Loading...
HomeMy WebLinkAboutDENALY ESTATES BLK 2 LT 15Onsite File Denaly Estates Block 2 Lot 15 #067-062-22 . v, Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP211049 PID Number: 067-062-22 Dwelling: 0 Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ■❑ New ❑ Upgrade Name Hultquist Homes Inc ABSORPTION FIELD 0 Deep Trench ElWide Trench E:1Bed ❑ Mound Site Address 25451 McIntyre Rd. F1 Other Phone 310-2501 Number of Bedrooms 4 Soil Rating Total depth from original grade 1.2 GPD/SF 8.9 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 2.9 Ft. Gravel depth beneath pipe 6.0 Ft. Subdivision Denaly Estates Block Lot 2 15 Fill added above original grade 1.5 Gravel length 42 Township Range Section Ft. Ft. Gravel width 3.0 Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line 504 Ft2 1 Ft. Well >100' >100' N/A N/A >25, TANK Fm] Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Greer Capacity 1250 Gal. Surface Water >100' >100' N/A N/A Material Plastic Number of compartments 2 Lot Line >5' >10' N/A N/A NA Foundation >10' >10' N/A N/A LIFT STATION Manufacturer Capacity Remarks Gal. Alarm location Electrical installed by Installer PIPE MATERIAL House to tank D3034 drainfield Tank to D3034 Alex Enterprises Drainfield D3034 Co/MTD3034 Inspector J. Millette BENCH MARK (Assumed elevation) 100 ft Inspdectes:ion 15` 3/9/21 3/12/21 Location and description 3rd 2nd Top of SW corner of foundation 4'h ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp OF A/ Conditional Approval: Date �,`Q'�. • gs�li� i * •qg TH Septic System Ben)aq"ySchiller /® �� _ Approve '-` �' Date (� - 3 - �F�� •. CE 12592 . �6F �� tF9FD ...... , �� W., l 1'k� ROFESSION� Note: this approval does not include well permit requirements. E,,,o. . v, DENALY ESTATES SUB, BLOCK 2 LOT 15 PERMIT # OSP211049 PID # 067-062-22 r EASEP>4Eiv!T � ^�` ....... - -. •` 'Q' T&E EASEiifiEM- EXISTING WELL • �. � � -� � `420, �. e LOT 14 , O .......... NEW 1250 GAL SEPTIC TANK w/ 20' ­., MANWAY LOT 16 ,42' LONG x 3' WIDE 6' _ © �' (VACAPM EFFECTIVE DEPTH, !' ABSORPTION TRENCH 4-BDRM HOME _ ExISTING WELL ALTERNATESITECAT III ;t W/ 100' RADIUS SEPTIC SYSTEM: APP - RATE 4.0, 20' LONG x 3' FCP WIDE, 6' EFF DEPTH O ABSORPTION TRENCH Col.", -__ 400. 2C0MT1 SV MH l 15'x 15 T&E C49-fVCi7T TH#1 A -- H##15 _ >12MT2 (2002) CO2 , �gO,gcENT y �. SEPTIC C jjv��.� .rr ��® . � A B C LEGEND � Al . 1 r .� 1H Benja i Schiller �jFc • CE 2592AEW OAO 7.1ober 12, `�i �i►��PROFESSlcffi .a PLAN AS -BUILT 0 40 80 hEEA FEET 111=40' FCO 2.3 48.2 MH 16.8 59.5 SV 21.0 62.6 2CO 24.2 65.1 CO1 60.7 89.9 MT1 61.8 91.1 CO2 1 43.4 1 50.6 MT2 1 42.2 1 49.4 CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANC FS - FLOW SPLITTER VALVE MH - MANHOLE MT - MONITORING TUBE SV -SEPTIC VENT TH - TEST HOLE DENALY ESTATES SUB, BLOCK 2 LOT 15 PERMIT # OSP211049 PID # 067-062-22 0� 98.0 FINISH GRADE 96.5 ORIGINAL GRADE Ov 11 II � nn II it 93.6 93.6 T 11 DRAINFIELD ROCK 87.6 87.6 42' NO GROUNDWATER 3/12/21 -76.5 F- FNGINE[RING PROFILE AS -BUILT (NO SCALE) AW;rV : 49 T'+ : Benja i Schiller (o�Fc�J�•.0,1.10. be�2zzz1.•��``�i RoF SIONP��` d SOILS LOG AND PERCOLATION TEST % 49 TM ... A ENG INEER ING .......... ••O Benja i Schiller : 0 CE 2592 LEGAL DESCRIPTION: DENALY ESTATES, BLOCK 2 LOT 15 c�t�F9FOpROFESSIONP'� PERFORMED FOR: HULTOUIST HOMES DATE: 3/5/21 PROJECT No.: PARCEL ID#: 067-062-22 TECHNICIAN: J. MILLETTE Professional Engineers Stamp: DEPTH TEST HOLE 1 (feet) 1lililllll 1106 SLOPE SITE PLAN 2 3 4 6 7 8 " GM (SILTY SANDY GRAVEL) 9 1 O WAS GROUND WATER ENCOUNTERED? NO IF YES « WHAT DEPTH? - L 11 DEPTH TO WATER AFTER MONITORING: NONE a DATE OF MONITORING: 3/12/21 P q E 12 13 "'. 14 15 16 17 18 u ; 19 20 PERCOLATION RATE: 1.3 (MIN/INCH) PERC. HOLE DIA.�INCHES) TEST RUN BETWEEN: 6 FT. and 7 FT, COMMENTS: GROSS TIME NET TIME DEPTH To NET DROP DATE READING (MINUTES) (MINUTES) WATER (INCHES) (INCHES) 3/5/21 1 1:06 6:38 016/616 616 2 1:13 7:42 016/616 61s 3 1:21 7:32 01— / 61s 61s 4 1:28 7:30 01—°� /6-1 1 61s 5 1:37 7:40 016/616 61s 6 1:46 7:45 016/6106 °— 61s /?JJhaza�Zon Vua`t'L-er 'J/Ija 1p Inco 1190 N. WasiIla-Fish hook Road Wasilla, AK 99654 (907)376-2041 Name: Hultquist Homes, Inc Address: 12570 Old Seward Hwy #204 City: Anchorage State: AK Zip Code: 99515 Well Site: Denaly Lot/Block: 1-15/132 Additional: McIntyre Rd, Eagle River Well Depth: 141 ft. From: To: Formation: 0 16 sand/gravel/silt Below Ground: 139 ft. 16 18 wet gravel Above Ground: 2 ft. 18 50 silt/gravel Gal Min: / 50+Artesian 50 58 silt/gravel/cobble/wet 58 82 silt Static Level: Artesian, 15 gpm overtop 82 125 wet sticky clay 125 141 gravel/water Casing: 141ft. of 6 in. x .25 in. steel Liner Pipe: N/A Screened: N/A Perforated: N/A Grouted: Yes 7 bags g ~ WATER QUALITY TESTING Depth: N/A Coliform e C0II/900mL. Nitrates , 3 4' S mg/L Develop. Method: Air' `�xsenic 2. 0 ug/L Use of Well: Residential Drilling Method: Rotary Misc: Other: Chlorinated to 50ppm The well was pumped 5' off the bottom with 100% draw down for 2 hours and recovered at 50+ Artesian . Date Drilled: 3/23/2021 Driller: Ben Mattson Development Services ®epartment Building Safety Division G� e ' On -Site Water Wastewater Program r 4700 Elmore Road �� P.O. Box 196650 4 Mark Begieh Anchorage, AK 99507 s T r Mayor www.muni.ora/onsite (907) 343-7904 Pump Installation L® Well Drilling Permit Number: SW OSP211049 Date of Issue: 02/26/21 Parcel Identification Number: 067-062-22 Legal Description Property Owner Name & Address: Denaly B2 X15 Hultquist Homes 12570 Old Seward Hwy #204 Anchorage, AK 99515 Pump Installation Date: 10/08/21 Pump Intake Depth Below Top of Well Casing: Pump Manufacturer's Name: NA Pump Model: NA Pump Size hp Pitless Adapter Burial Depth: feet Pitless Adapter Manufacturer's Name: NA Pitless Adapter Installer: unknown Well Disinfected Upon Completion? ✓❑ 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 Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation. 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 http:/Avww.muni.org/onsite On -Site Water & Wastewater System Permit Permit Number: OSP211049 Work Type: WellSeptic Initial Tax Code Number: 06706222000 Site Legal Address: DENALY ESTATES BLK 2 LT 15 G:0362 Site Mailing Address: Owner: EKLUTNA INC Design Engineer: FORGE ENGINEERING This permit is for the construction of: Effective Date: Expiration Date: Lot Size in Sq Ft: Total Bedrooms: 2/26/2021 2/26/2022 43403 Q Disposal Field © Septic Tank ❑ Holding Tank ❑ Privy R1 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. The recorded plat for this subdivision notes that artesian wells are common and that special drilling methods may be required to prevent waste of water via surface discharge. 2. Atest hole is required, in the location shown on site plan, priorto construction of absorption field in order to verify percolation rate and separations to impermeables and seasonal high groundwater. If results require a design change, construction shall stop pending review and approval of a change order. Construction may proceed at your own risk prior to 7 -day groundwater monitoring. Please submit results with inspection report (or change order, if required). Date: Date: .Z6 02 4 Veronica Digitally signed by Veronica Pope DN: cn=Veronica Pope, -US, o=Forge Engineering, emai I=office@forgecivi I. com Pope Received By: Date :2021.02.2615*11:10-09'00' Issued By: _rzkelelou Date: Date: .Z6 02 4 On -Site Water & Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 067-062-22 Property owner(s) Eklutna Inc. Day phone 310-2501 Mailing address 16515 Centerfield Drive #100 Eagle River, AK 99577 Site address NHN McIntyre Road Legal description (Sub'd., Block & Lot) Denaly Estates Sub, Block 2 Lot 15 Legal description (Township, Range & Section) Lot Size 43,403 Sq. Ft. Number of Bedrooms 4 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 IRUpgrade ElDuplex (D) ❑ Holding Tank ❑ Renewal 1-1Multiple 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: $1312 (RUSH) Waiver Fees: Date of Payment: Z - -Ce,- Zi Date of Payment: Receipt Number: (`}0"71? 9U Receipt Number: Permit No. OSP211049 Waiver No. Permit App_-'- : , _.,:c February 24, 2021 MOA Development Services, On-Site Water & Wastewater Program 4700 Elmore Rd Anchorage, AK 99507 2/24/21 Subject: Denaly Estates Sub, block 2 Lot 15 – McIntyre Rd Septic system design Dear On-Site Services Engineer: The owner of the above lot intends to build a 4-bedroom home on the property, so 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 as well as 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 is fairly contoured with slopes less than 25% running to the south. We are proposing a new septic system in the south west corner of the property. An existing subdivision test hole was used for this design and we intend to confirm soils with another test hole prior to construction. Historical soils tests for this lot and the surrounding lots indicate consistent GM/SM soils with percolation rates between 1 and 5 minutes per inch, and no groundwater in the month of October. Contour lines are shown on the site plan showing 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. The new system will be greater than 100’ from all wells and surface water. The alternate site is located greater than 12’ away from the primary site, and the tank will be a minimum of 5’ from proposed trenches. Please refer to the attached plan, profile page, and test hole log for the septic design. If this design is followed, there will be no adverse impacts to adjacent properties. Sincerely, Benjamin Schiller, PE Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211049, Rebecca Carroll, 02/26/21 ALTERNATE SITE CAT III SEPTIC SYSTEM: APP RATE 4.0, 20' LONG x 3' WIDE, 6' EFF DEPTH ABSORPTION TRENCH 420 1"=40' 42' LONG x 3' WIDE, 6' EFFECTIVE DEPTH ABSORPTION TRENCH 4-BDRM HOME 1250-GAL SEPTIC TANK w/ 20' MANWAY NOTE: NO SLOPES >25% WITHIN 50' OF THE PROPOSED SEPTIC SYSTEM EXCEPT WHERE NOTED. NO SURFACE WATER WITHIN 100'. 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 SUB, BLOCK 2 LOT 15 MCI N T Y R E R O A D FEET 0 40 80 20' T&E EASEMENT 30' T&E EASEMENT 15' x 15' T&E EASEMENT PROPOSED WELL 41 0 400 CLEARING LIMITS 100' WELL RADII TH#15 (2002) FCO 2CO CO CO MT MT MAINTAIN MINIMUM SEPARATION DISTANCES FROM TANK: 5' FROM TRENCH & 10' FROM FOUNDATION 10' 12' CONFIRMATION TEST HOLE & PERC TEST TO BE DONE PRIOR TO CONSTRUCTION 2/26/21 10'EXISTING SLOPE IN THIS LOCATION IS ABOUT 30%. THE CURRENT SEPTIC DESIGN MEETS CODIFIED SLOPE CRITERIA. EXISTING WELL Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211049, Rebecca Carroll, 02/26/21 DENALY ESTATES SUB, BLOCK 2 LOT 15 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 4" PERFORATED PVC (HOLES DOWN) DRAINFIELD ROCK 3' 6" 6" 2' 6" 6' DESIGN FACTORS:SYSTEM REQUIREMENTS: 600 GPD PEAK FLOW PERK RATE: 1-5 MIN/IN APPLICATION RATE: 1.2 GPD/SF 6' DEEP TRENCH SYSTEM 1250-GAL SEPTIC TANK BOTTOM OF TRENCH: 9' BELOW GRADE FLOW LINE ELEVATION: 3' BELOW GRADE TOP OF TRENCH: 6" ABOVE GRADE 600 GPD / 1.2 GPD/SF / 6' DEEP / 2 SIDES = 41.7 LF TRENCH REQUIRED (42 LF SPECIFIED) 2/24/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211049, Rebecca Carroll, 02/26/21 S ILS LOG - PERC LATI N TEST Tf- RI M Date Performed: 6/10/021\iNGINEERING Performed For: S4 Group Legal Description: Denaly Estates Block 2 Lot 15 DEPTH FEET) T.H. Location: See Attached Test 0 / Organic 1 - Boring Location Map0 . Q.2 - 3 d 5 Q GM/SM 6 Groundwater? Yes 7 - Depth 15' 8 - 0 Water Depth 9 - After Monitoring. None Date: 10/3/17 10 -Date Gross Time Net Time Depth Net Drop 11 - 0• 1 6/11 0 6' 12 -2 6/11 9 9 min. 0' 6" 13 -3 6/11 9 6" 14 -4 6/11 18 9 min. 0" 6" 15 -5 6/11 27 6' 16 -6 6/11 36 9 min. 0' 6' 17 - 18 - 19 - 20 - 21 - Percolation Rate 1.5 min/in Perc Hole Diameter 6" Test Run Between 6' & 7' omments: erformed By NorthRii Fng,I S CERTIFY THAT THIS TEST WAS erf ormed in Accordance with All State/Municipal Guidelines in Effect JN THIS DATE. DATE: DENALY ESTATES TH15 N OR THRI M P• ,, ENGINEERING * •' " ''BLOCK 8 LOTS 1-18 FOR PO Box 770724 t stiesa- Eagle River, Alda 995771/4., -•T E S T H L E LEG S4 GROUP 907.694.7028 0./•5Y 1 •' Oats: SHEET: GE TECHNICAL 10/5/17 15 of 18 MUNICIPALITY OF ANCHORAGE Ikus H f� Development Services Department 'lz Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 067-062-22 Expiration Date: /- i'�- Z 0 2- Z 1. GENERAL INFORMATION Complete legal description Denaly Estates, Block 2 Lot 15 Location (site address) 25451 McIntyre Rd Current property owner(s) HUltgUlst Homes Inc Day phone 310-2501 Mailing address 12570 Old Seward Highway #204, Anchorage, AK 99515 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: 4 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. Date: COSA Fee $ 7,5 +$Lu Waiver Fee $ Date of Payment Receipt Number COSA# 05C211611 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 W) Phone (907) 522-7773 Address 1399 W. 34th Ave Suite 101, Anchorage, AK 99503 Engineer's Printed Name Benjamin Schiller, P.E. Date 10/12/21 low o�TH q�t�i .� 6. DSD SIGNATURE / �•� System #1 Approved for L bedrooms �'— I� Y pp % �..• Ben�arrjr �5chillerCE 1292 •:� System #2 Approved for bedrooms �+�t��s�F 10 12%21 Disapproved �IPROFESSO0 . Conditional approval for bedrooms, with the following stipulations: lll�. yam WATER AND G WAS ]MATER z� o; J � SON \\`\ BY: Original Certificate Date: 1(-9115'171 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, Block 2 Lot 15 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA 0 Well log is filed with Onsite (or attached) Date drilled 3/23/21 Total depth 141 ft Cased to 141 ft ®❑ Sanitary seal is functioning correctly 0 Wires are properly protected Casing height (above ground) 24 in. Date of flow test for COSA 3/23/21 Static water level at beginning of test *0 ft. Comments *Well is artesian B. TANK DATA Age of tank(s) <1 years Tank type/material Septic/ Plastic Measured operating fluid level in septic tank New FE -1 Standpipes/foundation cleanout per record drawing Date of pumping Tank installed on 3/12/21 D. ABSORPTION FIELD DATA Deep Trench Which system tested (date installed) 3/9/21 Q ALL standpipes present per record drawing Total measured depth from grade 10.4 ft (max) Measured depth to pipe invert from grade 4A ft (min) ❑ N/A — pressurized field OR Monitor tubes go to bottom of effective. If not, state depth into effective F111 Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced N/A gallons Comments/Deficiencies: COSA Checklist yellow sheet Parcel ID: 067-062-22 Structure served by this system Well production at time of test 15 gpm Water storage tank volume N/A gallons Well disinfected for coliform test? ❑ Yes ❑ No 9 Coliform bacteria is Negative Nitrate 0.395 mg/L ❑ Nitrate less than MRL (ND) Arsenic 2.50 ug/L ❑ Arsenic less than MRL (ND) Collected by Wheaton Water Wells Date of Sample 9/7/21 C. LIFT STATION uired maintenance completed Age of lift stats years Lift station material Comments: Adequacy test date New System sults ❑ Pass For bedrooms Fluid h prior to test in Water added gal New depth i Elapsed time min Final fluid depth in Absorption rate 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' ✓l Yes Community Sewer Manhole/Cleanout > 100' ft Q✓ Yes if No ft / Yes if No ft Neighboring Tank > 100' Water Main > 10'✓Q Yes if No ft Private Sewer/Septic Line > 25' r71 Yes if No ft Absorption Field on Lot > 100' Yes if No ft Holding Tank > 100' [D Yes if No ft Neighboring Absorption Fields > 100' if No ft Animal Containment > 50' F� Yes if No ft M Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' [D 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' a Yes if No ft Property Line > 5' 0 Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' Q Yes if No ft Private Wells > 100' 0 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' ✓l 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'✓Q Yes if No ft Private Wells > 100' 0✓ Yes if No ft Water Service Line > 10' Yes if No ft Community Wells > 200' Yes if No ft Surface Water > 100' ✓❑ Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION 1 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 %, -4021` F .OF����� �.• 49 MJ • fid • Benjarrt,gtchiller ��29, •.. CE 1259210/12/21 • �w �'� PROFESSt4NP��.��� 00 d I m O 0 s �CD Lo C) � Z tig . m pQ; O• corn 00 0 to opm Nim AoO 41 J 4� d O W Q °E N r, H ZLd / Q / W / W m U m y, O O a. S c cO X U7 f d m U c- m m O Na.w m m m m f0 to U � > }.N Qldtnv�c n N / �N y 0 �) N ImLn0 a OQ C �ttoo cC U•-°+ I N r, H ZLd / Q / W / W / f - Ln // X U7 J m d 0 c- m m m m Q m L t rS =3 N S U d (D _C > � ol Ua >.N j a m t I=vr-:. o nmNO ° I °'Nmroa0 13 o aNI I mZm0cc `I =�>O O_m= a t- o N O O .Q �"i E +- m N L m N al Z m '� wS42) - S ox o N ?I O \! a U 6 21 U om 0— v� mtn�v0y,c c a c a` -tn ° m 0t3 N LLJaI WF-00� o ° Wda m X O C m O an d U O > Z i o a a D S mm 0 Q Q N of = a O C T O t{I - N �0 O O = O v- M m. O m t o: a. E c O «- U tt) m m> a N N mt ° O. N m EE0 '� m0�� oS_ s a 3 c a°m o