HomeMy WebLinkAboutNESTER LT 1Onsite File
Municipality of Anchorage IZOZ 91 Nhr
On -Site Water and Wastewater Section • (907) 343 < 04 Page" k of 3
ON-SITE WASTEWATER INSPECTION REP
Vnugrupa Permit Number: OSP201455 PID Number: 051-171-39
(Dwelling: ❑ Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑E Upgrade
Name
Sunova Beach Services, Inc.
Site Address
19337 Ganoe Street Chugiak, AK 99567
Phone Number of Bedrooms
907-727-5279 4
LEGAL DESCRIPTION
Subdivision Block Lot
Nester 1
Township Range Section
SEPARATION DISTANCES
To Septic Absorption Holding Sewer
From
Tank Field Lift Station Tank Line
Well 1>100'1 >100' 1>100'1 N/A 1>25'
Surface Water 1>100'1>100'1>100'1 N/A
Lot Line 1 >5' 1 >10' 1 >5 1 N/A I NA
Foundation 1>10'1 > 10' I >10' I N/A
Remarks
Installer
JR's Septic
Inspector J. Millette
BSORPTION FIELD
X Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound
❑ Other
Soil Rating Total depth from original grade
0.8 GPD/SF 11.5 Ft.
Depth to pipe invert from original grade Gravel depth beneath pipe
3.5 Ft. 8.0 Ft.
=ill added above original grade Gravel length
1.0 Ft. 47 Ft.
3ravel width Beds: Number of Lines Distance between lines
3.0 Ft. Ft.
total absorption area Number of trenches Dist. between trenches
752 Ft2 1 Ft.
TANK ❑ Septic 0 S.T.E.P. ❑ Holding ❑ Other
vlanufacturer Capacity
Greer 1,500 Gal.
Vlaterial Number of compartments
Plastic 2
LIFT STATION
vlanufacturer
Greer
alarm location
Downstairs utility room
Capacity
250 Gal.
Electrical installed by
DRS Electric
PIPE MATERIAL House to tank D3034 Tank to D1785
drainfield
Drainfield D1785 CO/MT D3034
BENCH MARK (Assumed elevation) 100 ft
Inspection 151 12/3/20 2�a 12/8/20 Location and description
3'd 4,h Bottom of siding @ point B.
ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp
Conditional Approval:
OF
Date .••••... 9S�®N
AF
� ,49th
ft... . ... ®®
...............
Septic System 06-1.
MICHAEL E. ANDERSON •°'�vc
T:° NO. CE -4381 ��\��mp
Approve V, `" Date '-2°t 2C �� F,p°••.° 1/11/21 ,,>•''C�.
Q,
Note: this approval does not include well permit requirements. ®� ®®®r� F®SS®U®�®'�
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PERMIT -'.. . . OSP201455
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| T15N FNW SEC 18 LIT
' |
'
EXISTING CRIB DECOMMISSIONED
IN PLACE PER U.P.C.
���Fl��O��1_17�_q(�
'---'' ~~' '' ' °°
47LONGxTvNoEx8'
EFFECTIVE DEPTH
ABSORPTION TRENCH.
�
~'
�--�MH2 2CO'
PT3 ILOT 2
THI
�
. `
°mm
1,500 GALLON
EXISTING SEPTIC TANK
DECOMMISSIONED IN
MEN
Lu
Lu/
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LU
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NEIGHBOR\ING
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ALTERNATE SITE: CATEGORY III
SYSTEM nN�----^Gx�""^`~Ex4'
EFFECTIVE DEPTH ABSORPTION
NEIGHBORING
~~.~ '~
AREA
' || m/ ---------- ExISTNGmEuL
11�NF�yVSE��IS[]F�8
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A B C D
GE||
' ||
PLAN AS -BUILT
0 40 80
LEGEND
2CO-DOUBLE CLEANOUT
FCO ' FOUNDATION CLEANOUT
MH'MANHOLE
MT'MONITORING TUBE
PT'pERC.TEST
TH'TEST HOLE |
MEN
LEGEND
2CO-DOUBLE CLEANOUT
FCO ' FOUNDATION CLEANOUT
MH'MANHOLE
MT'MONITORING TUBE
PT'pERC.TEST
TH'TEST HOLE |
PERMIT # OSP201455
102.7 -
PID # 051-171-39
UU.-t
107.2 FINISH GRADE
106.2 ORIGINAL GRADE
`11�_ NO GROUNDWATER 10/13/20
88.7
r
(-
PROFILE AS -BUILT
(NO SCALE)
'4
All RGE
`- 102.7
OF
49th -
MICHAEL E. ANDERSON
No, CE -4381
44SOFESV:�t'O
DRAINFIELD ROCK
94.7 944.71
47'
`11�_ NO GROUNDWATER 10/13/20
88.7
r
(-
PROFILE AS -BUILT
(NO SCALE)
'4
All RGE
`- 102.7
OF
49th -
MICHAEL E. ANDERSON
No, CE -4381
44SOFESV:�t'O
SOILS LOG AND PERCOLATION TEST
E N G I N E E R I N G
LEGAL DESCRIPTION: NESTER LOT I
PERFORMED FOR: DANIEL BENTON
DATE: 12/9/20 PROJECT No.:
PARCEL ID#: 051-171-39 TECHNICIAN: J. MILLETTE
DEPTH
(feet)
1 -
2 -
3 -
4-
5-
6-
7-
8-
9-
10-
11-
12-
13-
14-
15-
16-
17-
18-
19-
COMMENTS:
PERC. TEST #3 1
SLOPE
® �
�• 49th
.. .. ..... .... .
....e.I.... s..........u......uu...
L 61ICHAEL E. ANDERSON
�0���TO,•. NO. CE -4381 •°��
111121 •• C�
®�®S®ice®®
Professional Engineers Stamp:
SITE PLAN
WAS GROUND WATER ENCOUNTERED?
READING
IF YES @ WHAT DEPTH?
L
WATET O NNET
(INCHES)
DEPTH TO WATER AFTER MONITORING:
0
DATE OF MONITORING:
P
10:30
6:10
E
6
DATE
READING
GROSS TIME
(MINUTES)
NET TIME
(MINUTES)
WATET O NNET
(INCHES)
DROP
(INCHES)
12/9
1
10:30
6:10
4-°� /10�°-�
6
2
10:38
7:02
4-s /100
6-1
3
11:25
10
411 / 9 -s
5 16
4
11:37
10
416 /9-s
5-1
5
11:55
10
4-1 /916
5-s
6
12:08
10
4-1 /916
516
PERCOLATION RATE: 1.97 (MIN/INCH) PERC. HOLE DIA. 6 (INCHES)
TEST RUN BETWEEN: 3 FT. and 4 FT.
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: OSP201455
Work Type: Septic Upgrade
Tax Code Number: 05117139000
Site Legal: Address: NESTER LT 1 G:1155
Site Mailing Address: 19337 GANOE ST, Chugiak
Owner: SUNOVA BEACH SERVICES INC
Design Engineer: FORGE ENGINEERING
This permit is for the construction of:
Effective Date
Expiration Date:
Lot Size in Sq Ft:
Total Bedrooms:
,mss
t�Cl]AI'tI11CI1C
10/27/2020
10/27/2021
31068
Q Disposal Field Q 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
cc -*t 1 12-/q/to E F Clan e-� +0 8 PM kl
Received By: L'�v
Issued By:
10/27/20
Date:
Date: D 2 z0
3
MUNIMPALITY OF ANCHORAGE
€ v ti111_
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. 051-171-39
Property owner(s) Sunova Beach Services, Inc. Day phone 727-5279
Mailing address 2111 East 37th Avenue Anchorage, AK 99508
Site address 19337 Ganoe Street Anchorage, AK
Legal description (Sub'd., Block & Lot) Nester, Lot 1
Legal description (Township, Range & Section)
Lot Size 31,068 Sq. Ft. Number of Bedrooms Three (3)
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 1ZUpgrade ❑X
Duplex ❑
(D)
Holding Tank ElRenewal ❑
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.
(Signature of property owner or authorized agent)
Permit/Rush Fees: y y 6. 256- Co V11)
Date of Payment: 10-2-3-2-0
Receipt Number: 0 7 2 Ci+ S-
Permit No. OS P 2-0 J `i 55_!5
Permit App_:- : •
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
December 3, 2020
M.O.A. Development Services Department
On -Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
Subject: Nester, Lot 1 —19337 Ganoe Street
Septic System Design
Dear On -Site Services Engineer:
A three-bedroom house is currently in place on the subject lot. The owner has requested a new
septic system be constructed sufficiently large to serve a four-bedroom home. We are submitting
this design and permit application for the placement of a new septic system. An existing well is
currently in place and will continue to serve the house. The attached site plan identifies the location
of the home and the existing well. The proposed septic location is also shown. No conflicts exist
between this proposed system and any other well, water service lines or septic system on this lot
or adjacent lots.
The ground surface on the lot slopes to the west at a 10% grade in the area of the proposed system.
No septic tank or absorption system could be found on the lot. If they are located during
construction the existing septic tank will be decommissioned per U.P.C. There are no slopes
greater than 25% within 50' of the absorption trench. Ground contours are shown on the Site Plan
indicating the grade and direction of flow.
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, PE
<2/500
IW
W
U)
W
O
Z I
U
`\ E;
i MICHAEL E. ANDERSON
No, CE -4381
i��F�j'. ••. 12/4120 •o••••
%oftFESS\QN�,
N ESTER, LOT 1
T15N RTW SEC 18 LT 8
NEIGHBORING SEPTI
AREA
i EXISTING WELL
II -I
(I I T15N RTW SEC 18 LT 38
I
II II
II II
II
I I I I
I
1
\\
Go-4rI
47' LONG x T WIDE x 8'
EFFECTIVE DEPTH
ABSORPTION TRENCH.
ALTERNATE SITE:
CATEGORY III SYSTEM
w/15' LONG x 5' WIDE x 4'
EFFECTIVE DEPTH
ABSORPTION TRENCH.
APP. RATE 5 GPD/SF.
• I
I
i
I
LTLO�T 2
LEGEND
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEANOUT
FS - FLOW SPLITTER VALVE
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
NESTER, LOT 1
DESIGN FACTORS:
600 GPD PEAK FLOW
PERK RATE. 11.2 MIN/IN
APPLICATION RATE: 0.8 GPD/SF
SYSTEM REQUIREMENTS:
8' DEEP TRENCH SYSTEM
1,500 GALLON S.T.E.P. TANK
cam I
600 GPD / 0.8 GPD/SF / 8' DEEP / 2 SIDES = 46.88 LF TRENCH REQUIRED (47 LF SPECIFIED)
1.5' per nEp'
BOTTOM OF TRENCH: BELOW GRADE
FLOW LINE ELEVATION:3.5' BELOW GRADE
TOP OF TRENCH: 0.5' ABOVE GRADE
LE FABRIC
RATED PVC (HOLES DOWN)
'Diameter Holes @
cing.
!FIELD ROCK
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
FI-IMGE
1 f( E N G 1 N E E R I N G
\..,/
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 1
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)
NESTER LOT 1
10/5/20
J. Millette
DATE OF MONITORING:
WAS GROUND WATER ENCOUNTERED?
DEPTH TO WATER AFTER MONITORING:
IF YES @ WHAT DEPTH? -
2.0 6
5 6
051-171-39
Daniel Benton
5:33
10/6
1
2
3
6:03
6:34
1' OB
Professional Engineers Stamp:
10/23/20
No
None
10/13/20
9 m
9 m 15 s
9 m 30 s
5 0
16 / 11 0
16 6 0
16
4
5
6
5:33
6:03
6:34
10
10
10
5 0
16 / 11 0
16
5 0
16 / 11 0
16
5 0
16 / 10 8
16
5 0
16 / 10 0
16
5 0
16 / 10 0
16
6 0
16
6 0
16
5 8
16
5 0
16
5 0
16
GM
GM
GM w/ORGANICS
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201455, Deb Wockenfuss, 10/27/20
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)
NESTER, LOT 1
10/5/20
J. Millette
DATE OF MONITORING:
WAS GROUND WATER ENCOUNTERED?
DEPTH TO WATER AFTER MONITORING:
IF YES @ WHAT DEPTH? -
11.2 6
3 4
051-171-39
Daniel Benton
5:33
10/6
1
2
3
6:03
6:34
1' OB
Professional Engineers Stamp:
10/20/20
No
None
10/13/20
30
30
30
4 4
16 / 7 0
16
4 4
16 / 6 15
16
4 4
16 / 6 15
16
2 12
16
2 11
16
2 11
16
GM
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201455, Deb Wockenfuss, 10/27/20
4Q
Lot 8
N39°59'37"E 188.29
x
1 ' Tele. & Elec. Easement
CA
SheP c� —i
CD
O
L
CD
0
0
O
C)
C
P�
C(8hed
��T 1
/chimney .
link fence (iyp)
4-0 OH�r
.s.
6,0 k
rV
rS 1-]
L
*Gate breve! driveway 3Q p
3� O
1-
shed
O
LCA
CD
CI
Co0
Cp
9° ' "E 188.29
Nate; No septic vents or wel I were
Lot 38 found at this time
• 49th ••
90 ••op
00
Fr ,Fred 'Walatkia
• $
-S ;
F
EASEMENTS OF RECORD, OTHER THAN
THOSE SH0M ON THE RECORDED
PLAT ARE NOT SHOWN HEREON.
F8 17-2, pg 24
BE
A6.IDUILT NO CORNERS SET THIS DATE
C hMby bditlly Chia I have pvHf )r^ia4 r1p1
awrn
a itgpedwn
of Che tollQ deeri4ad rC�perty' L _
Aochorege Ramming 06104. AIMPA. and VW IM
Imprwemer11e ertualed Oereon are wlthlri 14 prvpmty line■
arld do not Owed Ap or encroach on Ins pragrty IV ing
ad}awnt thereto. tha' no mpravemCh
enLs on e property
adjacenth
thereto encroach an the prom In quegtJon ana
That niers are no rowwApip. trpn6ru4agn IIng4 of other
YUkle -easement& on said propertp except as Indlcalea
14man
CkMW at Ane"rggo. Aleake
INS L41h,tlmy 0 MARCH _, 24T7,
FREDWALATKA A AS5OCWES
Eroneere erd Surwyors
t407 -2#9-189b}
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water & Wastewater Section
Certificate of On -Site Systems Approval
Parcel I.D. 051-171-39
1. GENERAL INFORMATION
Phone: 907-343-7904
Fax: 907-343-7997
Expiration Date: L' Z q z
Complete legal description Nester, Lot 1
Location (site address) 19337 Ganoe Street Anchorage, AK
Current property owner(s) Daniel Benton
Mailing address
Real estate agent
Day phone 727-5279
2111 E. 37th Avenue Anchorage, AK 99508
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS:
4
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.
COSA Fee $ 280
Date of Payment 1 t7
Receipt Number 0 351 h
COSA # OSC211017
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 Phone (907) 522-7773
Address 1399 W. 34th Ave Suite 101, Anchorage, AK 99503
Engineer's Printed Name Michael E. Anderson, P.E. Date 1/15/21
OF
ff
49th •'®*:
6. DSD SIGNATURE v•'•"", ....�.............. .......I...
®T c UZ,�
System #1 Approved for bedrooms vd � rdICHAEL E. ANDERSON . ;
CE -4381 =a
System #2 Approved for bedrooms ®°s�F'••. 1/15/21 ,.••'�`�'`
Disapproved °! a°@e�m®Sa®A,•��
Conditional approval for bedrooms, with the following stipulations:
By: VV,_ 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: Nester, Lot 1 Parcel ID: 051-171-39
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) Well production at time of test 4.7 gpm
Date drilled Unknown Water storage tank volume None gallons
Total depth *46.2 ft Well disinfected for coliform test? ❑ Yes ❑ No
Cased to '40 ft ❑ Coliform bacteria is Negative
❑ Sanitary seal is functioning correctly Nitrate mg/L ❑ Nitrate less than MRL (ND)
❑ Wires are properly protected Arsenic ug/L ❑ Arsenic less than MRL (ND)
Casing height (above ground) 3** in. Collected by Forge Engineering
Date of flow test for COSA 11/17/20 Date of Sample
Static water level at beginning of test 38.6 ft.
Comments *Lowest static level during test **Concrete slab around casing
10/27/20
Well located under stairs in house.
Moisture sensor installed on floor slab with alarm to notify occupants of leak. Alarm in upstairs closet.
B. TANK DATA
Age of tank(s) <1 years
Tank type/material STEP/Plastic
Measured operating fluid level in septic tank New
❑ Standpipes/foundation cleanout per record drawing
Date of pumping Installed 12/3/20
D. ABSORPTION FIELD DATA Deep trench
Which system tested (date installed) 12/8/20
❑ ALL standpipes present per record drawing
Total measured depth from grade 12.5 ft (max)
Measured depth to pipe invert from grade ft (min)
❑ N/A — pressurized field
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective
C. LIFT STATION
❑ Required maintenance completed
Age of lift station `1 years
Lift station material Plastic
Comments: Installed 12/3/20
Adequacy test date New Construction
Results ❑ Pass For bedrooms
Fluid depth prior to test in
Water added gal
New depth in
Elapsed time min
❑ Code -required soil cover over field Final fluid depth in
❑ System presoaked Absorption rate gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months)
date of test) If yes, enter date
Gallons introduced gallons
Comments/Deficiencies:
Absorption trench constructed 12/3-8/2020.
COSA Checklist yellow sheet
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'
0
Yes
Community Sewer Manhole/Cleanout > 100'
® Yes
if No
ft
Q Yes
if No ft
Neighboring Tank > 100' 0 Yes
if No
ft
Private Sewer/Septic Line > 25' 0 Yes
if No ft
Absorption Field on Lot > 100' 7 Yes
if No
ft
Holding Tank > 100' F71 Yes
if No ft
Neighboring Absorption Fields > 100'
El Yes if No ft
Water Main > 10'✓Q
Animal Containment > 50' M Yes
if No ft
0 Yes
if No
ft
✓� Yes if No ft
Water Service Line > 10'
El
Yes
if No
Manure/Animal Excreta Storage > 100'
If septic tank is under driveway comment below
Community Sewer Main > 75' [DYes
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'
0
Yes
if No
ft
Surface Water > 100'
Q Yes if No ft
Property Line > 5'
Yes
Yes
if No
ft
Wells on Adjacent Lots:
✓l
Absorption Field > 5'
71
Yes
if No
ft
Private Wells > 100'
El Yes if No ft
Water Main > 10'✓Q
ft
Yes
if No
ft
Community Wells > 200'
✓� Yes if No ft
Water Service Line > 10'
El
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'
[Z]
Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
P/1
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
✓l
Yes
if No
ft
Private Wells > 100' ®✓ Yes if No ft
Water Service Line > 10'
FV -1
Yes
if No
ft
Community Wells > 200' Q✓ Yes if No ft
Surface Water > 100'
0
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
1/16/20
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