HomeMy WebLinkAboutLAKE HILL ACRES #2 LT 11 & 12Onsite File
Lake Hill Acres
#2
Lot 11 & 12
#051-051-25
Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3
ON -SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP201398 PID Number: 051-051-25
Dwelling: X Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New 0 Upgrade
Name
Vijay Patil
ABSORPTION FIELD
❑ Deep Trench ❑ Wide Trench ❑ Bed ❑■ Mound
Site Address
22535 Mirror Lake Drive, Chugiak, AK 99567
❑ Other
Phone
978-9698
Number of Bedrooms
3
Soil Rating
JTotal depth from original grade
3.0 GPD/SF
0.0 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
+0.5 Ft.
Gravel depth beneath pipe
0•5 Ft.
Subdivision Block Lot
Lake Hill Acres #2 12
Fill added above original grade
3.6 Ft.
Gravel length
43 Ft.
Township Range Section
Gravel width
5.0 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
215 FO
1
Ft.
Well
>100'
>100'
N/A
N/A
>25
TANK ❑ Septic ❑ S.T.E.P. ❑ Holding Fn] Other
Manufacturer
Anchorage Tank
Capacity
1500 Gal.
Surface Water
>100'
>100'
N/A
N/A
Material
Epoxy coated steel
Number of compartments
2
Lot Line
>5'
>5'
N/A I
N/A
NA
Foundation
> 1 0'
> 1 0'
N/A
N/A
LIFT STATION
Manufacturer
Capacity
Remarks Quantics category II system. Tank riser seals repaired
Gal.
on 8/18 after MOA, Anchorage Tank, & Mike N Anderson inspection.
Alarm location
Electrical installed by
Installer
PIPE MATERIAL House to tank D3034 Tank to D1785
drainfield
Northern Excavation
Drainfield D3034 CO/MTD3034
Inspector J. Millette
BENCH MARK (Assumed elevation) 100 ft
Inspection ection 1m 7/15/21 8/2/21
Location and description
2nd
Threshold of front door
3rd 4th
ON -SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
oFoZ\\\
Conditional Approval: Date
.-"%"`
*:49TM*/
Ben)am�r Schiller /
�00�sl Cs/2s/i22
Septic System
Approved Date ! 2 i
• • . ..' •��`�`'��/
�ilP .O ?10NA����
i
Note: this approval does not include well permit requirements.
`I\ VJ/VL/ IU)
LAKE HILLS ACRES SUB #2, LOT 11 & 12
PERMIT # OSP201398 PID # 051-051-25
40' RESERVED EASEMENT \\
10' UTILITY SEMENT) \�
43',LONG x 5' WIDE x .5' /
/TOE OF 3:1 SCOPE EFFECTIVE DEPTH /
f ABSOR�'TION TRENCH. /
CO3 (DJ CHARGI
�'
ObANICS AE14OCELL
TREATMENT POD -
CO2 (RETURN)-
�THA �
I /
�0�0 GA�.L01\1 STEP TANK
1 YPtINK tS ANCHORED FOR
} BUOYANCY -�
4' SU TION OVER PIPE /
I I DER DRIVEWAY -/
t LII\djTS OF DRIVEWAY
LOT 11 + 12
A
f
EXISTING HOLDING TANK
\ ` DECOMMISSIONED IN
\ PLACIr PER U.P.C.
®.;�or
'I Pam••• .sN
.4 .rH .9 1
..� .
Benja i Schiller
�Fc •. CE 2592
00 �i1'T� • Mar 13, 2024 . Aw
��1�e�PROFES510NP�s
04
`� �
100' PADIIJ
i
FUTURE HO SE
LOCATION 0
TH /
\/ %� 50' RADIUS
- - ��,•,"�
A B '�1
', THREE
BEDROOM
/ FCHOME f \
j ?
O � + }
O / �
IV�IRROR LAKE
I
EXISTING WELL.
�/ A B C
sommommilm
0 50 100
FEET
1 "=50'
1
FCO
30.0 v
14.0
MH1
51.8
65.8
MH2
59.1
' 73.3
C01
57.3
' 70.6
MT1
55.9
169.1
CO2
60.6
! 72.0
POD
62.5
73.0
CO3
64.3
MT2
79.3
r 86.0
,C04
77.3
83.5
LEGEND
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEAI`
POD - FILTER POD
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
PERMIT # OSP201398
PID # 051-051-25
HARGE LINE TO FILTER
JRN LINE FROM FILTER
105.9 FINISH GRADE 102.3 ORIGINAL GRADE
2" INSULATION ORETURN TO TANK
� L
O 1-p
103.5
MOA APPROVED FILTER SAND
102.8 --- -----
102.3 TYPE 2 ERS 102.8
-- — — _ 100.3102.3
94.3 100.3
I • 43' 94.3
GROUNDWATER @ 100.3 ON 10/8/20
88.3 NOTE:
ORGANICS WERE REMOVED FROM UNDER PERIMETER OF
MOUND AND REPLACED WITH IN SITU GM MATERIAL
PROFILE AS -BUILT
(NO SCALE)
.e.
. .
Benja i Schiller
CM1113.2024 •���� �
!�®® PROFESSIONP .�
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 Wastewater Disposal System Permit
Permit Number: OSP201398
Work Type: Septic Upgrade
Tax Code Number: 05105125000
Site Legal Address: LAKE HILL ACRES #2 LT 11 & 12 G:1561
Site Mailing Address: 22535 MIRROR LAKE DR, Chugiak
Owner: PATIL VIJAY
Design Engineer: FORGE ENGINEERING
This permit is for the construction of:
Effective Date
Expiration Date
Lot Size in Sq Ft
Total Bedrooms:
� ,C c
o -
c
Department
10/12/2020
10/12/2021
39425
Q Disposal Field CEJ Septic Tank ❑ Holding Tank ❑ Privy ❑ 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
3
Special Provisions:
1. Property sold in 2019 without a COSA. A COSA shall be submitted and approved to close out this permit.
2. Location of future home was not reviewed for code compliance and may not be able to be located where
shown. Septic system location was reviewed in relation to existing home only.
3. Stabilization of drainfield mound 2:1 side slope (on east side of trench) shall be confirmed prior to inspection
report approval.
rl
4. The septic system easement on Lot 11 shall be revised (as needed to incorporate full extend of septic system)
and recorded with the State Recorder's Office prior to final inspection report approval.
1
S -h' c
s `'°
re(o ca�e d
4-o Lo+
S l.-1(Z.wtc
5/5' Z o Z 1
2 :
S,? -Kr-
s p -km
reu1sP-d .
- �VI/1,�
'1I�,
t 1202
Received By:
Date:
Date
ro Ia 1ADa
i'•%4 U ; i t_e i !" A 4 - 1 ! I (OF ANCHORAGE
Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
Community Development Department
• - Water & WastewaterProgram
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel 1. D. 051-051-25
Property owner(s) Vijay Patil Day phone 978-9698
Mailing address 22535 Mirror Lake Drive Chugiak, AK 99567
Site address
Same
Legal description (Sub'd., Block & Lot) Lake Hill Acres #2, Lots 11 & 12
Legal description (Township, Range & Section)
Lot Size 39,425 Sq. Ft. Number of Bedrooms Tlnl^ee. )
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(® all that apply)
Absorption Field ❑X Initial
❑ Single Family (SF)
❑X
(w/wo ADU)
Septic Tank ❑X Upgrade
❑X
Duplex (D)
❑
Holding Tank ❑ Renewal
❑ Multiple Dwellings
❑
Privy ❑
(SF and/or D)
Private Well ❑
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.
a Q�
(Signature of property owner or authorized agent)
Permit/Rush Fees: i b. a5(COV)b ��
Waiver Fees:
Date of Payment: R 122�7�0Z0
Date of Payment:
Receipt Number: Q3060
Receipt Number:
Permit No. (M P ab j Sig
Waiver No.
Permit App_" -:. :'-.,:c,
CMZ
,kU
E N G I N E E R 1 N G
PO BOX 240773
ANCHORAGE, AK 99524
522-7773 677-7766 (FAX)
July 20, 2021
MOA Development Services Department
On -Site Water & Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
Subject: Lake Hill Acres 42, Lot 12 — 22535 Mirror Lake Drive
Septic System Design
Dear On -Site Services Engineer:
The holding tank on the subject lot has failed and must be replaced. An acceptable area has been
located for an advanced treatment system so the owner has decided to construct a new septic
system. An existing well is currently in place on the lot. We are submitting this permit application
for the construction of a new septic system to serve the home. The attached site plan identifies the
location of the three-bedroom home and the existing well and holding tank. The proposed septic
location is also shdwn. The owner of the property intends to eventually construct a new home on
the lot and the future location of the home is also shown along the fixture sewer service. The new
home will also be limited to three bedrooms. No conflicts exist between this proposed system and
any other well or septic system on this lot or adjacent lots.
The neve septic system is a Category II Quanics Treatment System. We are unable to use the
Advantex Treatment System due to the depth of the service line exiting the house. The cover over
the proposed tank is 6' which exceeds the allowable depth of 4' for the Advantex tank. The
Quanics tank and pod treat the septic effluent to a Category II standard. The proposed trench design
includes a 2' layer of sand to act as a filter and provide additional treatment. Sand filters are widely
accepted to provide this additional treatment through the pore spaces in the sand, which allows for
better aeration of the bacteria. We request a waiver allowing the Quanics system to be used with
the Engineering Receiving Soils specified in the design.
The location of the absorption trench is limited on the eastern boundary by the lot line and the
proposed location of the future structure. A drainage swale will be required between the mound
and the structure. We request a waiver allowing a 2:1 fill slope along the eastern boundary of the
septic mound. The ground surface will be covered with landscaping mat and revegetated to insure
no erosion occurs to the surface of the mound. All other slopes of the mound will be 3:1.
The ground surface on the lot is virtually flat with only a minor bias to the east and toward Mirror
Lake. There are no slopes greater than 25% within 50 feet downslope of either the new system.
Ground surface contours are shown on the site plan indicating 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 absorption trench will be constructed utilizing engineered receiving soils in conformance with
Section 15.65.210D3c and the attached design documents. The absorption trench will be
constructed in association with a Quanics Treatment System. The system will be 50' from the well
on this and adjacent lots.
Please refer to the attached test hole logs and plan and profile sheets for the septic design. If this
design is followed, there will be no adverse impacts to adjacent properties.
Sincerely,
Michael E. Anderson, P.E.
NONEENNEENFRITT-VUEM
LAKE 'H ILLS ACRES #2, LOT 122
10' UTILITYtASEMENT i O 40' RESERVED EASEMENT
i \
I r LOT �
r
SEPTIC EASEMENT 40' LONG x 5' WIDE x.5'
``+I TOE OF 3:1 SLOPE EFFECTIVE DEPTH /
ABSORPTION TRENCH.
ANICS AEROCELL
/QU?}
SHED r
TREATMENT POD D,'MUST MT
POco f DRAINAGE SWALE
1 B PLACED AT 20: FROM rf� 100 RADIUS
EACH END OF THE TRENCH.
FUTURE HOSE
I TLOC
H® PIJON %
r i TH2 / \
__M Co MT ISTijG SHED
QMH 50' RADIUS
LOT 12_
1,500 GALLON STEP TANK. TANK --MUST THREE
BEANCHORED FOR BOUYANCY.,,`SEE i BEDROOM J
MANU ACTWRER'S JREC��O��MMENDATIONS. /1 HOME
4' INSU,L/ATION OVER PIPE
I,� UNDER DRIVEWAY® .Fco
�LIM'ITS OF DRIVEWAY �IRROR
iDECOMMISSIONEXISTI G Lt f�
�HO`LDING TANK PER U. .C*
EXISTING WELL t�
r
r'
i LOT 13 �
� \ G 69—
�E N G I NE f SING NOTE\
� NO SLOPES >25% WITHIN 50' OR SURFACE WATER WITHIN 100' OF THE
.OF qCq ®�® LEGEND
PROPOSED SEPTIC SYSTEM
®�P . •• •• .,•�
CO - CLEANOUT
® 6�'••, �® 2CO - DOUBLE CLEANOUT
® ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS
_^•49th ... • •••„ FCO - FOUNDATION CLEANOUT
r�:: •••° >n PROPERTY ARE SHOWN. NO CONFLICTS WITH WELLS OR SEPTIC
®FS - FLOW SPLITTER VALVE
�.� ;................... f° •� SYSTEMS.
MICHAEL E. ANDERSON � MH - MANHOLE
00.0 T•,•• No. CE -4381 �•�•���� 0 50 100
�® cep 7121/21 '��®� FEET MT -MONITORING TUBE
Fa •°•••........••••' ®� SV -SEPTIC VENT
��a�PR®F®S®®� ®� 1"=50' TH - TEST HOLE
LAKE HILL ACRES #2, LOT 12 COA 2 -
DESIGN FACTORS: SYSTEM REQUIREMENTS:
450 GPD PEAK FLOW 5' WIDE TRENCH SYSTEM
PERK RATE: 15 MIN/IN QUANICS TREATMENT SYSTEM
APPLICATION RATE: 3 GPD/SF (SEE SITE PLAN)
450 GPD / 3 GPD/SF /5' WIDE * 1.0 (RED. FACTOR) = 30 LF TRENCH REQUIRED (40 LF SPECIFIED)
BOTTOM OF TRENCH: 0.0' ABOVE GRADE
FLOW LINE ELEVATION: 0.5' BELOW GRADE
TOP OF TRENCH: 3.0' ABOVE GRADE
T
2'0"
6"
6"
OG
1'
1'
H
4" TOPSOIL & SEED
3:1 SLOPE
REMOVE ORGANICS &
REPLACE WITH IN SITU
SILTY GRAVEL
2" DIRECT BURY INSULATION
4" PERFORATED PVC (HOLES DOWN)
S -1
4" TOPSOIL & SEED
2:1 SLOPE(EAST SLOPE)
DRAINFIELD ROCKI
REMOVE ORGANICS &
REPLACE WITH IN SITU
SILTY GRAVEL
\— MOA APPROVED SAND
ENGINEERED RECEIVING SOIL
TYPE IIA CLASSIFIED FILL
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
s
E N G I N E E R I N G'.
:�� 49th `.
;.MICHAEL E. ANDERSON
NO. CE -4381 •° �®
►�®�®®"R®F ESS®(� ®®
LEGAL DESCRIPTION:
PERFORMED FOR:
DATE:
PARCEL ID#:
SOILS LOG AND PERCOLATION TEST
TECHNICIAN:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
DEPTH
(feet)✏
PROJECT No.:
TEST HOLE 2
SLOPE
SLOPE
SITE PLAN
DATE READING GROSS TIME
(minutes)
NET TIME
(minutes)
DEPTH to
WATER NET DROP
PERC. HOLE DIA. (INCHES)PERCOLATION RATE: (MIN/INCH)
TEST RUN BETWEEN: FT. and FT.
COMMENTS:
(inches)(inches)
L a k e H i l l A c r e s #2 , l o t 12
8 /1 8 /2 0 2 0
M a s o n J a k u b i s i n ⌥
DATE OF MONITORING:
WAS GROUND WATER ENCOUNTERED?
DEPTH TO WATER AFTER MONITORING:
IF YES @ WHAT DEPTH? -
15 6
7 8
0 5 1 -0 5 1 -0 6
V I J A Y P A T I L ⌥
11:25
8/18
1
2
3
6 - 3 3
4
11:56
12:28
ORGANICS
Professional Engineers Stamp:
9/22/20
30
N O ⌥
2 '⌥
1 0 /8 /2 0 ⌥
CL/GM (BLUE CLAY GRAVEL MIX)
GM (SILTY GRAVEL)
2 1
4
6 - 430 2
6 - 430 2
ALL MEASUREMENTS TO 1/16".
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201398, Rebecca Carroll, 10/12/20
DEPTH
(feet)
1 -
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
1.9
20
C�)4t 2—
SOILS LOG AND PERCOLATION TEST
y
LEGAL DESCRIPTION: LAKE HILL ACRES #2, LOT 12
PERFORMED FOR: V I JAY PATI L
DATE: 7/16/21 PROJECT No.:
PARCEL ID#: 051-051-06 TECHNICIAN: J. MILLETTE
TEST HOLE A
rij? l ORGANICS SI nPF
ML - SILT
.1
;� ML/CL
WAS GROUND WATER ENCOUNTERED? NO
IF YES a WHAT DEPTH? -
DEPTH TO WATER AFTER MONITORING:
DATE OF MONITORING_
COMMENTS: TEST H
DATE
READING
GROSS TIME
(MINUTES)
NET TIME
(MINUTES)
DEPTH To
WATER
(INCHES)
NET DROP
(INCHES)
7/16/21
1
3:00
30
4-6786
216
2
3:31
30
4-6
2
3
4:02
30
4-516
116
4
4:33
30
4-516
116
PERCOLATION RATE: 20 (MIN/INCH) PERC. HOLE DIA. 6 (INCHES)
TEST RUN BETWEEN: 2 FT. and 3 FT.
RESOAKED PRIOR TO TEST.
Dayna M. Rumfelt
R
E
GISTEREDPROFESSIO N A L L A N D S URVEYORNo. LS 13322
NORTH
MIRROR
LAKE
5/10/24
ry
O�
,
X519,
��4✓`'�
/
47
/
Pio,
,--/LAKE HILL ACRES
Fi-
SUBDIVISION
N
/ SECOND ADDITION
PLAT 64-71
_.
CO
LOT 11
1
��
GRAItC D740CN
11 Y'
--j
�s
SS,
' 2—STORY LO
HOME
0
SCALE 1" = 50'
\ \V/E N
\ V
\ SURVEY
2890 S. BARNYARD
\ DAYNACAVE S. BARNYARD
�s�ip \
LOT 10
t \
.00,
L 0 T 12
O\, 0\ fW L
I
DER
h MAPPING
CIR., WASILLA, AK 99654
C#i (907)301-5177
� '1-••"', Jr
ss�k
LCI
o
�WJ
Fi-
155.00'
w
MIRROR
LAKE
N 83'14 00"
LOT 13 � ®F. c
co -
I EGEND .-'49T
REBAR � • ��...
° �jumfIRON PIPE � f Dayna elt
WELL No. LS 13322
<WJ �� �F.p�•
SEPTIC VENT
— — GUY WIRE ASBUILT — NO CORNERS SET THIS DATE
r ' I HEREBY CERTIFY THAT I HAVE PERFORMED
POWER POLE
L J IA SURVEY OF
-- -- OVERHEAD UTIUTY
NOTES
1. DIMENSIONS ARE RECORD PER PLAT 64-71.
2. UTILITIES OTHER THAN THOSE SHOWN MAY EXIST.
3. THIS SURVEY DOES NOT CONSTITUTE A BOUNDARY SURVEY
AND IS SUBJECT TO ANY INACCURACIES THAT A SUBSEQUENT
BOUNDARY SURVEY MAY DISCLOSE. UNDER NO CIRCUMSTANCES
SHOULD ANY DATA SHOWN BE USED TO ESTABLISH ANY FENCE,
STRUCTURE OR ANY OTHER IMPROVEMENTS.
4. ALL VISIBLE ABOVE GROUND FEATURES OF
THE EXISTING SEPTIC SYSTEM WERE LOCATED AT THE TIME OF
SURVEY AND SHOWN HERE ON.
LOTS 11 AND 12, LAKE HILL ACRES
SUBDIVISION SECOND ADDITION, PLAT NO.
64-71, ANCHORAGE RECORDING DISTRICT,
ALASKA,
AND THAT THE IMPROVEMENTS AS DEPICTED
HEREON EXIST AS SHOWN IN RELATION TO
THE PROPERTY LINES. EASEMENTS OF
RECORD OTHER THAN THOSE SHOWN ON
RECORDED PLAT No. 64-71 ARE NOT
SHOWN HEREON UNLESS OTHERWISE NOTED.
DATE: 6/21/2020 IFB: 2020-1
GRID: NW 1561 DRAWN: DMR
SCALE: 1" = 50' 1 FILE: 20-011AB
MUTINICIPALITY OF ANCHORAGE
ADVANCED WASTEWATER TREATMENT SYSTEM
MAINTENANCE AND REPAIR AGREEMENT
THIS MAINTENANCE AND REPAIR AGcan
EMENT, herein the "AGREEMENT" made and
,entered into as of this Day of 5,-0kr of 20 by an
dbetween
--vt I Pherein the "O'yNWER,' " and the Municipality of
j
Anchorage, herein the "MUNICIPALITY", in accordance with Anchorage Municipal Code
(AMC) 15.65.365. In consideration of the mutual covenants contained herein, the parties to this
Agreement agree as follows:
1. Advanced Wastewater Treatment Systems. The Municipality grants permission to the
Owner to utilize and operate an Advanced Wastewater Treatment System (AWWTS),
described as Advantex Waste Water Treatment System
located at (legal description)
Lake Hill Acres #2 Lot 12
2. Maintenance, Repairs and Alterations.
(Owner is required to read, understand and initial each. section)
1�Throuj
zhout the term of this Agreement. the Owner shall enter into a service agreement
with an AWWTS service and maintenance provider approved by the Municipality or the
manufacturer's representative. The AWWTS shall be maintained in a satisfactory
condition capable of performing as designed and producing treated septic effluent in
accordance with the equipment's approval for operation in the Municipality.
IT It shall be the responsibility of the Owner during the terin of this Agreement to pay for all
repair(s), maintenance, adjustment(s), replacement costs, and inspection costs. This
includes an annual maintenance fee (typically $400 to $600).
Owner agrees that only maintenance and repair personnel approved by the Municipality
or the manufacturer's representative will inspect and make any necessary maintenance
repairs or permitted alterations to the system.
Owner acknowledges that regular maintenance of an AWWTS reduces the potential
failure of the system, which could include sewage backup and costly repairs or drainfield
W
replacement.
(rt -v os/ivmm pnaf- 1 of A
Owner acknowledges that the Municipality may request records of maintenance and
repairs from the manufacturer's representative or maintenance provider.
Owner acknowledges that the fine for failing to maintain and repair an AWWTTS may be
assessed in accordance with AMC 14.60.030.
V A Owner agrees to grant the Municipality reasonable access to test and inspect the
I
AW TS. The Municipality will give at least 24-hour -notice.
�Jb Owner agrees that any sale or transfer of title of the property will not occur without a new
T— Certificate of On -Site Systems Approval.
A_ Owner agrees that the AWWTS installation and maintenance requirements as provided
by the AWWTS vendor/installer and approved by the Municipality are the governing
guidelines for the construction, maintenance and repair of the Owner's AWNVTS.
Owner agrees to maintain remote monitoring of the AVIWTS as required by the
AWWTS approval.
3. Term. The term of this Agreement shall begin on the date of approval by the
Municipality to operate the installed system, or upon transfer of title, and shall continue
while the AWWTS is operational or until title is transferred.
4. Nonwaives. The failure of the Municipality at any time to enforce a provision of this
Agreement shall in no way constitute a waiver of the provisions, nor in any way affect
the validity of the Agreement or any part hereof, or the right of the Municipality
thereafter to enforce every provision hereof.
5, Amendment. This Agreement shall only be amended by authorized representatives of
the Owner and Municipality. Any attempt to amend this agreement by either an
unauthorized representative or -unauthorized means shall be void.
6, Jurisdiction: Choice of Law. Any civil action arising from this Agreement shall be
brought in the Superior Court for the Third Judicial District of the State of Alaska at
Anchorage. The laws of the State of Alaska shall govern the rights and obligations of the
C�
parties under this Agreement.
7. Severability. Any provisions of this Agreement decreed invalid by a court of competent
jurisdiction shall not invalidate the remaining provisions of the Agreement.
(rev OS/IR/?OIR) P!a ap 11 i -If I
9 By: _ (signature)
I G�z ��� (print naive)
STATE OF ALASKA)
ss.
THIRD TUDICIAL DISTRICT
Date: Vl�Ido�v
The foregoing instrument Avas aclulowledged before me this 15 day
. ley �U1�1Q 1-i i
NOTARY PUBLIC FOR ALASKA
My Commission expires: oc5 )-aocoD NOTARY PUBLIC
ASHLEY HERRICK
STATE OF ALASKA
MY COMMISSION EXPIRES September 23, 2022
MUNICIPALITY:
Bv: � &u-' {signature) Date: 9 j 9 � � `oZ D
n
KvebC' C Com. rrn C (print name) Title:
(reg,. 05/19/201 R) Page.1 nf
Municipality of Anchorage Page
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: ~ ~),~,- PID Number:
Name: Wastewater System: D New ~ Upgrade
Addre.:~ ~0~ ~7~5~ , ~HO6~a~ ABSORPTION FIELD
~No. of~drooms:
Phone: ~ , ~ ~ DeepTrench ~ Shallow Trench ~ Bed ~ Mound ~her
Soil Rating: Total Depth from o~ grade:
LEGAL
DESCRI
PTION
GPD/Sq. Ft.
Lot: Block: Subdivision: Depth to pipe bottom from original grade: G~beneath pipe
Township: IRange: ISoction:~ Fill added above original grad,:l ~ ~ ~ravellength:
Gravel depth:
Number of lines:
Dislance ~n lines:
WELL: D New ~/5~ Upgrade
Ft. Ft.
Classification (Private, A.B,C); Total Depth: Cased To: Total abso~a: Pipe material:
)riller: Date Drilled: ~taticWater Level: Instal~ / Date installed:
GPM Ft. Ft,
SEPARATION DISTANCES ~ s~pti~ ~o~di,g ~ S.T.E.,.
TO Septic Absorption Lift Holding ~/Prlvate Manufacturer: Capacity in gallons:
From Tank Field Station Tank Sewer Lines ~ 3 500
Material: Number of Compaflments:
Su"ace LIFT STATION
.,er
Lot Size in gallons: ~ Manufacturer:
"~ump on" 18vol at: ~ I~vol at: High wator ~larm ~t:
BENCH MARK
Remarks: ~ ~ p~/~ ~/T , ~ ~
Location and Description:
I Assumed Elevation:
Inspections performe : ~W~/wCL/e Dates: 1st . '
2nd' ~~,
Reviewed and approved by: Date:
72-013 (1/91) MOA 25
Permit~No.
Page 2 of 2
Municipality of Anchorage
DEPARTMENT'OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: Lake Hill Acres #2, Lot 12
PIDNo.: 051-051-06
TH 8~
LUT 11 []TH
[]
TH 1
NEW
3500 GAL.
HDLDING
ELEVATIDNS
(NUT TD SCALE)
[] - :TEST HOLE
· - iMONITOR TUBE
o - iSEWER CLEANOUT
- !WELL
~K
155.0'
'O0"E
TH[]
SCALE 1' = 50'
LUT 1;~
100~
WELl_
HIRRUR
LAKE
SWING TIES
A ~ c = 38.5'
B T C = 48,8'
A ~ D = 30.5'
]~ £ D = 34.4'
GROUND
72-013A(2/91)MOA25
Contractual Agreement
Jr.'s Cesspool Pumping hereby agrees to service the holding
tank septic system located at 11&12/Lakehill Acers on an as
needed basis beginning May, 1992 at the cost of $100.00 per
3300 gallons.
This contract is renegotiable May, 1993
,RECEIVED
MAY 1 ~ 199~
.... ,- ... ) ..i',~,~OflOrage
3e t '
~. ' P. Health & Human Services
Barbara ~//Gibbs, Office Manager
Jr. 's Cesspool Pumping
Allan Hedtke, Property Owner
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
PAGE 1 OF
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW920032
DESIGN ENGINEER:EAGLE RIVER ENGINEERING SERVICES
OWNER NAME:BANDY ANDREW J
OWNER ADDRESS:PO BOX 193
JAMUL, CA. 92035-0193
PARCEL ID:05105106
DATE ISSUED: 3/18/92
EXPIRATION DATE: 3/18/93
LEGAL DESCRIPTION: LAKE HILL ACRES #2 LT 12
LOT SIZE: 40500 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
HOLDING TANK SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
THIS PERMITTED HOLDING TANK WILL SERVE THE COMBINED LOT
11/12 WHICH IS UNDER SINGLE OWNERSHIP. THE EXISTING SEPTIC
TANK, SEEPAGE PIT,DRAINFIELD, AND OUTHOUSE MUST BE PROPERLY
ABANDONED. AN EXECUTED COPY OF A PUMPING AGREEMENT/CONTRACT
MUST BE PROVIDED TO THIS OFFICE ALONG WITH AN AS-BUILT
RECEIVED BY: ~ J
DATE:
o o ~v~O
Louis Butera, P.E.
Registered CMl Engineer'
March 19, 1992
Robbie Robinson
Municipality of Anchorage
Dept. of Health & Human Services
825 L Street
Anchorage, AK 999502
RECEIVFD
MUnicipality of Anc
Dept. Health ~. u___ h_orage
· -,, ,uman ~erv/ce$
Re:
Lake Hill Acres//2, Lot 11
PID# 051-051-07
Lake Hill Acres #2, Lot 12
PID# 051-051-06
Dear Mr. Robinson:
As per our client, Alan Hedtke, the above referenced lots are owned by a single owner, and are
used as a single entity. Both well and holding tank are to be located on Lot 12.
If you have any questions please call our office at 694-5195.
Sincerely,
Louis Butera,.
Louis Butera, P.E.
Registered Civil Engineer
March 11, 1992
John Smith, P.E.
Manager, On-Site Services
Municipality of Anchorage
P.O. Box 196650
Anchorage, AK 99519
Acres//2, Lot 12
Re:
Lake
Hill
Narrative
/
Dear Mr. Smith,
The proposed holding mk installation will have very limited impact on adjacent properties for
the following reasons:
Because it is a holding tank and the waste is hauled off.
If you have any questions please call our office at 694-5195.
Sincerely,
Louis Butera, P.E.
SPECIFICATIONS FOR ON-SITE HOLDING TANK SYSTEM
LEGAL: LOT 12, LAKE HILL ACRES NO. 2
A. GENERAL
o
The well and septic plan are for a single family residence only.
The drawing and or site plan shall be a part of this specification.
All materials and workmanship shall meet the Anchorage Department of Health
and State Department Of Environmental Conservation requirements.
All soil tests are advisory to the design and are to be verified or modified in the
field by the engineer.
All excavations and depths are advisory and are to be verified or modified in the
field by the contractor to meet Municipality of Anchorage, Department of
Environmental Conservation requirements.
It is the responsibility of the owner to obtain all necessary permits or easements
and to locate any adjacent multi-family wells.
The excavation is to be exactly in the area shown on the site plan, any deviation
requires engineer approval.
It is always recommended that a surveyor locate the nearest lot line position and
the location of any easements.
B. HOLDING TANK
Holding tank is to be accessible to pumping vehicles.
The tank is to be a tank that is approved by the Municipality of Anchorage with
corrosion prevention standard, for septic tank as per Uniform Plumbing code.
The holding tank must have a six (6) inch diameter standpipe with an airtight cap
to provide pumping access. The standpipe must extend at least twelve (12) inches
above the surface of the ground.
The holding tank must have a watertight manhole to provide access to the interior
of the tank. The manhole must be at least twenty (20) inches in diameter.
The holding tank must be equipped with a high water alarm which registers both
visually and audibly inside the dwelling. The alarm must be positioned to allow
at least three hundred (300) gallons per bedroom of additional storage after the
alarm has been activated.
The holding tank is to secured against floatation.
Existing septic tank and pit to abandoned to code.
Alarm and wiring to be per Municipality of Anchorage electrical code.
BEDROOM CAPACITY
HOLDING TANK SIZE
=3
= +2,000 gallons
Twenty-four (24) hours notice required for all inspections.
% V~C~iNT EDT
3500 GAL /o~ /
BUTHBUSEO / ~¢ ~ ~Ag~ / MIRRBR
/ ' I - ~ /
NBTE, HBL~ZNG TANK IS TB ~E PLACE~ / /
100' FRBH L~KE WATER SURFACE, THE / /
WATER SURFACE SBBWN ~S FBBN RECB~ PLAT / /
AN~ ~S TB ~E VER~FZE~ ~Y CBNT~ACTBR / ~_ /
PBZBR TB TANK PLACENENT~ANK PBS~T~BN / oEPT~¢ /
NAY bE HBVE~ IF SEP~RAT~BN ~ST*NCES -~ /
A*E A~EQUATE. ~ELL. /
LBT 13 ~" ~+
RECURS/
~ /
NO KNOWN CURTAIN DRAINS :mm,,,,- ~%%%E%%D
SEP F[C S TE PLAN
LEGAL: LOT 11 ~ 12 LAKE HILLS ACRES NO.2
CLIENT: HEDTKE
CONTRACTOR: N/A
JOB
I
DATE..
~ 92-024~ 03/11/92~ SCALE 1 = 50
EAGLE RIVER, AK. 99577
(907) 694-5195 FAX: (907) 694-3,297
ROBERT SHAFCR, P.E
ROGER SHAFER, P.E.
CIVIL ENGIHcERB
1991
694.2979
FAX 694. t211
WEI L INSPI~CTION
& ~IOW TEt51
T~T
Fran EcklCy
' ' R
SLEgPE REA£FY
800 EaSt Oimond Blvd.
Anchora§¢, A~a~ka ~95~5
REFERENCE: Lo~
A~: your r~qc~.~t w~ haw ~ompl~d a pr~inary ~6s~m~.n~ of ~h~
r~f~.rcnced prop~r~Y fo/~ w~e and 6~p.~ approve, p~rpo6~.
Upon f.Lr~ i~s~e~ion o~ th~ prop~r~ w~ ob6~ue.d wha.~ app~a~s
ils cons./rua.~on, appar~gt ~roun~/ar ~na~oacba~, and prox.i~i~y
.th~ ~.ake, an approw6 ~nnot be ob~ned on the existin.g
di,~pos(z.~ 6 ys ~m.
W6 then perfo~me.d ~o.~ te~.~ng o~ J~ 27, 1991 for p~rpooes of
5 t~,t hol~ w~r~ e.x~v~t~d a~ ~hown on ,~h~ g~ch~d a~-b~l~ surve, y.
Th~ firsl ~hre~ ~t hol~ ~xeav~ on the. prop~r~y, (unnt¢~b~r~.~
Th.~ .f.a~i ~o ~ ho.~ (fabled. THI and TH2) r~v~d ~ ~.,i.t~ee. b~-~t~
soils. LoCs for th~ hol~ ~r~ ~a6he. d, Howard.% percolation
within lh~,6e. ~o ko.~ found soi[~ w~iak are. u~t~tab.f.6 for on-.~i~.
s~pt.i.c in6ial.[.ation d~ to .~h~r ~x~e~¢ poor
Unfortunately, wz ~gr~ ~o info~n yo~ .~:h~ d~ lo ~ooo~t 6o,Ll.~ and
~~.d.i.n~ tank wi~ r~qt~¢ p~r~o~¢ p~prn9 ~* a~-,, ............
~oca~d or~ the propg, rty, W~ aah $~.~Z p~rfo~ a flow ~e~ or~
.howE. v6~, hincq. ~6~6~ po~o~X h~b b~n .disc. onnect~d ~rom .thz
paop~r.~y, w~ w.i~ nz~d .~o ~66 a ~n~Xa~o~. (06 an~iaipa~e thc co~t of a
co~t $so.00 ~o tes.t ~or ~olifo~a b~6.~eria ~nd
WASfEWA~R ·
~,~t nY.I'E~ ............ ~e, ~ ~,a ~ uTI: 9n4. EAGLE RIVER, ALASKA gg577
Two
ROGER _I. S~AFEt~, p.E.
RJSI~r~
~,.dcipalily of Anchorage
DEPARTMEN'[ OF HEALTH & HUMAN SERVICES
625 "L" S[reeh Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
COMMENT[';
Township, Range, Secl~on.
SLOPE SITE PLAN
Reading
Date Gross Nat
Time Time
Water Droo
~ '/,~ 'l_.-~. ~""
~" "--L~"~
PFRCOLAIION RATE .~--.(4E~[mmule$/,,,cl~) PERC HOLE DIAMETER
EST ~'~UN BETWEEN__~ FT AND "~ FT
PEnPonMFr~ u¥ 17034 Eagl,~ R ;var LooF..l~, ~21~~ ~ [ ~.....~.~,,~ CLH I FY THAT THIS rEL;T WA,, r LIII.OHMED IN
ACCORDANCE WI), A[~F~N~R~Umr~FI. INES mN EFFECT ON'HIS DATE. DATE ~ ~ ,--
/2-0()8 ~Rev
Municipalily ol Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 L" Street. Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
F-ER F ON M t'.'l.'l FOR
!
5
7
9
!0
11
t2
13
I
I_
LFG~',I
Townsh;p, Range. Sem~on:
SLOPE
WA~ GROUNO WATER
FNCOIJNTERED?
IF YES, AT WHAT
DEPTH?
Oeplh ID Waler A~ler
MondorinD? ~ ~,
SITE PLAN
Reading O~te
....
PERCOLATION RATE
TEST RUN BETWEEN --
GROSS Nar L3~pth to J~J ~. !
Til~le Time Water D,,~
'~) Immulesnnchl PLHC; HOLE OIAMETER
COMMENTS
' S & S ENGIN.EERING ~ ~ ~ , ' ....
FEHFONMLD UY 17034 Ea-le-,: .... , ~- o^~d Ne,.304~-~ (.;LRTIF¥ THAT THIS TE,'-;!
,A. CGOIII..),A, NCF.. Wl'~,,~t.R~l~_.~l~]JC~l~,Sg'~/'~^! GJJIDELINES'IN I-f fi'CT ON THIS DATE. UATE
HEALTH DEPARTMENT
32~ '~'~' .~T. ANCHORAGE, ALASKA 99501 ~ ~11
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME
LOCATION
MAILING
ADDRESS~
LEGAL DESCRIPTION
SEPTIC TANK:
DISTANCE FROM WELL
LIQUID CAPACITY
~p~..~..,~..,~ NUMBER OF /
MATERIAL COMPARTMENTS
GALLONS, INSIDE LENGTH ~'"'"~"~INSIDE WIDTH ~'."~'",,4/"DEPTHLIQUID
SEEPAGE SYSTEM:
SEEPAGE PiT:
NUMBER OF PITS / OUTSIDE DIAMETER OR WIDTH /~/"('~,'~ENGTH
. , BUILDING FOUNDATION.
TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) SQ. ET.
NEAREST LOT LINE
TILE DRAIN FIELD:
,,~..-. /
DISTANCE FROM WELL "/~/~')"'~ FOUNDATION ~"~"" ! TOTAL LENGTH ~..~ J
, NEAREST LOT LINE ~//~J'~' OF LINES
NUMBER OF LINES // ·DISTANCE BETWEEN LINES - TRENCH WIDTH ~:~'~ /! IN. TOTAL EFFECTIVE
/
ABSORPTION AREA /'¢z~ ~'~ SQ. FT. LENGTH OF EACH LINE ~'"~'~/ ~ / ~
DEPTH: TOP OF TILE TO FINISH GRADE e"~, ~- / II
DEPTH OF FILTER MATERIAL BENEATH TILE'. ~ /! IN. ABOVE TILE 6
WELL: TYPE ~ 1~ I I1~ d DEPTH (~ ~ /~) DISTANCE FROM ,-'"' /' --. WATER
, , BUILDING FOUNDATION,..~. J"I~,)JL-J. SAMPLE '~L/"J~ . NEAREST
U/~/~.~) NEAREST ~,~'~/ SEPTIC ~'~,~ / SEEPAGE /~Z)0 / OTHER
LOT LINE . SEWER LINE , TANK ' , SYSTEM. r...~', , CESSPOOL ~ , SOURCES
DISTANCES:
DIAGRAM OF SYSTEM
· ' ," --
DATE
APPROVED
MUHMPAUTY OF r HCHORAG
.; ,.
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. 051-051-25
1. GENERAL INFORMATION
Expiration Date:
Complete legal description Lake Hill Acres #2, Lot 11 & 12
Location (site address) 22535 Mirror Lake Drive, Chugiak, AK 99567
Current property owner(s) Vijay Patll Day phone (907)978-9698
Mailing address 22535 Mirror Lake Drive, Chugiak, AK 99567
Real estate agent Day phone
2. TYPE OF DWELLING:
FM-1 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 2
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
Private Septic
❑E
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for:
Received by:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 2-
Date of Payment
Receipt Number
COSA # 0!5:, G 2_ I I SZ
Date:
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
Distance:
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 Phone (907) 522-7773
Address 1399 W. 34th Ave Suite 101, Anchorage, AK 99503
Engineer's Printed Name Benjamin Schiller, P.E. (M.J.) Date 11/2/21
-�' OF Aq�1�1
All �IAQ
P
6. DSD SIGNATURE : •:.': '^'�'"'
-14
System #1 Approved for 3 bedrooms '. • BenjarrnlSchiller
System #2 Approved for bedrooms �+�����rF , . 1Ej 2592
Disapproved
Conditional approval for bedrooms, with the following stipulations:
By: Original Certificate Date: Y o Zo 1-
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: Lake Hill Acres #2, Lot 11 & 12
If more than 1 septic system on lot: COSA Checklist #
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled Unknown
Total depth 93+* ft
Cased to Unknown ft
FE-1 Sanitary seal is functioning correctly
W Wires are properly protected
Casing height (above ground) 18+ in.
Date of flow test for COSA 10/6/21
Parcel ID: 051-051-25
of Structure served by this system
Well production at time of test 1.2 gpm
Water storage tank volume gallons
Well disinfected for coliform test? ❑ Yes ❑ No
®❑ Coliform bacteria is Negative
Nitrate 0.405 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by Forge Engineering
Date of Sample 10/13/21
Static water level at beginning of test 25 ft.
Comments *Lowest reading during well testing. No well log
B. TANK DATA
Age of tank(s) <1 years
Tank type/material Quanics / Steel
Measured operating fluid level in septic flank New
®❑ Standpipes/foundation cleanout per record drawing
Date of pumping Installed on 9/28/21
D. ABSORPTION FIELD DATA Mound System
Which system tested (date installed) 8/2/21
❑® ALL standpipes present per record drawing
Total measured depth from grade 3.6 ft (max)
Measured depth to pipe invert from grade 3.1 ft (min)
❑ N/A — pressurized field
❑® Monitor tubes go to bottom of effective. If not, state
depth into effective
Fm] 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
STATION
❑ Requl aintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date
Re Its ❑ Pass For bedrooms
Fluid de prior to test in
Water added gal
New depth
Elapsed time ml
Final fluid depth in
Absorption rate gpd
Any rejuvenation treatment (past 12 mon s
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'
Community Sewer Manhole/Cleanout > 100'
Q Yes
if No
ft
Q Yes
if No ft
Neighboring Tank > 100' Q✓ Yes
if No
ft
Private Sewer/Septic Line > 25' Q Yes
if No ft
Absorption Field on Lot > 100' Q Yes
if No
ft
Holding Tank > 100' F/� Yes
if No ft
Neighboring Absorption Fields > 100'
Animal Containment > 50' r7l Yes
if No ft
✓� Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' �✓ Yes
if No
ft
0 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' Q Yes if No ft
Property Line > 5'
0
Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
0
Yes
if No
ft
Private Wells > 100' Q Yes if No ft
Water Main > 10'
Q
Yes
if No
ft
Community Wells > 200' 0✓ Yes if No ft
Water Service Line > 10'
P/1
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'
✓�
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'
Yes
if No
ft
Private Wells > 100' Q Yes if No ft
Water Service Line > 10'
P/1
Yes
if No
ft
Community Wells > 200' Yes if No ft
Surface Water > 100'
Q
Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
1 certify that l have determined through field inspections and review �.'
of Municipal records that the above systems are in conformance with � TH
MOA COSA guidelines in effect on this date.
Be njarrrySchiller
r % CE 12592
4 �sl�c�, • . 11 /2/21 • , • F��®
-�.
COSA Checklist yellow sheet `��pROFESSION����,"���"