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Home My WebLink AboutDENALY ESTATES BLK 2 LT 14Onsite File Denaly Estates Block 2 Lot 14 #067-062-21 (Rev 05/02/18) i , �QJ 5 F Of Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP201134 PID Number: 067-062-21 Dwelling: N Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: FE -111 New ❑ Upgrade Name Yvonne & James Huber ABSORPTION FIELD ❑ Deep Trench IRE Wide Trench ❑Bed ❑ Mound Site Address 25413 McIntyre Rd El Other Phone Number of Bedrooms Soil Rating Total depth from original grade 4 0.8 GPD/SF 7.0 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 3.0 Ft. Gravel depth beneath pipe 4.0 Ft. Subdivision Denaly Estates Block Lot 2 14 Fill added above original grade --3.1 min —5.2 max Ft. Gravel length 2@ 38 Ft. Township Range Section Gravel width 5.0 Ft. Beds: Number of Lines n/a Distance between lines n/a Ft. SEPARATION DISTANCES To From Septic Tank Absorption Field Lift Station Holding ! Tank I Sewer Line Total absorption area 760 Ftz Number of trenches 2 Dist. between trenches 8.0 Ft. Well 100'+ 100'+ ( 25'+ TANK ®Q Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Infiltrator Capacity 1537 Gal. Surface Water 100'+ 100'+ Material Number of compartments Lot Line 5'+ 10'+ NA Plastic 2 Foundation 10'+ 10'+ LIFT STATION Manufacturer Capacity Remarks Standpipes bent during site grading. Fields are Gal. a minimum of 8.0' apart as dimensioned on site plan. Alarm location Electrical installed by Installer Groundbreakers PIPE MATERIAL House to tank 3034Tank to 3034 drainfield Drainfield 3034 CO/MT3034 Inspector Pannone Engineering BENCH MARK (Assumed elevation) 409 ft Inspdection 1" 7/22/20 3'd 7/23/20 2„d 7/22/20 4`h 8/6/20 Location and description Top of foundation wall see site plan ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional Approval: Date �P,�� OF A�, kS� .. • Steven •R. .Pannone.�.✓` �� _` �CE /.81 AC Septic System Approved Date jot3bOd _IV2_ Note: this approval does not include well permit requirements. (Rev 05/02/18) i , �QJ 5 F Of C) m^- A C) v = REVISIONS -+- III--n ON �_cnD�7Dcn�-iZ�stnD�7Dt/»0tnr- -< 0�1�7_O rTtDp Z. m /�. m z 0' Q,x D�f?1 . OOmF;Oz Cf) Z Zcn NDomOZZ� (7l �o c Com m - � rn rx >U' m-< M:jx> xwm 00 < F-3 W m D00 M -f DC7D.�7 n�m X Z-< m-�M> '70 Ln mC) ��-n rx m m -n> --I ziLn r*io 0T (n 00-_1>F40 �i!'1Oz�zmr?�Q0 rn� rj �r�ozp=i--lmo�z in 0. On Oz- D z Om 0) D S ;] O •• O�CJ1�_� x DO Z m.. O �DCVJIOrn- -' Cep O WmZ N 6)� 00 p�nNU Nm OZ -100 I —0 O�`< NMO�O� I �.. C7D -' W r 7q -> pm Z (� O m fTl �O OPCS -P, O O(n >�m-0 Ox ZO CO — O F' b- 0(,) *iG� �� zm O�7 rrl rr-� rrn ADO ZDO O-OCOrn -< cn0 mm D� O <� �ZM0 0-u O-i� U) Dr J O ='' `Z K 0 DU1 'o K � -i0 Z --A a U1 = " a FTI n N mO 0 P p rri CA Z O v cn O m cn • O 'T1 / m I D � IN N D—\ i�> \gym REVISIONS DATE /15/2020 O gZ p \y /�. m D D Q,x CO nm m �o� O m0 � O0� Oto m m n �v0 mC) / ziLn J Z O' r Om n O in 0. On 0) 0) 0) 0 j i rn -I, N LJ / D / -n m 3 D / /mz / o O; / \\ W - m l i n / 1 \ \ u � /m / I+ — C z + m O NOTES: P6• NNONE EAG SVC LLC (C.I. 1088) RECORD DRAWING P.O. BOX 1807 PAUMER, AK 99645 PHONE (907) 745-8200 FAX (907) 745-8201 DENALY ESTATES B2 L14 SITE: 25413 MCINTYRE RD DRAWN ACP YVONNE & JAMES HUBER SITE PLAN 14161 KOSO DR EAGLE RIVER, AK 99577 »„ ��PjE OF At,, '........ .. ..... Steven R. onnona o CE -8149 .• 5 �,Ess;a1 REVISIONS DATE /15/2020 c)Kn�nO-�-t SCALE 1 " = 50' — P.I.D. NO 067-062-21 PERMIT NO. OSP201134 i nO N- i0 O J V O O 0) 0) 0) 0) i Ut 0) -' N N 0) tT co J -' D J 4, 0 m 1 CO CP J U1 -P U1 tT J 03 »„ ��PjE OF At,, '........ .. ..... Steven R. onnona o CE -8149 .• 5 �,Ess;a1 REVISIONS DATE /15/2020 SCALE 1 " = 50' — P.I.D. NO 067-062-21 PERMIT NO. OSP201134 SHE 2 OF 3 A n II f7 � n n N F o 1 N 1 1 a 1 O O I f D o f I r- u q m f IO 1U IO �z it Z � D F D � p 1 D IZ V I 1 p U I 1 N N N+T T - _ ' i = m � A i 00 O N; NOTES: PANNONE ENG SVC LLC (C.I. 1088) """ REVISIONS DATE RECORD DRAWING P.O. BOX 1807 Pi'CMER, AK 09645 '�E OF 14p 12/15/2020 PHONE (907) 745-8200 FAX (907) 745-8201 - ��P 5�9, REV 1:12/16/20 7SCALE DENALY ESTATES B2 L14 xst�c� NTs P.I.D. NO DRAWN ACP SITE: 25413 MCINTYRE RD 067-062-21 YVONNE & JAMES HUBER ',� .cE-91aBtp.fitPERMIT N0. 14161 KOSO DR OSP201134 PROFILE a ' SHEET EAGLE RIVER, AK 99577 3 OF 3 a: R OWNER OF LAND: Yvonne & James Huber ADDRESS: Bore Hole Data Depth From To LEGAL DESCRIPTION Denaly Estates Block 2 Lot 14 DATE: 6-11-20 p 2 PERMIT NUMBER: OSP201134 DATE OF ISSUE: 6-3-20 TAX IDENTIFICATION NUMBER 06706221000 Is well located at approved perrnit location: mYes ❑No Method of Drilling: ®air rotary cable tool Depth of Well: 144 Casing Type: Steel Wall thickness 250 inches Diameter: 6 inches, depth 144 feet Liner type Static Water Level: Flowing feet Recovery Rate 50 ® gpm gph Method of Testing Air Well Intake Opening Type: ® open end Fopen hole Screened Start feet Stopped Perforations Start feet Stopped Grout Type: Bentonite Volume: 150 lbs Depth: from 2 feet, to 42 feet Well Disinfected Upon Completion: ®yes 1-1 no Method of Disinfection: Chlorine 50 PPM Comments: 2 4 4 18 18 41 41 70 70 79 79 87 87 92 92 131 131 144 Casing Stickup Overburden Silty Sand & Gravel Tight Silty Sand & Gravel w/ Clay Tight Silty Sand & Gravel Hardpan Sand & Gravel w/ Clay Clay Clay & Gravel Sand & Gravel Drillers Name: Cole Sullivan ATTENTION: It is the responsibility of the property owner to submit a copy of the well log to the proper authority. Municipality of Anchorage: Department of Health & Human Services and/or Department of Environmental Conservation. Matsu Borough: Department of Environmental Conservation. ARCTIC PUMP & WELL INC. Jim Sullivan PO Box 770197 Eagle River, AK 99577 s B AXE (907) 688-2510 (907)243-2282 iima.arctiepump.com Well Drilling Permit Number: OSP201134 Parcel Identification Number 067-062-21-000 Date of Issue:6-3-20 Ar -clic Pump & bell, Inc. Page I of I Legal Description:Denaly Estates Property Owner Name & Address: Lot: 1.4 WM Construction Block: 2 PO BX 4042 Palmer AK 99645 Pump Installation Date: 12-1-20 Pump Intake Depth below Top of Well Casing: 13 Pump Manufacturer's Name: Pump Model: Jet Pump Size: Pitless Adapter Burial DepthA 3 Pitless Adapter Manufacturer's Name: B-10 Pitless Adapter Installer: U/K Well Disinfected Upon Completion? Yes Method of Disinfection: Chlorine Comments: Pump Installer Name: Arctic Pump & Well, Inc. Ar -clic Pump & bell, Inc. Page I of I Municipality of Anchorage- P.O. Box 196650 0 4700 Elmore Road Anchorage Alaska 99519-6650 0 (907) 343-7904 a Fax (907) 343-7997 http://www.muni.org/Onsite Development ices Department On -Site Water and Wastewater Section alcor S Ddpar tment x* K X VARIANCE/WAIVER X* x X Waiver-#: OSV201090 COSA#:OSC201689 Permit#:OSP201134 PID#: 067-062-21 Legal Description: Denaly Estates Block 2 Lot 14 Engineer: Pannone Engineering Services Applicant: James Huber Your request for a waiver of the required 8.0 feet horizontal separation between the two sections of absorption field has been approved. The approved separation distance is 5.0 feet. See engineer's waiver request for justifications. This waiver approval applies to the existing dual trench absorption field only. Any future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. ■■v 000vva0av2v0vvaaaaaavv0vv0a000v0vavaav00vv0vavvvavv0evvvavv0va0av0v00vevavaI Waiver is Granted: X Waiver is not Granted: Date: 3/d 020 Approved by: xwa, cajucB Name of Reviewer ■■avvvvvavvavvvvvvvvvsavvavvvvvvavavvamvveaavemmvamvevvevvvmvvavvvvamvavvvavvv� R Steven R. Pannone, Principal Registered Professional Engineer E-mail: steve@paneng k.com 23 December 2020 Municipality of Anchorage Development Services Department On -Site Water & Wastewater Program 4700 Elmore Rd. P. O. Box 196650 Anchorage, Alaska 99519 Subject: Denaly Estates B2 L14 Drain Field Separation Waiver Ladies and Gentlemen: I am requesting a waiver for the subject property for a separation distance from an adjacent drain field to be less than twice the affective depth, in this case from 8 feet to a distance of less than 8 feet. The code requires that two adjacent drain fields be separated by eight feet or twice the affective depth. The contractor installed the two drain fields on this property eight feet apart. This separation distance was verified by PES and the MoA Inspector during the two bottom of excavation inspections. The system was backfilled and additional fill was added. The MoA has informed PES that the As -Built Survey is more correct than the Record Drawing and that we need to apply for a separation waiver. I disagree. However the issuance of a COSA and approval of the Record Drawings are being withheld until a waiver is applied for and paid for. The soils in this area are typically Hydrologic Soils Group A which contains organics underlain by silty sand and gravel. PES conducted a percolation tests on the lot and found a percolation rate of under five minutes per inch (3.8 mpi) at the depth of the drain fields. The soil composition and percolation rate confirms the soil classification of HSG A. Due to the nature of and drainage capacity of the soils found in the area (HSG A) the designed infiltration line of 45% for septic system installation in these soils should be used instead of the assumed/worst case soil classification infiltration line of 25%. The slopes and soil types enable installation of any conventional system without the system effluent affecting the adjacent drain field located less than 8 feet away. As a result of the separation distance of less than 8 feet with a 45% infiltration line that will not affect the adjacent drain field. If you have any questions or concerns, please contact me at 745-8200. Sincerely, Steven R. Pannone, P.E. Owner/Civil Engineer Ndailling.- P.O. Box 1807, Pah-ner, AK 99645-1,807 Telephone: (907) 745-8200 FAX: (907) 745-8201 THIS SURVEY WAS PREPARED FOR WM CONSTRUCTION. AND SHOULD ONLY BE mgm USED FOR A SINGLE PROPERTY ACTION. RE -USE OF THIS DRAWING BY THE 1 . THE HEREON REPRESENTED SURVEY DOES ORIGINAL CLIENT OR BY OTHERS, FOR ADDITIONAL USES AT A LATER DATE e 18NOT CONSTITUTE A BOUNDARY SURVEY. WITHOUT EXPRESS WRITTEN CONSENT OF HANSON LAND SOLUTIONS IS A`6�ap IT IS SUBJECT TO ANY INACCURACIES VIOLATION OF FEDERAL COPYRIGHT LAW. UNLESS GROSS NEGLIGENCE IS 05-. THAT A SUBSEQUENT BOUNDARY SURVEY DISCOVERED, THE LIABILITY OF SAID SURVEYING COMPANY SHALL BE LIMITEDa ��p,, MAY DISCLOSE. TO THE AMOUNT OF FEES COLLECTED FOR SERVICES IN PREPARATION OF r ry 2. INFORMATION PRESENTED HEREON IS A THIS PRODUCT. `) REPRESENTATION OF VISIBLE IMPROVEMENTS AND CONDITIONS PRESENT AT THE TIME THE SURVEY WAS PERFORMED ON DECEMBER 9, 2020. Qy 3. DIMENSIONS OBTAINABLE FROM THIS DOCUMENT ARE LIMITED TO THOSE BEARINGS AND GROUND DISTANCES 1 ` a SPECIFICALLY LABELED HEREON. THE 20' WIDE M.E.A. DOCUMENT DOES NOT PURPORT TO EASEMENT~ ~ / PRESENT A BASIS FOR SCALING TO DIMENSIONS NOT LABELED HEREON. (D K . 3 0J P. 1 1) 4. THIS DOCUMENT IS NOT TO BE USED IN SUPPORT OF ANY NEW CONSTRUCTION. f 5. EASEMENTS, COVENANTS AND L '�' ^0 '030WIDE I &E DENARESTRICTIONS NOT APPEARING ON THE ~/ EASEMENT RECORDED SUBDIVISION PLAT MAY EXIST. DETERMINATION OF THEIR (PLAT 2000-12 } EX i STENCE I S THE RESPONS I B I L I TY OF / 1 18, L 0 CK 2 THE OWNER. f 6. THIS SURVEY WAS COMPLETED IN lb � �.`' SUBSTANTIAL ACCORDANCE WITH ASPLS P' j w. MORTGAGE LOCATION SURVEY STANDARDS, 14 1.08 ACRES¢ _ . L EOf NO RECOVERED PLASTIC CAP ON #5 REBAR t I {} UTILITY POLE y I o, TEST HOLE ` 3 rWg WATER WELL v GAS STUB STORY METER, ELECTRIC (� V �MHHOUSE r, SEPTIC CLEANOUT/'VENT ELECTRIC LOAD CENTER o ' Vis' O �p G TELEPHONE PEDESTAL COMMUNICATIONS PEDESTAL MH MANWAY RISER /v 600 — —E — — — OVERHEAD ELECTRIC 15 \J �% �' �a cati? s ;_ DECK f � BUILDING ' Dal 4. - _ 15 x 15 T &E CONCRETE PAD EASEMENT, DEKA L Y ES TA TES\v �x c (PLAT 2018-29) ASPHALT SURFACE SUBDI VISI L 0 TS1 , 12 CULVERT 1-�1 L0C � s --- DITCH LINE TRA C TS A & 8 �' N74 °5811 "JY 255.65 MEASURED DATA 2O0 0 40 60 80 `� 4 � (N74°45'W) (254.70') RECORD PER PLAT (2018-29) 4 US SURVEY FEET HANSON LAND SOLUTIONS 305 E. FIREWEED AVE. PALMER, ALASKA 90645 (907)746-7738 ,OF, , N9 N a 'GR G N SON' q Ul tQ 7L f 22 1 Q' A L �81jk T SUR Vf T I HEREBY CERTIFY THAT THIS DOCUMENT REPRESENTS A SURVEY MADE BY ME OR UNDER MY DIRECT SUPERVISION, OF THE FOLLOWING REAL PROPERTY: LOT 14, 8L OCA" 2 VENAL r ES TA T, CS S0 ,011VISION LATS 1--18, 9L ooff 2 8 TRA OTS A 8 B (Pt AT 2018-29)_ ANCHORAGE RECORDING DISTRICT LOCATED WITHIN WY SEC. 23, T.14. R.1W. SM, AK CONTAINING 1.08 ACRES MORE OR LESS SCALE:1'=40' JOB:20-128 DV+1+I . ELF FILE : 20-128 AB CK:CEH 112/22/20101 OF O1 MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program POBox 186850 w7OQElmore Road Anchorage, Alaska gg519-OG5V Phone: 4 Fox, (907) 343-7997 Permit Number: O8P201134 Work Type: VVeU3epUo|nitia| Tax Code Number: 06706221000 Site Legal Address: DENALYESTATES BLK 2 L 14 G:0362 Site Mailing Address: 25413 MC IMTYRE RD, Eagle River Owner: HUBERYVDNNEL&JAMES R Design Engineer: PANNONE ENGINEERING SERVICES This permit isfor the construction of: Effective Date Expiration Date: Lot Size in Sq Ft: Total Bedrooms: b/3/202U G/3/2O21 47171 2 Disposal Field 2 Septic Tank OHolding Tank 0 Privy 2 Private Well El Water Storage All construction shall beinaccordance with: 1. The attached approved 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 15.85.Provide notification bycalling (807)343-7BO4(24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall bmeither: a. Opened and Closed onthe same day, or b. Covered, sealed, and heated hoprevent freezing pecial Provisions: The recorded plat for this subdivision notes that artesian wells are common and that special drilling methods may be required koprevent waste ofwater via surface discharge. Received By: Issued By: MUNICIPALITY OF ANCHORAGE Community Development Department Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On -Site Water & Wastewater Program ON-SITE SEWERIWELL PERMIT APPLICATION Parcel I.D. 067-062-21 Property owner(s) YVONNE & JAMES HUBER Day phone Mailing address 14161 KOSO DR, EAGLE RIVER AK 99577 Site address 25413 MCINTYRE RD, EAGLE RIVER AK 99577 Legal description (Sub'd., Block & Lot) DENALY ESTATES B2 L14 Legal description (Township, Range & Section) Lot Size 47,171 Sq. Ft. Number of Bedrooms 'Ll APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑X Initial ❑X Single Family (SF) ❑X (w/wo ADU) Septic Tank ❑X Upgrade ❑ Duplex (D) ❑ Holding Tank ❑ Renewal El Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑X 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: & Waiver Fees: Date of Payment: 51-17-1,;16 -16 Date of Payment: Receipt Number: 65-91 7 Receipt Number: Permit No. OS PA G 1 l 3y Waiver No. Permit App__- : • . ..:c Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201134, Rebecca Carroll, 06/03/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201134, Rebecca Carroll, 06/03/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201134, Rebecca Carroll, 06/03/20 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Parcel I.D. 067-062-21 Certificate of On -Site Systems Approval Expiration Date: fl&cA 1. GENERAL INFORMATION Complete legal description Denaly Estates B2 L14 Location (site address) 25413 Mclntyre Rd ER 99577 Current property owner(s) Huber, James Day phone Mailing address Real estate agent Day phone 2. TYPE OF DWELLING: F-1 Single Family (w/wo ADU) F-1 Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) AA 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ❑ Private Septic n. Water Storage El Holding Tank El Community Well ❑ Community El Public Water System ❑ Public Sewer n Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ Date of Payment 1119- [;21V20.'?0 Receipt Number 6 3 3.2 COSA # 0 Is C a() I Date of Payment Receipt Number Waiver # () S 109 C) 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 Phone (907) 745-8200 Address P.O. Box 1807 Palmer, AK 99645 Engineer's Printed Name Steven R. Pannone P.E. Date 2_1012-10-( OF A/q�s� �: 49��•�•_� 6. DSD SIGNATURE System #1 Approved for bedrooms Steven Pannone System #2 Approved for bedrooms CE n S1-r5i \` y pp s Disapproved gni �''`�' �\✓ Conditional approval for bedrooms, with the following stipulations: By: �� ' Original Certificate Dater Oa 0 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 B2 L14 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 6117!2020 Total depth 144 ft Cased to 144 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 18+ in. Date of flow test for COSA new Static water level at beginning of test flowing ft Comments Artesian well 1=1111111_1iMILIff ill Age of tank(s) new years Tank type/material Wt. Measured operating fluid level in septic tank na ❑ Standpipes/foundation cleanout per record drawing Date of pumping na d tq aw D. ABSORPTION FIELD DATA wide trench Which system tested (date installed) new ❑ ALL standpipes present per record drawing Total measured depth from grade -12 (+'_ 21 ft (max) Measured depth to pipe invert from grade-e(+/"2)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: COSA Checklist yellow sheet a Parcel ID: 0647-062-21 Structure served by this system 1 Well production at time of test 50 qpm Water storage tank volume na 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 Hanson Land Solutions Date of Sample 72A 112020 C. LIFT STATION ❑ Required maint, Age of liftstati Lift statio aterial completed years Adequacy test date New Results a Pass For 4 bedrooms Fluid depth prior to test in Water added gal 7*4&t) New depth in Elapsed time '— min Final fluid depth I in Absorption rate 600+ gpd Any rejuvenation treatment (past 12 months) 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' 0 Yes Community Sewer Manhole/Cleanout > 100' r Yes if No ft M Yes if No ft Neighboring Tank > 100' M Yes if No ft Private Sewer/Septic Line > 25'F71 Yes if No ft Absorption Field on Lot > 100' M Yes if No ft Holding Tank > 100' 0✓ Yes if No ft Neighboring Absorption Fields > 100' 0 Yes if No. Water Main > 10' Animal Containment > 50'[,✓ Yes if No ft M Yes if No ft Q Yes if No. Water Service Line > 10' M Yes if No Manure/Animal Excreta Storage > 100' If septic tank is under driveway Community Sewer Main > 75' F✓ Yes if No ft M Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' 0 Yes if No ft Surface Water > 100' M Yes if No. Property Line > 5' ❑✓ Yes if No ft Wells on Adjacent Lots: M Absorption Field > 5' F Yes if No ft Private Wells > 100' 0 Yes if No. Water Main > 10' Q Yes if No ft Community Wells > 200' Q Yes if No. Water Service Line > 10' M 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' Q✓ Yes if No ft Wells on Adjacent Lots: Water Main > 10' 0 Yes if No ft Private Wells > 100' U✓ Yes if No Water Service Line > 10' M Yes if No ft Community Wells > 200' Yes if No Surface Water > 100' El Yes if No ft F. ENGINEER'S COMMENTS t_ ( / C`tck (�i�" A-, ctni C�lLt "R rt j' (fit-' �r'CSfPtif Qe. o�,rfl RfC.L ,17!3„2 ayj a.A1 F G. ENGINEER'S CERTIFICATION I 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 OF A(„ Q k� S� OFES Qw ft ft ft ft i�