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HomeMy WebLinkAboutOVERLOOK ESTATES #2 LT 1Onsite File #068-041-33 Municipality of Anchorage On -Site Water and Wastewater Program • (907) 343-7904 Page 1 of 3 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP211123 PID Number: 068-041-33 Dwelling: ❑I■ Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: * New ❑ Upgrade Name: Midnight Sun Construction ABSORPTION FIELD [:]Deep Trench *Shallow Trench ❑ Bed ❑ Mound Address P.O. Box 210994,Anchorage, AK 99521 ❑ Other Phone Number of Bedrooms Soil Rating depth from original grade 907-727-1433 4 JTotal 1.0 GPD/SF 4.3 / 3.7 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 3.8/3.2 Ft Gravel depth beneath pipe 0.5 / 0.5 Ft. Subdivision Block Lot Overlook Estates #2 1 Fill added above original grade -0.3/1.6 Ft Gravel length 60 / 60 Ft. Township Range Section Gravel width 5/5 Ft. Beds: Number of Lines N/A Distance between lines N/A Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line 600 Fe 2 >6 Ft. Well >100' >100' N/A N/A >25' TANK 9 Septic ❑ S.T.E.P. [:]Holding ❑ Other Manufacturer Greer Capacity 11250 Gal. Surface Water >100' >100' N/A N/A Material Number of compartments Lot Line >5' >10' N/A N/A Plastic 2 NA Foundation >10' >10' N/A N/A tti;STATION Manufac Capacity Gal. Curtain Drain None Noted Remarks Pump on level at in. Pum level at i High water alarm at in. Pump make and model Electrical Inspects ertormed by PIPE MATERIAL House to tank D3034 Tank to drainfield D3034 Installer Curt Whitters Excavating Drainfield D3034 CO/MT 3034 Inspector L.Tidwell BENCH MARK (Assumed elevation) 100 ft Inspection1s' 7/22/21 7/22/21 Location and description 2^a s'd 7/23/21 4'h Bottom of Siding at SE Corner of Home COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL Engineer's Stamp F. • k,4 Conditional Approval: Date ��Q'• • ' ' , rte* •49 TH '�*�� o� r . _....... Benjamin=chiller �� r (0 �F'• CE 12592 ••`7 5/11/22 Approved ( Date PROFESSIONP��®��� Inspection Report_9-1-12.doc VANTAGE AVENUE NOTE: ENGIN EEpING PLAN AS -BUILT 49 TH �•� 0 50 100 Benja m Schiller FEET , /11%222,.�� '� 1°=50' F�RROFESSi A B LEGEND FCO 4.8 18.7 MH1 17.4 18.8 SV1 22.0 20.9 2CO 24.1 22.3 C01 35.2 24.3 MT1 93.0 79.0 CO2 95.5 81.0 CO3 30.6 32.2 MT2 30.5 31.8 C04 89.2 78.4 CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FS - FLOW SPLITTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE OVERLOOK ESTATES #2, LOT 1 PERMIT # OSP211123 PID # 068-041-33 93.6 — N Ov 97.4 ORIGINAL GRADE 97.8 FINISH GRADE DMNFIELD ROCK 93.6 93: ti 93:1: MO APPRQVED'SAND 90.9 90.9 NO GROUNDWATER 7/22/21 83.3 O I— O U75 98.4 FINISH GRADE 96.8 ORIGINAL GRADE Ca nn n 93.6 DRAINFIELD ROCK r :MOQ:APPRCjVEDSAND s: 90.8 90.8 60' NO GROUNDWATER 7/22/21 82.3 PROFILE AS -BUILT ENGINES 0.ING (NO SCALE) MR OVERLOOK ESTATES #2, LOT 1 PERMIT # OSP211123 lNGINE80.1NG PID # 068-041-33 uv wgmmmmm��� (NO SCALE) TH Benjel in Schiller CE 12592 \4!28/22 • •'�yO F ;� FROFESSI0�1`� SOILS LOG AND PERCOLATION TEST EHG IH EEAIHG LEGAL DESCRIPTION: OVERLOOK ESTATES #2 LOT I PERFORMED FOR: MIDNIGHT SUN CONSTRUCTION DATE: 712121 PROJECT No.: PARCELID#: 068-041-33 TECHNICIAN: L.TIDWELL DEPTH (feet) 1 - 2 - 3 - 4 - 5 - 7 8 - 9 - 10- 11- 12- 13- 14- 15- 16 17 18 19 COMMENTS: TEST HOLE 1 SLOPE WAS GROUND WATER ENCOUNTERED? NO IF YES @ WHAT DEPTH? - L DEPTH OF WATER AFTER MONITORING: DRY 0 DATE OF MONITORING: 7/22/21 P SITE PLAN DATE READING GROSS TIME (MINUTES) NET TIME (MINUTES) DEPTH To WATER (INCHES) NET DROP (INCHES) 7/2/21 TEST HOLE PRESOAKED PRIOR TO TESTING: 1 2:54 2:43 0-616 616 2 2:57 3:43 0-616 616 3 3:00 4:34 0-616 616 4 3:05 4:42 0-616 616 5 3:10 4:45 0-616 616 6 3:16 4:47 0-616 616 PERCOLATION RATE: 0.79 (MIN/INCH) PERC. HOLE DIA. 6 (INCHES) TEST RUN BETWEEN: 4 FT. and 5 FT. A =;: 0 O't 3 :1 3 0 — 2. u°,=r a 0 0 > < — CD Q 3 3- 3F 3000 =r CD 3 w o =0 F —(A < CD CD 0 0 30. 3 't7 ;Do M 0 CD < 0 3to 5: no rm — a 0 *< C,:1 to :1 0 a =.� -- ;K — 0 1 3 0 V 0 CD 0 6r V) =r CD —VO ,t '+ '0 -o C 2.- --, <, =r lb o ', rn 0 X :3CD > C 0 C, 0 :L o .00 , -< 00 0 �o :3 a Q. 0 0 M:) 2 —0 00 0 CL 3-4 o = -0 no CLZ F—O 0 5:z 2. 0 3 2. 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Ln c 0 cfl 4� OD (P m cnO0 Em U) 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 htip://www.murii.org/onsite On -Site Water & Wastewater System Permit Permit Number: OSP211123 Work Type: WellSeptic Renewal Tax Code Number: 06804133000 Site Legal Address: OVERLOOK ESTATES #2 LT 1 G:0465 Site Mailing Address: 27365 VANTAGE AVE, Eagle River Owner: MIDNIGHT SUN CONSTRUCTION LLC Design Engineer: FORGE ENGINEERING This permit is for the construction of: Effective Date Expiration Date: Lot Size in Sq Ft: Total Bedrooms: mcnr O G = ' , h l n Deparrment 4130/2021 4/30/2022 55475 Q Disposal Field R1 Septic Tank ❑ Holding Tank ❑ Privy R1 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 (2417). 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 II � Special Provisions: 4 1) A test hole is required prior to construction of the absorption field, located as shown on the site plan. The test hole shall confirm separations to impermeables and seasonal high groundwater, as well as the percolation rate. Construction may proceed at your own risk prior to 7 -day groundwater monitoring. If results require a design change, construction shall stop pending On-site review and approval of a change order. Please submit results with the inspection report (or change order, if applicable). L12) The absorption fields shall be at least 20 ft up -gradient from the cutbank to the road to comply with AMC 5.65.21013.1. e. Date: a Date: J 0 47 Veronica Pope Received By:*'� 2021.04.30 16:45:29 -08'00' Issued By:Nj_)tlelt� Date: a Date: J 0 47 ON-SITE SEPTICIWELL PERMIT APPLICATION Parcel I.D. 068-041-33 Property owner(s) Midnight Sun Construction . Day phone 727-1433 Mailing address P.O. Box 210994, Anchorage, AK 99521 Site address 27365 Vantage Avenue, Eagle River, AK 99577 Legal description (Sub'd., Block & Lot) Overlook Estates #2 Lot 1 Legal description (Township, Range & Section) Lot Size 55,475 Sq. Ft. Number of Bedrooms Four (4) APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field 0 Initial E Single Family (SF) (w/wo AD U) Septic Tank 0 Upgrade ❑ Duplex (D) ❑ Holding Tank ❑ Renewal ElMultiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well 0 Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: 1y 5 Waiver Fees: Date of Payment: 30 X0„21 Date of Payment: Receipt Number: Qy 9j Receipt Number: Permit No. O S i 2 I 1 1 2 3 Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client FormsTermit Application.doc April 28, 2021 aE E E R I N G PO BOX 240773 ANCHORAGE, AK 99524 522-7773 677-7766 (FAX) FORGECIVII.COM MOA Development Services, On -Site Water & Wastewater Program 4700 Elmore Rd Anchorage, AK 99507 Subject: Overlook Estates Sub #2, Lot 1 Septic System Permit Dear On -Site Services Engineer: Vec 49 m gja in Schiller .:...� CE 12592 The permit for the construction of a well and septic system on Lot 1, Overlook Estates Subdivision #2 has expired. A site visit was conducted and there have been no substantial changes to this lot or to the surrounding area since the permit was originally issued. The current design and permit conditions meet all code requirements. We therefore request the renewal of the permit for the well and septic system on this lot. Sincerely, Benjamin Schiller, PE 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.munt.org/0nsite On -Site Water & Wastewater System Permit Permit Number: OSP191464 Work Type: WellSeptic Initial Tax Code Number: 06804133000 Site Legal Address: OVERLOOK ESTATES #2 LT 1 G:0465 Site Mailing Address: Owner: ' MIDNIGHT SUN CONSTRUCTION LLC Design Engineer: FORGE ENGINEERING This permit is for the construction of: Effective Date Expiration Date: Lot Size in Sq Ft Total Bedrooms: 111e�7r n cn riepartt1 ent. 10/18/2019 10/17/2020 55475 IBJ Disposal Field 0 Septic Tank ❑ Holding Tank ❑ Privy Q Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Special Provisions: 1) Atest hole is required prior to construction of the absorption field, located as shown on the site plan. The test hole shall confirm separations to impermeables and seasonal high groundwater, as well as the percolation rate. Construction may proceed at your own risk prior to 7 -day groundwater monitoring. If results require a design change, construction shall stop pending On-site review and approval of a change order. Please submit results with the inspection report (or change order, if applicable). 2) The absorption fields shall be at least 20 ft up -gradient from the cutbank to the road to comply with AMC 15.65.210B.1.e. Received By: Issued By: Date: t Date: �� 1 4 MUNICIPALITY OF ANCHORAGE nd �� �/ p ` U'. Community Development Department= Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On -Site Water & Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 068-041-33 Property owner(s) Midnight Sun Construction Mailing address P.O. Box 210994 Anchorage, AK 99521 Site address NHN Vantage Avenue Eagle River, AK Day phone 727-1433 Legal description (Sub'd., Block & Lot) Overlook Estates #2, Lot 1 Legal description (Township, Range & Section) Lot Size 55,475 Sq. Ft. Number of Bedrooms Four (4) APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑X Initial ❑X Single Family (SF) ❑x (w/wo ADU) Septic Tank ❑X Upgrade EJDuplex (D) ❑ Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑x Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. -o'�'I. a Q"�� (Signature of property owner or authorized agent) Permit/Rush Fees: JJ - 00 Date of Payment: l Receipt Numb�err: 16 l81� Permit No. W Pl Waiver Fees: Date of Payment: Receipt Number: Waiver No. Permit App_" -:•,_.mac, j , 111i U �J PO BOX 240773 ANCHORAGE, AK 99524 522-7773 677-7766 (FAX) October 10, 2019 MOA Development Services Department On-Site Water & Wastewater Program 4700 Elmore Rd Anchorage, AK 99507 Subject: Overlook Estates #2, Lot 1 – NHN Vantage Well and Septic System Design Dear On-Site Services Engineer: The owner of the above lot intends to build a 4-bedroom home on the property. We are submitting this permit application for the construction of a new well and septic system to serve the home. The attached site plan identifies the location of the home as well as the proposed well, septic location and alternate site. No conflicts exist between this proposed system and any other well or septic system, whether on this lot or adjacent lots. The ground surface on the lot slopes to the west, at an approximate 20% slope. There are no slopes steeper than 25% within 50’ down slope of the proposed absorption trenches. Ground contours are shown on the site plan showing the grade and direction of flow. Storm water drainage will not impact this septic system. The new trench will be constructed parallel to the slope as much as possible. Test holes on the lot and in the subdivision indicate coarse gap graded gravel with few fines. The absorption rate of effluent is much faster than 1 minute per inch. A 2’ M.O.A. approved sand liner is required and has been designed in to the system. Wells on this and adjacent lots are shown. The new system will be a minimum of 100’ from all wells and surface water, and more than 5’ away from the septic tank. The alternate site is located more than 6’ away. Please refer to the attached test hole logs, soils lab analysis, 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. 10/10/19 Avenue Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191464, Rebecca Carroll, 10/18/19 460 470 450 FCO 10050 0 FEET 1"=50' 4-BDRM HOME NOTE: SLOPES >25% ARE WITHIN 50' OF THE PROPOSED SEPTIC SYSTEM. THE TRENCHES HAVE BEEN DESIGNED TO MEET THE STEEP SLOPE PROVISION OF THE ORDINANCE. NO SURFACE WATER WITHIN 100' OF THE PROPOSED SEPTIC SYSTEM. ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS PROPERTY ARE SHOWN. NO CONFLICTS WITH WELLS OR SEPTIC SYSTEMS. CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FS - FLOW SPLITTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE LEGEND COMT OVERLOOK ESTATES #2, LOT 1 VANTAGE AVENUE 10/18/19 10' T&E EASEMENT PROPOSED WELL 1,250 GALLON SEPTIC TANK w/20' MANWAY 2-60' LONG x 5' WIDE x .5' EFFECTIVE DEPTH ABSORPTION TRENCHES WITH 2' MOA APPROVED SAND LINER. PROPOSED TEST HOLE NOTE: PLACE TEST HOLE AND COMPLETE PERCOLATION TEST PRIOR TO CONSTRUCTION TO VERIFY SUBSURFACE SOIL CONDITIONS. CO CO CO 2CO SV MH MT FS ALTERNATE SITE Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191464, Rebecca Carroll, 10/18/19 OVERLOOK ESTATES #2, LOT 1 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 10/10/19 DESIGN FACTORS: SYSTEM REQUIREMENTS: 600 GPD PEAK FLOW PERK RATE: <1 MIN/IN APPLICATION RATE: 1.0 GPD/SF 5' WIDE TRENCH SYSTEM 1,250 GALLON SEPTIC TANK 4" PERFORATED PVC (HOLES DOWN) DRAINFIELD ROCK 5' 6" 6" 3' 6" BOTTOM OF TRENCH: 4.0' BELOW GRADE FLOW LINE ELEVATION: 3.5' BELOW GRADE TOP OF TRENCH: .5' ABOVE GRADE 600 GPD / 1.0 GPD/SF /5' WIDE *1.0 RED. FACTOR = 120 LF TRENCH REQUIRED (120 LF SPECIFIED) 2' MOA APPROVED SAND GEOTEXTILE FABRIC Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191464, Rebecca Carroll, 10/18/19 ��U U 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. 068-041-33 1. GENERAL INFORMATION Expiration Date: Complete legal description Overlook Estates #2 Lot 1 Location (site address) N H N Vantage Ave, Eagle River, AK 99577 Current property owner(s) Midnight Sun Construction LLC Day phone (907)727-1433 Mailing address PO Box 210994, Anchorage, AK 99521 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: 4 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ❑■ Private Septic 0 Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ / Date of Payment Receipt Number 0'1532t COSA #_0SG22121-17 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. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm Forge Engineering (M.J.) Phone (907) 522-7773 Address 1399 W. 34th Ave Suite 101, Anchorage, AK 99503 Engineer's Printed Name Benjamin Schiller, P.E. Date 5/17/22 i `'TH 49 '�P9 6. DSD SIGNATURE % .`�_.. System #1 Approved for 4 bedrooms �% BenjamLa/Schiller / System #2 Approved for bedrooms ����srF�. 5/17%222 '�� Disapproved lll\ pROFESSIO Conditional approval for bedrooms, with the following stipulations: rN/ orf A. 6 ON-SITE G, WATER AND �_� WASTLV'ATER z JPRUGKAM f^ 1 JJ �O SER\I\G�G` By: Original Certificate Date: � 20- zZ 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: Overlook Estates #2 Lot 1 Parcel ID: 068-041-33 If more than 1 septic system on lot: COSA Checklist # 1 of 1 Structure served by this system 1 A. WELL DATA limil Well log is filed with Onsite (or attached) Date drilled 7/6/20 Total depth 400 ft Cased to 164 ft no Sanitary seal is functioning correctly ❑® Wires are properly protected Casing height (above ground) 24 in. Date of flow test for COSA 7/6/20 Static water level at beginning of test 120 ft. Comments New construction B. TANK DATA Age of tank(s) `1 Tank type/material _ years Septic/Plastic Measured operating fluid level in septic tank N/A 9 Standpipes/foundation cleanout per record drawing Date of pumping NEW CONSTRUCTION 9/12/21 D. ABSORPTION FIELD DATA Shallow Trench Which system tested (date installed) 9/12/21 © ALL standpipes present per record drawing Total measured depth from grade 4.0/5.3 ft (max) Measured depth to pipe invert from grade 3.5 / 4.8 ft (min) ❑ N/A — pressurized field M 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 _gallons Comments/Deficiencies: NEW CONSTRUCTION 9/12/21 COSA Checklist yellow sheet Well production at time of test 1.5 gpm Water storage tank volume N/A gallons Well disinfected for coliform test? ❑ Yes ❑ No All Coliform bacteria is Negative Nitrate mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by Forge Engineering Date of Sample 5/10/22 TS TATION Requireinti Age of lift station Lift station material Comments: nance completed `- .years Adequacy test date NEW R ults ❑ Pass For bedrooms Fluid dNh prior to test in Water adde gal New depth Elapsed time Final fluid depth in Absorption rate or Any rejuvenation treatment (past 12 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' ❑✓ Yes Community Sewer Manhole/Cleanout > 100' E✓ Yes if No ft M Yes if No ft Neighboring Tank > 100' Q Yes if No ft Private Sewer/Septic Line > 25' F71 Yes if No ft Absorption Field on Lot > 100' ✓/ Yes if No ft Holding Tank > 100' Yes if No ft Neighboring Absorption Fields > 100' Yes if No ft Water Main > 10'✓0 Animal Containment > 50' ❑✓ Yes if No ft [D Yes if No ft Yes if No ft Water Service Line > 10' Yes if No Manure/Animal Excreta Storage > 100' If septic tank is under driveway comment below Community Sewer Main > 75' Q Yes 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' ❑✓ Yes if No ft Surface Water > 100' QQ Yes if No ft Property Line > 5' Yes Yes if No ft Wells on Adjacent Lots: Q Absorption Field > 5'✓Q if No Yes if No ft Private Wells > 100' Yes if No ft Water Main > 10'✓0 ft Yes if No ft Community Wells > 200' 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' Yes if No ft Water Service Line > 10' 0✓ Yes if No ft Community Wells > 200' ❑✓ Yes if No ft Surface Water > 100' Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION I certify that I 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 OF !4Lq�1�� '. BenjarkRr Schiller : ��9 •, CE 12592Am j ��lF• • 6/1/22 • 'F�n.. i�ki,,PROFESS16 ;: