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HomeMy WebLinkAboutGOLDEN VIEW HEIGHTS LT 6KOnsite File Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP191155 PID Number: 020-043-07 Dwelling:❑ Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: X New ❑ Upgrade Name ANTHONY BROOKS ABSORPTION FIELD ■❑ Deep Trench El Wide Trench El Bed El Mound Site Address ❑ Other Phone Number of Bedrooms Soil Rating depth from original grade 4 1.2 GPD/SF JTotal 9.0 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 3.0 Ft. Gravel depth beneath pipe 6.0 Ft. Subdivision Block Lot GOLDEN VIEW HEIGHTS LT 6K Fill added above original grade 1 + Ft. Gravel length 42 Ft. Township Range Section Gravel width 2.0 Ft. Beds: Number of Lines 0 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 504 Ft2 1 Ft. Well 100'-1- 100'+ 50'+ TANK X Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer ANCH TANK Capacity 1250 Gal. Surface Water 100' + 100'+ Material Number of compartments Lot Line 10'+ 10'+ NA STEEL 2 Foundation 10'-x- 10'+ LIFT STATION Manufacturer Capacity Remarks Gal. Alarm location Electrical installed by PIPE MATERIAL House to tank 3034Tank to 3034 drainfield Installer MIKE N ANDERSON, P.E. Drainfield 3034 CO/MT 3034 inspector MIKE N ANDERSON, P.E. BENCH MARK (Assumed elevation) 101.5 ft Inspection1s' 9-15-19 9-15-19 Location and description 2�d GARAGE SLAB 3m 4th ON-SITE WATER AND WASTEWATER SECTION APPROVAL Elgin&e Stamp Conditional Approval: Date 4,q'.° a000.O 49_x' 4 °�i .A� .o o G fj ` � ° ° . e ........ VO ° MICHAEL N. ANDLRSCid° o . cE-snz9 ,•'`` �, ��� Ji Septic System{ I6&MA Approved Date f 9o�b f'�0 ° (2( �9�(�( °:' Note: this approval does not include well permit requirements. (Rev 05/02/18) Permit No. OSP191155 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: GOLDEN VIEW HEIGHTS LT 6K MARK A B C01 4 44 /� TC01 / 15 40 TCO2 / 22 38 / 25 30 �yCp�02 27 32 9'004 MT1 27 30 C05 22 32 PID No.: 020-043-07 i NEW 1250 GALLON STEELTAf�k — �pq—= — — "— — MT TCO 3 \\TH#1 BENCH, ARAGE SLAB // IITC . B FENCE lX I � I \ WELL j \ A UC05 !- —' DRIVEWAY \ � N I — T — — ASBUIL 1— - — SCALE: 1"=50' 0 r ® e CTCO2 \\ 11MSNCf+AOE C_��\�♦®® FlLTER FABRIC @ INSULATION MMb.0 ORG ®M •••M♦♦♦ i49 TH 97 1.250 urw na. ...... GALLON 7. 97 97 SP/GP •' 51EEL TANK Ba -7 7 ® ..MICHAEL N. ANDERSON:* ♦ %' No. CE 9469 \IW ®®® CN, 2-18-19 �. SEPTIC SECTION 84 ®♦®® EES,\C ®®® N.T.S. DRY, MAY 2019 Certified Drilling Log DOC CO dba BILL 8& COLE ULLMAN' WATER WELLS el—P P.O. Box 670269, Chugiak, AK 99567 688-2759 OWNER OF LAND: Anthony & Brandy Brooks ADDRESS: 6481 West Cir. Anchorage, AK LEGAL DESCRIPTION Golden View Heights Lot 6K DATE: 6-19-19 PERMIT NUMBER: OSP191155 DATE OF ISSUE: 5-29-19 TAX IDENTIFICATION NUMBER 02004307000 is well located at approved permit location: ®Yes [—]No Method of Drilling: ®air rotary ❑cable tool Depth of Well: 260' Casing Type: Steel Wall thickness ,250 inches Diameter: 6 inches, depth 84 feet Liner type Static Water Level: 80 feet Recovery Rate 1 ® gpm ❑ gph Method of Testing Air Well Intake Opening Type: ❑ open end ®open hole ❑ Screened Start feet Stopped ❑ Perforations Start feet Stopped Grout Type: Bentonite Volume: 50 lbs Depth: from 2 feet, to 42 feet Well Disinfected Upon Completion: ®yes ❑ no Method of Disinfection: Chlorine 50 PPM Comments: WATER QUALITY TESTING Coliform Nf- CoV100mL Nitrates mg/L Arsenic N V) Ug/L. is 1 125III, Bore Hole Data Depth From To 0 2 2 4 4 44 44 65 65 69 69 75 75 99 99 175 175 181 181 260 Casing Stickup Overburden Tight Silty Sand & Gravel Hardpan Silt & Sand w/ Gravel Wet Hardpan Bedrock Gray w/ Quartz Bedrock Gray Bedrock Gray w/ Quartz Bedrock Gray Drillers Name: Cole Sullivan ATTENTION: It is the responsibility of the property owner to submit a copy of the well log to the proper authority. Municipality of Anchorage: Department of Health & Human Services and/or Department of Environmental Conservation. MatSu Borough: Department of Environmental Conservation. www.sullivanwaterwells.com Pump Installati®n L®g Well Drilling Permit Number: SW OSP191155 Date of Issue 5-29-19 Parcel Identification Number: 02004307000 Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation. I 30.0' I I � I I 95 i \ \ Lot L-2 Lot L-1 WEST CIRCLE Lot 6L N N c 5 (L 0 Y m O N O :Z L L 0 6-0 2 0to 1 a d7: :Z S� • : RE�� o 0 Y m O N O L L 0 Q a a - m o 0 0 m a �� Na r U m N = m m L> Q 00 U � :OF c m O > Ca OL OL ^N O O n I w N O O fV a� C O O I me m� mo a�Q U m .,dl � c0 a m� m 0 y o m O mzat+°-oco j we N —=c � zw E rnam 0L m . o, a o zo0o+ j E y. ° `mo 'mEo o , uoorclao ,m=mNOmr m aa m : OO ° T 1 6 L °x° C. a Lco o rm w`IvcU; _00 p L m S m O O C La`pN _> c+mom O `ozc O �� roma NI ��om.0Lq I cm woo ac« 0 o 000 tOa`ma o aEc m U Y m m> N N m N 0 N C >` - m m C L H a y m p O c 0 L o L 0 Q 3 mo 0 = U MUNICIPALITY OF ANCHORAGE m mf„r On-Site Water&Wastewater Program No5e; PO Box 196650 4700 Elmore Road • Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997 http://www.muni.org/onsite .1''� i l)cpartmcnt 4NCM00.PG`` On-Site Water & Wastewater System Permit Permit Number: OSP191155 Effective Date: 5/29/2019 Work Type: WellSeptic Initial Expiration Date: 5/28/2020 Tax Code Number: 02004307000 Site Legal Address: GOLDEN VIEW HEIGHTS LT 6K G:3238 Site Mailing Address: 6481 WEST CIR, Anchorage Owner: BROOKS ANTHONY & BRANDY Lot Size in Sq Ft: 43888 Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING Total Bedrooms: 4 This permit is for the construction of: 0 Disposal Field El Septic Tank ❑ Holding Tank ❑ Privy El Private Well 0 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 Received By: Date: li Issued By: COAZ Date: 9 19 MUNICIPALITY OF ANCHORAGE • (. : r Development Services Department r' Phone: 907-343-7904 On-Site Water & Wastewater Section / Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 020-043-07 Property owner(s) ANTHONY BROOKS Day phone Z ct 2. ^D s L o Mailing address PO BOX 111797 ANCH AK Site address Legal description (Sub'd.. Block & Lot) GOLDEN VIEW HEIGHTS LT 6K Legal description (Township, Range & Section) Lot Size 43888 Sq. Ft. Number of Bedrooms /f APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (2]all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) (w/wo ADU) Septic Tank ❑ Upgrade ❑ 01 Holding Tank ❑ Renewal ❑ !� Q ,i1.Ie if; ❑ Privy ❑ 4r .,- d/,•r D) Private Well 1711 N a.9 3 eois,Water Storage 111i9 THIS APPLICATION INCLUDES A WAIVER REQUEST FO68- 9 S I '' Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. Iri/AAiL (Signature of property owner or authorized agent) Permit/Rush Fees: ZC:)4 Waiver Fees: Date of Payment: 01360 Date of Payment: Receipt Number: loWD'S Receipt Number: Permit No. 3S1O1 1155 Waiver No. G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc April 15, 2019 Municipalities of Anchorage Departments of Health and Human Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Fax 249-7847 Re: New septic and well permit Legal: GOLDEN VIEW HEIGHTS LT 6K To Whom it may concern: This is a request for a septic and well permit on the above referenced lot. A perc test was excavated on the lot and found poorly grade sand and gravel (SP/GP)the full depth of 16 feet. No water was found during excavation or after the 7 day monitoring period. The new system is a simple gravity flow 3 bedroom system with 5 feet of effective depth. This new system will not impact any of the neighboring properties. The slope is very gentle slope to the west,see the site plan. Sincerely1 V V Michael N. Anderson, P.E. 4661 Natrona Anch, Ak 99516 Ph 727-8864 DESIGN CRITERIA: , MOUND OVER (TH#1) o -- GRADE 4 BDRM X 150 = 600 GPD - SOILS = 600/1.2 = 500 GPD �.0 o�G 500 GA/12 =42' SP'GP 30 �e� FILTERFABRICPPE (1)TRENCH SEWER ROCK $6.0' DEEP 6.0' EFFECTIVE 9'0 2.0'WIDE 12.0' 42' LONG 16 SEPTIC FIELD SECTION l � r' I I - - _-E 156TH AVE- — 7 7\ , „ , ..... , ___ ., o '--., . / �\ O r \ r— — — — - - -ol - - - - - - -• 1 1\ WELL /i I \ n \ / Qt SEPTIC r / --' S__1 I W `l — _ _. I �,--\ C\ 77, > J I �SEPTI�j __, WELL'I pl It.S TI\ ,___ \ / �' I.I PROPERTY LINE • I ---, \ / -. \\ I PROPOSED 21 .WELL \ , _I \DRAINAGE FIELD J SEPTIC -- �a ° �� /94j mg 1 �� \N ' \CI SEPTICS/ _ .__�I \ I I WELL. -WEST CIR- PROPOSED HOUSE�~ I / SEP}IC - \ I/�1SOPT1\ /\ rrlI .E__/ / -- rr �! lr PROPOSED WELL / U I j r'I �`-�� ���100'RADIUS pI �� WELD / I /�`\ �\ '' ��` O -GOLDEN WOOD LN- " / r / \ / \ - - — \ I i WEAL \CC 1 WELL r)\I WELL \\ �\. I I �l 1 1 1 1 I I r Q I I . .... I. ....,� ......„..... ......___......., _ _,_ _ _ _ _ _ _ _ _r _ _ _ 1--- I I i y Septic Design Prepared for tootssi ili O ��1 inANTHONY BROOKS •'' '..\••• & •A a '. . GOLDEN VIEW HEIGHTS, LOT 6K — : 49TH , \* # Anchorage, Alaska • • • Michael N. Anderson, P.E. DATE: 4/15/2019 % •;MICHNoL N.E •A46 RSON; - 4601 NATRONA AVE DRAWN: DJR 4_, .� i ANCHORAGE, ALASKA 99516 )1'�O•;;•• ' • '�\ •� (907) 727-8864/FAX: (907) 345-1391 SCALE: 1"=200' 44��•';��44 I-' \ 1 \ / - I 11 \\ // \ I -- ,-- / \ I / ` I /'I / ` S' / \ \ abbQEN VIEW HEIGHTS\ \ GOLDEN VIEW HEIGHTS i /' `LOT L-2 \ LOT L•1 / \ \ / I \\ \ \ / \ 4 \ \ ®WELL \\ \ I \ \\ 1L z-PROPERTY LINE J V \ - - /1 I , 1 / I \ ® / 1 �10T&E • N—PROPOSED /// EASEMENT \ WELL / 1 RGEN ` \ --- \ /`\ 1 / 2--b 2-5 PERCENT /' .— SvO p� GENS \ 2'' ESLOPE ' \\ — cop ,l �CO1 `#1 � NT •\\ ---- --q PROPOSED _//� 1 MT 1111 \\ VAGA tii \\ okt\SEW HOUSE g I 1 1111 CO I \\p 1 \ CI ; I 11 ' .NIM TCS'CI) 11 1111 j z 1`.. 2-5 PERCENT d C• =L C01 II /O ��� \ SLOPE ' \` 1 0 ,� 1 re z I ~'�. ---- GALLON S-SpFRC SEPTIC TANK COpF ENT GOLDEN VIEW HEIGHTS 1 LOT 6L PROPERTY LINE J PROPOSED WELL i -WEST CIR- 100'RADIUS / / / -- - - / / `\ / \ // / I\ 1 i� .'\ ) / I / 1 \`\ // I /\ I e\ I I \ x' I SEPTIC ` I \ // /' `\\ \% 11 \\ SEPTIC \1 SEPTIC �`\ \ I / I \ \ \ I / I / \ I 1 \1\ r/ 1 r/ / 1 \ ` GOLDEN VIEW Fj!`IGHTS \\ GOLDEI�*IEW HEIGHTS I GOLDEN VIEW HEIGHTS // \\ \\\ r,� —hE}FyA _ \\\ /^'� LOT 7_B--_ \ LOT 7C /r \ \ / Septic Design Prepared for .�����SIMi44 ANTHONY BROOKS • •'.• • OF /14,,44. ��•• • GOLDEN VIEW HEIGHTS, LOT 6K ;' 49TH :,* t, Anchorage, Alaska • • Michael N. Anderson, P.E. �� MICHAEL.N. ANDERSON:' DATE: 4/15/2019 �..�� No. C 94j61.:', . ff 4601 NATRONA AVE DRAWN: DJR ��� �!' : ANCHORAGE,ALASKA 99516 •t ••.. •• .� (907) 727-8864/FAX: (907) 345-1391 SCALE: 1"=50' fit. SS Al'44 �\� �� ©i= �/� Municipality of Anchorage d AAFAGINEE . SEAtf-, to Development Services Department {' •`•`" �f • • r• •r ,A% On-Site Water and Wastewater Section �+; 49TH •••,� 4700 Elmore St. •` �_ P.O.Box 196650 Anchorage,AK 99519-6650 „,d �, ii • www.muni.orq/onsite j” p' (907)343-7904 • MICHAEL N. ANDERSON ;,� /� rP�0r�9• CE-9469 ,.". , •••l CJ am' Soils Log - Percolation Test ld� ,?n{fs����\:t..\',... Soils Performed For: Art 4-PH)r+�( V29/19{J� L, Date Performed: /y 4 Legal I-• . ion &Nl ili,41V% vi.,,W /iYl•ski- i Township, Range.Section: J , I r tl 4 Ct , Slope Site Plan Depth (Feet) d v-g ' 1-' 2- 4 -' 3- GA 14-r-P(lt 01 4- 5- 6- Lr /e'7 1 7- 8- WAS GROUND WATER "IV ENCOUNTERED? S 1 0- IF YES,AT WHAT DEPTH? L Depth to Water After 0 11- Monitoring? �( P 1 E 12- Date ? �l'� 13- 14- Reading Date Gross Time Net Time Depth to Water Net Drop 15- 1./,if 1100.!^ Lit 5--4• k 16 L. !t 5 /t `1' 17- ° �t'�►^` G t S/, 18- G ! .S/r 19- 20- PERCOLATION RATE 2- (minutes/inch) PERC HOLE DIAMETER 4 TEST RUN BETWEEN y FT AND 04,5"-- FT COMMENTS /�/( (1.-!{1 41 n,7 �F t f f(.1 t PERFORMED BY: k.A f1 As% I !,1 CERTIFY THAT THIS TEST AS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 2 r 3AIZIO ONOS ONIM . w 0 00) o i+\ ---••,...........c....,,...1 m—f I—CO _ Z I ��� O O r*7 Z o m r vmi C.+ 4 II v m 0 .. O O Z o v co m m c) . COim o x o• o - z 5.7 c Jx • /L'Z - m m0 m N Z • • D cn m �D� ,,, G1 O m II m m /.l o X � " O r I- Z D Iv O m to '9 Z A O I— .. • . ' m O m Z Z TI 0' w• -I M 1 Z. m 00 t-'17(1H0°.9.Z -a;7;14. — — . r0 I�.O'�� N (n m _I o U O 71 . z C7 J E0 _. m D 0 .L'L9 'F"' .0'9 r co 70 On 01D o o v co (no ri.''' o ,0'94 co v 0 O Z 0'9 w 'VN Cl) 0 z Co ma - C) .., opo I— _ W }ra .0'S:tr (b o' n Cli cn I W LP cn Xm rri C.+ o ., V) w co co m (p O O O N 4t. N P1 D = — — — Z 0 Z Z ^W Z C) — _ `f— 0 r m * 0 — — o — m m to ;'r — co co co oo co co co co co co oo co co co co(p x cncncnc)U)U) ncncncncncncncncncn-1 o 'coCO in in incncnin-Coi.):Pi.000000ao� m coco CO A -oozKr-xc--=o-lmO(7DJD D -0 O 0o 0o co co co co co co co co co co co Cbooco0 Z Un cii cri cn cn cm vl cnUnU U)01U)CnCn(n-0 _I Co Co Co Co 01 CocoCoCoCoCoCoCoUiCOCO0 D .co'co'co 0000oo(p'co'co 0000cocoCo(n 0 m m (7 I- 0 r I 7 ,trL'62l 3„14,00.00 S mm COOf rnrn rnrn CION o.o> O R r I �° r-- PLOT PLAN X AS BUILT __ SCALE 1" = 30' GRID SW 3238 Project No. 19-005/B1 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Associates , inc . (907) 522-6476 Phone (907) 522-4625 Fax �.c.• ppO Professional Land Surveyors kenOlangsurvey.com vl O F A �‘p jonathanOlangsurvey.com i'`�! .•'•'Q1/4sA 00, . ..'�- pp I hereby certify that I have surveyed the following described property: ��\ AVO Off: 49TH �� LOT 6K, GOLDEN VIEW HEIGHTS SUBDIVISION (PLAT No. 84-475) 0 * : — . * 4 Anchorage Recording District, Alaska, and that the Improvements situated thereon are 0 within the property lines and do not encroach onto the property adjacent thereto, that 0VA no improvements on the property lying adjacent thereto encroach on the surveyed 0 a 0 premises and that there are no roadways, transmission lines or other visible Q c� KEN ETH LAN o easements on said property except as indicated hereon. '� 0 04 .'•411,111q 4 , Dated this the 5� Day of Ft:P.:ALL.,h 14'-+' , . �S-520 .•' _ at Anchorage, Alaska ��OQO4FSsgoNAQ�o" It is the responsibility of the owner to determine the existence of any easements, Opppo covenants, or restrictions which do not appear on the recorded subdivision plat. AECC963 MUNICIPALITY, OF ANCHORAGE 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. 020-043-07 1. GENERAL INFORMATION Expiration Date: `7 ` % 7 1020 Complete legal description GOLDEN VIEW HEIGHTS LT 6K Location (site address) 6481 WEST CIR ANCH, AK Current property owner(s) ANTHONY BROOKS Mailing address Real estate agent 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: q Day phone Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well 0 Private Septic 3 6 ? 8 9 170 . Water Storage ❑ Holding Tank Community Well ❑ Community a J,4 Public Water System ❑ Public Sew �ZO a a ti Waiver request for: 4 ti Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ d • OD Waiver Fee $ Date of Payment 01119 ( lb20 Receipt Number, 2q(pq,% 3 COSA # 6SG201 O j D Date of Payment Receipt Number Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted. Namaof Firm MIKE N ANDERSON, P.E. Phone 727-8864 Address 4661 NATRONA AVE ANCH AK Engineer's Printed Name MIKE N ANDERSON, P.E. Date 1-15-20 6. DSD SIGNATURE System #1 Approved for _y__ bedrooms System #2 Approved for bedrooms Disapproved Conditional approval for bedrooms, A s a gym. j�,� °•o es o a°oa J i� 'ia IN e e r.y !°.� F' IT o4 9 i M ;-%. y ��oseaeo ea a eo-0000 eo 0ae 'i r�0 Y,ese°.. oe see ooe oo o.°o>rd MICHAEL N. ANDERSCN CE - 9469 with the following stipL1lgkwSm% ON-SIT"E By. Original Certificate Date: 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 COSA Checklist Legal Description: GOLDEN VIEW HEIGHTS LT 6K If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 6/19/19 Total depth 260 ft Cased to 84'+ ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 30"+ in. Date of flow test for COSA NEW Static water level at beginning of test 80 ft. Comments B. TANK DATA Age of tank(s) NEW years Tank type/material STEEL Measured operating fluid level in septic tank NEW OR Standpipes/foundation cleanout per record drawing Date of pumping NEW D. ABSORPTION FIELD DATA NEW SYSTEM Which system tested (date installed) NEW ❑ ALL standpipes present per record drawing Total measured depth from grade 9.0 ft (max) Measured depth to pipe invert from grade 3.0 ft (min) ❑ N/A — pressurized field OR Monitor tubes go to bottom of effective. If not, state depth into effective OR Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced 0 gallons Comments/Deficiencies: NEW HOUSE AND ON -SITE SYSTEMS COSA Checklist yellow sheet Parcel ID: 020-043-07 Structure served by this system Well production at time of test 1+ gpm Water storage tank volume 0 gallons Well disinfected for coliform test? ❑ Yes ❑ Nc FW Coliform bacteria is Negative Nitrate mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by MNA Date of Sample 10/25/19 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date NEW Results [✓ Pass For t' bedrooms Fluid depth prior to test 0 in Water added NEW gal New depth in Elapsed time min Final fluid depth in Absorption rate gpd Any rejuvenation treatment (past 12 months) If yes, enter date E. SEPARATION DISTANCES ❑✓ Yes if No ft From Private Well on Lot to: (Please enter distances if less than required or if community well) 0✓ Septic Tank/Lift Station on Lot > 100' if No ft Community Sewer Manhole/Cleanout > 100' Water Main > 10'✓Q Fv Yes if No ft M Yes if No ft Neighboring Tank > 100' Q✓ Yes if No ft Private Sewer/Septic Line > 25' [ Yes if No ft Absorption Field on Lot > 100' P/ Yes if No ft Holding Tank > 100' Z✓ Yes if No ft Neighboring Absorption Fields > 100' Animal Containment > 50' E✓ Yes if No ft M Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' MYes if No ft Q Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' M Yes if No ft Surface Water > 100' ❑✓ Yes if No ft Property Line > 5' r✓ Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' F Yes if No ft Private Wells > 100' 0✓ Yes if No ft Water Main > 10' Yes if No ft Community Wells > 200' ✓0 Yes if No ft Water Service Line > 10' Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ❑✓ 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'✓Q Yes if No ft Private Wells > 100' E✓ Yes if No ft Water Service Line > 10' Q✓ Yes if No ft Community Wells > 200' E✓ Yes if No ft Surface Water > 100'✓� Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION l certify that l 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. COSA Checklist yellow sheet 6 @ #'A.k*k +ere 'e �"y,+c e e •® o a aaoo oo°msc°@ a �} = MICHAEL N. ANDERSCN `%,,°@ E-469 °a°