HomeMy WebLinkAboutDENALY ESTATES BLK 2 LT 11Onsite File
Denaly Estates
Block 2
Lot 11
#067-062-18
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Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3
ON-SITE
WASTEWATER INSPECTION REPORT
Permit Number: OSP201277
PID Number: 067-062-18
Dwelling: X Single Family (SF)
❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project:■❑ New ❑ Upgrade
Name
Troy Davis Homes, Inc.
ABSORPTION FIELD
❑ Deep Trench ❑l■ Wide Trench ❑ Bed ❑ Mound
Site Address
25316 Black Pine Cir, Eagle River, AK
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
(907) 357-9394
4
0.8 GPD/SF
1.5/1.5 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
1.0 / 1.0 Ft.
Gravel depth beneath pipe
0.5 Ft.
Subdivision
Block Lot
Denaly Estates
2 11
Fill added above original grade
1.6/2.3 Ft.
Gravel length
2 @ 75 Ft.
Township Range Section
Gravel width
5.0 Ft.
Beds: Number of Lines
Distance between lines
Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
2
Dist. between trenches
From
Tank
Field
Tank
Line
750 Ft2
>6 Ft.
Well
>100'
>1 00'
N/A
N/A
>25
TANK 9 Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer Capacity
Greer 1250 Gal.
Surface Water
>1
>100'
N/A
N/A
Material
Plastic
Number of compartments
2
Lot Line
>5'
>10'
N/A
N/A
NA
Foundation
>1 0'
>1 0'
N/A
N/A
LIFT STATION
Manufacturer
Capacity
Remarks All lines after tank
are insulated
Gal.
Alarm location
Electrical installed by
PIPE MATERIAL House to tank F628 Tank to F628
drainfield
Installer
Alex Enterprises
Drainfield D3034 CO/MTD3034
Inspector J. Millette
BENCH MARK (Assumed elevation) 100 ft
Inspection fs, 2/22/21
2/23/21
Location and description
dates: 3,d 2/25/21
41,2/26/21 nd
Bottom of siding @ point B
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
'~pF ���1
,�� lief
Conditional Approval:
Date
low • ' '
*.STM.. ..., ..''4.
IJJ.. ... .........�
I¢ '• . Benja• . •Schiller
Septic SysteZ
���Vsl
Appro
Date
' • . Cs/%2192 • .� lodw
,.r
ilii
Note: this approval
does include
PROFESSIO04�•�
not well permit requirements.
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DENALY ESTATES
PERMIT # • 067-062-11
vll .V
o�- NORTH TRENCH F- o
98.3 FINISH GRADE 96.7 ORIGINAL GRADE
2" INSULATION
95.7 DRAINFIELD ROCK
95.2 95.2
I-® 75'
GROUNDWATER @ 89.2 ON 7/29/20
~ 81.7
O� SOUTH TRENCH 1--o
97.3 FINISH GRADE �_ i- 95.0 ORIGINAL GRADE
N
H
uw_lvi •►
95.7
Ewe
PROFILE AS -BUILT
(NO SCALE)
Wheaton Water V40, Dnc.
1190 N. Wasilla-Fishhook Road
Wasilla, AK 99654
(907)376-2041
Name:
Troy Davis Homes
Address:
1689 S Knik Goose Bay Rd. #400
City:
Wasilla
State: AK Zip Code: 99654
Well Site:
Denaly
Lot/Block: L11/B2
Additional:
Well Depth:
161 ft.
From: To: Formation:
0
5 topsoil
Below Ground:
159 ft.
5
14 silt/gravel brown
Above Ground:
2 ft.
14
26 wet grey silt/gravel
Gal/Min:
50
26
68 damp silt
68
90 soft cleay
Static Level:
16 ft.
90
110 hard clay
110
134 med clay
Casing:
161ft. of 6 in. x .25 in. steel
134
145 gravel/silt/water
145
155 silt/gravel brown
Liner Pipe:
N/A
155
161 gravel/water/ fine brown sand
Screened:
N/A
Perforated:
N/A
Grouted:
Yes
Depth:
N/A
WATER QUALITY TESTING
Develop. Method:
Air
Coliform I Col/100rr�L
Nitrates I.3 L
Arsenic • S �g/L
Use of Well:
Residential
l Z7 2D
Drilling Method:
Rotary
Mlsc:
chlorinated to 50ppm
Other:
welded ring 50'
off bottom
The well was pumped 5' off the bottom with 100% draw down for 2 hours and recovered at 50.
Date Drilled:
9/21/2020
Driller: Ben Mattson
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
G 8
Q'A � wN,<
m o
4700 Elmore Road
�A w � �.
P.O. Box 196650
Mark Begich Anchorage, AK 99507
s n T v
Mayor www.muni.oro/onsite
(907)343-7904
Pump Installation Log
Well Drilling Permit Number: SW OSP Date of Issue:
Parcel Identification Number:
Legal Description Property Owner Name & Address:
I il 1 Denaly X1182 Troy Davis Homes, Inc.
1689 Knik Goose Bay Road :400
Pump Installation Date: 10/27/20
Pump Intake Depth Below Top of Well Casing: N/A
Pump Manufacturer's Name: N/A
Pump Model:
Pump Size hp
Pitless Adapter Burial Depth: feet
Pitless Adapter Manufacturer's Name:
Pitless Adapter Installer: Unknown
Well Disinfected Upon Completion? 0 Yes ❑ No
Method of Disinfection: Sterilene
Comments: Artesian Well, Jet Pump installed inside the house
Pump Installer Name: Wheaton Water Well, Inc.
1190 N. Wasilla-Fishhook Road
Wasilla, AK 99654
feet
Wasilla, AK 99654
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
a
BLACK PINE CIRCLE
444.3
11 V-IrI... ............................ ............
\ ORIVEK,AY
\ ` Lot 11 �\ MANHOLE-,
CANT
cnNT
1.3'x6.3'
IVA 56,801 S.F.
\ \\ SEPTIC l 452.3
PIPES
13.30 _ ` o N 12.0
\\CLEARING LIMITS
j�I M N
100' PROTECTIVE) I GARAGE SLAB
\\ \\ WELL RADIUS o ;
125, .
EL. 453.4 1.33;
\\ \\ 443.7 6 43,g•
B30. CONY
�O \................................. \\ ..............\\ . \.�. ......
414.5
\ 414.5 N \\ \\\
LEGEND
104.8
103.0
EXISTING ELEVATION
PROPOSED ELEVATION
SURFACE DRAINAGE
NOTES:
1) DATUM: M.O.A. 1972 POST—QUAKE
0
6
M
�TBM - TOP OF J" REBAR \
ELEVATION = 466.2
40' ACCESS
. O EASEMENT
-WELL'.
L\,4 ai.i N
2.0' CANT
-� SETBACK LINES
... ..... .........
—�10' T&E EASEMENTS
1
I Lot 18
20' M.E.A. EASEMENT—
Lot
ASEMENT Lot 11 \\ \\ / Lot 13
30' M.E.A. EASEMENT \\ \\
PLOT PLAN AS BUILT X SCALE _1" =_40_ GRID _ SW 0362__ Project No.
11500 Daryl Avenue, Anchorage, Alaska 99515-3049
Lang & Associates inc. (907) 522-6476 Phone o00 4
(907) 522-4625 Fax o'O FA poo
Professional Land Surveyors ken®Iangsurvey.com o �.. ., 9
jonothan®langsurvey.com SOP... A •.S�O�x
I hereby certify that I have surveyed the following described property:1
LOT 11, BLOCK 2, DENALY ESTATES SUBDIVISION (PLAT No. 2018-29) ....
within the property lines and do not encroach onto the property adjacent thereto, that t7
no improvements on the property lying adjacent thereto encroach on the surveyed PY. KENNETH .LANG o
premises and that there are no roadways, transmission lines or other visible V c, ll
easements on said property except as indicated hereon.
202
{¢`
__4
Dated this the ___ Day of l� Lk____, X21 _, at Anchorage, Alaska �44��10 Ngo
SSIONA� �o
It is the responsibility of the owner to determine the existence of any easements,
covenants, or restrictions which do not appear on the recorded subdivision plat. AECC963
7/30/20
MUNICIPALITY 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
e
Parcel I.D. 067-062-18
Property owner(s) Troy Davis Homes, Inc. Day phone 907-357-9394
Mailing address 1689 Goose Bay Road, Suite 400 Wasilla, AK 99654
Site address 25316 Black Pine Circle Eagle River, AK
Legal description (Sub'd., Block & Lot) Denaly Estates, Block 2, Lot 11
Legal description (Township, Range & Section)
Lot Size 56,801 Sq. Ft. Number of Bedrooms Four (4)
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑X
Initial 0
Single Family (SF) ❑X
ADU)
Septic Tank
19Upgrade
El(w/wo
❑
(D)
Holding Tank
ElRenewal
ElDuplex
Multiple
Multiple Dwellings ❑
Privy
El
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: t I 0 q (CpU I b" j9
Date of Payment: 7 gh_0
Receipt Number: 09370 D
Permit No. d S? 2 U 1) `1 q
Permit App__- : - :
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
PO BOX 240773
ANCHORAGE, AK 99524
522-7773 677-7766 (FAX)
July 27, 2020
M.O.A. Development Services Department
On-Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
Subject: Denaly Estates, Block 2, Lot 11 – 25316 Black Pine Circle
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 permit application for the construction of 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 on this lot or
adjacent lots.
The ground surface on the lot slopes to the southwest at grades approximating 20%. There are no
slopes greater than 25% within 50 feet downslope of either the primary or alternate site. Ground
contours are shown on the site plan indicating the grade and direction of flow. Stormwater drainage
will not impact this septic system. The new trench will be constructed parallel to the slope as much
as possible.
Wells on this and adjacent lots are shown. The new system will be a minimum of 100’ from all
wells and surface water and more than 5’ from the septic tank.
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, PE
7/27/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201277, Rebecca Carroll, 07/30/20
ALTERNATE SITE: CATEGORY III
TREATMENT SYSTEM w/30'
LONG x 5' WIDE x .5' EFFECTIVE
DEPTH. APP. RATE - 5 GPD/SF.
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
TH1
BLACK PINE CIRCLE
DENALY ESTATES, BLOCK 2, LOT 11
1"=50'
4-BDRM HOME
1,250 GALLON SEPTIC
TANK w/20" MANWAY.
MT
7/29/20
10050 0
FEETMcINTYRE ROAD40' ACCESS EASEMENT
10' T&E EASEMENTS
20' M.E.A EASEMENT
30' M.E.A EASEMENT
TH2
43
0
42
5
43
5
42
0
2-75' LONG x 5' WIDE x .5'
EFFECTIVE DEPTH
ABSORPTION TRENCHES.
MT CO
2CO
SV MH
FCO
CO
PROPOSED WELL
EXISTING WELL
EXISTING WELL
MT CO
MTCO
FS
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201277, Rebecca Carroll, 07/30/20
DENALY ESTATES, BLOCK 2, LOT 11
DESIGN FACTORS: SYSTEM REQUIREMENTS:
600 GPD PEAK FLOW
PERK RATE: 6-15 MIN/IN
APPLICATION RATE: .8 GPD/SF
5' WIDE TRENCH SYSTEM
1,250-GALLON 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:1.5' BELOW GRADE - MEASURED FROM HIGH SIDE.
FLOW LINE ELEVATION: 1.0' BELOW GRADE - MEASURED FROM HIGH SIDE.
TOP OF TRENCH: 2' ABOVE GRADE - MEASURED FROM HIGH SIDE.
600 GPD / .8 GPD/SF /5' WIDE * 1.0 (RED, FACTOR) = 150 LF TRENCH REQUIRED (150 LF SPECIFIED)
7/28/20
4" PERFORATED PVC (HOLES DOWN)
DRAINFIELD ROCK
5'
6"
1.5'
2'
3
1
4" TOPSOIL AND REVEGETATE
2" INSULATION &
GEOTEXTILE FABRIC3
1
6"
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201277, Rebecca Carroll, 07/30/20
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
PERC. HOLE DIA. (INCHES)PERCOLATION RATE: (MIN/INCH)
TEST RUN BETWEEN: FT. and FT.
COMMENTS:
(inches)(inches)
Denaly Estates, Block 2, Lot 11
7/22/20
M. JAKUBISIN
DATE OF MONITORING:
WAS GROUND WATER ENCOUNTERED?
DEPTH TO WATER AFTER MONITORING:
IF YES @ WHAT DEPTH? -
5.2 6
6 7
067-062-18
Troy Davis Homes
12:05
7/22/20
1
2
3
0 0
16 / 6 0
16
12:36
1:07
1' OB
Professional Engineers Stamp:
7/29/20
30
NO
7.5'
7/29/20
GM (SILTY SANDY GRAVEL)
6 0
16
0 0
16 / 5 12
16 5 12
1630
30 0 0
16 / 5 12
16 5 12
16
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201277, Rebecca Carroll, 07/30/20
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 2
SLOPE
SLOPE
SITE PLAN
DATE READING GROSS TIME
(minutes)
NET TIME
(minutes)
DEPTH to
WATER NET DROP
PERC. HOLE DIA. (INCHES)PERCOLATION RATE: (MIN/INCH)
TEST RUN BETWEEN: FT. and FT.
COMMENTS:
(inches)(inches)
Denaly Estates, Block 2, Lot 11
7/22/20
M. JAKUBISIN
DATE OF MONITORING:
WAS GROUND WATER ENCOUNTERED?
DEPTH TO WATER AFTER MONITORING:
IF YES @ WHAT DEPTH? -
8.0 6
5 6
067-062-18
Troy Davis Homes
12:07
7/22/20
1
2
3
0 0
16 / 3 15
16
12:41
1:12
1' OB
Professional Engineers Stamp:
7/29/20
30
NO
7.5'
7/29/20
GM (SILTY SANDY GRAVEL)
3 15
16
0 0
16 / 3 12
16 3 12
1630
30 0 0
16 / 3 12
16 3 12
16
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201277, Rebecca Carroll, 07/30/20
MUNICIPALITY OF ANCHORAGE
S1�
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. 067-062-18
1
Expiration Date: (P — �5—`
GENERAL INFORMATION
Complete legal description Denaly Estates Sub, Block 2, Lot 11
Location (Site address) 25315 Black Pine Circle, Eagle River, AK
Current property owner(s)
Mailing address
Real estate agent
Troy Davis Homes, Inc Day phone (907) 357-9394
1689 S Knik Goose Bay Rd #400, Wasilla, AK 99654
2. TYPE OF DWELLING:
❑ Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
Day phone
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
Private Septic
0
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ )20 Waiver Fee $ _
Date of Payment 3 `� / a Date of Payment
Receipt Number 2 2. (v Receipt Number
COSA # 0.5 C Z j 10 5 t^j 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 Date 3/3/21
OF . --%,k
l
low Vol
*. 49TH
6. DSD SIGNATURE `
System #1 Approved for bedrooms" : r'
lBenjarr _RiSchiller
System #2 Approved for bedrooms %��F���. CE 12592
�l'FgFO..... • ���,
P �
Disapproved e, ROFE0iZP
�aa4R ~>
Conditional approval for bedrooms, with the following stipulations:
J p`�
� ON -SST
ATE
14/1 R AND m
r S GV TER oma;
Original Certificate Date: _ 6 —Z.
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
COSA Checklist
Legal Description: Denaly Estates Sub, Block 2, Lot 11
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
OR Well log is filed with Onsite (or attached)
Date drilled 9/21/20
Total depth 161 ft
Cased to 161 ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) 24 in.
Date of flow test for COSA 9/21/20
Static water level at beginning of test 16 ft.
Comments
B. TANK DATA
Age of tank(S) 2123/21 years
Tank type/material Septic/Plastic
Measured operating fluid level in septic tank New
❑® Standpipes/foundation cleanout per record drawing
Date of pumping Tank Installed 2/23/21
D. ABSORPTION FIELD DATA Shallow Trenches
Which system tested (date installed) 2/26/21
FE� ALL standpipes present per record drawing
Total measured depth from grade 3.1/3.8 ft (max)
Measured depth to pipe invert from grade 2.6/3.3 ft (min)
❑ N/A - pressurized field
Q Monitor tubes go to bottom of effective. If not, state
depth into effective
FE -1 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: 067-062-18
Structure served by this system
Well production at time of test 50 gpm
Water storage tank volume gallons
Well disinfected for coliform test? ❑ Yes ❑ N
❑ 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
Hired maintenance completed
Age of lift static years
Lift station material
Comments:
Adequacy test date NEW SYSTEM
sults ❑ Pass For bedrooms
Fluid th prior to test in
Water add gal
New depth in
Elapsed time
Final fluid depth in
Absorption rate gpd
Any rejuvenation treatment (past 12mo s)
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'
r✓ Yes
if No
Community Sewer Manhole/Cleanout > 100'
7✓ Yes
if No
ft
M Yes
if No
Neighboring Tank > 100' P/ Yes
if No
ft
Private Sewer/Septic Line > 25' 0✓ Yes
if No
Absorption Field on Lot > 100' ❑✓ Yes
if No
ft
Holding Tank > 100' F/ Yes
if No
Neighboring Absorption Fields > 100'
Yes
if No
Animal Containment > 50' F✓ Yes
if No
P/ Yes
if No
ft
Manure/Animal Excreta Storage > 100'
—❑✓
Community Sewer Main > 75' 0✓ Yes
if No
ft
Yes
if No
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' ❑✓ Yes if No ft Surface Water > 100'
ft
ft
ft
ft
ft
0✓ Yes if No ft
Property Line > 5'
r✓ Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
7 Yes
if No
ft
Private Wells > 100'✓Q Yes if No _
Water Main > 10'
✓Q Yes
if No
ft
Community Wells > 200'✓0 Yes if No _
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' Yes if No ft If absorption field is under driveway comment below
Property Line > 10'
P/
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
✓�
Yes
if No
ft
Private Wells > 100'
Water Service Line > 10'
F/�
Yes
if No
ft
Community Wells > 200'
Surface Water > 100'
0
Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
l certify that I 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
ft
[✓ Yes if No ft
0 Yes if No ft
OF Ad
4 :0.
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Benja &hil
�'c�G, •, • CE 12592 • �`4���
3/3/21• �vA-'
�d� PROFESSIONA ®,