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Home My WebLink AboutEKLUTNA WEST LT 1L ANDERSON rENGINE`ERING PO BOX 240773 ANCHORAGE, AIK 99524 December 1, 2005 MM&M Contracting P.O. Box 670495 Chugiak, AK 99567 Attention: Arlene Subject: Lot 1, Eklutna West Subdivision Septic System Construction and Certification Dear Arlene: On June 22, 2005, a new absorption system composed of a 77' long x 3' wide x 8' effective depth absorption trench was installed on the subject lot to dispose of the septic effluent from the six -bedroom duplex. In addition, a new 2,000 -gallon septic tank was installed to collect and treat the sewage generated in the house. All work was completed in conformance with standards set by the State of Alaska Department of Environmental Conservation and 18AAC 72. The lot is served by the Dawn Water System, which is a community water system regulated by ADEC. The current status of the water system is unknown, but it is thought to be in conformance with ADEC requirements. Attached is a copy of the State of Alaska Department of Environmental Conservation Application for On -Site Water and Sewer System Approval and Documentation of System Installation along with additional backup information. Please call if you have any questions or require additional information. Sincerely, Michael E. Anderson, P.E. Attachments is-voui Date Received STATE OF ALASKA DEPARTMENT OF ENVIRONMENTAL CONSERVATION APPLICATION FOR ON-SITE WATER AND SEWER SYSTEM APPROVAL OR DOCUMENTATION OF SYSTEM INSTALLATION I. GENERAL INFORMATION Source of Water and Containment (Check all that Apply) Type of Water Supply Sys(cm Legal Description of the Location ❑ Well (Drilled or Driven) [3urface (Identify) ❑ Private Lot 1 Eldutna West S/D ❑ Roof Catchment Annlicant Name: ❑ Holding Tank (—]Other (Identify) Applicant is: (Check one) ❑ Other: Michael E. Anderson family) ❑ Bank ❑ Certified Installer. No. Is a sanitary seal or well cap installed on the well casing? ❑Ycs ❑ No Is drainage directed away from or around the casing within a radius of I(1 feet of the well casing? ❑ Yes ❑ No ❑Owner/hui Wer ■ Enghicer Mailine Address Sodic Water Level (Feet) Tvpe of Residence: Pump Rate (If available) To(al Number of Bedrooms P.O. Box 240773 Sewer Lines on Lot Absorption Area on Lot Plex V 6 Closest Edge of an Absorption Area on Adjacent Lot If toxic materials are stored on the property, including fuel tanks, paints, lubricants and other petroleum ❑ Single Family Wtulfi-Familv based materials, pesticides. fungicides or herbicides indicnte distance from con(nminants to well casing: Cif V. State, Zin Code Telenhone: Sampler is: Anchorage, AK. 99524 ❑ Buyer ❑ Engineer Address i22-7773 Send Anprovalto: Water Sample Results: Attach Copy ❑ Satisfactory -Date ❑ Unsatisfactory - Date ❑ Applicanf .r Other (Bold for pickup by Michael E. Anderson) H. WATER SUPPLY SYSTEM Source of Water and Containment (Check all that Apply) Type of Water Supply Sys(cm Treatment of Waler (Check all that Apply) ❑ Well (Drilled or Driven) [3urface (Identify) ❑ Private ❑ None ❑ Chlorination ❑ Roof Catchment ❑ Filtration ❑ Mineral Removal ❑ Holding Tank (—]Other (Identify) ❑ Public (Serves more than one ❑ Other: family) Well Data Is the height of the well casing more the 72" above the ground? ❑Ycs ❑ No Is a sanitary seal or well cap installed on the well casing? ❑Ycs ❑ No Is drainage directed away from or around the casing within a radius of I(1 feet of the well casing? ❑ Yes ❑ No Is well wire enclosed in conduit? ❑ Yes ❑ No Date Drilled Depth of Well (Feet) Sodic Water Level (Feet) Yield (If available) Pump Rate (If available) Separation Distance from the Well Casing to each of the Following Sources of Contamination: Septic/Holding Tank on Lot Sewer Lines on Lot Absorption Area on Lot Closest Septic/Holding Tank on Adjacent Lot Closest Sewer Lines on Adjacent Lot Closest Edge of an Absorption Area on Adjacent Lot If toxic materials are stored on the property, including fuel tanks, paints, lubricants and other petroleum On Lot On Adjacent Lot based materials, pesticides. fungicides or herbicides indicnte distance from con(nminants to well casing: Water Sample Taken by: (Name) Sampler is: ❑ Buyer ❑ Engineer Address ❑ Banker ❑ Government Official Water Sample Results: Attach Copy ❑ Satisfactory -Date ❑ Unsatisfactory - Date Comments/Recommendations: Lot is Currently Served by the Dawn Water System. This System is Regulated by ADEC and It's Current Status is Unknown. I certify that the above information and that provided in Section IV is correct: Signature ` r Typed/PrintedNameDat AA icy, fitice r`-Fro.c Michael E. Anderson P.E. / CE -4381 a. !Vote: Must be signed by a Cerliyzed Atstaller, Prof essioleal Engineer, DECstaff, or Owner/Builder III. WASTEWATER DISPOSAL Legal Description: Lot 1 Eklutna West SID Septic Tank/Absorption System ❑ Package Treatment fSpec ifv Brand Name or Process) ❑ Holding Tante- Specify Capacity of Tank Septic Tank Size (Gallons) Where Waste is Disposed Tqucncy of Pumping Septic Tank Outfall Discharged To: Subsurface 2 ❑ Other (Specify): (Outhouse, Incinerator, etc,) M NEW SYSTEM Name of Installer MM&M CONSTRUCTION Date Installed 6/22/2005 Owner/Builder ❑ Certified Installer Other: Septic Tank Type/Manufacturer No. CONTRACTOR STEEL / ANCH. TANK Septic Tank Size (Gallons) Number of Compartments Soil Type and Rating GP -SP 190 S.F./BDRM 2000 2 Adequacy Test Performed by: (Name) Type Soil Absorption System Dimensions/Size Soil Absorption System Type/Quantity Backfill Material Used for DEEP TRENCH 3' X 77'X WEDISoil Absorption System 80 CY .75"-3" Percolation Test Results (Attach Copy of Report) Percolation Test by: (Name) M. ELDRIDGENETECH 0.8 GPD/SF Lot Linc Minimum Ground Cover over Minimum Ground Cover over Cleanout Pipes/Caps Installed on Cleanout Pipes/Caps Installed on .Absorption Arca > 4' Septic Tank > W Septic Tank 0 Yes ❑ No Absorption System 0 YES ❑ No Separation i Water Supply Source on Lo Nearest Water Supply Source on Nearest Body of Water Water Table/Bedrock Lot Line Distance To: NA Adjacent Lot > 150' > 100' > 4'/6' > 10' Comments/Recommendations FOUNDATION CLEANOUT PRESENT OUTSIDE OF FOUNDATION: i I certif • that the above information, and that provided in Section 1V is correct: Signature �., r Typed/Printed Name Title, Reg./Cert No., Inst. No. Date � Wil!i �LL�2 c <. 6t. - 'Zo NOTE: Must be signed by a Certified Installer, Professional Engineer,, DEC staff, or approved OlvnedSuilder LJ L'.i 1J 11lVV JYJII✓Lvl Name of Installer Datc Installed ❑ Owner/Builder ❑ Certified Installer ❑ Other: No. Septic7'anlc'I:ppc/,Manufacturer Septic Tank Size (Gallons) Number of Compartments Soil Type and Rating Type Soil Absorption System Dimensions/Size Soil Absorption System Type/Quantity Backfill Material Used for Soil Absorption System Adequacy Test Resulls (Attach Copy of Report) ❑ Pass ❑ Pail Adequacy Test Performed by: (Name) Date Septic Tank Pumped (Attach Copy of Receipt) Minimum Ground Cover over Absorption Area Minimum Ground Cover over Septic Tank Cleanout Pipes/Caps Installed on Septic Tank ❑ Yes ❑ No Cleanout Pipes/Caps Installed on Absorption System ❑ Yes ❑ No Separation Water Supply Source on Lo Distance To: I Nearest Water Supply Source on Adjacent Lot Nearest Body of Water Water Tablc/Iledrock Lot Linc Comments/Recommendations I certify that the above information and that provided in Section IV is correct: Signature Typed/Printed Name Michael E. Anderson Title, Reg./Cert No. a :'"`'-._T ^' P.E. / CE -44' ^-_, Nitc:::- NOTE: Must be signed by a Professional Engineer. = 'S. Re.-est-eqa si7fhal F " �` Yc t Lnglhrer _..:.,:. MONITOR TUBE > 10' E C LOT 1, EKLUTNA WEST S/D PROJECT 4 M0545 PAGE I of 2 GENERAL N❑TESt 1. MAINTAINED 100 FOOT SEPARATION DISTANCE FROM WELL ON LOT AND/OR ANY ADJOINING LOTS WELL, 2. MAINTAIN MINIMUM OF 10 FOOT SEPARATI❑N FROM ANY PROPERTY LINES, 3, FOUNDATION CLEANOUT PLACED WITHIN 3 FEET OF FOUNDATION, SAS SIZINGi 6 BDRM X 190 SQ, FT./BDRM = 1140 SQ, FT, OF SAS REQUIRED 1140 SQ. FT. OF SAS = 71,25' TOTAL LENGTH OF TRENCH 2 X 8' ED 2 X 8' ED X 77' L = 1232 SQ. FT, OF SAS INSTALLEDi 2000 GALLON STEEL/ANCHORAGE TANK SEPTIC TANK VENTS TWO (2) COMPARTMENT SEPTIC TANK ---------------------- 1E---•-- ------ - Top V ew NO SCALE LOT 1, EKLUTNA WEST S/D PROJECT 4 M0545 PAGE 2 of 2 MOUNDED BACKFILL OVER TRENCH GROUND LEVEL——�I--- GEOTEXTILE FABRIC 6' 7p e O A7 d. O e d CAPPED 4' PERFORATED SEWER• O PIPE HOLES DOWN .ROCK „ O a PERF. PIPE THROUGHOUT TRENCH AREA d ' O CAPPED CLEANOUT CAPPED MONITOR TUBE SOLID PIPE ABOVE TRENCH l� I I 4' GROUND COVER O d a a e . O a' O BOTTOM OF TRENCH 8' EFFECTIVE DEPTH OF SEWER ROCK FOUNDATION F FOUNDATION CLEANOUT SEPTIC TANK VENTS TRENCH MONITOR TUBE - / (WITHIN 3' OF BUILDING) FERNCO TYPE TANK CONNECTOR / (TYPICAL) C/O - GROUND LEVEL C/O GEOTEXTILE FABRIC FLOW 2000 GALLON SEPTIC TANK (LEVEL) CAPPED 4' PERF PIPE LEVEL HOLES DOWN 10' SOLID 4' AHS/PVC 10' SOLID 4' AHS/PVC SEWER ROCK HORIZON PIPE 2 2X GRADE PIPE 8 27. GRADE Side View NO SCALE 6' TO GROUND WATER TO IMPERMEABLES SOILS// // End View NO SCALE FOUNDATION F FOUNDATION CLEANOUT SEPTIC TANK VENTS TRENCH MONITOR TUBE - / (WITHIN 3' OF BUILDING) FERNCO TYPE TANK CONNECTOR / (TYPICAL) C/O - GROUND LEVEL C/O GEOTEXTILE FABRIC FLOW 2000 GALLON SEPTIC TANK (LEVEL) CAPPED 4' PERF PIPE LEVEL HOLES DOWN 10' SOLID 4' AHS/PVC 10' SOLID 4' AHS/PVC SEWER ROCK HORIZON PIPE 2 2X GRADE PIPE 8 27. GRADE Side View NO SCALE Frontier Surveys, LLC Project No: 21-317 Date: 06/08/2021 Ordered By: Ally Hartman Plat: 72-186 Grid: 1461 Scalel"=30' N89° 27'26"E 157.00' 10UTILITY EASEMENT — Lot 1— — Eklutna West Subdivision r= —' —_ —■ —_ —_ —. 28,959 Sq. Ft. +/- 24335 Homestead Road I 2 Story Wood Frame Duplex With Attached 2 Car Garage & 1 Car Garage (S) iS)ii5{ I I to a = `D 78.2 54.0 x2 3 N � X2 N N � N M 2 23.7 14.1, 0 13.0. 0 0...13.0 0 14.2 PAVED DRIVEWAY my _ 33' R.O.W. AK DOT R.O.W. TAKE BK. 481, PG. 233 CULVERT A LT, 589.27' 26"W 71.99' A O� _ EDGE OF PAVEMENT l - J � – — C HOMESTEAD ROAD – EDGE OF PAVEMENT y Electric Meter/Outside Power —x— Fence LTA Tel. Pedestal Gas Meter ® Deck p: Sign �t g `S, Septic Q Watervalve —ou—Overhead Utility 0 15 30 60 General Notes: 1. This document is created for the purpose of a single property transaction and is subject to Federal Copyright Laws, 2. Excepting for gross negligence, the liability for this survey shall not exceed the cost of preparing this survey. Scale in Feet 3. All measurements/setbacks are to the visual/apparent building footprint. 4. All dimensions to property lines are plus/minus 0.1ft. This survey complies with the.ASPLS Mortgage Location Standards. The survey represents visible improvements and 1 OFt 1 t t conditions at the time of the survey. This document does not constitute a boundary survey and is subject to any A t I1 _ gss�i// ' inaccuracies that a subsequent boundary survey may reveal. It is the responsibility of the Owner to determine the _ p�. • existence of any easements, covenants, or restriction which do no appear on the record plat. Under no circumstances should this document be used for construction or for establishing a boundary or fence line. Q ' H As -Built Survey of.• ... ..... .. ...... .� Lot 1 Eklutna West Subdivision .............................: Pi", �� Fc M.St gl•, ; 0j Is -s rz �� I, Pierre Stragier, hereby certify that this Mortgage Inspection Survey was performed by me, or 06/09/2021 J��_� under my direct supervision on June 3rd, 2021. rff�f�t�ROFESSIONAvv�.�� Frontier Surveys, LLCi FRONTIER, 650 W. 58th Ave. Suite E Anchorage, Alaska 99518 907.460.1686 - info@frontiersurveys.com &"t�z PROFESSIONAL SEAL www.frontiersurveys.com GREA,FR ANCHORAGE AREA BOR [GH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME ~/"~ /c-~/~/~''~ MAILING ADDRESS P~ [~/2'°/~ ~l~:~ LOCATION ~)FF'////~4~'~'2'~-/.~ ~__)~1~~. ~ LEGAL DESCRIPTION ,'~Jg~7"6 SEPTIC TANK: DISTANCE FROM WELt ~/1~)~' MANUFACTURER INSIDE LENGTH INSIDE WIDTH T" MATERIAL LIQUID DEPTH NUMBER OF ' COMPARTMENTS t LIQUID CAPACITY 4~''~O, GALLONS. SEEPAGE 'P~: NUMBER OF PITS __ DIAMETER __ OR WIDTH LINING MATERIAL CRIB SIZE: DIAMETER__ BUILDING FOUNDATION , NEAREST LOT LINE__ LENGTH DEPTH DEPTH DISTANCE FROM: WELL ~/g//¢/~'~4"~7' ~' ~ TOTAL EFFECTIVE ~)~.~ ABSORPTION AREA (WALL AREA) ~') SQ. FT. ADDITIONAL ABSORPTION WELL: TYPE BUILDING FOUNDATION CESSPOOL APPROVED - CONSTRUCTION NEAREST LOT LINE /f~///~' , OTHER SOURCES DISAPPROVED NEAREST SEWER LINE DEPTH ~///~ DISTANCE FROM: SEPTIC ~t,/'//'~ SEEPAGE TANK , SYSTEM REMARKS DISTANCES: INSTALLED BY: piPe MATERIAL:C~3T ~-~?~/~ LOT SLOPE: 'I7pew~ H /ooI DIAGRAM OF SYSTEM DATE ~/~ ~/~' AP.ROVED G.A.A.B, GRE/ ~,'r ANChOrage Area Bo~ ,Jgh DEPARTMENT OF ENVIRONMENTAL QUALITY 5330 "C" STREET ANCHORAGE, ALASKA 99503 TELEPHONE 274-456! NAME OF APPLICANT EGALDESCR'PT'ON ~NSTALLA¥~ON OF~ SEPTIC TANK BEEFAGE PIT FINANCED THROUGH SOIL TEST RESULTS PERMit NO, SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT MAILING f - DRAIN FIELD OTHER . ! BE INSTALLED BY . / "~O0 //~ p ID WITHOUT SOIL TEST COMPLETION DATE ANTICIPATED FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEFTIC TANK TYFE ~ ~ REA MINIMUM DISTANCES, REQUIREMENTS / FOUNDATION TO SEPTIC TANK ~ FOUNDATION TO SEEPAGE PIT SEPTIC TANK TO SEEPAGE PIT WALL SEPTIC TANK ~ TO NEAREST LOT LINE, · SEEPAGE PIT WATER MAIN TO SEPTIC TANK DRAIN FIELD , DRAIN ~ SEEPAGE PIT ~/~) ~ I ALSO CONSIDER AREA WELLS· , SEEPAGE Pit SEPT'O TANK, /~'"~Or SEEPAGE PIT ~dO~ , DRAIN FIELD /~O TO RIVER, LAKE, STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS·. // .... ~ CONFORM TO BORO~GH~EGULATIONS REGARDING INSTALLATION. DIAGRAM OF I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. 0 ~ E GEOTECHNICAL 8- DEVELOPMENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Russell Oyster 694-2774 Soils ~ Foundations Earl Ellis 688-2280 Land Development SOIL LOG Perfomed for: Legal Description: ~-~-~ Depth (feet) 0 Sot] Characteristics 5 6 7 8 9 10 11 12 Ground Water Encountered: Yes No Proposed Installation: Seepage Pit Comments: ~'-,~ ~--~.~.~ Perfomed by: h'~"~ ~.~,~ ~'~'If yes, ~/depth Drain Fte~d Date: -MUNICIPALITY -O - -NCH - - - - - - - ---- 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. 051 062 60 Expiration Date:. O _ Z - Z 02 3 1. GENERAL INFORMATION Complete legal description EKLUTNA WEST LOT 1 Location (site address) 24335 HOMESTEAD Current property owner(s) BUXTON Day phone Mailing address Real estate agent Day phone 2. TYPE OF DWELLING: 0 Single Family (w/ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 6 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ❑ Private Septic 7 Water Storage ❑ Holding Tank ❑ Community Well FA Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: NONE Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 5 50 Date of Payment (0 LAI L,2 0 � , Receipt Number 0 9 2Q 01b COSA # O SC 01 1 3 � 5 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. Name of Firm C&M ENGINEERING Address 20182 TULWAR Engineer's Printed Name CHARLES BALZARINI 6. DSD SIGNATURE System #1 Approved for _Le, -7 bedrooms System #2 Approved for bedrooms Disapproved Phone 8545558 Date 6/10/21 of A/- *: 49 TH * l �j.. INARLES G BALZARINI .% ��'c��/•. CE -13854 .•��`�� Conditional approval for bedrooms, with the following stipulations: - WATER AN ri W44 Q- �� Q trVA-r,— '"M)))))lilh�� y: Original Certificate Date: 6 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: GOSA Checklist Septic System Advisory Well Flow Advisory COSA Checklist blue sheet X Nitrate Advisory Arsenic Advisory Other COSA Checklist Legal Description: EKLUTNA WEST LOT 1 If more than 1 septic system on lot: COSA Checklist # 1 of 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. Comments SERVED BY PUBLIC WELL B. TANK DATA Age of tank(s) 16 years Tank type/material SEPTIC STEEL Measured operating fluid level in septic tank 50 0 Standpipes/foundation cleanout per record drawing Date of pumping TANK LEVEL MEASURED PRIOR TO PUMPING D. ABSORPTION FIELD DATA TRENCH Which system tested (date installed) 2005 0 ALL standpipes present per record drawing Total measured depth from grade 12 ft (max) Measured depth to pipe invert from grade 4 ft (min) ❑ N/A — p�--�r-s�.ed-fteM 0 Monitor tubes go to bottom of effective. If not, state depth into effective 0 Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced 750 gallons Comments/Deficiencies: COSA Checklist yellow sheet Parcel ID: 051 062 60 Structure served by this system 1 Well production at time of test gpm Water storage tank volume gallons Well disinfected for coliform test? ❑ Yes ❑i No ❑ Coliform bacteria is Negative Nitrate mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by Date of Sample C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 6/2/21 Results ❑✓ Pass For 6 bedrooms Fluid depth prior to test 0 in Water added 750 gal New depth 0 in Elapsed -time 1 min Final fluid depth 0 in Absorption rate 750 gpd Any rejuvenation treatment (past 12 months) If yes, enter date NA NA 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' ❑✓ Yes Community Sewer Manhole/Cleanout > 100' ✓❑ Yes if No ft M Yes if No Neighboring Tank > 100' ✓❑ 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' 0✓ Yes if No Neighboring Absorption Fields > 100' Yes if No Animal Containment > 50' E✓ Yes if No ❑✓ Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ✓❑ Yes if No ft 0 Yes if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' 0 Yes if No ft Surface Water > 100' ft ft ft ft ft ❑✓ Yes if No ft Property Line > 5' ❑✓ Yes if No ft Wells on Adjacent Lots: Absorption Field > 5'✓Q Yes if No ft Private Wells > 100' ❑✓ Yes if No. Water Main > 10' F71 Yes if No ft Community Wells > 200' Yes if No Water Service Line > 10' 0✓ 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' Il Yes if No ft If absorption field is under driveway comment below Property Line > 10' 0 Yes if No ft Wells on Adjacent Lots: Water Main > 10'✓❑ Yes if No ft Private Wells > 100' ❑✓ Yes if No Water Service Line > 10' ❑✓ Yes if No ft Community Wells > 200' Yes if No Surface Water > 100' 0 Yes if No ft F. ENGINEER'S COMMENTS System was constructed when duplexes were under jurisdiction of the ADEC. System was constructed with typical moa required features like after tank cleanouts and drainfield cleanouts. Foundation cleanout is under back porch. G. ENGINEER'S CERTIFICATION / certify that / 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. 6/10/21 COSA Checklist yellow sheet °F A/,,, l� s*:49TM ••*fir �. • CHARLES G BALZAR191 �� '�c,•.• CE -13854 .••c�� 11 `� ' `lliF�PR0FE QA, -- ft ft ft ft