HomeMy WebLinkAboutSUN VALLEY HEIGHTS BLK 1 LT 4Sun Volley
Heights
Block 1
Lot 4
#017-062-24
Inspection Report_9-1-12.doc
Municipality of Anchorage
On -Site Water and Wastewater Program • (907) 343-7904 Page of
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP141463
PID Number: 017-062-24
Dwelling: ® Single Family (SF)
❑ Duplex (D)
❑ Multiple (SF and/or D) Project: ❑ New ® Upgrade
Name:
Annette Kittleson
ABSORPTION FIELD
® Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound
Address
13321 Alpine Drive, Anchorage, AK 99516
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
3
0.8 GPD/SF
9.0 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
4.0 Ft.
Gravel depth beneath pipe
5 Ft.
Subdivision Block Lot
SUN VALLEY HEIGHTS
1 4
Fill added above original grade
1.36 — 2.3 Ft.
Gravel length
60 Ft.
Township Range Section
Gravel width
2 Ft.
Beds: Number of Lines
Distance between lines
- Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Lift Station
Tank
Line
600 Ft2l
2
10 Ft.
Well
200+
200'+
NA
NA
NA
TANK ® Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
ANCHORAGE TANK
Capacity
1 1000 Gal.
Surface water
100'+
100'+
NA
NA
Material
STEEL
Number of compartments
2
Lot Line
51+
10'+
NA
NA
NA
Foundation
5'+
10'+
NA
NA
LIFT STATION
Manufacturer
Capacity
Gal.
Curtain Drain
NA
'50'+
NA
NA
Remarks None known. 'Desryh GI'1Gwyca{ -6
Pump on level at
in.
Pump off level at
in.
High water alarm at
in.
2 X 30r
Pump make and model
Electrical Inspections performed by
PIPE MATERIAL House to tank 3034 dTrai nnfld 3034
Installer Mike Anderson
eld
Drainfield 3034 CO/MT 3034
Inspector ARCTERRA
BENCH MARK (Assumed elevation) 100 ft
Inspeection 18'11/11/14
11/11/14
Location and description
ction
2nd
3" 11/11/14
0 11/28/14
Garage Floor
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
Engin
OF AZ�
Conditional Approval:
Date
���<%
�4
/* TH - *+
10
KENNETH FE '
71
Approved
Date /
a:°'Sss10
ear's Stam
Inspection Report_9-1-12.doc
iwrl�
A -C=38,1'
B -C=47.5'
A -D=41.1'
B -D=50,0'
A -E=59.6'
B -E=100,0'
A -F=64,7'
B -F=96.0'
A -G=78,3'
B -G=91.0'
A -H=94,1'
B -H=104,0'
A -I=81,2'
B -I=104,2'
A -J=75,2'
B -J=106,3'
AS -BUILT SYSTEM DETAILS/SITE PLAN
SUN VALLEY HTS L4 B1
WATER
26.5
LOT 4
NEW 1000 -GAL
E SEPTIC TANK
0 In
x
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cos CO Co \DIVEF
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SEPTIC
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SCALE, NTS
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AW\ '•�1'ESSIOt11S'
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Permit; USP141463
PID# 017-062-24
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EXISTING CRIB
93' CIRCUMFERENCE
W/ 4' RINGS 9' TOTAL ED I
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30'
SCALE, 1' = SW
ONITOR TUBE
FINAL GRADE l
SEWER ROCK
TRENCH 1
30'
FINAL GRADE
SEWER ROCK
TRENCH 2
84.70
TUBE LLFxa>r
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1 7B.70 .
SCALE: NTS
30' —
PREPARED FOR1
ANNETTE KITTLESON
13321 ALPINE DRIVE
ANCHORAGE, AK 99516
FIELD BOOKS caJPuTm:
BOUND' BC DRAWN:
BMW
STWIM ABC ctimm: KMD
AsBuILT•. WAL DAM
12/01/14
DWG. FILE: GRID:
SW2938
ACRD FILE JOB N..:
14-201
84.70
TUBE LLFxa>r
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SCALE: NTS
On -Site Wastewater Disposal System Permit
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water & Wastewater Program
4700 Elmore Road, PO Box 196650
Anchorage, AK 99519-6650
Telephone: (907) 343-7904
Permit Number: OSP141463
Tax Code Number: 01706224000
Work Type: Septic None
Permit Effective Dates: October 29, 2014 to October 29, 2015
Design Engineer: ARC TERRA CONSULTING INC
Subdivision: SUN VALLEY HEIGHTS
Site Legal Address: SUN VALLEY HEIGHTS BILK 1 LT 4 G:2938
Owner/Address: KITTLESON REVOCABLE LIVING
TRUST KITTLESON ALICIA ANNETTE / TTE 13321 ALPINE DRIVE ANCHORAGE AK 995163132
Site Mailing Address: 13321 ALPINE DR, Anchorage
This permit is for the construction of:
Y Disposal Field Y Septic Tank N Holding Tank N Privy
Lot Size in Sq Ft: 40487
Total Bedrooms: 3
N Private Well N Water Storage
All construction must 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 must notify the Development Services
Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either:
A. Open and Close on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received
Issued By
By: /� i , Date: ✓�/
Date: 2`i
MUNICIPALITY OF
Community Development Department
Development Services Division
On -Site Water & Wastewater Program
ANCHORAGE
Phone: 907-343-7904
Fax: 907-343-7997
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 017-062-24
Property owner(s) ANNETTE KITTLESON
Mailing address 'v ' rt"' uv� �"I V L, 11V Vr7VRnu C, mr\ Uvo 10
phone
Site address 13321 ALPINE DRIVE, ANCHORAGE, AK 99516
Legal description (Sub'd., Block & Lot) SUN VALLEY HEIGHTS BLOCK 1, LOT 4
Legal description (Township, Range & Section)
Lot Size 40487 Sq. Ft. Number of Bedrooms
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(® all that apply)
Absorption Field Initial ❑ Single Family (SF) ii*n
Septic Tank Upgrade (w/wo ADU)
Holding Tank ❑ Renewal ❑ Duplex (D) ❑
Multiple Dwellings ❑
PrivyElU ITTAT and/or D)
Private Well
Water Storage ❑
(lCf 142014 11111
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.
(Stpare property owner or authorized agent)
Permit/Rush Fees:
Date of Payment: to t l5� I`{
Receipt Number: 0.25 4
Permit No. 05e141gb3
Permtt App_9-1-12.doe
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
�RCTERRq a
ARC1m
ERRA
CONSUL'T`ING, INC
a 212 E. 51" Ave, Anchorage, AK. 99503
U Office (907) 868-3791, Fax (907) 868-3793
October 10, 2014
Municipality of Anchorage
Development Services Department
On -Site Water & Wastewater Program
P.O. Box 196650
Anchorage, AK 99519-6650
Subject: Upgrade Sewer Permit — Sun Valley Heights Block 1, Lot 4
It has been determined that the absorption field of the subject property is
saturated. Subsequently, the owner has requested we proceed forward to obtain
a septic permit to upgrade the septic system.
The general slope of this lot is from west to east at a grade of approximately 2-8%
over the septic area. On October 2, 2014 a testhole was performed to investigate
soils and groundwater. The results of this test are attached for your review. The
proposed upgrade will serve the existing 3 -bedroom house. We propose to install
two 29' long deep trenches. Groundwater was not encountered at excavation or
at monitoring.
The property and adjacent lots are served by community water. There is no
surface water within 100' of the proposed system and there are no known curtain
drains within 50'. We do not expect there to be any adverse effect on adjacent lots
by the development of this system. If you have any questions, please contact me
at 868-3791 / FAX 868-3793.
Respectfully submitted,
ArcTerra Consulting, Inc.
Kenneth M. Du us, P. .
Attachments: On -Site Sewer Application
Wastewater Absorption System Details/Site Plan
Soils Log/Percolation Test
20441 PTARMIGAN BLVD • EAGLE RIVER, AK 99577-8736 • PH (907) 868-3791 • FAX (907) 868-3793
WASTEWATER DISP❑SAL SYSTEM DETAILS/SITE PLAN
SUN VALLEY HTS L4 131
PROPERTY SERVED BY COMMUNITY WELL
NO PUBLIC WELLS WITHIN 200' OF
PROPOSED SYSTEM,
NO PRIVATE WELLS WITHIN 200' OF
PROPOSED SYSTEM EXCEPT AS NOTED.
NO SEPTIC SYSTEMS WITHIN 200' OF
PROPOSED WELL EXCEPT AS NOTED.
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Scale; 1'= 100'
DESIGN DETAILS PAGE 1 OF 2
3 BDRM X 150 GPD = 450 GPD
450 GPD/0.8 GPD PER SQ. FT. (8 MIN/IN,)= 563 SQ, FT
(563SF / 2x4' (GRAVEL) = 71 FT. TRENCH
USE 2 TRENCHES - 36' (L) X 2' (W) X 4' (ED)
Total depth of system is 9' from, original grade.
Total depth of gravel below distrlbutlon pipe Is 4'
NOTES:
1, INSTALL 1000 GAL SEPTIC TANK & INSULATE TANK IF <4' COVER,
2, INSULATE TRENCHES WITH 2' HD BURIAL FOAM IF < 3' OF FILL.
MIN. 2' FILL WITH INSULATION, >3' COVER NO INSUL REQ,
3, CONTRACTOR WILL ENSURE MINIMUM 2% SLOPE INTO SEPTIC TANK,
4, CONTRACTOR WILL ENSURE ALL SEPARATIONS TO ADJACENT
WELLS, SEPTICS EASEMENTS, PROPERTY LINES, ETC.,,
PREPARED FOR;
ANNETTE KITTLESON
13321 ALPINE DRIVE
ANCHORAGE, AK 99516
FIELD BOOKS
BOUNDARY, BOUNI
5TANiNG: Sy ��i�
AS3:iILP. viA-1
DYT, -1LF:
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No: 14-201
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. AK. 99577-53
LOT 8
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LOT 3
N 94• 07' O1' E 263.19
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LOT 7
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259.40 LOT 6
N 91' 54' 50• E
30
LOT 5
PROPERTY SERVED BY COMMUNITY WELL
NO PUBLIC WELLS WITHIN 200' OF
PROPOSED SYSTEM,
NO PRIVATE WELLS WITHIN 200' OF
PROPOSED SYSTEM EXCEPT AS NOTED.
NO SEPTIC SYSTEMS WITHIN 200' OF
PROPOSED WELL EXCEPT AS NOTED.
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Scale; 1'= 100'
DESIGN DETAILS PAGE 1 OF 2
3 BDRM X 150 GPD = 450 GPD
450 GPD/0.8 GPD PER SQ. FT. (8 MIN/IN,)= 563 SQ, FT
(563SF / 2x4' (GRAVEL) = 71 FT. TRENCH
USE 2 TRENCHES - 36' (L) X 2' (W) X 4' (ED)
Total depth of system is 9' from, original grade.
Total depth of gravel below distrlbutlon pipe Is 4'
NOTES:
1, INSTALL 1000 GAL SEPTIC TANK & INSULATE TANK IF <4' COVER,
2, INSULATE TRENCHES WITH 2' HD BURIAL FOAM IF < 3' OF FILL.
MIN. 2' FILL WITH INSULATION, >3' COVER NO INSUL REQ,
3, CONTRACTOR WILL ENSURE MINIMUM 2% SLOPE INTO SEPTIC TANK,
4, CONTRACTOR WILL ENSURE ALL SEPARATIONS TO ADJACENT
WELLS, SEPTICS EASEMENTS, PROPERTY LINES, ETC.,,
PREPARED FOR;
ANNETTE KITTLESON
13321 ALPINE DRIVE
ANCHORAGE, AK 99516
FIELD BOOKS
BOUNDARY, BOUNI
5TANiNG: Sy ��i�
AS3:iILP. viA-1
DYT, -1LF:
ACAD RLE FILE
carr a m�:
CHECKED:
DkflL
Oft?C:
No: 14-201
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A'it,f A1sULTING
. AK. 99577-53
WASTEWATER DISPOSAL SYSTEM DETAILS
SUN VALLEY HTS L4 B1
j
treet Light EOSe�en ols.o KEY BOX
WATER LINE
MARK PRIOR TO CONSTRUCTION
A
LOT 4 ��
c
} 1-4% \
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3- /. L CO
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9
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3
Co
°-° PLITTER
`1
9.5 CO CO COs 2-6% \
Dec o
DIVERTER _
� MT' ;EXISTING CRIB
- '93' CIRCUMFERENCE
.4 EXISTING 1000 -GAL S.T, '.. - W/ 4' RINGS 9' TOTAL ED
DECOMMISSION PER CODE --- --'
-"
.. & INSTALL NEW 1000 -GAL
.: SEPTIC TANK W/ COs & DIVERTER
259,40
° 5450" E
nl R1
FLAG PROPERTY LINES
WATER LINES, WELL
RADII & EASEMENTS
PRI❑R TO CONSTRUCTI❑N
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/ �pNE ( S/
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NO SLOPES >25%
WITHIN 100' OF
PROPOSED SYSTEM
PREPARED FOR:
ANNETTE KITTLESON
13321 ALPINE DRIVE
ANCHORAGE, AK 99516
RELD 130GKS
STfMG- STAK±
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AcAD Tom: FILE
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nip: SW293f
.roe No.. 14--201
Scale: 1'= 30'
PAGE 2 OF 2
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RSL `M`SIILTING
PR AK. 99577-3
QsftCTERRq
ARC 1 ERRA
CONSULTING, INC
212 E. 515` Ave, Anchorage, AK. 99503
Office (907) 868-3791, Fax (907) 868-3793
SOILS PERCOLATION TEST
Performed for: Annette Kittleson Date Performed: 10/2/2014
OF ALS
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Project: SUN VALLEY HEIGHTS BLOCK 1, LOT 4 TEST HOLE #
Depth
(Feet) SEE ATTACHED SITE PLAN
-
oRG/OL FOR HOLE LOCATION
1
SM/sp w/ occ. cobbles
HOLE PRESOAKED
20- PRIOR TO TESTING
TH 14-1
Was Ground water encountered? NO What depth? NA
Depth to water after monitoring? DRY Date? 10/09/14
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
1
10/03/14
1:00
6"
-
2
1:30
30 min
1 15/16"
4 1/16"
3
*
1:31
-
6"
4
1 2:01
30 min
1 15/16"
4 1/16"
5
*
2:02
6"
6
2:32
30 min
2"
4"
7
8
9
10
11
12
*
Water
Added
Percolation Rate 7.5 (min/in) Pere Hole Diameter 6"
Test Run Between 4 feet and 5 feet
I, Kenneth M. Duffus, certify that this test was performed in accordance with all State
and Municipal guidelines in effect on this date.
GRE
'ER ANCHORAGE AREA BO"~UGH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
~ I ~/(1 . DESCRIPTION . / ,~,
SEPTIC TANK:
DISTANCE ~/~ ~ '*
FROMWELL---~[I~ANUFACTURER(~-/g~-~-//~-' MATERIAL. (~-~ / _cN"oUMMpB:RRTr~IFENTS /
'-- ¥/25o
INSIDE LENGTH . INSIDE WIDTH '-"~" _L.IQUID DEPTH ~ LIQUID CAPAClT ¢ GALLONS.
SEEPAGE PIT: . ~ · -
/~,~c~,,,~,__Z_:/ __ /~
NUMBI-"R OF PITS ~. ~4~.a~d~q'~¢'~7~-/ OR WIDTH L.ENGTH ~' DEPTH
LINING MATERIAL :~A~/~i_ CRIB SIZE: DIAMETER-~ DEPTH DISTANCE FROM:
: 7' X4'. TOTAL EF*ECT,VE %:'7
BUlL.DING FOUNDATION , NEAREST LOT LINE ABSORPTION AREA (WALL. AREA) SQ. FT.
ADDITIONAL. ABSORPTION
WELL:
/_ ,
BUILDING NEAREST NEAREST
FOUNDATION__ -, LOT L. INE SEWER LINE
CESSPOOL . , OTHER SOURCES__
APPROVED DISAPPROVED REMARKS
DEPTH DISTANCE FROM:
SEPTIC SEEPAGE
TAN K --, SYSTEM
DISTANCES:
INSTALLED
Form No, EQ-031
DIAGRAM OF SYSTEM
DA . __ APPROVE
GREATER ANCHORAGE: AIRE;A BOROUGH
C~EP.~RTME:IklT OF ENVIRONMENTAL QUALITY
SEWAGE DISPOSAL SYSTEM -- APPLICATION ANI) PERMIT
INSTALLATION LOCATION
LEGAL DESCRIPTION ~
SOIL TEST RESULTS ~:
SEPTIC TANK --~____ , SEEPAGE Pit J~:~.~'-- -. DRAIN FIELD /O
WELL TO SEPTIC TANK t3'¢2 / /I
D~AIN F ELD .... ~ ...... AL~O CON~[DER A~A WELLS
WATER MAIN TO SEPTIC TANI( ~ ) SEEPAGE PIT /~
SEPTIC TANK, --~ , SEEPAGE ~l'r __~__, DRAIN FIELD /O~
T. H,-I
SILTY SAND TRACE
GRAVEL {SM)
.U
SILT SOME SAND
(SM -
Note
Test hole
20.0'
No Wote¢ Table T.D.
extended with Auger type drilling rig,
Engineering ~ G~ological Consultants
Mike K ittleson
· LOG OF TEST
Anchorage
Property
BORING
Alaska
DA3'[': 9-10-73 IsCALE- I" '- 3' OWN eY G.AW. BY W E O. NO. 36607
,�1'� a AGE 8LI
• Municipality of Anchorage =
On -Site Water and Wastewater Program
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 017-062-24
1. GENERAL INFORMATION
Expiration Date: / I-//- / G
Complete legal description SUN VALLEY HEIGHTS BLOCK 1, LOT 4
Location (site address) 13321 ALPINE DRIVE, ANCHORAGE, AK 99516
Current Property owner(s) KITTLESON REV. LIVING TRUST Day phone
Mailing address 13321 ALPINE DRIVE, ANCHORAGE AK 99516
Real Estate Agent Day phone
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
❑
Individual
Individual Water Storage
❑
Holding Tank
❑
Communify Class A Well
Public Water System
®
❑
r.nmmirnify
Public Sewer
❑
❑
WaiverNariance request for: Distance:
Received by: 131G efACI-.- Date: /Z-s=/Y
COSA to be released to the engineer, unless otherevise requested by the engineer.
COSA Fee $
Date of Payment
Receipt Number
COSA# pSGly ((n (i
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 ARCTERRA CONSULTING, INC. Phone 868-3791
Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577
Engineer's Printed Name KENNETH M. DUFFUS 12/02/14
Engineers Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition
of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface
conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate
during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are
subject to these various and dynamic characteristics and are outside the control of the
evaluator of the well and septic system. Therefore,
ArcTerra can not give any estimate of how long a
system will function satisfactory for current or future f O�
occupants or can ArcTerra guarantee that no unseen v L
encroachments, deficiencies or discrepancies exist. 4T
.3 It t
6. DSD SIGNATURE F
P K ner at. nI- 's
1� System #1 Approved for bedrooms.'ss /
System #2 Approved for bedrooms. \ psoras ,nob`
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
By: Original Certificate Date:
Theunlcipalit 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 blue sheet 10.10A2.dm
If more than 1 septic system is on the lot:
COSA Checklist # of
Structure served by this system _
Certificate of On -Site Systems Approval Checklist
Legal Description: SUN VALLEY HEIGHTS BLOCK 1, LOT 4 Parcel ID: 017.062.24
A. WELL DATA - CLASS A
Well type A If A. B, or C provide PWSID # 213962 Well Log (YIN)
Date completed Sanitary seal (YIN) Y Wires properly protected (YIN)
Total depth _ft. Cased to _ft. Casing height (above ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level
Well production g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Coliform _colonies/100 mL Nitrate _ mg/L
Arsenic: ug/L Date of sample:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPTIC / STEEL
Tank size 1000 gal. Number of Compartments 2
Foundation cleanout (YIN) Y Depression over tank (YIN) N
Date of pumping NA -NEW TANK Pumper
C. ABSORPTION FIELD DATA
Collected by:
Date installed 1111112014
Cleanouts (YIN) Y
High water alarm (YIN) N
Date installed 11/1112014 Soil rating (g.p.d./ft2 or ft2/bdrm) 0.8 System type DEEP TRENCH
Length 60 ft. Width 2 ft. Gravel below pipe 5 ft.
Total depth 11.2 ft. (Measured 11/28/14) Eff. absorption area 600 112 Monitoring tube Y Depression over field N
Date of adequacy test NA- NEW FIELD Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test _ in. Water added gal. New depth in.
Elapsed Time: min. Final fluid depth in. Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) If yes, give date
D. LIFT STATION
Date installed
"Pump on" level at _ in.
Datum
Size in gallons
"Pump off" level at _ in.
Cycles tested
E. SEPARATION DISTANCES - PUBLIC WATER
WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
Sewer /septic service line
Animal containment areas
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 51+
Manhole/Access(Y/N)
High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Holding tank
Manure/animal excrete storage areas
Absorption field 5'+
Water main 10'+ Water service line 101+ Surface water 1001+
Wells on adjacent lots 2001+
ABSORPTION FIELD ON LOT TO:
Property line 101+ Building foundation 101+ Water main 10'+
Water Service line 101+ Surface water 1004 Driveway, parking/vehicle storage 104
Curtain drain 50'+(NONE KNOWN) Wells on adjacent lots 2001+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I 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.
Engineer's Printed Name KENNETH M. DUFFUS
Date 12101/2014
COSA brown sheet_10-10-12.doc
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