HomeMy WebLinkAboutASHLAND OVERLOOK ESTATES LT 3Onsite File
Ashland
Overlook
Estates
Lot 3
#020-101-99
Municipality of Anchorage
On-Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP201002 PID Number: 020-101-99
Dwelling: ❑■ Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: I■❑ New ❑ Upgrade
Name
TOLLEFSEN RYAN & BRIANNA
ABSORPTION FIELD
❑ Deep Trench ■❑ Wide Trench ❑ Bed ❑ Mound
Site Address
NHN ASHLAND CIRCLE ANCHORAGE, AK 99516
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
907-242-6911
6
6 GPD/SF
1.0 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
0.5 Ft.
Gravel depth beneath pipe
0.5 Ft.
Subdivision Block Lot
ASHLAND OVERLOOK ESTATES 3
Fill added above original grade
10.7 Ft.
Gravel length
30 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
1
Dist. between trenches
From
Tank
Field
Tank
Line
150 Ft2
N/A Ft.
Well
>50'
>50'
N/A
N/A
>25
TANK 9 Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
ADVANTEX
Capacity
3000 Gal.
Surface Water
> 50'
> 50'
N/A
N/A
Material
STEEL
Number of compartments
2
Lot Line
>5'
>5'
N/A
N/A
NA
Foundation
>10'
>10'
N/A
N/A
LIFT STATION
Manufacturer
Capacity
Remarks
Gal.
Alarm location
Electrical installed by
PIPE MATERIAL House to tank D3034 drainfield Tank to
D3034
Installer
NORTHERN EXCAVATING
Drainfield D3034 Co/MTD3034
Inspector J.MILLETTE / L.TIDWELL
BENCH MARK (Assumed elevation) 100 ft
Inspection 15t 6/10/20 6/26/20
Location and description
dates: 2°°
GARAGE SLAB
3`° 6/26/20 4`"
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
-..Pof �L Ali
Conditional Approval: Date
®L9TH & r
Septic System
Benjarka'Schiller
¢� �'F�,/•• •��`�r®
App Date?
n���
CE 12592
�`�J'1�C9FOp3/..
- A����e
ROFESS10��4
Note: this approval does not include well permit requirements.®�
(kev u5iuzi16)
ASHLAND OVERLOOK ESTATES SUB, LOT 3
PERMIT # OSP201002
PID # 020-101-99
*hasTH
�r I
Ben a in Schiller�J.v
CE 12592
10,18,21
,,11fi�pRpFESS10NP��++
PLAN AS -BUILT
0 100 200
FEET
1 "=100'
A
1-1
CHAIN-LINK FENCE
1 \�
EXISTING\WELL
SECTION LINE EASEMENT
A B C D
FCO 2.6 63.5
MH1
72.5
44.2
MH2
62.3
44.1
2CO
68.3
51.3
C01
80.7
61.6
MT1
62.0
62.8
CO2
58.8
62.2
LEGEND
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEANC
FS - FLOW SPLITTER VALVE
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
ASHLAND OVERLOOK ESTATES SUB, LOT 3
PERMIT # OSP201002
U1.1i
0 0
MONITORING TUBE 0 96.5 FINISH GRADE 85.8 ORIGINAL GRADE :�i 0
ABANDONED 4/L ------------- n -n-
85.3
ENGINEERING
30'
NO GROUNDWATER 3/6/18
PROFILE AS -BUILT
(NO SCALE)
85.3
84.8
OF -kk
49
Benja in <Schiller
CE 12592
"PROFESS
jz• •J
Permit Number: #SW201002 Date of Issue: 1-95-2020 Parcel Identification Number: 02090199000
Date Started: 6-23-20 Date Completed: 6-26-20 Is well located at approved permit location? x Yes ❑ No
Legal Description: Ashland Overlook Estates Lot 3
Property Owner Name & Address: Tollefsen Ryan & Brianna
Borehole Data: Depth (ft)
Method of Drilling x air rotary ❑ cable tool
Soil Type, Thickness & Water Strata From To
Casing type: steel
stick up 0 2
Wall Thickness: .250 inches
bedrock 2 226
Diameter: 6 inches Depth: 43 feet
Liner Type:
Diameter: inches Depth: feet
Casing stickup above ground: 2 feet
Static water level (from ground level): 49 feet
H2O 197 204
Pumping level: 220 feet after
2 hours pumping 20 gpm
Recovery Rate: 20 gpm
Method of Testing: air lift
Well Intake Opening Type:
❑ Open End x Open Hole
❑ Screened Start feet Stopped feet
❑ Perforations Start feet Stopped feet
Grout Type: bentonite chips Volume: $bgs
,,,,,
De the Start 0 feet Stopped 41 feet
Pump: Intake Depth feet
Pump size hp Brand Name
WATER ITY TESTING
Cpill t,r1 Col/100ml-
rates n �L
Arw*�D ug/L
Well Disinfected Upon Completion? x Yes ❑ No
Method of Disinfection: chlorine tablets
Comments:
Well Driller: Alpine Drilling & Enterprises
PO Box 110496
Anchorage AK 99511
3
Lit i
Y43 -
19q
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Well Drilling Permit Number:
For, • MIM., tm• • •
Parcel Identification Number: 020 -101 -moo
Date of Issue: -
15_2020
Legal Description
Ashland Overlook Estates
Block
Lot
3
Property Owner Name & Address:
Crown Pointe/ Ryan & Brianna Tollefsen
P.O. Box 112313
Anchorage, AK 99511
Pump Installation Date: 5 -31 -2020
Pump Intake Depth Below Top of Well Casing. 190 feet
Pump Manufacturer's Name: Myers
Pump Model•2 N FL72-S-P4-02 i
Pump Size: 3/4 hp
Pitless Adapter Burial Depth: NIA feet
Pitless Adapter Manufacturer's Name: N/A
Pitless Adapter Installer: N/A
Well Disinfected Upon Completion? 0 Yes ❑ No
Method of Disinfection: chlorine tablets
Comments:
PLEASE SAVE FOR COSA.
Pump Installer Name:
Company: Aarow Pump & Well Service, LLC
Mailing Address: P.O. Box 11049E
icityAnchorage state. AK Zip: 99511
Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation.
41UNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
Anchorage, AlasPO Box 196650 1 4700 Elmore Road
ka 99519-6650 Phone; (907) 343-7904 Fax: 0907j 343-7997
http:// ,H, Muni.org/onsite
Can -Site Water & Wastewater System Permit
Permit Number: OSP201002
Work Type: WellSeptic Initial
Tax Code Number: 02010199000
Site Legal Address: ASHLAND OVERLOOK ESTATES LT 3 G:3338
Site Mailing Address:
Owner: TOLLEFSEN RYAN & BRIANNA
Design Engineer: FORGE ENGINEERING
This permit is for the construction of:
9 Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy
Effective Date:
Expiration Date:
Lot Size in Sq Ft:
Total Bedrooms:
Q Private Well
1/15/2020
1/14/2021
136845
❑ Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65, Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Received By: jh'kj_1rA
/J
1.
Issued By: 0�tC�X'
Date:
Date: f 5 C/20,20
N.
Ept/Aks
MUNICIPALITY F ANCHORAGE
O
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. 020-101-99
Property owner(s) Margaret & Larry Robbins Family Trust
Mailing address P.O. Box 1239 Lavernia, TX 78121
Site address NHN Ashland Circle Anchorage, AK 99516
Day phone
Legal description (Sub'd., Block & Lot) Ashland Overlook Estates, Lot 3
Legal description (Township, Range & Section)
Lot Size 136,845 Sq. Ft. Number of Bedrooms Six (6)
242-6911
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑X
Initial 0
Single Family (SF) Q
(w/wo ADU)
Septic Tank
Q
Upgrade ❑
Duplex (D) ❑
Holding Tank
❑
Renewal ❑
Multiple Dwellings ❑
Privy
❑
(SF and/or D)
Private Well
0
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: 910 Waiver Fees: _
Date of Payment: L c-2126 y) Date of Payment:
Receipt Number: 0 1 (jaUr) Receipt Number:
Permit No. ®J PA610®A Waiver No.
Permit App_'-'-:. :'-..:c
PO BOX 240773
ANCHORAGE, AK 99524
522-7773 677-7766 (FAX)
January 10, 2020
MOA Development Services Department
On-Site Water & Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
Subject: Ashland Overlook Estates, Lot 3 – NHN Ashland Drive
Septic System Design
Dear On-Site Services Engineer:
The owner of the above lot intends to build a 6-bedroom home on the property. We are submitting
this permit application for the construction of a new well and septic system to serve the home. 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
on this lot or adjacent lots.
The ground surface on the lot slopes to the west at grades approximating 25%. There are no slopes
greater than 25% within 50 feet downslope of the absorption trenches. We are proposing to place
a Category 3 Advantex Treatment System on the lot so separation distances to groundwater,
bedrock, wells and steep slopes are minimized. Ground surface contours are shown on the site
plan indicating the grade and direction of flow. Storm water 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,
Michael E. Anderson, PE
1/10/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201002, Rebecca Carroll, 01/15/20
x x x1075107010801065ALTERNATE SITE
FCO
200100 0
FEET
1"=100'
30' LONG x 5' WIDE x .5'
EFFECTIVE DEPTH
ABSORPTION TRENCH
6-BDRM HOME
NOTE:
NO SLOPES >25% WITHIN 50' OR 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
ASHLAND OVERLOOK ESTATES, LOT 3
1/15/20
CHAIN-LINK FENCE
10' T&E EASEMENTS
10' T&E EASEMENTS
33' SECTION LINE EASEMENT
ASHLAND DRIVE
3,000 GALLON ADVANTEX
RECIRCULATION TANK
w/2-AX20 PODS.
PROPOSED WELL
EXISTING WELL
EXISTING WELL
MH
MH
2CO
CO
CO
MT
NOTE:
SHALLOW BEDROCK IS LOCATED THROUGHOUT
THIS PROPERTY. SEPTIC TANK PLACEMENT
MAY REQUIRE BLASTING OR OTHER MEASURES
TO REMOVE BEDROCK.
GROUNDWATER WAS FOUND AT 4' BELOW THE
SURFACE. SEPTIC TANK MAY REQUIRE
ANCHORING TO PREVENT FLOATING.
CONTRACTOR MUST PROVIDE ANCHORING IN
ACCORDANCE WITH MANUFACTURER'S
RECOMMENDATIONS.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201002, Rebecca Carroll, 01/15/20
ASHLAND OVERLOOK ESTATES, LOT 3
DESIGN FACTORS: SYSTEM REQUIREMENTS:
900 GPD PEAK FLOW
PERK RATE: 2-3 MIN/IN
APPLICATION RATE: 6 GPD/SF
5' WIDE ABSORPTION TRENCH
3,000 GALLON ADVANTEX RECIRCULATION TANK
w/2 - AX20 PODS
TYPICAL TRENCH SECTION
(NO SCALE)
4" PERFORATED PVC (HOLES DOWN)
DRAINFIELD ROCK
5'
6"
6"
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: 1.5' BELOW GRADE
FLOW LINE ELEVATION: 1.0' BELOW GRADE
TOP OF TRENCH: 2.5' ABOVE GRADE
900 GPD / 6 GPD/SF /5' WIDE * 1.0 RED. FACTOR = 30 LF TRENCH REQUIRED (30 LF SPECIFIED)
1/15/20
2.5'
6"
GEOTEXTILE FABRIC
3
1
3
1
PLACE TOPSOIL &
REVEGETATE MOUND.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201002, Rebecca Carroll, 01/15/20
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)
Ashland Overlook Estates, Lot 3
10/16/19
J. Williams
DATE OF MONITORING:
WAS GROUND WATER ENCOUNTERED?
DEPTH TO WATER AFTER MONITORING:
IF YES @ WHAT DEPTH? 4'
1.9 6
2 3
020-101-99
ROBBINS
10/21
1
2
3
4
5
6
0/5 4
16
1' OB
Professional Engineers Stamp:
1/15/20
10
yes
4'
10/23/19
SANDY SILTY GRAVEL
GM
BEDROCK
2:07/2:17 5 4
16
5 3
16
5 3
16
5 3
16
5 3
16
5 3
16
0/5 3
16
0/5 3
16
0/5 3
16
0/5 3
16
0/5 3
16
10
10
10
10
10
2:08/2:28
2:29/2:39
2:40/2:50
2:51/3:01
3:02/3:12
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201002, Rebecca Carroll, 01/15/20
MUNICIPALITY OF ANCHORAGE
ADVANCED WASTEWATER TREATMENT SYSTEM
MAINTENANCE AND REPAIR AGREEMENT
THIS MAINTENANCE AND REPAIR AGREEMENT, herein the "AGREEMENT" made and
entered into as of thi/sp Day of J , of 20 �(% , by and between
i��( C'nz�(/ , herein the "OW\BR," and the Municipality of
Anchorage, herein the "MUNICIPALITY", in accordance with Anchorage Municipal Code
(AMC) 15.65.365. In consideration of the mutual covenants contained herein, the parties to this
Agreement agree as follows:
1. Advanced Wastewater Treatment Systems. The Municipality grants permission to the
Owner to utilize and operate an Advanced Wastewater Treatment System (AWWTS),
described as Advantex Waste Water Treatment System
located at (legal description)
Ashland Overlook Estates L3
2. Maintenance, Repairs and Alterations.
(Owner is required to read, understand and initial each section)
Throughout the term of this Agreement, the Owner shall enter into a service agreement
with an AWWTS service and maintenance provider approved by the Municipality or the
manufacturer's representative. The AWWTS shall be maintained in a satisfactory
condition capable of performing as designed and producing.treated septic effluent in
accordance with the equipment's approval for operation in the Municipality.
It shall be the responsibility of the Owner during the term of this Agreement to pay for all
repair(s), maintenance, adiustment(s), replacement costs, and inspection costs. This
includes an annual maintenance fee (typically $400 to $600).
Owner agrees that only maintenance and repair personnel approved by the Municipality
or the manufacturer's representative will inspect and make any necessary maintenance,
repairs or permitted alterations to the system.
Owner acknowledges that regular maintenance of an AWWTS reduces the potential
failure of the system, which could include sewage backup and costly repairs or drainfield
replacement.
(rev. 05/18/2018) Page 1 of 3
Owner acknowledges that the Municipality may request records of maintenance and
repairs from the manufacturer's representative or maintenance provider.
Owner acknowledges that the fine for failing to maintain and repair an AWWTS may be
assessed in accordance with AMC 14.60.030.
AL Owner agrees to grant the Municipality reasonable access to test and inspect the
AWWTS. The Municipality will give at least 24-hour notice.
X— Owner agrees that any sale or transfer of title of the property will not occur without a new
Certificate of On -Site Systems Approval.
Owner agrees that the AWWTS installation and maintenance requirements as provided
by the AWWTS vendor/installer and approved by the Municipality are the governing
guidelines for the construction, maintenance and repair of the Owner's AWWTS.
Owner agrees to maintain remote monitoring of the AWWTS as required by the
AWWTS approval.
3. Term. The term of this Agreement shall begin on the date of approval by the
Municipality to operate the installed system, or upon transfer of title, and shall continue
wlule the AWWTS is operational or until title is transferred.
4. Nonwaiver. The failure of the Municipality at any time to enforce a provision of this
Agreement shall in no way constitute a waiver of the provisions, nor in any way affect
the validity of the Agreement or any part hereof, or the right of the Municipality
thereafter to enforce every provision hereof.
5. Amendment. This Agreement shall only be amended by authorized representatives of
the Owner and Municipality. Any attempt to amend this agreement by either an
unauthorized representative or unauthorized means shall be void.
6. Jurisdiction: Choice of Law. Any civil action arising from this Agreement shall be
brought in the Superior Court for the Third Judicial District of the State of Alaska at
Anchorage. The laws of the State of Alaska shall govern the rights and obligations of the
parties under this Agreement.
7. Severability. Any provisions of this Agreement decreed invalid by a court of competent
jurisdiction shall not invalidate the remaining provisions of the Agreement.
(rev. 05/18/2018) Page 2 of 3
OWNER:
By;signature) Date: v
/e Fes/ (print name)
STATE OF ALASKA )
) ss.
THIRD JUDICIAL DISTRICT )
The foregoing instrument was acknowledged before
20x6 , byl C q an
TAY PtltfC FOR ALASKA
My Colmnissioil expires: 1.1--�223
me this 1 day of
MUNICIPALITY:
By: (signature)
Y
(print name)
SABRA L. GILLILAND
Notary Public
State of Alaska
My Commission Expires Jan 11, 2023
Date: oZ4
Title:
(rev. 05/18/2018) Page 3 of 3
.3
MUNICIPALITY OF ANCHORAGE
Development Services Department T Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 020-101-99
1. GENERAL INFORMATION
Expiration Date: 12(9"2dZZ -
Complete legal description Ashland Overlook Estates Lot 3
Location (site address) 17191 Ashland Dr, Anchorage, AK 99516
Current property owner(s) T011efsen, Ryan & Brianna Day phone 907-242-6911
Mailing address 17191 Ashland Dr, Anchorage, AK 99516
Real estate agent Day phone
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 6
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
Private Septic
❑■
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: Distance:
Received by:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $_7.5 4 _r `i 5
Date of Payment f oAh
Receipt Number 0487ID
COSA # OS G Z ► I GO L-1
Date:
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater
disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in
effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm Forge Engineering Phone (907) 522-7773
Address _1399 W. 34th Ave Suite 101, Anchorage, AK 99503
Engineer's Printed Name Benjamin Schiller, P.E.
6. DSD SIGNATURE
System #1 Approved for bedrooms
System #2 Approved for bedrooms
Disapproved
Date 10/6/21
OF k.4
. BenjamjrvSchiller
9. ;062292 .����
<<lF, PROFESSIAW
Conditional approval for bedrooms, with the following stipulations:
ry
�N-SATE
WAS, V ND m
OGF'
S E C) 9\V/ I r,
�- 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:
Ashland Overlook Estates Lot 3
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 6/26/20
Total depth 226 ft
Cased to 43 ft
❑® Sanitary seal is functioning correctly
0 Wires are properly protected
Casing height (above ground) 24 in.
Date of flow test for COSA 1-15-2020*
Static water level at beginning of test 49 ft.
Comments Well flow information taken from well log.
B. TANK DATA
Age of tank(s) 1 years
Tank type/material Advanced Treatment/ Steel
Measured operating fluid level in septic tank New
OR Standpipes/foundation cleanout per record drawing
Date of pumping New
D. ABSORPTION FIELD DATA 5' Wide
Which system tested (date installed) 6/26/20
0 ALL standpipes present per record drawing
Total measured depth from grade 11.7 ft (max)
Measured depth to pipe invert from grade 11.2 ft (min)
❑ N/A — pressurized field
R Monitor tubes go to bottom of effective. If not, state
depth into effective .
Parcel ID:
Structure served by this system 1
020-101-99
Well production at time of test 20 gpm
Water storage tank volume N/A 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 Forge Engineering
Date of Sample 10/4/21
C. LIMSTATION
❑ Require intenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date New
sults ® Pass For bedrooms
Fluid th prior to test in
Water adde gal
New depth in
Elapsed time in
®❑ Code -required soil cover over field Final fluid depth in
"�'�,
❑ System presoaked Absorption rate gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12
date of test)
Gallons introduced NSA gallons If yes, enter date
Comments/Deficiencies: North monitoring tube does not extend to bottom of field. See profile drawing.
COSA Checklist yellow sheet
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Q
Yes
Septic Tank/Lift Station on Lot > 100'
ft
Surface Water > 100'
Community Sewer Manhole/Cleanout > 100'
Property Line > 5'✓1
✓� Yes
if No
ft
❑✓ Yes
if No
ft
Neighboring Tank > 100' 0✓ Yes
if No
ft
Private Sewer/Septic Line > 25' M Yes
if No
ft
Absorption Field on Lot > 100' 0✓ Yes
if No
ft
Holding Tank > 100' 0✓ Yes
if No
ft
Neighboring Absorption Fields > 100'
Q Yes if No ft
Water Service Line > 10'
Animal Containment > 50' 0 Yes
if No
ft
0✓ Yes
if No
ft
Manure/Animal Excreta Storage > 100'
—0✓
Community Sewer Main > 75' Q 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'
Q
Yes
if No
ft
Surface Water > 100'
Q Yes if No ft
Property Line > 5'✓1
Yes
Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
Q
Yes
if No
ft
Private Wells > 100'
Yes if No ft
Water Main > 10'
✓0
Yes
if No
ft
Community Wells > 200'
Q Yes if No ft
Water Service Line > 10'
Q
Yes
if No
ft
If septic tank is under driveway
comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10'
0✓
Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'✓Q
Yes
if No
ft
Private Wells > 100' Yes if No ft
Water Service Line > 10'
Q
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
1 certify that l 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.
COSA Checklist yellow sheet
11
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