HomeMy WebLinkAboutDENALY ESTATES BLK 2 LT 12Onsite File
#067-062-19
Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 4
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP191486 PID Number: 067-062-19
Dwelling: ❑ Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑ Upgrade
Name
TROY DAVIS HOMES
ABSORPTION FIELD
❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound
Site Address
25301 MCINTYRE RD. CHUGIAK,AK 99567
❑ Other
Phone
Number of Bedrooms
Soil Rating
ITotal depth from original grade
907-310-2501
4
1.0 GPD/SF
3.4 / 3.9 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
2.9/3.1 Ft
Gravel depth beneath pipe
0.5/0.8 Ft.
Subdivision Block Lot
DENALY ESTATES 2 12
Fill added above original grade
5.4/5.2 Ft.
Gravel length
60 / 60 Ft.
Township Range Section
Gravel width
5 Ft.
Beds: Number of Lines
N/A
Distance between lines
N/A Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
600 Ft2
2
6.9 Ft.
Well
>100'
>100'
N/A
N/A
>25'
TANK 0 Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
GREER
Capacity
1250 Gal.
Surface Water
>100'
>100'
N/A
N/A
Material
Number of compartments
Lot Line
>5'
>10'
N/A
N/A
NA
PLASTIC
2
Foundation
>1>10' �'
N/A
N/A
LIFT STATION
urer
Capacity
Gal.
Remarks 2' SAND LINER INSTALLED
Alarm location
1 installed by
Installer
PIPE MATERIAL House to tank D3034 Tank to
drainfield D3034
WHITTERS CONSTRUCTION
Drainfield D3034 CO/MTD3034
Inspector L.TIDWELL
BENCH MARK (Assumed elevation) 100 ft
Inspection1st 6/1/20 2�a 6/5/20
Location and description
3`d 6/6/20 4th
TOP FOUNDATION AT SE CORNER OF THE HOME
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
Conditional Approval: Date
Ped . � : .:,.... ,"`.,..........
'chiller
Septic System
Approved �
Benjarr
®�
^ �h ck Date 3 0�
��'sl'•.�2/za592 .•' �``�
-
Note: this approval does not include well permit requirements.
F9F
PR4FESS>Q# --
io,.., ncrnv.l o
�I ♦vv VJ/VG/IVB
DENALY ESTATES SUB, BLOCK 2 LOT 12
PERMIT # OSP191486 PID # 067-062-19
M -EA. EASEMENTS
LOT 11-- {LOT 18
\\
\ \ \ \
EASEMENTS �c
WELL
LOT 12
\ / ..
CLEARING_ \
LIMITSEDROO\�
Fo
\ M t
/�1,250 GALLON
_-SEPTIC,TANK
MH1 f w/20" MANWAYsvi
V `�
2CO / \
hoT 13
\ v \ P �\ TH2® �- , 400
ALTERNATE SITE: CAT III TREATMENT SYSTEM
1.00' PROTECTIVE WELLMfg' w/2 LONG x 5' WIDE x 0.5' EFF DEPTH
RADIUS LOT 7, BLOCK 2. \ �, FS® TH1 ABSORPTION TRENCH
\ ` ` sss- APP, RATE - 5 GPD/SF
\
Ti
01
3 � EXI
STIN\G WELL
2-60' LONG x�5�WIDE x.5'
EFFECTIVE DEPTH
\ 0— - ABSORPTIONS RENCHES
\ 15',x 15' T&E EASEMENT \
A B c D LEGEND
C
49 TH
.PLAN AS -BUILT
Ben'an Schiller ®`
0 50 100
-. 3/12/21 .., bE ME FEET
FCO
1 4.8 1
36.6
MH1
1 28.6 1
29.7
SV1
1 31.65 1
26.8
2C0
34.7
24.8
C01
78.8
93.7
MT1
76.7
92.5
CO2
46.7 44.8
CO3
89.1
100.7
C04
64.6
1 55.8
R72
1 60.8 1 58.9
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEANOUT
FS - FLOW SPLITTER VALVE
MH - MANHOLE
MT - MONITORING TUBE
9F RaSS10��'� SV - SEPTIC VENT
FE
oP 1 =50
������-•�a��� TH -TEST HOLE
DENALY ESTATES SUB, BLOCK 2 LOT 12
PERMIT # OSP191486 PID # 067-062-19
MAN".
N _
0 I— O
U 94.0 FINISH GRADE 88.6 ORIGINAL GRADE v
85.7,<, i s s :untt_ryt�CCtZt�UU# �1, s
.a � •� - 85.7
MOA APPROVED SAND a 85.2
85.
82.6 82.6
60'
70.6 GROUNDWATER 10/24/19
68.6
I— Ill. N m
0
93.2 FINISH GRADE 88.0 ORIGINAL GRADE v
n
84.9 84.9
84.1
:MOA APPROVED SAND w a
82.0 82.0
® 60'
70.0 GROUNDWATER 10/24/19
68.0
PROFILE AS -BUILT
(NO SCALE)
! 49 P
BenJ ain Schiller
2E 12592
g��
VWheGJJ I' on 1:71'.�atl4s ll WA�O, Mc.
1190 N. Wasilla-Fishhook Road
Wasilla, AK 99654
19071376_20al
Name:
Troy Davis Homes
Address:
1689 I<nil< Goose Bay Rd.
City:
Wasilla State: AK Zip Code: 99654
Well Site:
Denaly Estates
Lot/Block: 12/2
Additional:
MOA Permit # OSP1914
Well Depth:
141 ft
From: To: Formation:
0
18 silt/gravel/cobble
Below Ground:
139 ft
18
21 wet sand/gravel/silt
Above Ground:
2 ft.
21
55 silt/gravel
Gal / Min:
50 gpm
55
75 dry silt
75
103 wet clay
Static Level:
0 ft
103
109 wet clay/gravel
109
117 clay
Casing:
141 ft. of 6" steel casing
117
126 wet clay/gravel
126
136 wet clay
Liner Pipe:
N/A
136
141 gravel/water
Screened:
N/A
Perforated:
N/A
Grouted:
7 bags casing seal
Depth:
N/A
WATER Q .MY TESTING
Develop. Method:
Air
Collform eq Col/100mL
Ntrates mg/L
Arsertic ug/L
Vii -
Use of Well:
Residential
Drilling Method:
Rotary
Misc:
Other:
well disinfected with chlorine 50
PPM
The well was pumped 5' off the bottom with 100% draw down for 2 hours and recovered at 50 gpm .
Date Drilled:
11/1/2019 Driller: Ben Mattson
Development Services Department
Building Safety Division
8
On -Site Water & Wastewater Program
o ,<
*,4
4700 Elmore Road
P.O. Box 196650
Mark Begich Anchorage, AK 99507 s" E T Y
Mayor www.muni.org/onsite
(907) 343-7904
Pump Installation L®
Well Drilling Permit Number: SW OSP Date of Issue:
Parcel Identification Number:
II Legal DescriptionII Property Owner Name & Address: I)
Denaly 1-12132 Troy Davis Homes, Inc.
Pump Installation Date: 10/27/20
Pump Intake Depth Below Top of Well Casing: N/A
Pump Manufacturer's Name: N/A
Pump Model: N/A
Pump Size N/A hp
Pitless Adapter Burial Depth: feet
Pitless Adapter Manufacturer's Name: Unknown
Pitless Adapter Installer: Unknown
Well Disinfected Upon Completion? ✓0 Yes ❑ No
Method of Disinfection: Sterilene
Comments: Artesian Well, Jet Pump installed inside the house
Well is plugged
Pump Installer Name: Wheaton Water Well, Inc.
1190 N. Wasilla-Fishhook Road
Wasilla, AK 99654
feet
1689 Knik Goose Bay Road #400
Wasilla, AK 99654
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
Lot 11 \\
.6 \ \ \ \ 7p' T&E EASEMENTS
414 — \
alas
\ S 88 00 54'E 353.97'(C) 354.1 R' /a1
—y
TBM - AJ
ELEVATION P4 0. 2�� \ \
N
.......\
...............................
X25
l�� \ n
IZ WELL 100' PROTECTIVE RADIUS
10.0'x16.1' \ \ \
DECK I
/ SETBACK LINES \rte
O Lot 2 s4'2 CLEARING
\ \ �� 46,896 S. F.. LIMITS
•� � SPLIT-LEV
�• RESIDENCEL 12.0 /
\ \ 34.0' /J
\ 7 5'x2D.0'
\ \ PORCH / ..... ..��
\
LEGEND \
104.8 EXISTING ELEVATION
103.0 PROPOSED ELEVATION
SURFACE DRAINAGE
NOTES:
1) DATUM: M.O.A. POST -QUAKE
V12.2 l
SEPTIC
PIPES
e
J
GRAVEL B• �S
DRIVEWAY r/ O•
PIPES
V;/ 15'x15' T&E EASEMENT
Lot 13
\
\
Lot 18
M.E.A. EASEMENT
^30' M.E.A. EASEMENT
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L
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Sox 196650 4700 Elmore Road
Anchorage, Alaska 99519650 Phone: (907) 343-7904 Fax: (907) 343-7997
hUp:/twww.muni.orglonsite
On -Site Water & Wastewater System Permit
Permit Number: OSP191486 Effective Date:
Work Type: WellSeptic Initial Expiration Date:
ax Coda Number: 06706219000
Site Legal Address: DENALY ESTATES BLK 2 LT 12 G:0362
_.._.___.__"$ite Matling-Ad"dress;�`"25301�MC`INTYRE'RD; Eagle�River --'�^�___.__ _
Sc ��
Claitt'tI116t]C
1013012019
10/2912020
Owner: TROY DAVIS HOMES INC Lot Size in Sq Ft: 46896
Design Engineer: FORGE ENGINEERING Total Bedrooms: 4
This permit is for the construction of:
Q Disposal Field Z Septic Tank ❑ Holding Tank ❑ Privy 0 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 (2417).
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
LpeciSpeclal Provisions: 1. The recorded plat for this subdivision notes that artesian wells are common and that
al drilling methods may be required to prevent waste of water via surface discharge.
Received By: Avy Date: ) 'C
Issued By: 1,(-A, Date: 1013 �
i f
/ r
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. - . 067-062-19 -
Property owner(s) Troy Davis Homes Day phone 310-2501
Mailinq-address-1.689 Knik_Goose-Bay _Rd -#400,_W- asilla,-AK-99654 -
Site address 25301 McIntyre Rd. Chugiak, AK 99567
Legal description (Sub'd., Block & Lot) Denaly Estates, Block 2, Lot`.12
Legal description (Township, Range & Section)
Lot Size 46,896 Sq. Ft. Number of Bedrooms 4
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(N all that apply)
Absorption Field
❑X
Initial 0
Single Family (SF) 0
(w/wo ADU)
Septic Tank
Q
Upgrade ElDuplex
(D) ❑
Holding Tank
❑
Renewal ❑
Multiple Dwellings ❑
Privy
❑
(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)
r
Permit/Rush Fees: ?Ji2 Waiver Fees:
Date of Payment: 16124 Date of Payment:
Receipt Number: 4.36(061D Receipt Number:
Permit No. a,5p l R t (4? to Waiver No.
Permit App_-'-: • :..,:c
II
PO BOX 240773
ANCHORAGE, AK 99524
522-7773 677-7766 (FAX)
October 29, 2019
MOA Development Services Department
On-Site Water & Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
Subject: Denaly Estates, Block 2, Lot 12 – 25286 McIntyre Rd Septic system design
Well and Septic System Design
Dear On-Site Services Engineer:
The owner of the above lot intends to build a 4-bedroom home on the property. We are submitting
this application for a permit to construct a new well and septic system. The attached site plan
identifies the location of the home and the proposed well, septic location and alternate site. No
conflicts exist between this proposed system and any other well or septic system, whether on this
lot or adjacent lots.
The ground surface on the lot slopes moderately to the south at grades from 5% to 15%. Ground
contours are shown on the site plan showing the grade and direction of flow. Storm water drainage
will not impact this septic system. The new trenches 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. The alternate site is located
more than 16’ away.
Please refer to the attached test hole logs and plan and profile sheets for the septic design. If this
design is followed, there will be no adverse impacts to adjacent properties.
Sincerely,
Michael E. Anderson, P.E.
10/29/19
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP191486, Rebecca Carroll, 10/30/19
395
390
400
FCO
10050 0
FEET
1"=50'
2-60' LONG x 5' WIDE x .5'
EFFECTIVE DEPTH
ABSORPTION TRENCHES
1,250 GALLON
SEPTIC TANK
w/20" MANWAY
NOTE:
SLOPES >25% ARE WITHIN 50' OF THE ABSORPTION TRENCH. TRENCH
DESIGN COMPLIES WITH AMC 15.65.210B.1.e. NO SURFACE WATER
WITHIN 100' OF THE PROPOSED SEPTIC SYSTEM
ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS
PROPERTY ARE SHOWN. NO CONFLICTS WITH WELLS OR SEPTIC
SYSTEMS.
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEANOUT
FS - FLOW SPLITTER VALVE
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
LEGEND
DENALY ESTATES, BLOCK 2, LOT 12
McINTYRE ROAD10/29/19
15' x 15' T&E EASEMENT
40 LF - 18" CPEP
CLEARING
LIMITS
10' T&E EASEMENTS
M.E.A. EASEMENTS
TH1
TH2
PROPOSED WELL
SV
MH 2CO
FS
CO
CO
CO
CO
MT
MT
ALTERNATE SITE
FOUR BEDROOM HOME
100' PROTECTIVE WELL
RADIUS LOT 7, BLOCK 2.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP191486, Rebecca Carroll, 10/30/19
DENALY ESTATES, BLOCK 2, LOT 12
DESIGN FACTORS: SYSTEM REQUIREMENTS:
600 GPD PEAK FLOW
PERK RATE: <1 MIN/IN
APPLICATION RATE: 1.0 GPD/SF
5' WIDE TRENCH SYSTEM
1,250-GAL SEPTIC TANK
TYPICAL TRENCH SECTION
(NO SCALE)
NOTES:
1. GRADE AREA OVER TRENCH TO DRAIN AWAY
2. PROVIDE 3' OF COVER OVER TRENCHES AND 4' OVER SEPTIC TANK, OR 2'
WITH 2" OF INSULATION
3. CHECK GROUNDWATER AT TIME OF CONSTRUCTION. IF LEVEL IS HIGHER
THAN PREVIOUSLY OBSERVED, CALL ENGINEER IMMEDIATELY
BOTTOM OF TRENCH: 4' BELOW GRADE
FLOW LINE ELEVATION: 3.5' BELOW GRADE
TOP OF TRENCH: 0.5' ABOVE GRADE
600 GPD / 1.0 GPD/SF /5' WIDE * 1 (RED. FACTOR) = 120 LF TRENCH REQUIRED (120 LF SPECIFIED)
10/29/19
4" PERFORATED PVC (HOLES DOWN)
5'
6"
3'
2'
6"
6"
DRAINFIELD ROCK
MO.A.APPROVED SAND
GEOTEXTILE FABRIC
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP191486, Rebecca Carroll, 10/30/19
LEGAL DESCRIPTION:
PERFORMED FOR:
DATE:
PARCEL ID#:
SOILS LOG AND PERCOLATION TEST
TECHNICIAN:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
DEPTH
(feet)
PROJECT No.:
TEST HOLE 1
SLOPE
SLOPE
SITE PLAN
DATE READING GROSS TIME
(minutes)
NET TIME
(minutes)
DEPTH to
WATER NET DROP
TEST HOLE PRESOAKED PRIOR TO TESTING:
PERC. HOLE DIA. (INCHES)PERCOLATION RATE: (MIN/INCH)
TEST RUN BETWEEN: FT. and FT.
COMMENTS:
(inches)(inches)
DENALY ESTATES, BLOCK 2, LOT 12
10/17/19
J. WILLIAMS
DATE OF MONITORING:
WAS GROUND WATER ENCOUNTERED?
DEPTH TO WATER AFTER MONITORING:
IF YES @ WHAT DEPTH? -
3 6
4 5
pid
TROY DAVIS HOMES, INC.
10:40/10:50
10/22/19
1
2
3
4
5
6
0/3 4
16
10:52/11:02
11:04/11:14
11:15/11:25
11:26/11:36
11:37/11:47
1' OB
Professional Engineers Stamp:
10/29/19
10
NO
14'
10/24/19
GRAVEL WITH SAND
GW
3 4
16
0/3 5
1610 3 5
16
10
0/3 4
1610 3 4
16
10
10
0/3 5
16 3 5
16
0/3 5
16 3 5
16
0/3 5
16 3 5
16
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP191486, Rebecca Carroll, 10/30/19
LEGAL DESCRIPTION:
PERFORMED FOR:
DATE:
PARCEL ID#:
SOILS LOG AND PERCOLATION TEST
TECHNICIAN:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
DEPTH
(feet)
PROJECT No.:
TEST HOLE 2
SLOPE
SLOPE
SITE PLAN
DATE READING GROSS TIME
(minutes)
NET TIME
(minutes)
DEPTH to
WATER NET DROP
TEST HOLE PRESOAKED PRIOR TO TESTING:
PERC. HOLE DIA. (INCHES)PERCOLATION RATE: (MIN/INCH)
TEST RUN BETWEEN: FT. and FT.
COMMENTS:
(inches)(inches)
DENALY ESTATES, BLOCK 2, LOT 12
10/17/19
J. WILLIAMS
DATE OF MONITORING:
WAS GROUND WATER ENCOUNTERED?
DEPTH TO WATER AFTER MONITORING:
IF YES @ WHAT DEPTH? -
<1 6
4 5
pid
TROY DAVIS HOMES, INC.
9:40/9:45
10/22/19
1
2
3
4
5
6
0/6
9:48/9:53
9:55/10:00
10:03/10:08
10:10/10:15
10:18/10:23
1' OB
Professional Engineers Stamp:
10/29/19
4M 30S
NO
18'
10/24/19
GRAVEL WITH SAND
GW
6
0/6 6
0/6 6
0/6 6
0/6 6
0/6 6
4M 30S
4M 30S
4M 30S
4M 30S
4M 30S
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP191486, Rebecca Carroll, 10/30/19
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. 067-062-19
Expiration Date: (�7 j S'2_1
1. GENERAL INFORMATION
Complete legal description Denaly Estates Sub, Block 2, Lot 12
Location (site address) 25301 McInyre Road
Current property owner(s) Troy Davis Homes, Inc Day phone (907) 357-9394
Mailing address 1689 S Knik Goose Bay Rd #400, Wasilla, AK 99654
Real estate agent Day phone
2. TYPE OF DWELLING:
❑■ Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
4. TYPE OF WATER SUPPLY:
Private Well
Water Storage
Community Well
Public Water System
Waiver request for:
Received by:
4
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ $120
Date of Payment ) 2 .2 Q'
Receipt Number 0
COSA # OSC211108
TYPE OF WASTEWATER DISPOSAL:
Private Septic
❑■
Holding Tank
❑
Community
❑
Public Sewer
❑
Date:
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
Distance:
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 Forge Engineering Phone (907) 522-7773
Address 1399 W. 34th Ave Suite 101, Anchorage, AK 99503
Engineer's Printed Name Benjamin Schiller Date 3/11/21
OF k.4
TH
6. DSD SIGNATUREZ""'
System #1 Approved for bedrooms �' /
Benjam(ySchiller
System #2 Approved for bedrooms ����Fc��l , . CE 12592 W
. �,
Disapproved l`F�PROFEWQ P�``�=
Conditional approval for bedrooms, with the following stipulations:
OF
WATER AND m
R z�
PROGRAM
By: 2 V -P Original Certificate Date:
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: DENALY ESTATES SUB, BLOCK 2, LOT 12 Parcel ID: 067-062-19
If more than 1 septic system on lot: COSA Checklist # 1 of 1 Structure served by this system 1
A. WELL DATA
❑® Well log is filed with Onsite (or attached)
Date drilled 11/1/19
Total depth 141 ft
Cased to 141 ft
❑® Sanitary seal is functioning correctly
FE -1 Wires are properly protected
Casing height (above ground) 24 in.
Date of flow test for COSA 4/15/19
Static water level at beginning of test 0 ft.
Comments
B. TANK DATA
Age of tank(s) <1 years
Tank type/material SEPTIC / PLASTIC
Measured operating fluid level in septic tank NEW
FN_1 Standpipes/foundation cleanout per record drawing
Date of pumping TANK INSTALLATION 6/5/20
D. ABSORPTION FIELD DATA
Which system tested (date installed) 6/6/20
❑o ALL standpipes present per record drawing
Total measured depth from grade 3.413.9 ft (max)
Measured depth to pipe invert from grade 2,9/3-1 ft (min)
❑ N/A — pressurized field
❑® Monitor tubes go to bottom of effective. If not, state
depth into effective
❑® 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: NEW CONSTRUCTION SEPTIC SYSTEM
COSA Checklist yellow sheet
Well production at time of test 50 qpm
Water storage tank volume N/A gallons
Well disinfected for coliform test? ❑ Yes ❑ No
Q Coliform bacteria is Negative
Nitrate 1.39 mg/L ❑ Nitrate less than MRL (ND)
Arsenic 4.58 ug/L ❑ Arsenic less than MRL (ND)
Collected by WHEATON WATER WELLS
Date of Sample 10/27/20
C. LIFT STATION
ired maintenance completed
Age of lift sta t _ years
Lift station material
Comments:
Adequacy test date NEW
Results ❑Pass For 4 bedrooms
depth prior to test in
Water a - -ed gal
New depth in
Elapsed time
Final fluid depth in
Absorption rate gpd
Any rejuvenation treatment (past 12 m
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'
El
Yes
Community Sewer Manhole/Cleanout > 100'
Q✓ Yes
if No
ft
Q✓ Yes
if No ft
Neighboring Tank > 100' ❑✓ Yes
if No
ft
Private Sewer/Septic Line > 25' 0 Yes
if No ft
Absorption Field on Lot > 100' Q Yes
if No
ft
Holding Tank > 100' 0 Yes
if No ft
Neighboring Absorption Fields > 100'
Q Yes if No ft
Water Main > 10'
Animal Containment > 50' 0 Yes
if No ft
Q Yes
if No
ft
0 Yes if No ft
Water Service Line > 10'
❑✓
Yes
if No
Manure/Animal Excreta Storage > 100'
If septic tank is under driveway comment below
Community Sewer Main > 75' ❑✓ Yes
if No
ft
0 Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
El
Yes
if No
ft
Surface Water > 100'
❑✓ Yes if No ft
Property Line > 5'
0
Yes
if No
ft
Wells on Adjacent Lots:
Q
Absorption Field > 5'
Q
Yes
if No
ft
Private Wells > 100'
Q Yes if No ft
Water Main > 10'
Q
Yes
if No
ft
Community Wells > 200'
0 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'
Q✓
Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
Q
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
Q
Yes
if No
ft
Private Wells > 100' ❑✓ Yes if No
Water Service Line > 10'
Yes
if No
ft
Community Wells > 200' ❑✓ Yes if No
Surface Water > 100'
Q
Yes
if No
ft
F. ENGINEER'S COMMENTS
,
- OFG. ENGINEER'S CERTIFICATION r' !4Cq'pk��)
1 certify that 1 have determined through field inspections and review% * .� lH *'
of Municipal records that the above systems are in conformance with ' ' ' ' ' ' ' ' ' '
MOA COSA guidelines in effect on this date. , , ..
, , , , , ,
• '.. Benjarr�r} .chiller
�c,9 CE 12592
�1 �sl�c�• .03/11/2021. •V�
l�lF�PROFESS10Np —
COSA Checklist yellow sheet
ft
ft
Lot 11 \
Lot 18
414.5
414.5 \ \ \ \ 10' T&E EASEMENTS449.0
\\
\\ —\ 449.0
\ / S 88'00'54"E 353.97' C 354.18' R
TBM — EDGE OF PAVEMENT \
ELEVATION = 410.82 O
\ 12�..\.\..........\.\..........:.
WELL 100' PROTECTIVE RADIUS I \ \
I �S 10.0'x16.1' \ \
DECK f \ \ 20' M.E.A. EASEMENT
SETBACK LINES \
\\ \ 30' M.E.A. EASEMENT
Lo 12 542' / CLEARING \
j46,896 S.F.\ N 34. SP LIMITS \ \ \ \ LIT -LEVEL
oRESIDENCE 12.0'
\ 7.5'x20.0' \
PORCH N
—MANHOLE,
20.0'cli12.2 \
\ \ / SEPTIC
\ PIPES C_.)
Lot 13
\ �l
• GRAVEL
.,DRIVEWAY • O
SEPTIC PIPES
\ • gyp, �/
� 15'x15' T&E EASEMENT
LEGEND
398.0
104.8 EXISTING ELEVATION 398.0\
103.0 PROPOSED ELEVATION
SURFACE DRAINAGE \
NOTES:
1) DATUM: M.O.A. POST -QUAKE
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