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HomeMy WebLinkAboutHOKAMA HEIGHTS #1 LT 2 Hokama Heights #1 Lot 2 #017-342-15 Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3 ON -SITE WASTEWATER INSPECTION REPORT Permit Number: OSP231276 PID Number: 017-342-15 Dwelling: 9 Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑■ New ❑ Upgrade Name Elisa Blanquart ABSORPTION FIELD 9 Dee Trench ❑ Bed ❑ Mound p ❑Wide Trench Site Address 5510 De Armoun Road ❑ Other Phone Number of Bedrooms Soil Rating depth from original grade 3 1.2 GPD/SF JTotal 10 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 4.0 Ft. Gravel depth beneath pipe 6.0 Ft. Subdivision Block Hokoma Heights #1 Lot 2 Fill added above original grade 0.5 Gravel length 35 Township Range Section Ft. Ft. Gravel width 3 Ft. Beds: Number of Lines N/A Distance between lines N/A Ft. SEPARATION DISTANCES To Septic Tank Absorption Field Lift Station Holding Sewer Total absorption area Number of trenches 1 Dist. between trenches From Tank Line 420 Ft2 N/A Ft. Well >100' >100' N/A N/A >25 TANK Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Greer Capacity 1000 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 > 1 0' > 1 0' N/A N/A LIFT STATION Ma rer Capacity Gal. Remarks Alarm location I installed by Installer PIPE MATERIAL House to tank D3034 Tank to D3034 drainfield Red Dog Masonry Drainfield D3034 CO/MTD3034 Inspector J. Opheim BENCH MARK (Assumed elevation) 100 ft Inspdection 15' 1/16/24 2nd 1/17/24 Location and description 3'd Bottom of Siding @ SW Corner 4`h ON -SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp .� Conditional Approval: Date ^" •'4c41�j� /*:49TH •* Septic System ¢ Benja%` /Schiller C Approved Date 3 2 20 �/'���klF . , %116/242 , . •�������/ �llt` Note: pROFESS10 --4 this approval does not include well permit requirements. k.- VV/VL/ 10) AsBuilt Feet 0 50 100 2/28/20243 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: � .2 Date of Issue: Parcel Identification Number: - - Legal Description Block Lot Property Owner Name & Address: jko �Awl�. e►y G 01 6le,6t(kWk Fug 1 l7 S Pump Installation Date: J -- Pump Intake Depth Below Top of Well Casing:_ feet Pump Manufacturer's Name: & r"tj Pump Model: S 5 Q lt O% - 2 30 Pump Size: hp Pitless Adapter Burial Depth: / 0 feet Pitless Adapter Manufacturer's Name: Pitless Adapter Installer: N A Well Disinfected Upon Completion? 4 Yes ❑ No Method of Disinfection: CAID, �c c(_6r0&A-e_ Comments: Pump Installer Name: �%a)e n V Gvl Company: 14eA Mailing Address: City: A hJ State: 4 Zip: 1, l� I I Attention: The pump installer shall provide a pump installation log to On -site within 30 days of pump installation. ALTERNATE SITE Benjamin Schiller CE 12592 R E G ISTEREDPROFE S S I O N A L E N GINEER 1"=50' 35' LONG x 3' WIDE, 6' EFFECTIVE DEPTH ABSORPTION TRENCH 1,000-GAL SEPTIC TANK CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FS - FLOW SPLITTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE LEGEND 2CO PERMIT # OSP231276 PID # 017-342-15 HOKAMA HEIGHTS #1, LOT 2 A B FCO 2.1 MH SV A B C C 48.2 59.9 64.6 2CO CO1 MT1 68.5 87.2 86.4 CO2 62.9 61.8 64.7 66.8 73.3 74.7 105.9 FEET 0 50 100 FCO GRIFFIN ROAD 3-BDRM HOME 700 PLAN AS-BUILT 1/24/24 DE ARMOUN ROAD 30' NATURAL L.S. EASEMENT 20' ACCESS EASEMENT 10' T&E EASEMENT 705 710 715 720 725 NEW WELL NEI G H B O R I N G S E P T I C NEIGHBORING SEPTIC OFF PAGE 100' WELL RADIUS NEIGHBORING WELL RADIUS NEIGHBORING WELL RADIUS NEIGHBORING WELL RADIUS NEIGHBORING WELL RADIUS CO1 CO2 MT1 MT2 SV MH MT2 62.1104.7 BM TH#1 PROFILE AS-BUILT (NO SCALE) 95.9 91.6 96.4 100.4 FC O MH SV PERMIT # OSP231276 PID # 017-342-15 HOKAMA HEIGHTS #1 LOT 2 97.6 FINISH GRADE 35' MT 1 TH # 1 NO GROUNDWATER 7/24/23 87.1 93.1 CO 1 CO 2 81.1 87.1 93.1 97.1 ORIGINAL GRADE MT 2 2C O 95.7 Benjamin Schiller CE 12592 R E GISTEREDPROFE S S I O N A L E N GINEER 1/23/24 1000 GAL SEPTIC TANK MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Well Log Permit Number: #__________ Date of Issue: ________ Parcel Identification Number: __________________ Date Started: _________ Date Completed: _________ Is well located at approved permit location? Yes No Legal Description:_________________________________________________________________________ Property Owner Name & Address: _______________________________________ _______________________________________ _______________________________________ Borehole Data: Depth (ft) Soil Type, Thickness & Water Strata From To Method of Drilling air rotary cable tool Casing type: _________ Wall Thickness: inches Diameter: inches Depth: feet Liner Type: _________ Diameter: inches Depth: feet Casing stickup above ground: feet Static water level (from ground level): feet Pumping level: feet after hours pumping gpm Recovery Rate: gpm Method of Testing: _________ Well Intake Opening Type: Open End Open Hole Screened Start feet Stopped feet Perforations Start feet Stopped feet Grout Type: _________ Volume: _________ Depth: _________ Start feet Stopped feet Well Disinfected Upon Completion? Yes No Method of Disinfection: Comments: Well Driller: _____________________________ Company: _____________________________ Mailing Address: _____________________________ Water Sample Results: Arsenic: _________ ug/L Nitrates: _________ mg/L Total Coliform Bacteria:_________ colonies/100mL Attention: The well driller shall provide a well log to the On-site Water and Wastewater Section within 30 days of completion. 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: OSP231276 Work Type: WellSeptic Initial Tax Code Number: 01734215000 Site Legal Address: HOKAMA HEIGHTS #1 LT 2 G:2937 Site Mailing Address: Owner: BLANQUART FAMILY TRUST Design Engineer: FORGE ENGINEERING This permit is for the construction of: Effective Date: Expiration Date: 0, .S ^v De paI-tment Lot Size in Sq Ft: Total Bedrooms: 8/23/2023 8/22/2024 40676 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 ,SSc�t�� fii, orq — Issued By: Date: Date: �Z3 3 MUNICIPALITY OF 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 IZ-Ver 14., to Parcel I.D. 01734215 Property owner(s) Elisa Blanquart Mailing address 5540 De Armoun Rd, Anchorage, AK 99516 Site address NHN De Armoun Rd, Anchorage, AK 99516 Day phone Legal description (Sub'd., Block & Lot) Hokama Heights #1, Lot 2 Legal description (Township, Range & Section) Lot Size 40,676 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑X Initial 0 Single Family (SF) ❑X (w/wo AD U) Septic Tank ❑X Upgrade ❑ (D) ❑ Holding Tank ❑ RenewalDuplex ❑ 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: 13? 2 Waiver Fees: Date of Payment:/2-7- 20 2 S Date of Payment: Receipt Number: © D Receipt Number: Permit No. o SP I- 3 r/ 2 ?- ( Waiver No. Permit App_::- : ,_.,:c: August 21, 2023 MOA Development Services, On-Site Water & Wastewater Program 4700 Elmore Rd Anchorage, AK 99507 Subject: Hokama Heights #1, Lot 2 - NHN De Armoun Rd Septic system design Dear On-Site Services Engineer: The owner of the above lot intends to build a 3-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. The ground surface on the lot slopes uniformly but only moderately to the west. No slopes >25% are within 100’ of the proposed system or alternate site. Contours 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. Wells on this and adjacent lots are shown. No conflicts exist between this proposed system and any other well or septic system, whether on this lot or adjacent lots. The new system will be a minimum of 100’ from all wells and surface water, and more than 5’ away from the septic tank. The alternate site is located more than 12’ away. Please refer to the attached test hole log, plan and profile pages 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 OSP231276, Deb Wockenfuss, 08/23/23 ALTERNATE SITE Benjamin Schiller CE 12592REGISTEREDPROFESSION A L E N GINEER 1"=50' 35' LONG x 3' WIDE, 6' EFFECTIVE DEPTH ABSORPTION TRENCH 1,000-GAL SEPTIC TANK CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FS - FLOW SPLITTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE LEGEND 2CO HOKAMA HEIGHTS #1, LOT 2 FEET 0 50 100 ≥10' FCO GRIFFIN ROAD 3-BDRM HOME 700 SEPTIC PLAN 8/21/23 DE ARMOUN ROAD 30' NATURAL L.S. EASEMENT 20' ACCESS EASEMENT 10' T&E EASEMENT 705 710 715 720 725 NEW WELL LOCATION NEI G H B O R I N G S E P T I C NEIGHBORING SEPTIC OFF PAGE 100' WELL RADIUS NEIGHBORING WELL RADIUS NEIGHBORING WELL RADIUS NEIGHBORING WELL RADIUS NEIGHBORING WELL RADIUS CO1 CO2 MT1 MT2 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231276, Deb Wockenfuss, 08/23/23 HOKAMA HEIGHTS #1, LOT 2 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 12592REGISTEREDPROFESSION A L E N GINEER 4" PERFORATED PVC (HOLES DOWN) DRAINFIELD ROCK 3' 6" 3'-6" 6' DESIGN FACTORS:SYSTEM REQUIREMENTS: 450 GPD PEAK FLOW PERK RATE: 1.08 MIN/IN APPLICATION RATE: 1.2 GPD/SF DEEP TRENCH SYSTEM 1,000-GAL SEPTIC TANK BOTTOM OF TRENCH: 10' BELOW GRADE FLOW LINE ELEVATION: 4' BELOW GRADE 450 GPD / 1.2 GPD/SF / 6 DEEP / 2 SIDES = 31.3 LF TRENCH REQUIRED (35 LF SPECIFIED) GEOTEXTILE FABRIC 6" 8/21/23 PROVIDE ADDITIONAL MIN 6" FILL TO ACCOUNT FOR SETTLEMENT Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231276, Deb Wockenfuss, 08/23/23 LEGAL DESCRIPTION: PERFORMED FOR: DATE: PARCEL ID#: SOILS LOG AND PERCOLATION TEST 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 DEPTH (feet) TEST HOLE 1 DATE READING START TIME NET TIME (minutes) DEPTH to WATER NET DROP PERCOLATION RATE: (MIN/INCH) (inches)(inches) DATE OF MONITORING WAS WATER ENCOUNTERED? DEPTH TO WATER AFTER MONITORING IF YES @ WHAT DEPTH? 1.08 7/17 1 2 3 4 5 6GM (SANDY GRAVEL) Professional Engineers Stamp: NO HOKAMA HEIGHTS #1, LOT 2 7/17/23 017-342-15 MERIT HOMES 9:41 0 1 2 SANDY ORGANICS 3:50 Benjamin Schiller CE 12592REGISTEREDPROFESSION A L E N GINEER PERC TEST LOCATION TECHNICIAN: M. Jakubisin 6 1 2 - DRY 7/24/23 COMMENTS: SITE PLAN 6 0 16 USCS SOIL CLASSIFICATION WAS VISUALLY DETERMINED 8/21/23 0 1 2 4:28 6 1 2 6 0 16 0 1 2 5:25 6 1 2 6 0 16 0 1 2 5:58 6 1 2 6 0 16 0 1 2 6:15 6 1 2 6 0 16 0 1 2 6:29 6 1 2 6 0 16 BOH Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231276, Deb Wockenfuss, 08/23/23 MUNICIPALITY OF ANCHORAGE m 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. 017-342-15 Legal description HOKAMA HEIGHTS #1 LT 2 Site address 5510 DE ARMOUN RD Anchorage AK Current property owner(s) MERIT HOMES LLC Expiration Date: 3/11/2025 X The On -site system(s) is/are approved for 3 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: Original Certificate Date: 3/22/2024 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory x Tank Age Advisory Arsenic Advisory Other COSA Approval June 2022 MUNICIPALITY OF ANCHORAGE ID Development Services Department On -Site Water & Wastewater Section Phone: 907-343-7904 Fax: 907-343-7997 Certificate of On -Site S A A �'r Systems Approval Application t ` �r �:r� . E 1. GENERAL INFORMATION Parcel I.D. 017-342-15 Complete legal description Hokama Heights #1 Lot 2 Location (site address) 5510 De Armoun Road, Anchorage, AK 99516 Current property owner(s) Merit Homes LLC Day phone (907) 830-4217 2. ON -SITE SYSTEMS SIZED FOR J BEDROOMS 3. TYPE OF WATER SUPPLY: 0 Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units ❑ Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: ❑■ Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel 0 Plastic ❑ Concrete ❑ Fiberglass Age < 1 - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed O Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: 0 Distance: By applying for this entitlement, this property is subject to inspection by municipal On -site staff to verify the accuracy of the information provided. COSA Fee $ _ 1 Waiver Fee $ Date of Payment Date of Payment COSA # ® GZ Lt 10 (P �1 Waiver # COSA Application —June 2022 Nitrate Advisory Certificate of On -Site Systems Approval # OSC241065 Subdivision: HOKAMA HEIGHTS #1, Block: , Lot: 2 A water sample revealed a nitrate concentration of 5.96 milligrams per liter (mg/L). The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Since nitrates are known to slowly increase, we recommend you monitor the water quality. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. Madmg Address P O Box 196650 *�AnchoragexAlaska 99519 6650 * www muni org From Northern Testing Laboratories, Inc. Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells. SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners, food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil. TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization. TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home water treatment systems such as softening or iron filtration does not readily remove nitrate. The best method for limiting nitrate in well water is source control. This can include avoiding overdosing of fertilizer near the well and maintaining good separation distances between septic tank leach fields and the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate. TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect the activity of nitrate in water. This laboratory uses several different wet chemical methods approved under the public water supply laboratory certification program. They also have test kits available, which the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can monitor the change in nitrate levels from their well. They recommend comparing the test kit results against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples. Ma�hng Address P O Box 196650 *Anchorage, Alaska 99519 6650 * www muni org COSA Checklist_June 2022 COSA Checklist Legal Description: Parcel ID: If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____ A. WELL DATA Well log is filed with Onsite (or attached) Date drilled Total depth ft Cased to ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) in. Date of flow test for COSA Static water level at beginning of test ft. Well production at time of test gpm Water storage tank volume 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 Date Comments __________________________________________________________________________________ B. TANK DATA Measured operating fluid level in septic tank Date of pumping Required maintenance completed, if AWWTS Comments: C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade ft (min) N/A – pressurized field. Per record drawings, field is insulated. Monitor tubes go to bottom of effective. If not, state depth into effective Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Adequacy test date Results Pass Fluid depth prior to test in Water added gal New fluid depth in Elapsed time min Final fluid depth in Absorption rate gpd FIELD STATUS – POST RECOVERY Effective depth (per record drawings) in Effective depth used in Effective depth remaining in Comments/Deficiencies: COSA Checklist_June 2022 E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) Septic Tank/Lift Station on Lot > 100’ Yes if No ft Neighboring Tank > 100’ Yes if No ft Absorption Field on Lot > 100’ Yes if No ft Neighboring Absorption Fields > 100’ Yes if No ft Community Sewer Main > 75’ Yes if No ft Community Sewer Manhole/Cleanout > 100’ Yes if No ft Private Sewer/Septic Line > 25’ Yes if No ft Holding Tank > 100’ Yes if No ft Animal Containment > 50’ Yes if No ft Manure/Animal Excreta Storage > 100’ Yes if No ft N/A – Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundations > 10’ Yes if No ft Tank to Property Line > 5’ Yes if No ft Field to Property Line > 10’ Yes if No ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No ft If tank or field is under driveway comment below F. ENGINEER’S COMMENTS G. CERTIFICATION & 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, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm Phone Engineer’s Printed Name Date