HomeMy WebLinkAboutGOLDEN VIEW HEIGHTS LT 4C1Onsite File
Golden View
Heights
Lot 4C1
#020-042-55
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Pump Installation Log
1-IJeR DrMing Pcwinil Number: SN8 Dale of Issue:
Parcel Identification Number. 0
LcWal Dc!wripdon Property Omvner Nann- & Address:
GAW (V 0 01) (1
9-Y
PP fristallation W
1ptake Depth Bcloxvrop of I.Vell Casing: L -,)U fect
Pvinp Manufacturer's Name,
pump 'Model: /(:'(%
PUDIP sizr. hp
Pitim, Adapter Burial Depth, I k `,'eget
I Pitless Adapter- Installer:
Wefl DjSi-'JfCCNA COM-PletiOtA? U'irs -j; Nu
Method of DisinfMiow.,
Comments: t-, �,-s
I Pump Installer Name:
Attention. The pump iristalley stall pv.-Videapump Aillstalladwi eg, -,..D the DSD M -hi -i 210 day. (.,f PLL.-'np instadator,
Municipality of Anchorage
On-Site Water and Wastewater Section • (907) 343-7904 Pagd of
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP191529 PID Number: 020-042-55
Dwelling: ® Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ® Upgrade
Name
JAMES M FEJES
ABSORPTION FIELD
❑ Deep Trench ® Wide Trench ❑ Bed ❑ Mound
Site Address
6241 GOLDEN WOOD LANE, ANCHORAGE
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
6
1.2 GPD/SF
6 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
2 Ft.
Gravel depth beneath pipe
4 FL
Subdivision Block Lot
GOLDEN VIEW HEIGHTS 4C1
Fill added above original grade
VARIES 2.31- 2.52 +/- Ft.
Gravel length
2 @ 38' 76 Ft.
Township Range section
Gravel width
5 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
760 Ft2
2
10+ Ft.
Well
1 QQ'+
1 QQ'+
25'+
lZ Septic [IS.T.E.P. El Holding El Other
Manufacturer
Manufacturer
GREER
Capacity
1500 & 1000 Gal.
Surface Water
1001+
1001+
Material
HDPE
Number of compartments
1 & 2
Lot Line10'+
10'+
NA
Foundation
10'+
10'+
LIFT STATION
Manufacturer
Capacity
Gal.
Remarks Undoc, system decommissioned per code.
Well documented with attached COSA submittal.
Alarm location
Electrical installed by
Installer A+
PIPE MATERIAL House to tank 3034 Tank to 3034
drainfield
Drainfield 3034 CO/MT 3034
Inspector FWC
BENCH MARK (Assumed elevation) 100 ft
Inspectionddates: 1s 1/28/2020 1/29/20
Location and description
2�d
3'd 1/30/20 4'" 01/31/2020
BOTTOM OF SIDING
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
�.�.®
-� °�a
Conditional Approval: Date
.t�,�.���
���p.,.•'
•• TH
"' .
• Curtis Huffman :
Septic System"
Approve r 2
�+— t Date — Z- ea?
�� �'F�• CE 128991
�0c�s -
2/�/�020 . •ti�c�.®
�PROFESSIONP
OPROFIiSSOW'a`
..�
Note: this approval does not include well permit requirements.
kmev 05102_i8)
GOLDEN VIEW HEIGHTS LOT 4C1 PID: 020-042-55 PERMIT:
LOT 4A
A -C=35.3'
B -C=37.3'
A -D=38,2'
B -D=36.4'
A -E=40.6'
B -E=35.9'
A -F=45.1'
B -F=36,0'
A -G=68,7'
B -G=56.1'
A -H=84.5'
B -H=72.7'
A -I=67.7'
WELL RADII
STAKED
CONST.
TH19-1
C MT G
TH19-2 H COIF
RESERVE
u -I
ESMT.
91.53
1,500 GALLON
1-COMPART.
HDPE TANK
OSP191529
o;
rn I
DCO B
F �
E 0 EXISTING
MT
C of 0 BM HOUSE s
0 1 J MT A
0
DECOMMISSIONED _ 06)
UNDOCUMENTED - �-
SYSTEM & INSTALLED
NEW 1500—GAL SINGLE o
COMPARTMENT & 1000—GAL '
SEPTIC TANKS
W/ NEW FIELDS
SCALE, 1' = 30'
CO
DCO CO 97.09 CO DCO
91.19
90.8190.44 'amu
1.000 -GALLON
HDPE TANK
SEPTIC SECTION
SCALES NTS
MT
FINAL GRADE
FILTER FABRIC TH19-1
& INSULATION
ORG/OL
87.08
SEWER ROCK 4•
83.08 -/am -9P
88.23 CO MT FINAL GRADE CO MT 88.41
85.92
ORIGINAL GRADE
FILTER FABRIC DRY
& INSULATION 12/18/19
3.9 8'2 83.97 BOH
SEWER ROCK 4• 89.9
79.92 79.92 RELATIVE ELM
B -I-72.1' GOLDEN VIEW HEIGHTS LOT 4C1
A -J=49.0' PREPARED FOR:
B -J=57.4' JAMES M FEJES
6241 GOLDEN WOOD LANE
ANCHORAGE, AK 99516
FIRST WATER CONSULTING
13030 Sues Way su E:
Anchorage, Alaska 99516 DRAWN:
(907)350-9566 SCALE:
firstwaterAKOgmail.com
TH19-2
GRND. WTR.
012. 12/18/19
W/ 88.82 ELEV.
SUPPORTSERVICES:
OFAL
• O�
C 9 TH
02/06/2020 > tis Huffmane
LCG CE 128991 �`�
FWCS 01 /31 /2020.x'
1" = 30' FEssioll
12/23/19
F P('i N
MUNICIPALITY OF ANCHORAGE
Development Services Department -343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 020-042--55
Property owner(s) JAMES M. FEJES Day phone 907-331-8556
Mailinq address PO BOX 113064, ANCHORAGE, AK 99511
Site address 6241 GOLDEN WOOD LANE, ANCHORAGE, AK 99516
Legal description (Sub'd., Block & Lot) GOLDEN VIEW HEIGHTS LOT 4C1
Legal description (Township, Range & Section)
Lot Size 94,870 Sq. Ft. Number of Bedrooms 6
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption FieldX❑
InitialX❑
Single Family (SF)
(w/wo ADU)
Septic Tank
®
Upgrade 7XDuplex
(D) ❑
Holding Tank
ElRenewal
F]Multiple
Dwellings ❑
Privy
❑
(SF and/or D)
Private Well
❑
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.
FWCS - Brent Western
(Signature of property owner or authorized agent)
Permit/Rush Fees: 5?6-
Date of Payment: nLL/?! 17
Receipt Number: 03491& D
Permit No. 0,9 P&M.9
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
Michael N. Anderson, P.E.
Civil/Structural Engineering and Construction
4661 Natrona Ave. Anchorage, Alaska 99516
Phone 345 -3377 / Fax 345 -1391
Support Services
Brent M. Western
907-440-4601
December 23, 2019
Municipalities of Anchorage
On-Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
RE: NEW SEPTIC SYSTEM PERMIT
LEGAL: GOLDEN VIEW HEIGHTS LOT 4C1
Weve been requested to obtain a septic permit on the above referenced lot that currently has an
undocumented system, which will be decommissioned per code. We propose to install two
shallow trenches to serve the 6-bedroom property, which per the owner includes the guest cabin.
The design is based on the recent test holes conducted on December 11, 2019.
The slopes are moderate at 10-17% at the proposed septic location. The lot and area are served
by private water. The design will not impact any of the neighboring properties. Please contact
Brent M. Western or me if you have any questions.
Sincerely,
Michael N. Anderson, P.E.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP191529, Rebecca Carroll, 12/23/19
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP191529, Rebecca Carroll, 12/23/19
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP191529, Rebecca Carroll, 12/23/19
Michael N. Anderson, P.E.
Civil/Structural Engineering and Construction
4661 Natrona Ave. Anchorage, Alaska 99516
Phone 345 -3377 Fax 345 -1391
SOILS LOG - PERCOLATION TEST
LEGAL DESCRIPTION: GOLDEN VIEW HTS. LOT 4C1
PERFORMED BY: FWCS / MNA - I MIKE N. ANDERSON CERTIFY THAT THIS TEST WAS
PERFORMED IN ACCORDANCE WITH ALL STATE & MUNICIPAL GUIDELINES IN EFFECT
ON THIS DATE. DATE: 12/18/19
DEPTH
FEET
OG
SOILS
1
ORG/OL
2
3
4
5
6
7
8
SP/sm gp
Trace of silt w/
9
occ. cobbles to 6
sand/silt inc. w/ depth
10
11
12
13
14
15
16
17
BOH
18
19
20
Reading Date Gross
Time
Net
Time
Depth to
Water
Net
Drop
12/11/19 10 min 5/16 5 11/16
10 min 4/16 5 12/16
10 min 4/16 5 12/16
10 min 5/16 5 11/16
10 min 6/16 5 10/16
10 min 5/16 5 11/16
PERCOLATION RATE 1.7 (MIN / INCH)
TEST RUN BEWTWEEN 4 & 5 FT
PERC HOLE DIAMETER 6
PRE-SOAKED PRIOR TO TEST & ALL READINGS TO
THE 1/16TH. 6 WATER START DEPTH PER READING.
GROUND WATER ENCOUNTERED: NO
IF YES, AT WHAT DEPTH: NA
DEPTH TO WATER AT MONITORING: DRY
DATE: 12/18/19
TESTHOLE # 19-1 DATE PERFORMED: 12/11/2019
SEE SITE PLAN FOR SLOPE & LOCATION
COMMENTS:
VERIFY GROUNDWATER MT
AT TIME OF CONSTRUCTION
PERFORMED FOR: MATT OSTRANDER
12/18/19
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP191529, Rebecca Carroll, 12/23/19
Michael N. Anderson, P.E.
Civil/Structural Engineering and Construction
4661 Natrona Ave. Anchorage, Alaska 99516
Phone 345 -3377 Fax 345 -1391
SOILS LOG - PERCOLATION TEST
LEGAL DESCRIPTION: GOLDEN VIEW HTS. LOT 4C1
PERFORMED BY: FWCS / MNA - I MIKE N. ANDERSON CERTIFY THAT THIS TEST WAS
PERFORMED IN ACCORDANCE WITH ALL STATE & MUNICIPAL GUIDELINES IN EFFECT
ON THIS DATE. DATE: 12/18/19
DEPTH
FEET
OG
SOILS
1
ORG/OL
2
3
4
5
SP/sm gp
Trace of silt w/
6
occ. cobbles to 6
sand/silt inc. w/ depth
7
8
9
10
SM/ml
11
12
13
14
15
BOH
16
17
18
19
20
Reading Date Gross
Time
Net
Time
Depth to
Water
Net
Drop
12/11/19 10 min 0 6
10 min 0 6
10 min 2/16 5 14/16
10 min 1/16 5 15/16
10 min 2/16 5 14/16
10 min 2/16 5 14/16
PERCOLATION RATE 1.6 (MIN / INCH)
TEST RUN BEWTWEEN 3 & 4 FT
PERC HOLE DIAMETER 6
PRE-SOAKED PRIOR TO TEST & ALL READINGS TO
THE 1/16TH. 6 WATER START DEPTH PER READING.
GROUND WATER ENCOUNTERED: YES
IF YES, AT WHAT DEPTH: 13
DEPTH TO WATER AT MONITORING: 12
DATE: 12/18/19
TESTHOLE # 19-2 DATE PERFORMED: 12/11/2019
SEE SITE PLAN FOR SLOPE & LOCATION
COMMENTS: TH19-2 IS 5-6 LOWER IN ELEVATION
THAN TH19-1
VERIFY GROUNDWATER MT
AT TIME OF CONSTRUCTION
PERFORMED FOR: MATT OSTRANDER
12/18/19
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP191529, Rebecca Carroll, 12/23/19
W
6
5
.
1
'30.4'3
8
.
2
'
14.3'4.2'22.5'18.4'4.1'14.1'18.4'2.1'22.9'
EXISTING
HOUSE
GUEST
HOUSE
GARAGE
20.3'
2
0
.
2
'
20.3'
2
0
.
1
'38.0'38.0'32.1'
32.1'
SHED
SHED
N00° 03' 09"W 329.64'S00° 03' 00"E 329.60'N89° 59' 32"E 259.06'
S89° 59' 05"W 104.64'S89° 59' 05"W 94.50'
R=50.00'L =6 4 .3 5 'N00° 03' 09"W 140.00'N89° 59' 32"E 200.00'N00° 03' 09"W 140.00'25'25'CLEAN OUT 99.1'118.0'
10' UTILITY EASEMENT
10' UTILITY EASEMENT
10' X 20' UTILITY EASEMENT
JADEWOOD CIRCLE
GOLDEN WOOD LANE
29.1'
62.6'60.0'71.8'
55.4'
100.6'
41.4'99.1'46.8'44.5'16.0'26.3'36.9'60.1'LOT 4C1
LOT 1C LOT 3A2
LOT 4C2
LOT 4C3
LOT 5BLOT 5A1
LOT 4B
LOT 4A
94,870 SQUARE FEET
2.18 ACRES
PARCEL ID:
020-042-55-000
LOT 5A2
28,000 SQUARE FEET
0.64 ACRES
PARCEL ID:
020-042-52-000
N89° 59' 32"E 200.00'
NOTES:
1.THIS DRAWING SHALL NOT BE MODIFIED FOR USE
AS A PLOT PLAN WITHOUT THE EXPRESSED
WRITTEN CONSENT OF LCG LANTECH.
2.ZONING IS R-7 FOR BOTH LOTS. SINGLE-FAMILY
RESIDENTIAL, MINIMUM SIZE 20,000 SQUARE FEET.
3.AREAS SHOWN ARE FROM MOA PROPERTY CARDS.
CLEAN OUT
WATER WELL
FENCE
Gravel
Concrete
Overhang
Wood Deck
LEGEND:
DRAWN DATE:
DRAWN BY:
SCALE:
CHECKED BY:
11/29/2019
SC
ADS/AP/OP
1"=40'
PLAT:
WORK ORDER:1277.01
71-157
FB/PG: 816/43
GRID:SW3238
ORDERED BY:MATT OSTRANDER
SURVEY CERTIFICATION: LCGLANTECH, INC HAS CONDUCTED A PHYSICAL
SURVEY OF THE PROPERTY AS SHOWN ON THIS DRAWING AND CERTIFIES
THAT THE IMPROVEMENTS SITUATED THEREON ARE WITHIN THE
PROPERTY LINES AND NO ENCROACHMENTS EXIST OTHER THAN NOTED.
EXCLUSIONARY NOTE: IT IS THE OWNERS' RESPONSIBILITY TO DETERMINE
THE EXISTENCE OF ANY EASEMENTS, COVENANTS, RESTRICTIONS OR
RIGHT-OF-WAY TAKINGS WHICH DO NOT APPEAR ON THE RECORDED
SUBDIVISION PLAT. UNDER NO CIRCUMSTANCES SHOULD ANY DATA
HEREON BE USED FOR CONSTRUCTION, FOR ESTABLISHING PROPERTY
LINES, OR FOR PLOT-PLAN PURPOSES.
250 H Street
Anchorage, Alaska 99501
Survey Department
Phone: 562-5291
Mainline
Phone: 243-8985
AECC 668
LEGAL
DESCRIPTION:
W
XAS-BUILTADDRESS:
6241 GOLDEN WOOD LANELOTS 4C1 & 5A2
GOLDEN VIEW HEIGHTS
SUBDIVISION
EPLAMS
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. 020-042-55
1. GENERAL INFORMATION
Complete legal description GOLDEN VIEW HEIGHTS LOT 4C1
Expiration Date: rJ
Location (site address) 6241 GOLDEN WOOD LANE, ANCHORAGE, AK 99516
Current property owner(s) JAMES M FEJES Day ,hone
Mailing address
Real estate agent
PO BOX 113064, ANCHORAGE, AK 99511
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. /NUMBER OF BEDROOMS:
6
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER
DISPOSAL:
Private Well
®
Private Septic
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.
i
COSA Fee $ o`�� Q
Waiver Fee $
Date of Payment 2(,%�a4?15
Date of Payment
Receipt Number CoO 0
Receipt Number
COSA #ySG 12616QO
Waiver # i
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 FIRST WATER CONSULTING Phone 907-350-9566
Address 13030 SUES WAY, ANCHORAGE, AK 99516
Engineer's Printed Name CURTIS HUFFMAN, PE Date 2/4/2020
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. 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 in land use, OF A tl�
local soil characteristics, groundwater levels that may fluctuate during the year, quality of �t '�V • " ' f�`l
construction (workmanship & materials), the water usage of the family being served by the �•`�• •' • • : 1.A
system and maintenance. 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 f_49 TM '• !�
well and septic system. Therefore, any estimate of how long a system will function satisfactory 1 • • .. " . • • • • • • .... .
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting & FWCS ( • • • • • •
rj
/ Curtis Huffman
6. DSD SIGNATURE
VX'
2/4/2020
CE 128991 c�`4//
j �Vsf • . 2/a/Zo2o . • � "�
System #1 Approved for bedrooms r�l�F�PRpFESS10�P���".4001
�'
System #2 Approved for bedrooms
Disapproved
1
Conditional approval for bedrooms, with the following�Gtsi�i�! pF ��/i�`��ir
AS
��TFU. M
v\IX Original Certificate Date: Z' �3 ^ 7L'Z_0
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
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Other
Legal Description: GOLDEN VIEW HEIGHTS LOT 4C1 Parcel ID: 020-042-55
If more than 1 septic system on lot: COSA Checklist # —_of _ Structure served by this system _
A. WELL DATA
® Well log is filed with Onsite (or attached)
Date drilled CIRCA 1960
Total depth 135'+ ft (PER ACOUSTIC READING)
Cased to 40+ ft
® Sanitary seal is functioning correctly
® Wires are properly protected
Casing height (above ground) 12+ in.
Date of flow test for COSA 12/12/2019
Static water level at beginning of test 52 ft.
Well production at time of test 1.9 gpm
Comments
B. TANK DATA — NEW TANKS
Age of tank(s) 0 years
Tank type/material SEPTIC / HDPE
Measured operating fluid level in septic tank
® Standpipes/foundation cleanout per record drawing
Date of pumping
D. ABSORPTION FIELD DATA — NEW FIELDS
Which system tested (date installed) 1/31/2020
® ALL standpipes present per record drawing
Total measured depth from grade 8.52 ft (max)
Measured depth to pipe invert from grade 4.52 ft (min)
❑ N/A — pressurized field
® Monitor tubes go to bottom of effective. If not, state
depth into effective
® 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:
Water storage tank volume NA gallons
Well disinfected for coliform test? ❑ Yes ® Nc
® Coliform bacteria is Negative
Nitrate mg/L ® Nitrate less than MRL (ND)
Arsenic ug/L ® Arsenic less than MRL (ND)
'
Collected by Fwcs
Date of Sample 12//12/2019
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date
Results ❑ Pass For bedrooms
Fluid depth prior to test in
Water added gal
New depth -in
Elapsed time min
Final fluid depth in
Absorption rate gpd
Any rejuvenation treatment (past 12 months)
If yes, enter date
FW'
C5
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 if No ft
Wells on Adjacent Lots:
Community Sewer Manhole/Cleanout > 100'
® Yes
if No
ft
® Yes
if No
Neighboring Tank > 100' ® Yes
if No
ft
Private Sewer/Septic Line > 25' ® Yes
if No
Absorption Field on Lot > 100' ® Yes
if No
ft
Holding Tank > 100' ® Yes
if No
Neighboring Absorption Fields > 100'
Surface Water > 100'
® Yes
Animal Containment > 50' ® Yes
if No
® Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ® Yes
if No
ft
® Yes
if No
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' ® Yes if No ft Surface Water > 100'
ft
ft
ft
ft
ft
® Yes if No ft
Property Line > 5'
® Yes if No ft
Wells on Adjacent Lots:
Absorption Field > 5'
® Yes if No ft
Private Wells > 100' ® Yes if No _
Water Main > 10'
® Yes if No ft
Community Wells > 200' ® Yes if No _
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'
® Yes
if No
_ ft
Wells on Adjacent Lots:
Water Main > 10'
® Yes
if No
ft
Private Wells > 100' ® Yes if No ft
Water Service Line > 10'
® Yes
if No
ft
Community Wells > 200' ® Yes if No
Surface Water > 100'
® Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
OF A
i
I certify that 1 have determined through field inspections and review �A-Q•: • • • • • • ����q
of Municipal records that the above systems are in conformance �?' •:�
with MOA COSA guidelines in effect on this date. •: • • 71'I • • • ::
.... .... ....�......
Curtis Huffman
(�1�F�, •. CE 128991
i is�� • . ,2/6/202Q • ����
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