HomeMy WebLinkAboutOVERLOOK ESTATES #2 LT 6Onsite File
Overlook
Estates #2
Lot 6
#068-041-38
(Rev 05/02/18)
Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3
ON-SITE
WASTEWATER INSPECTION REPORT
Permit Number: OSP211169
PID Number: 068-041-38
Dwelling: ❑■ Single Family (SF)
❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑■ New ❑ Upgrade
Name
Midnight Sun Construction
ABSORPTION FIELD
❑Deep Trenc Wide Trench ❑Bed ❑Mound
Site Address
N H N Vantage Ave
Ott
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
4
1.0 GPD/SF
3.7/4.1 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
3.2/3.6 Ft.
Gravel depth beneath pipe
0.5/0.5 Ft.
Subdivision
Block Lot
Overlook Estates #2
6
Fill added above original grade
0.7/1.2 Ft.
Gravel length
60/60 Ft.
Township Range Section
Gravel width
5/5 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
2
Dist. between trenches
From
Tank
Field
Tank
Line
600 Ft2
9.6 Ft.
Well
>100'
>100'
N/A
N/A
>25'
TANK ❑ Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer Capacity
Greer 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
t>_1 of
>1 0,
N/A
N/A
LffqTATION
Manufacturer
Capacity
Gal.
Remarks
Alarm location
Elects ' talled by
PIPE MATERIAL House to tank D3034Tank to D3034
drainfield
Installer
Curt Whitters Excavating
Drainfield D3034 co/MTD3034
Inspector J. Millette
BENCH MARK (Assumed elevation) 100 ft
Inspection15' 7/8/21
7/8/21
Location and description
Bottom of Siding @ SW Corner
3'd 7/12/21
4,h 7/12/21
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
Conditional Approval:
Date
• 4�'fl,�
O,dew �Q.
O *��r
STM
% �••• BenjamLnSchillerCE
��� F���IF
Septic System
Approve 1� ��r
Date ZO -2
. • 11/17/21 , . •��,ire
Fop
ROFESSI�NP����
Note: this approval does not include well permit requirements.
1\®,\ O
(Rev 05/02/18)
OVERLOOK ESTATES SUB #2, LOT 6
PERMIT # OSP211169 PID # 068-041-38
VANTAGE AVENUE
LOT 6
WELL
Ro
ENGINE i�E Rl HHG
*:49-
..... .......
Benjja i Schiller
CE 2592
513122
PLAN AS -BUILT
0 50 100
�m ; FEET
111=50'
CO3
1250 -GAL SEPTIC TANK
W/ 20" MANWAY.
2 - 60' LONG x 5' WIDE, 0.5'
EFFECTIVE DEPTH
ABSORPTION TRENCHES.
A_______ B C
FCO
22.0
9.1",
MH1
21.1
17.2
svi
25.9
16.3
2CO
28.2
16.0
13.5
22.2
MT1
25.0
15.2
CO2
__35.1
27.5
MT2
36.8,
28.7
CO3
47.8
70.0
'MT3
47.4
'70.2
C04
58.377.3
MT4
57.2+76.5
LEGEND
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEAN(
FS - FLOW SPUTTER VALVE
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
OVERLOOK ESTATES SUB #2, LOT 6
PERMIT # OSP211169 P I D # 068-041-38
cy) Co
OF— �— 0
02 96.3 FINISH GRADE 95.6 ORIGINAL GRADE 0
92.4DRAINFIELD ROCK
-
'
91.9 MCA APPROVED SAND
89.6 89.6
60'
NO GROUNDWATER 7/8/21
80.6
&M,
0 ►
C\J N 0 "t
94.3 FINISH GRADE 93.1 ORIGINAL GRADE 7> 0
DRAINFIELD ROCK
89.5 - 89.5
89.0 MOA APPROVED SAND, 89.0,
87.0 87.0
60'
NO GROUNDWATER 7/8/21
78.1
*' i.I-- N: - �--
PROFILE AS -BUILT
(NO SCALE)
49 7H
.......... .......
Benja •
Schiller
CE 12592
5/3/22
PERMIT # OSP211169
EN 41N FE 0.1NG
PROFILE AS -BUILT
(NO SCALE)
Xg mi •.,�
..........
' • • • • . . Benja n Schiller '
j jF� •.. CE 12592
����\��PRO ESS�NP���
SOILS LOG AND PERCOLATION TEST
E N G I N E E R I N G
LEGAL DESCRIPTION: OVERLOOK ESTATES #2 L6
PERFORMEDFOR: MIDNIGHT SUN CONSTRUCTION
DATE: 7/2/21 PROJECT No.:
PARCELID#: 068-041-38 TECHNICIAN: L.TIDWELL
DEPTH
(feet)
1-
2-
3-
4-
5-
6-
7
8
9
10
11
12
13
14
15
16
17
18
1
COMMENTS:
GP
TEST HOLE
WAS GROUND WATER ENCOUNTERED?
NO
GROSS TIME
(MINUTES)
IF YES a. WHAT DEPTH?
N/A
L
7/2/21
DEPTH TO WATER AFTER MONITORING:
DRY
0
3:35
DATE OF MONITORING:
7/8/21
P
2
3:39
4:15
DATE
READING
GROSS TIME
(MINUTES)
NET TIME
(MINUTES)
DEPTH TO
WATER
(INCHES)
NET DROP
(INCHES)
7/2/21
1
3:35
3:16
0-65/16
65116
2
3:39
4:15
0-69/16
6%6
3
3:43
4:53
0-6%6
65116
4
3:50
5:03
0-6%6
6%6
5
3:55
5:08
0-016
69/16
6
4:01
5:14
0-6%6
69/16
PERCOLATION RATE: 0.87 (MIN/INCH) PERC. HOLE DIA. !--(INCHES)
TEST RUN BETWEEN: 4 FT. and 5 FT.
® DOC CO dba
BILL 8, COLE
to-MLLIVAN WATER WELLS
P.O. Box 670269, Chugiak, AK 99567 688-2759
www.sullivanwaterwells.com
Pump Installation Log
Well Drilling Permit Number: SW OSP211169 Date of Issue 5-28-21
Parcel Identification Number: 06804138000
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
Certified Drilling Log
P DOC CO dba
BILL Sc COLE
��► ULLIVAN WATER WELLS
el—P.O. Box 670269, Chugiak, AK 99567 688-2759
OWNER OF LAND: Midnight Sun Construction
ADDRESS:
LEGAL DESCRIPTION Overlook Estates #2 Lot 6
DATE: 7-13-21
PERMIT NUMBER: OSP211169 DATE OF ISSUE: 5-28-21
TAX IDENTIFICATION NUMBER 06804138000
Is well located at approved permit location: ®Yes [—]No
Method of Drilling: ®air rotary ❑cable tool
Depth of Well: 124
Casing Type: Steel Wall thickness .250 inches
Diameter: 6 inches, depth 124 feet
Liner type
Static Water Level: 101 feet
Recovery Rate 20 ® gpm ❑ gph
Method of Testing Air
Well Intake Opening Type: ® open end ❑open hole
❑ Screened Start feet Stopped
❑ Perforations Start feet Stopped
Grout Type: Bentonite Volume: 50 lbs
Depth: from 2 feet, to 42 feet
Well Disinfected Upon Completion: ®yes ❑ no
Method of Disinfection: Chlorine 50 PPM
Comments:
�—
Bore Hole Data
Depth
From To
0 2
2 4
4 6
6 22
22 104
104 121
121 124
Casing Stickup
Fill
Overburden
Silty Sand & Gravel w/ Cobbles
Hardpan & Cobbles
Silty Sand & Gravel Tight
Sand & Gravel Water
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.
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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
http://www.muni.org/onsite
On -Site Water & Wastewater System Permit
Permit Number: OSP211169
Work Type: WellSeptic Initial
Tax Code Number: 06804138000
Site Legal Address: OVERLOOK ESTATES #2 LT 6 G:
Site Mailing Address:
Owner: MIDNIGHT SUN CONSTRUCTION LLC
Design Engineer: FORGE ENGINEERING
This permit is for the construction of:
Effective Date
Expiration Date
Lot Size in Sq Ft:
Total Bedrooms:
nr
Department
5/28/2021
5/28/2022
55082
Q Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy Q 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 test hole is to be provided prior to construction of the drainfield to verify percolation rate and separations to
groundwater and impermeables. If results require a design change, construction shall stop pending Onsite
review and approval of a change order. Please submit results with the inspection report (or change order, if
required).
2. A splitter valve shall be provided prior to the dual trenches (shown but not labeled on the site plan).
Received By: Date:
Issued By: ('� � Date: 5 C)21
Id
MUNMPALITY 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. 068-041-38
Property owner(s) Midnight Sun Construction LLC Day phone 727-1433
Mailing address PO Box 210994, Anchorage, AK 99521
Site address NHN Vantage Ave
Legal description (Sub'd., Block & Lot) Overlook Estates Sub #2, Lot 6
Legal description (Township, Range & Section)
Lot Size 55,082 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) ❑
Septic Tank INUpgrade El(w/wo ADU)
Duplex (D) ❑
Holding Tank ElRenewal ElMultiple 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: � Q 0 Waiver Fees:
Date of Payment: 5 Z 201 i Date of Payment:
Receipt Number: C 2 3 ~I Receipt Number:
Permit No. 0 S P a 11 .l b `� Waiver No.
Permit App_'.:- : .-..:c
May 24, 2021
MOA Development Services, On-Site Water & Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
5/24/21
Subject: Overlook Estates Sub #2, Lot 6 – Vantage Ave
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 moderately sloped with grades between 25-35% running to the
south. There is one small section of existing slope that is at or under 45% down grade from where
we are proposing a new septic system. The current design meets all steep slope provisions as stated
in 15.65.210.B.4 of the MOA Wastewater Code. 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 GP/GM soils with percolation
rates under 1 minute 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 6’ away from the primary site, and the tank will be a minimum of 5’ from
proposed trenches as well as 10’ from the building foundation.
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
OSP211169, Rebecca Carroll, 05/28/21
Benjamin Schiller
CE 12592R
EGISTEREDPROFES S I O N ALENGINEER
1"=50'
1250-GAL SEPTIC TANK
W/ 20" MANWAY.
MAINTAIN 10' MIN FROM
FOUNDATION & 5' MIN
FROM TRENCHES.
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEANOUT
FS - FLOW SPLITTER VALVE
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
LEGEND
TH-6 PANNONE
OVERLOOK ESTATES SUB #2, LOT 6
FEET
0 50 100
NOTE:
NO SLOPES >46% WITHIN 50' OR SURFACE WATER WITHIN 100' OF THE
PROPOSED SEPTIC SYSTEM. THE PROPOSED DESIGN MEETS THE STEEP
SLOPE PROVISIONS STATED IN SECTION 15.65.215.B.4 OF MOA
WASTEWATER CODE FOR SLOPES BETWEEN 25-46%.
NO WELLS OR SEPTICS ON SURROUNDING LOTS WITH IMPACTS TO THIS
PROPERTY.
VANTAGE AVENUE
EA
G
L
E
R
I
VE
R
R
O
A
D
10' T&E EASEMENT
10' T&E
EAS
E
M
E
N
T
455
445
435
425
PROPOSED WELL
4-BDRM HOME
CONFIRMATION
TEST HOLE & PERK
CO
CO
CO
CO
MT
MT
MT
MT
2CO
FCO
2 - 60' LONG x 5' WIDE, 0.5'
EFFECTIVE DEPTH
ABSORPTION TRENCHES.
MAINTAIN 10' MIN FROM
FOUNDATION & 6' MIN
BETWEEN TRENCHES.
ALTERNATE SITE
May 24, 2021
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211169, Rebecca Carroll, 05/28/21
OVERLOOK ESTATES SUB #2, LOT 6
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
Benjamin Schiller
CE 12592R
EGISTEREDPROFE S S I O N ALENGINEER4" PERFORATED PVC
(HOLES DOWN)
DRAINFIELD ROCK
5'
6"
6"
5'
6"
DESIGN FACTORS:SYSTEM REQUIREMENTS:
600 GPD PEAK FLOW
PERK RATE: <1 MIN/IN
APPLICATION RATE: 1.0 GPD/SF
SHALLOW TRENCH SYSTEM w/ 2' SAND LINER
1250-GAL SEPTIC TANK w/ 20" MANWAY
BOTTOM OF TRENCH: 6.0' BELOW GRADE
FLOW LINE ELEVATION: 5' 6" BELOW GRADE
TOP OF TRENCH: 6" ABOVE GRADE
600 GPD / 1.0 GPD/SF /5' WIDE * 1.0 RED FACTOR = 120 LF TRENCH REQUIRED (120 LF SPECIFIED)
MOA APPROVED FILTER SAND
2'
May 24, 2021
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211169, Rebecca Carroll, 05/28/21
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211169, Rebecca Carroll, 05/28/21
MUNICIPALITY OF /ANCHORAGE RUSH
Development Services Department r Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 068-041-38
1. GENERAL INFORMATION
Expiration Date: 7, 2 c - 2- Z
Complete legal description Overlook Estates #2 Lot 6
Location (Site address) NHN Vantage Ave, Eagle River, AK 99577
Current property owner(s) Midnight Sun Construction LLC Day phone
Mailing address
Real estate agent
PO Box 210994, Anchorage, AK 99521
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
❑■
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 $ 2 0
Date of Payment 5/3 1 a oar
Receipt Number 0 4� 1 G 1)
COSA# OSG22.12-9 6
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 (M.J.) Phone (907) 522-7773
Address 1399 W. 34th Ave Suite 101, Anchorage, AK 99503
Engineer's Printed Name Benjamin Schiller, P.E. Date 5/18/22
6. DSD SIGNATURE
System #1 Approved for 4 bedrooms
. System #2 Approved for
Disapproved
Conditional approval for
bedrooms
* . TH
.. s •..
..........
I
r ' •.� Benjamini5chiller
�� �F� •. CE 12592 A'
d isTF . • 5/18/22 • .'�v�
PROFESS(ONa����
bedrooms, with the following stipulations:
i
By: Original Certificate Date: (e
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
ti'
`J= ON-SITE
m�
WATER ANU'-
Q WASTF-V`!aFR
p
J PROGf,AM
J
\�
`
i
By: Original Certificate Date: (e
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:
Overlook Estates #2 Lot 6
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
Q Well log is filed with Onsite (or attached)
Date drilled 7/13/2021
Total depth 124 ft
Cased to 124 ft
no Sanitary seal is functioning correctly
9 Wires are properly protected
Casing height (above ground) 24 in.
Date of flow test for COSA 7/13121
Static water level at beginning of test 101 ft
Comments New construction
B. TANK DATA
Age of tank(s) <1 years
Tank type/material Septic / Plastic
Measured operating fluid level in septic tank N/A
no Standpipes/foundation cleanout per record drawing
Date of pumping New construction 7/12/21
D. ABSORPTION FIELD DATA Wide Trench
Which system tested (date installed) 7/8/2021
n ALL standpipes present per record drawing
Total measured depth from grade 4.4/5.3 ft (max)
Measured depth to pipe invert from grade 3.9/4.8 ft (min)
❑ N/A — pressurized field
0 Monitor tubes go to bottom of effective. If not, state
depth into effective
no Code -required soil cover over field
❑ System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced _gallons
Parcel ID: 068-041-38
Structure served by this system
Well production at time of test 20 Qpm
Water storage tank volume gallons
Well disinfected for coliform test? ❑ Yes ❑ No
❑ Coliform bacteria is Negative
Nitrate 3.91 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by Forge Engineering
Date of Sample 5/10/22
STATION
❑ Requir aintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date N/A
hv',sUlts ❑Pass For bedrooms
Fluid dbqh prior to test in
Water adde gal
New depth
Elapsed time mi
Final fluid depth in
Absorption rate gpd
Any rejuvenation treatment (past 12
If yes, enter date
Comments/Deficiencies: New construction. Measurements for trenches are North / South.
COSA Checklist yellow sheet
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'
Q Yes
if No
Community Sewer Manhole/Cleanout > 100'
Q✓ Yes
if No
ft
M Yes
if No ft
Neighboring Tank > 100' M Yes
if No
ft
Private Sewer/Septic Line > 25' P( Yes
if No ft
Absorption Field on Lot > 100' [Z] Yes
if No
ft
Holding Tank > 100' Yes
if No ft
Neighboring Absorption Fields > 100'
Animal Containment > 50' Yes
if No ft
0✓ Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' Q Yes
if No
ft
Q✓ Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' []✓ Yes if No ft Surface Water > 100' M✓ Yes if No ft
Property Line > 5'
Q 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'
0 Yes
if No
ft
Community Wells > 200' E] 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' 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' 0 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' El Yes if No ft
F. ENGINEER'S COMMENTS
. or
G. ENGINEER'S CERTIFICATION ��Q•.•' ��}¢
l certify that I have determined through field inspections and review
of Municipal records that the above systems are in conformance with
MOA COSAguidelines in effect on this date. , • , ,
• ; �� . ...
•' Benjarr�r Schiller
��a�Fc •. • CE 12592 Ar,��
�J'l<c • 6/1/22• •'�� ,,,.'r
klk� pROFESStON,�
COSA Checklist yellow sheet