/17/19 411i 5/13/19 1 Top of foundation COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL Engineer's Stamp OF A�,SP� Conditional Approval: Dated 'or co �teven�'[�. E�annorae� CE 8149 ApprovedDate C� FD /_P0 .rLn IJPUW IVII RCPUI L_ I- 1- 1 L.UUi. FC T1 T2 DCO Ci 5.5 10.7 84.9 16.4 85.9 15.3 91.0 41.0 18.5 Scale M2 118 15.7 Sheet __IV5�0 jil 4 BR H OU DECOMMISSIONED EXISTING WELL PER CODE PRIMARY/ RESERVE DRAIN FIELD (P) INSTALL CO AND MT AT EACH END ui ui 10' UTILITY EAXMENT w M2—/ i7 3.4 DRIVEWAY lo 10609 SEPTIC TANK (NEW) INSTALLED FOUNDATION CLEAN OUT, AND DOUBLE CLEAN OUT ti 3 BR HOUSE (P) DESIGN PARAMETERS —PR|MARY/RESERVESEPTIC SY5T NO. BEDROOM: 3(450gpd) TANK SIZE: 1000g PERCR4TE: 1-5 MPI SOIL RATING: 1.2QzD/SF AREA ROD: 375 SF SYS.TYPE DEEP TRENCH 7.0'ED ` MIN LENGTH: 2b.8LF USE: 3OLFx2.5'Wx7.0' E.D, 12.0' TO TOTAL AREA: RECORD DRAWING DRAWN BY: DRM PLAN PANNONE ENG SVC, LLC P.O. BOX 100217 ANCHORAGE, AK 99510 PHONE (907) 272-8218 FAX /907\ 272-8211 H|NSON SU8D|NS|ON, LOT 1, 2, 8c 3 SHERLYN DARLENE SHEARS 4915 W. 87TH AVENUE ANCHORAGE' AK 99502 ' � � OF. Date 8/23/2019 Scale 011-161-56 Sheet 94.7' 1 NEW 1060g SEPTIC TANK WN] w a olmim 4.5 /GQ �P 1060g SEPTIC TANK NOTES: RECORD DRAWING DRAWN BY: DRM NEW HOUSE *DISTANCES SHOWN ARE MINIMUM DISTANCES OUTSIDE OF SOIL BEARING PRISM, OR 4:1 INFILTRATION LINE FOR THE PURPOSE OF JUSTIFICATION OF WAIVER, NOT ACTUAL DISTANCE MEASURED IN FIELD. PANNONE ENG SVC, LLC P.O. BOX 100217 ANCHORAGE, AK 99510 PHONE (907) 272-8218 FAX (907) 272-8211 HINSON SUBDIVISION, LOT 1, 2, & 3 SHERLYN DARLENE SHEARS 4915 W. 87TH AVENUE DESIGN DETAILS ANCHORAGE, AK 99502 3.8 SM/ SW —86.8 -20.0 NO WATER ENCOUNTERED IN SURROUNDING AREA TO AT LEAST 20' NEW HOUSE 4.0 ---- ---- j 4: /Nfi E ICTRAT1pf�— Dote OF. kjsk�� W m PSE .9�1 W m zo F F ? FILTER FABRIC D F 0 0 0 o J 0 o 4" 0 PERF PIPE o 0 � OSP191012 Z m 3 w w w w o DRAIN ROCK 6'• o o� U. v L) o u 2E C ABOVE PIPE INV M 94.7' 1 NEW 1060g SEPTIC TANK WN] w a olmim 4.5 /GQ �P 1060g SEPTIC TANK NOTES: RECORD DRAWING DRAWN BY: DRM NEW HOUSE *DISTANCES SHOWN ARE MINIMUM DISTANCES OUTSIDE OF SOIL BEARING PRISM, OR 4:1 INFILTRATION LINE FOR THE PURPOSE OF JUSTIFICATION OF WAIVER, NOT ACTUAL DISTANCE MEASURED IN FIELD. PANNONE ENG SVC, LLC P.O. BOX 100217 ANCHORAGE, AK 99510 PHONE (907) 272-8218 FAX (907) 272-8211 HINSON SUBDIVISION, LOT 1, 2, & 3 SHERLYN DARLENE SHEARS 4915 W. 87TH AVENUE DESIGN DETAILS ANCHORAGE, AK 99502 3.8 SM/ SW —86.8 -20.0 NO WATER ENCOUNTERED IN SURROUNDING AREA TO AT LEAST 20' NEW HOUSE 4.0 ---- ---- j 4: /Nfi E ICTRAT1pf�— Dote OF. kjsk�� 8/23/2019 PSE .9�1 Scale * C 9 TH 1"=5' P.I.D. NO ® 011-161-56 SAteven P Sone WPERMIT N0. CE e crl,�low, 8149 R�,.;01 OSP191012 Sheet 3 uni' dp Ut y of Anchorage P.O. Box 196650 0 4700 Elmore Road Anchorage, Alaska 99519-6650 0 (907) 343-7904 0 Fax (907) 343-7997 http://www.muni.org/Onsite Development Services Department On -Site Water and Wastewater Section w uc,,a rttncttt * * * * VARIANCE/WAIVE? REVIEW * * * * Waiver#: OSV191000 COSA#: Permit#:OSP191012 PID#: 011-161-56 Legal Description: Hinson Lot 1 Engineer: Pannone Engineering Services Applicant: Sheryin Darlene Shears Your request for a waiver of the required 10 feet horizontal separation from the absorption field to the east and west property line has been approved. The approved separation distance is 2.0 feet. In addition, your request for a waiver of the required 10 feet horizontal separation from the absorption field to the foundation has been approved. The approved separation distance is ,ft;.0 5.0 feet. See engineer's waiver request and section drawing for justifications. This waiver approval applies to the proposed primary and reserve absorption field only. Any other fixture upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. ................................................ ■ ............................. ■ 1 Waiver is Granted: X Waiver is not Granted: �J c, ,0 �► � 'J Date: � �c d ! Approved by: v�1 Name of Reviewer .............................................................................. I **** VARIAN C EMAIVE R REVIEW **** Steven R. Pannone, Principal Registered Professional Engineer E-mail: steve@panenaak.com August 23, 2019 Municipality of Anchorage Development Services Department On -Site Water & Wastewater Program 4700 Elmore Road P. 0. Box 196650 Anchorage, Alaska 99519 Subject: Hinson, Lots 1, 2, and 3 Septic System to Foundation Waiver Modification OPS191012 / OSV 191000 Ladies and Gentlemen: Drain Field to Foundation Waiver: I am writing to request a modification of the separation distance waiver between the proposed septic system and the building foundation from a distance of nine feet (9.0') to a distance of five feet (5.0'). The five feet requested is a conservative distance to ensure the field (including any portion of the field that is wider than 5' due to Bluffing during installation) is within the waived offset, and the section on sheet 3 shows the minimum distance that the field would cause no adverse effects for the purpose of justification. 1 am also requesting the waiver be modified to include the septic tank at a distance of seven feet (7.0'). The soil conditions and lot constraints were such that the foundation was installed closer than the original waiver was issued to after the septic system was in place. The soils in this area are typically Hydrologic Soils Group A made up of sand. Sheet 3 of the plan set shows a section with a 25% infiltration line, and a 1:1 soil bearing prism. Both of these are very conservative for this soil type. The soil bearing prism passes beneath the bottom of the lateral drain pipe and the bottom of the septic tank, also the infiltration line passes beneath the bottom of the foundation at the requested separation distance. Granting this waiver 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, ®e`4aaaaeg®Rai OF q ........... A V : R H f.... 0 0 .....................................1 d % Steven R. Pannone o®edaaA��,��o pyo. Steven R. Pannone, P.E. Owner/Civil Engineer Attachments: -Site Plan ................... Anchorage Mailing: P.O. Box 100217, Anchorage, AK 99510-0217 PalrnerMailing: P.O. Sox 1807, Palmer, AK 99645 Telephone: (907) 7415-8200 FAX: (907) 745-8201 Municipality of Anchorage Community Development Department On -Site Water & Wastewater Program 4700 Elmore St. M P.O. Box 196650 m Anchorage, AK 99507-6650 is w�yw.rnuni.o.rg/ ,, sfl M (907) 343-7904 Legal Address: Sub ivisionBlock , > Lot' � �- T R Section Lot On-site Water & Wastewater Program certified contractor performing the well decommissioniinng 1 . Name: (� i �,jr� Signature Company: 51-t. 4 i OLK W'�Cfer b'/e t s Well decommissioning date: 3 `- ! g /q Method of decommissioning: AMC 15:55.0601-1 a. ❑ h, ❑ c. Location: Use the space below to provide a drawing of the property showing the following items; North Arrow Decommissioned well, Other water wells on the property, Two separate swing -tie distances for each well shown in the drawing, Note: The swing -tie distances shall be measured from either permanent structures of property corners. �t CZ L4 t � \3 N Weld Y: ry4Y - - = YE .rn In �f . i .; 00 .Jei 09 Wzq ry V qI0�6 Lo 00 .Jei 09 Wzq ry V qI0�6 rn pV 00 LAJ CF) I C3 co W® MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://vrwvv.muni.org/onsite On—Site Water & Wastewater System Permit Permit Number: OSP191012 Work Type: WellSeptic Initial Tax Code Number: 01116156000 Site Legal Address: HINSON LTS 1,2 & 3 G:2324 Site Mailing Address: 8620 JADE ST, Anchorage Owner: SHEARS GREGORY R & Design Engineer: PANNONE ENGINEERING SERVICES This permit is for the construction of: Q Disposal Field Z Septic Tank ❑ Holding Tank ❑ Privy Effective Date: Expiration Date Lot Size in Sq Ft Total Bedrooms: Dcparrmcnt 1/30/2019 1/3012020 30923 21 Private Well ❑ 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 B� Issued By: Date: Date: 1 30 0 3 L�G�UR64\JJ � __ MUNICIPALITY OF ANCHORAGE 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. 011-161-56 Property owner(s) Sheryln Darlene Shears Day phone Mailing address 4915 W. 87th Avenue, Anchorage, AK 99502 Site address 4915 W. 87th Avenue Legal description (Sub'd., Block & Lot) Hinson, Lots 1, 2, & 3 Legal description (Township, Range & Section) Lot Size 30,923 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑X Initial R Single Family (SF) ❑X Septic Tank ❑X Upgrade ❑ (w/wo ADU) Holding Tank ❑ RenewalDuplex (D) ❑ ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑X Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Separation to lot line / Separation to foundation Distance: 279' 1 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: Imo)/ Waiver Fees: ,2'Z- Date 2 �S Date of Payment: l hLI ig Date of Payment: / j j 4 !j q Receipt Number: Receipt Number: 06-27(Q� Permit No. D Sp l 10 l a Waiver No. C60 Q 1600 Permit App_:- :. ..:c: Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191012, Rebecca Carroll, 01/30/19 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE Pannone Engineering ServiceS LLC osP1g1o12,Rebecca carroll,o1/30/19 Steven R. Pannone, Principal Registered Professional Engineer E-mail: steve@panengak.com January 11, 2019 Municipality of Anchorage Development Services Department On -Site Water & Wastewater Program 4700 Elmore Road P. O. Box 196650 Anchorage, Alaska 99519 Subject: Hinson, Lots 1, 2, and 3 Septic System to lot line and septic system to foundation Waiver Request Ladies and Gentlemen: Drain Field to Foundation Waiver: I am writing to request a separation distance waiver between the proposed septic system and the building foundation for a distance of nine feet (9.0'). The soils in this area are typically Hydrologic Soils Group A made up of sand. Sheet 3 of the plan set shows a section with a 25% infiltration line, and a 1:1 soil bearing prism. Both of these are very conservative for this soil type. The soil bearing prism passes beneath the bottom of the drain field and the infiltration line basses well beneath the bottom of the foundation at the requested separation distance. Drain Field to lot line Waiver: I am writing to request a separation distance waiver between the proposed septic system and the lot line for a distance of two feet (2.0'). Due to the size of the lot, it is not possible to install a septic system further than 10' from the lot line. On the east the drain field will be adjacent to the Jade Street R.O.W., and on the west the drain field will be adjacent to an internal lot line between Lots 1 and 2, the same parcel. Granting this waiver will not pose a threat to the safety of this lot or the surrounding lots. Anchor -age Mailing: P.O. Box 100217, Anchorage,AK 99510-0217 Palmer Mailing: P.C. Box 1.807, Palmer, AK 99645 Telephone: (907) 745-8200 FAX: (907) 745--8201 Page 2 of 2 Please contact rneifyou have any comments orconcerns. Sincerely, Steven R.Pannone, P.E. Owner/Civil Engineer Attachments: -Site Plan Anchorage Mailing: P.O.Box 1OOZl7 Anchorage AK 99510-0217 Palmer Mailing: P.O.Box 18O7,Palmer, AK9B645 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191012, Rebecca Carroll, 01/30/19 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191012, Rebecca Carroll, 01/30/19 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191012, Rebecca Carroll, 01/30/19 MUNICIPALITY OF ANCHORAGE Development Services Departments Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 011-161-33 Legal description HINSON LT 1 Site address 8620 JADE ST Current property owner(s) SHERLYN SHEARS Expiration Date: ✓ S 2-� Z X The On-site system(s) is/are approved for 3 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: Original Certificate Date: 6/5/2023 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 Services 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 work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory Other COSA Approval_June 2022 MUNICIPALITY OF ANCHORAGE ` 4� Development Services Department l` P p 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. 011-161-33 Complete legal description Hinson Lot 1 Location (site address) 8620 Jade Street, Anchora Current property owner(s) Sherlyn Shears 2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS e, AK 99502 Day phone (907) 229-3554 3. TYPE OF WATER SUPPLY: ❑ Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units X Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: 0 Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel X Plastic ❑ Concrete ❑ Fiberglass Age 3yrs - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed *Deep Trench ❑ 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 $ S �/ Waiver Fee $ Date of Payment_ Date of Payment COSA # _ 0 SL z- Waiver # COSA Application—June 2022 Hinson Lot 1 011-161-33 8/2/22 Alaska Sewer & Drain 6/10/19 5.9 N/A N/A N/A 5/24/23 0/0 673 120 0/0 > 450 0 Benjamin Schiller, P.E.5/24/23 (907) 522-7773 MUMCIPALIRITY OF ANCHORAGE Development Services Department \' Phone: 907-343-7904 On-Site Water & Wastewater Section ~`J Fax: 907-343-7997 Parcel I.D. 311-161-33 Certificate of (fin -Site Systems Approval Expiration Date: /�DqO GENERAL INFORMATION Complete legal description Hinson, Lot 1 Location (site address) 8620 Jade Street Current property owner(s) Sherlyn Shears Mailing address Real estate agent Day phone 4915 W. 87th Avenue, Anchorage, AK 99502 2. TYPE OF DWELLING: E] Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ❑ Private Septic (� Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System E Public Sewer ❑ Waiver request for: Distance: Received by. "Y`` (� ' ( iii' Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 15� Waiver Fee $ Date of Payment 1C 31 11 Date of Payment Receipt Number 0 O ( 1� I tl Receipt Number COSA # OS c 191 3L-1 S 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. 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. 6. DSD/SIGNATURE �! System #1 Approved for 3 bedrooms 22 System #2 Approved for bedrooms Disapproved Conditional approval for Phone (907) 745-8200 Date 07/29/2019 bedrooms, with the following stipulations: .III (IU111i.. Original Certificate Date: � 1 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 Legal Description: Hinson, Lot 1 If more than 1 septic system on lot: COSA Checklist # 1 of 1 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. Comments B. TANK DATA Age of tank(s) 0 years Tank type/material Plastic Measured operating fluid level in septic tank New © Standpipes/foundation cleanout per record drawing Date of pumping New D. ABSORPTION FIELD DATA Which system tested (date installed) 3117/19 X ALL standpipes present per record drawing Total measured depth from grade 12 ft (max) Measured depth to pipe invert from grade 5.0 ft (min) ❑ N/A — pressurized field ® Monitor tubes go to bottom of effective. If not, state depth into effective X 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: Structure served by this system 1 011-161-110 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 of Sample C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date New Results ❑ Pass For 3 bedrooms Fluid depth prior to test 0 in Water added 0 gal New depth 0 in Elapsed time 0 min Final fluid depth 0 in Absorption rate 450+ gpd Any rejuvenation treatment (past 12 months) N 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' ❑ Yes if No 7.4 Community Sewer Manhole/Cleanout > 100' ❑ Yes if No ft ❑ 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' ❑ Yes if No ft Neighboring Absorption Fields > 100' if No ft Animal Containment > 50' ❑ Yes if No ft ❑ Yes if No ft ft If septic tank is under driveway comment below Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ❑Yes _ if No ft ❑Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑ Yes if No 7.4 ft Surface Water > 100' Q✓ Yes if No ft Property Line > 5' ✓0 Yes if No ft Wells on Adjacent Lots: ✓l Yes Absorption Field > 5' 7 Yes if No ft Private Wells > 100' 0✓ Yes if No ft Water Main > 10'✓Q Yes if No ft Community Wells > 200'✓� Yes if No ft Water Service Line > 10' 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 7.6 ft If absorption field is under driveway comment below Property Line > 10' ❑ Yes if No 7.2 ft Wells on Adjacent Lots: Water Main > 10' ✓l Yes if No ft Private Wells > 100' U Yes if No ft Water Service Line > 10' ❑✓ Yes if No ft Community Wells > 200' Yes if No ft Surface Water > 100' 0 Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION / certify that / 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. 7/29/2019 COSA Checklist yellow sheet