HomeMy WebLinkAboutT12N R3W SEC 26 W2 NE4 NW4 NE4 NE4Onsite File
T12N R3W
Section 26
W2 NE4 NW4
NE4 NE4
#017-432-35
Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP201498 PID Number: 017-432-35
Dwelling: ❑ Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑ Upgrade
Name /el'�YYlO Ili®r7 s
HELENAQMANE GG_ ABSORPTION FIELD
Site Address I
❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound
7100 HUFFMAN RD, ANCH AK
El Other
3 0.8 GPD/SF $
LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe
Subdivision Block Lot 2 Ft 6
T12N R3W SEC 26 W2 NE4 NW4 NE4 NE4
Fill added above original grade Gravel length
Township Range Section 1.5
Ft. 47
Gravel width Beds: Number of Lines I Distance between
SEPARATION DISTANCES
2 Ft
T
From
Septic
Tank
Absorption
Field
lift Station
Holding
Tank
Sewer
Line
Total absorption area
864 FP
Numbei
Well100'+
100'.+.
50r+
TANK D Septic EJ S.T.EP
Manufacturer
GREER TANK
:Surface Water
Water
100'+
10
NA
Material
PLASTIC
Lot Line
10'+
101+
Foundation
10'+
101+
LIFT STATION
Manufacturer
Remarks
lines
:hes Dist. between trenches
Ft.
ding Q Other
-apacity
1000 Gal.
Vumber of compartments
2
'apacity
location Electrical installed by
Installer
PIPE MATERIAL House to tank 3034 d aintieid 3034
MIKE N ANDERSON, P.E. Drainfield 3034 co/MT3034
Inspector MIKE N ANDERSON, P.E. BENCH MARK (Assumed elevation) 103.2 R
Inspection
dates: v, 9/20/21 2-w9/21/21 description
Location and
3 I ¢,h CORNER OF SIDING
ON-SITE WATER AND WASTEWATER SECTION APPROVAL .�
OF
�onditionalApproval: Date "'��:•'• •oar-`;,
:r497f1
. ...........
• MICHAEL N. ANDERSEN : `z`
Septic System 7CE - 94 4
�a
Approve=Date &� r ° , t 2 jj3 (. • ° - : y
Note: this approval does not include well permit requirements.
(Rev
Permit No. OSP201498 Page 2 of 2
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone: 343-4744
On—Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: T12N R3W SEC 26 W2 NE4 NW4 NE4 NE4
MARK
A
B
FCO
55
18
TC01
57
20
TCO2
62
23
C01
42
32
CO2
43
33
CO3
35
46
C04
52
34
MT
53
35
ECOM-W€
23
27
I / I
/ I
BENCH,
1/ I
i
-00H021,VEWAY'
CoCo
�l
M3=BEDROOM RESERGE FIELD I � /
WELL
I / 1
1 / I
WELL
\\ ASBUILT
SCALE:
PID No.: 017-432-35
iTTO OF SIDING
i
i
NEW 1000 GALLON PLASTIC TANK
DECOMMISSIONED WELL /
PER MOA SUBMITTAL
WELL CUT-OFF & SEPTIC
BURIED
1
DRY JULY 2021
F
AW
49TH
:MICHAEL N. ANDERSON:
•. No. CE 9469 .:
®%' 2-13-21 .•.•• o
o®
Municipality of Anchorage K ��i E ,t?s� j
Development Services Department ' tib;• • ° • • • • • °
On -Site Water and Wastewater Section
4700 Elmore St.
a
f� 40TH R�
P.O. Box 196650 Anchorage, AK 99519-6650
wWW.muni.orq/On51te
(907) 343-7904 �� • • , ..... ° .
- MICHAEL N. fii:�,LF(SC:� ,°`•
16
Soils Log - Percolation Test u
Performed Fo y
or: P Date Performed
Legal Description: 'T- J'Z �.J W t, 2 Township, Range, Section: -
Dept 1 - GrT jSr D tC� t,a61
(Feet)
1-1 co�•
2-
3-
4-
1 15-
6-
7- P-cr, ,PI Cz1-rf
8-
9-
WAS GROUND WATER
Gross Time
Net Time
3Drn,�
ENCOUNTERED?
j D
10-
s
IF YES, AT WHAT DEPTH?
L
11-
Depth to Water After
P
. J1
Monitoring?
v
E
12-
//
Date:
I,rt
13-
14-
1 f3v do V,
16-
17-
18-
19-
20 -
COMMENTS A --t L
Reading
Date
Gross Time
Net Time
3Drn,�
Depth to Water
co It
IO �
Net Drop
?j"
3n
DFArnnrnu n
. J1
- • t� ^^�,=a„� I-LKU HUGE DIAMETER 4-/1
TEST RUN BETWEEN ^ FT AND ] tI�LFT
PERFORMED BY: _ /l4 AIA I CERTIFY THAT THIS TEST WAS
PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
MUNICIPALITY OF ANCHORAGA
Development Services Depal rtment
Phone: 907-343-7904
On -Site Water & Wastewater Section
Fax: 907-343-7997
Well Log
Permit Number: # 201498 Date of Issue: 2-22-21 Parcel Identification Number:
I - -
Date Started: 3-1-21 Date iCompleted: 3-3-21 Is well located at approved permit location? Yes R No [__j
SEC -
Legal Description: T12N R3W SEC 26 W2 NE4 NW4 NE4 NE4 G:2839
Property Owner Name & Address: –RQbale®-
ge-fell- IV_%Lft4ndos
.1100 Huffman Rd.
Anchorage, AK
Borehole Data: Depth (ft)
Soil Type, Thickness & Water Strata From TO
Method of Drilling nM❑ air rotary F] cable tool
Casing type: steel
Wall Thickness: -250 inches
Diameter: _!Jnches Depth: 47 .—feet
Liner Type:
Diameter: —inches Depth: feet
Casing stickup above ground: -?_feet
stick up
0
2
overburden
2
3
silt & gravel (dry)
3
47
bedrock
47
300
Static water level (from ground level): _31 feet
Pumping level: --- — -- —feet after
hours pumping
Recovery Rate: i--gpm
Method of Testing: airlift
Well Intake Opening Type:
n Open End Q Open Hole
❑ Screened Start ---feet Stopped feet
❑ Perforations Start feet Stopped feet
bentonite volume: 2bass
Grout Typ'e._
Depth: 20' Start 2—feet Stopped _?O feet
Well Disinfected Upon Completion? Yes No
Method ofDisinfection: tabs Comments:
Well Driller: Johnny Kay
Company: Hefty Drilling, Inc.
Mailing Address: P.O. Box 112130 Anch, AK99511
Water Sample Results:
Arsenic: U&L
Nitrates: _(\I mg/L
Total Coliform Bacteria colonies/100mL
Attention: The well driller shall provide a well log to the
0n -site Water and Wastewater Section within 30 days of
completion.
Well Drilling Permit Num
Development Services Department
Building Safety Division
On -Site Water A Wastewater Program
4700 Elmore Road °
P.O. Box 196650 =. z
4 G:
Anchorage, AK 99507 s A E r Y
wwwauni.org/onsite
(907) 343-7904
Pump Installation Log
r: SW� i3�q Date of Issue: .,,�A-62j
Parcel Identification Number:
Legal Description i Property Owner Name & Address:
NC 1V1`L.
( Ci2x, '-, q ge re_n iea m o n of o ,.s
Pump Installation Date:21
Pump Intake Depth Below Top of Well Casing: 0 feet
Pump Manufacturer's Name: 'Iy4z'
.'�-
Pump Model: 'C-3 C'
Pump Size hp
PitIess Adapter Burial Depth: i J feet
Pitless Adapter Manufacturer's Name: C.1_1W1%_41 /6
Pitless Adapter Installer:
Well Disinfected Upon Completion? [] Yes [] No
Method of Disinfection: Vt1 � I I ,
Comments:
Pump Installer Name: Johnny Kay
Hefty Drilling, Inc.
Attention. The pump installer shall provide a pump installation log to the DSA within 30 days of pump installation.
DEVELOPMENT SERVICES DEPARTMENT" a
On -Site Water and Wastewater Section f
www.muni.org/onsite `
Leg a(Address: Well DecommtSSlontn
Subdivision T12N R3W SEC 26 W2 NE4 NW4 NE4 NE4 Block Lot
T
R Section Lot
On-site Water & Wastewater Section certified contractor performing the well decommissioning:
Name:
MIKE ANDERSON, P.E.
Company:
SAME
Well decommissioning date 9/20921
907-343-7904
Fax: 343-7997
Signature: dFd,
• �A
Method of decommissioning: AMC 15.55.060L1 a. ❑ b. ❑ C, ❑
Location: Use the space below to provide a drawing of the property showing the following items:
• North arrow
• Decommissioned well location
• Location of other water wells on the property
• Two separate swing -tie distances for each well shown on the drawing
Note: The swing -tie distances shall be measured from either permanent structures or the property comers.
G:\Development Servicesl& lding SafetylOn Site Water and WastewateriFormstClient Formslwell Decommisioning
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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
httpIlww .muni.org/onsite
On -Site Water & Wastewater System Permit
Permit Number: OSP201498
Work Type: WellSeptic Upgrade
Tax Code Number: 01743235000
Site Legal Address: T12N R3W SEC 26 W2 NE4 NW4 NE4 NE4 G:2839
Site Mailing Address: 7100 HUFFMAN RD, Anchorage
Owner* ROHALEY DONALD L &
Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING
This permit is for the construction of:
Effective Date:
Expiration Date:
Lot Size in Sq Ft:
Total Bedrooms:
2/22/2021
4
54360
0 Disposal Field 0 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 (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
Special Provisions:
1) A portion of the proposed field is outside the 30 ft radius of the percolation test. An additional perk test shall
be done at time of construction to verify application rate.. If results require a design change, construction shall
stop pending Onsite approval of a change order. Please submit results with the inspection report.
2) A 3 -bedroom reserve field shall be shown on the record drawing and shall be located so that the entire length
is within the 30 ft radius of percolation tests.
3) Existing well is to be decommissioned due to proximity to septic system and high nitrates. Decommissioning
log shall be submitted to close out this permit.
Com
Received By: Date: ZZ
f
Issued By: �AA� �Q31 t�� X�O a �� I
Date:
MUNICIPALITY OF
Ae
Development Services DepartmentQ . F
On -Site Water & Wastewater Section
Parcel I.D. 017-432-35
ON-SITE SEPTICIWELL PERMIT APPLICATION
Property owner(s) Helen Ramondos
Mailing address 7100 HUFFMAN RD, ANCH, AK
Site address SAME
Day phone
Legal description (Sub'd., Block & Lot) T1 2N R3W SEC 26 W2 NE4 NW4 NE4 NE4
Legal description (Township, Range & Section)
Lot Size 54,360 Sq. Ft. Number of Bedrooms 3
Phone: 907-343-7904
Fax: 907-343-7997
APPLICATION IS FOR:
APPLICATION IS AN: TYPE OF DWELLING:
(N all that apply)
Absorption Field
X❑
Initial ❑ Single Family (SF) 0
(w/wo AD U)
Septic Tank
0
Upgrade Q
Duplex (D) ElHolding
Tank
ElRenewal
ElMultiple Dwellings ❑
Privy
❑
(SF and/or D)
Private Well
Water Storage
❑
THIS APPLICATION INCLUDES A 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)
X225 Permit/Rush Fees: $168.75 COVID-19 ) W 37085 (COVID-1
( aiver Fees:
4' Date of Payment: �- ` "Z �Date of Payment: 0
Receipt Number: 00q,'19 % of 3166 Receipt Number:
1 C,60 Permit No. OSP201498 Waiver No. OSV261087�
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client FormsTermit AA:(plication. doc
Sept. 7, 2021
Municipalities of Anchorage
Departments of Health and Human Services
P.O. Box 196650
Anchorage, Alaska 99519-6650
Fax 249-7847
Re: New septic tank & well permit CHANGE ORDER REQUEST
Legal: T12N R3W SEC 26 W2 NE4 NW4 NE4 NE4
To Whom it may concern:
This is a request for a change order for the septic system and well permit on the
above referenced lot. The system has no septic tank therefore a new 1000 gallon
plastic tank has been installed, see the site plan. A new well is also installed, see the
attached site plan. We are requesting a change order to add a new septic field for a
3 bedroom field. The test hole showed silty gravel (GM) for the entire depth of 14
feet. The perc was 8 minutes inch with no water during or after the 7 day monitoring
period. This new field will not impact any of the neighbors or encroach on any wells,
septic or open water issues.
Sincerely /7;' '
Michael N. Anderson, P.E.
4661 Natrona Ave.
Anch, Ak 99516
Ph 727-8864
Feb. 7, 2021
Municipalities of Anchorage
Departments of Health and Human Services
P.O. Box 196650
Anchorage, Alaska 99519-6650
Fax 249-7847
Re: New septic tank & well permit
Legal: T12N R3W SEC 26 W2 NE4 NW4 NE4 NE4
To Whom it may concern:
This is a request for a septic tank and well permit on the above referenced lot. The
system has no septic tank therefore a new 1000 gallon plastic tank is proposed, see
the site plan. A new well is also proposed due to very high nitrates, see the attached
water test. This tank replacement and water well will not impact any of the
neighbors or encroach on any wells, septic or open water issues.
Sincerely
Michael N. Anderson, P.E.
4661 Natrona Ave.
Anch, Ak 99516
Ph 727-8864
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201498, Rebecca Carroll, 02/22/21
DESIGN CRITERIA:MOUND OVER
(TH#1) u, GRADE
3 BDRM X 150 = 450 GPD 0HORG FILTER FABRIC
SOILS = 450/0.8 = 562 GPD 1' & INSULATION
562 GA/10 = 56' 4"0 PIPE
GM -2.0
(1) TRENCH -7.0
I I `SEWER ROCK
T DEEP
5' EFFECTIVE 2.0
2.0' WIDE 14
56' LONG TRENCH NO WATER JULY 2021
-UPPER HUFFMAN RD-
I
I �
1` EXISTING LOG CRIB
REMOVED AND
\\ PLACED W/ SAND
i
/
WEL��
/
r
\ r
\ I
SEPTIC \
1
SEPTIC FIELD SECTION
PROPERTY LINE
I
®vm ---i—
I I
EXISTING 1 rl
\\ BEDROOM
p \ HOUSE /
Lr
I
1 %!
PROPOSED NEW
-- WELL W/ 100'
RADIUS
/I--- \
-\
SEPTIC �\
Septic Design Prepared for
HELEN RAMONDOS
T12N R3W SEC 26 W2 NE4 NW4 NE4 NE4
•
�cae Anderson, • • DATE:
4601 NATRONA AVE DRAWN:
ANCHORAGE, ALASKA 99516
(907) 727-8864 / FAX: (907) 345-1391 SCALE:
4
SEPTIC\
1
EXISTING WELL
TO BE
DECOMMISSIONED
®®®®WRITA%OF
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9/9/2021 0 � MICHAEL N. ANDERSON:
® No. CE 9469'•,,:Ar
DJR ®®8-30-21'�
1"=100'
Municipality of Anchorage
Development Services Department
On -Site Water and Wastewater Section
4700 Elmore St.
P.Q. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
Soils Log - Percolation Test 11 `��F'•� '�'�°
D
Performed For:
• n K �. 5 Date Performed: d
Legal Description: _7` L-) -7r—e- Z tQ Township, Range, Section:
l NZ `I N Q144 Irl (� �{ N C
1-
2-
3-
4-
5-
6-
7-
8-
9-
10-
11-
12-
13-
14-
15-
16-
17-
18-
19-
20 -
COMMENTS
�7 IA4
�vve-��-
WAS GROUND WATER
Date
ENCOUNTERED?
I Q
49TH
'•, ;� P
IF YES, AT WHAT DEPTH?
L
j
. . :..Vo..0 ...........
MICHAEL N. ANDERSON
C�c
Date:
;
Soils Log - Percolation Test 11 `��F'•� '�'�°
D
Performed For:
• n K �. 5 Date Performed: d
Legal Description: _7` L-) -7r—e- Z tQ Township, Range, Section:
l NZ `I N Q144 Irl (� �{ N C
1-
2-
3-
4-
5-
6-
7-
8-
9-
10-
11-
12-
13-
14-
15-
16-
17-
18-
19-
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COMMENTS
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�vve-��-
WAS GROUND WATER
Date
ENCOUNTERED?
I Q
Depth to Water
S
IF YES, AT WHAT DEPTH?
L
Depth to Water After
Monitoring?
r�/ yJ a
E
Date:
�Z f
Site Plan
C/
Reading
Date
Gross Time
Net Time
Depth to Water
Net Drop
C/
f rt
,-,# 3
rcrcwu+� ��n rvli c (minuteslinch) PERC HOLE DIAMETER f�
TEST RUN BETWEEN `SFT AND FT
PERFORMED BY: N 't I CERTIFY THAT THIS TES W S
PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:7 '-L-
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9/6/24 (A+)
N/A
Benjamin Schiller, P.E.
(907) 522-7773
Oct. 25, 2022
Municipalities of Anchorage
On-Site Water and Waste Water Section
4700 Elmore Rd
Anchorage, Alaska
Phone 343-7904
Re: Septic system connection
Legal: T12N R3W SEC 26 W2 NE4 NW4NE4 NE4
To whom it may concern:
This letter is in reference to the new proposed 2-bedroom home to be built by the owner which will connect into the existing 3-bedroom septic system. Spinell Homes Inc. has provided a plot plan showing where the new house will be located and it appears that they have enough elevation to connect to the existing 1000 gallon septic tank located in the front yard of the original house. From the plot plan the elevation of the garage slab is 930 which will be field verified during excavation for a min. slope of 2 percent.
Sincerely
Michael N. Anderson, P.E.
4661 Natrona
Anch, Ak 99516
Ph 727-8864
AsBuilt
6/1/23
Feet
0 40 80
Received Date/Time 12/08/2020 15:44
12/08/2020 13:30Collected Date/Time
1206587001
Matrix
SGS Ref.#
Client Sample ID 7100 Huffman
Client Name
Project Name/#
Printed Date/Time 12/21/2020 16:20Mike N. Anderson, P.E.
Technical Director Stephen C. Ede
7100 Huffman
Drinking Water
Sample Remarks:
Parameter Results LOQ Units Method
Allowable
Limits
Prep
Date
Analysis
Date InitContainer ID
Metals by ICP/MS
DMM12/18/20EP200.8ug/LArsenic 12/10/20ND5.00 (<10)B
Waters Department
EWW12/18/20SM21 4500NO3-Fmg/LTotal Nitrate/Nitrite-N 15.8 2.00 (<10)*C
Microbiology Laboratory
A.L12/09/20SM21 9223B100mLE. Coli Negative 1 A
A.L12/09/20SM21 9223B100mLTotal Coliform Negative 1 A
Page 2 of 5
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MUNICIPALITY OF ANCHORAGE
K I
Development Services Department 1 Phone: 907-343-7904
On -Site Water & Wastewater Section _ Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 017-432-35
1. GENERAL INFORMATION
Expiration Date:
Complete legal description T12N R3W SEC 26 W2 NE4 NW4 NE4 NE4
Location (site address) 7100 HUFFMAN RD ANCH, AK
Current property owner(s) DON & WASSILISSIA ROHALEY Day phone
Mailing address SAME
Real estate agent
2. TYPE OF DWELLING:
0 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
E
Private Septic
E
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 $ �gov + � 16 s- IeU SH Waiver Fee $
Date of Payment %/1/6121 Date of Payment
Receipt Number 01C,7-753' Receipt Number
COSA # O S C M I (v7 I 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 MIKE N ANDERSON, P.E. Phone 727-8864
Address 4661 NATRONA AVE ANCH AK
Engineer's Printed Name MIKE N ANDERSON, P.E. Date 11-12-21
6. DSD SIGNATURE
System #1 Approved for 3
System #2 Approved for _
Disapproved
Conditional approval for
T H
,/oae..• •• a e. o •. a., .
.s.eoe ee ..........
bedrooms
N;
/AICHAtl Ft�CERSCrd ; :•
bedrooms _ _�=-' C-_9 9
bedrooms, with the following stip
ulatioux. "~�
IT Y Oj- A44, -i
�y
WATER Amin m=_
G WAST" v 'ATER z
� `�S
Original Certificate Date: 12--
TheMunicipality 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 engineers work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
Legal Description: T12N R3W SEC 26 W2 NE4 NW4 NE4 NE4 Parcel ID: 017-432-35
If more than 1 septic system on lot: COSA Checklist # of Structure served by this system
A. WELL DATA
IN Well log is filed with Onsite (or attached)
Date drilled 313121
Total depth 300 ft
Cased to 47 ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) 24 in.
Date of flow test for COSA t1130/21
Static water level at beginning of test 31 ft.
Comments
B. TANK DATA
Age of tank(s) new years
Tank type/material
Measured operating fluid level in septic tank new
❑ Standpipes/foundation cleanout per record drawing
Date of pumping new
Well production at time of test 2+ gpm
Water storage tank volume 0 gallons
Well disinfected for coliform test? ❑ Yes ❑ No
❑ Coliform bacteria is Negative
Nitrate mg/L On Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by MNA
Date of Sample 11/30121
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA NEW
Which system tested (date installed) 2021
Adequacy test date NEW
AN ALL standpipes present per record drawing
Results MV Pass For 3 bedrooms
Total measured depth from grade 9.5 ft (max)
Fluid depth prior to test in
Measured depth to pipe invert from grade 3.5 ft (min)
Water added gal
❑ N/A — pressurized field
nm monitor
Monitor tubes go to bottom of effective. If not, state
depth in
depth into effective
s Ela
ped time min
❑ 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 months)
date of test)
Gallons introduced 0 gallons
If yes, enter date
Comments/Deficiencies:
COSA Checklist yellow sheet
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances
if less than required or if community well)
Yes
if No
Septic Tank/Lift Station on Lot > 100'
If absorption field is under driveway comment below
Property Line > 10'
Community Sewer Manhole/Cleanout >
100'
if No
E✓ Yes
if No
ft
M 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' [✓J Yes
if No
ft
Holding Tank > 100' Q✓ Yes
if No
ft
Neighboring Absorption Fields > 100'
Animal Containment > 50' [✓ Yes
if No
ft
F✓ Yes
if No
ft
Community Sewer Main > 75' Cp Yes
if No
ft
Manure/Animal Excreta Storage > 100'
�]✓ 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' Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5' Yes
if No
ft
Private Wells > 100' Q Yes
if No
ft
Water Main > 10' Q Yes
if No
ft
Community Wells > 200' P/1 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'
21
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'
Yes
if No
ft
Community Wells > 200' ❑✓ Yes if No ft
Surface Water > 100'
Q
Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
l certify that 1 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
w
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