HomeMy WebLinkAboutRIDGECREST HEIGHTS LT 2Onsite File
RIDGECkLmmbST
HEIGHT
PID# 015�4914�13
of M, v " I
I �� �:
(Rev 05102118)
Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP211390
PID Number: 015-491-13
Dwelling: ❑■ Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: 0 New ❑ Upgrade
Name
HOME RENEWAL
ABSORPTION FIELD
X Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound
Site Address
11361 MAEL ST, ANCH
❑ Other
Phone
Number of Bedrooms
Soil Rating
depth from original grade
4
0.8 GPD/SF
JTotal
8.0 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
1.0 Ft.
Gravel depth beneath pipe
7.0 Ft.
Subdivision Block Lot
RIDGECREST HEIGHTS LT 2
Fill added above original grade
2.0+ Ft.
Gravel length
54 Ft.
Township Range
Section
Gravel width
2.0 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
750 Ft2
Ft.
Well
1001+
1001+
501+
TANK IN Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer Capacity
ANCH TANK 1250 Gal.
Surface Water
1()0'+
100'+
Material
Number of compartments
Lot Line
0'+
110'+1
1 0'+
NA
PLASTIC
2
Foundation1
0'+
10'+
I
LIFT STATION
Manufacturer
Capacity
Remarks
Gal.
Alarm location
Electrical installed by
Tank to
PIPE MATERIAL House to tank 3034 d3034
Installer
MIKE N ANDERSON, P.E.
rainfield
Drainfield 3034 CO/MT 3034
Inspector MIKE N ANDERSON, P.E.
BENCH MARK (Assumed elevation) 103.5 ft
Inspdeation 1-' 8/25/22 8/26/22
Location and description
2"tl
TOP OF MANHOLE
3`' 4t
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
Conditional Approval:
•' • • �' qs,�+
Date
��p�
49TH
..........
........ .�
..........
MICHAEL N. ANDERSON ; act
¢
Septic System
Approve � �'�
Date
J,•.• C - 6469 •:��,
Note: this approval does not include
well permit requirements.
1
(Rev 05102118)
Permit No. OSP211390
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: T12N, R3W, SEC 23, S2NE4SE4NW4 PARCEL 25A PID No.: 015-491-04
MARK
A
B
01
15
15
01
25
27
02
30
32
62
32
37
C)3
33
38
04
46
65
C 5
100
73
M T
99
73
/ WELL \\ I \
I
\\ I
WELL
R — C04
CO3\ TJh91 01 ( //
TC
�--" BENCH 40
l
❑9
i II II �
/ II IIS
NEW 250 GALLON_PLASTC TANK
DRIVEWAY
�I
SEPTIC SECTION No WATER o ea FEB 2021
N.T.S.
0
40
49 LH—
...
'•'
:MICHAEL N. ANDERSON;
No. CE 9469
9-7-22
Development Services Department
Building Safety Division
On -Site Water ,& Wastewater Program o
4700 Elmore Road
P.O. Box 196650
Mark Begich Anchorage, AK 99507 s A E' T Y
Mayor www.muni.org/onsite
(907) 343-7904
Pump Installation Log
Well Drilling Permit Number: *SW Date of Issue:
Parcel Identification Number:
Legal Description Property Owner Name & Address:
Pump Installation Date:
8-)-- 2.�,
Pump Intake Depth Below Top of Well Casing: 1 gO feet
Pump Manufacturer's Name: Ftp, U
Pump Model: FPS
S 5�� i �, i�j 3, 00 �30 v. 1056--, 2-w,
Pump Size 3/.� hp
Pitless Adapter Burial Depth: f ( feet
Pitiless Adapter Manufacturer's Name: C_C W150
PitIess Adapter Installer: Ao yh CU I
Well Disinfected Upon Completion?] Yes ❑ No
Method of Disinfection: 1
Comments:
Pump Installer Name: Johnny Kay
Hefty Drilling, Inc.
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
Development Services Department Ll
P p Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Well Log
Permit Number: #_211390 Date of Issue: 9-29-21 Parcel Identification Number:
Date Started: 10-7-21 Date Completed: 10-8-21 Is well located at approved permit location? Yes X No ❑
Legal Description: T12N R3W SEC23 S2NE4SE4NW4 Parcel 25A G:2638
Property Owner Name & Address: Home Renewal Co.
Borehole Data: Depth (ft)
Soil Type, Thickness & Water Strata From To
casing stick up
0
12
overburden
2
14
silt & gravel w/ clay layers
4
160
hard pan
160
190
wet silt & gravel
190
215
coarse gravel w/ H2O
215
220
coordinates
N61°7'6"
W 1490 45'35"
Water Sample Results:
Arsenic: ug/L
Nitrates: mg/L
Total Coliform Bacteria: colonies/100mL
<g -ZZ -22
Method of Drilling n air rotary ❑ cable tool
Casing type: steel
Wall Thickness: •250 inches
Diameter: 6 inches Depth: 220 feet
Liner Type:
Diameter: inches Depth: feet
Casing stickup above ground: 2 feet
Static water level (from ground level): 160 feet
Pumping level: feet after
hours pumping _gpm
Recovery Rate: 20 apm
Method of Testing: airlift
Well Intake Opening Type:
Open End ❑ Open Hole
❑ Screened Start feet Stopped feet
❑ Perforations Start feet Stopped feet
ume:
20' Start 0
20
II Well Disinfected Upon Completion? Yes No II
Method of Disinfection: tabs Comments:
Well Driller: Johnny Kay ❑ ❑
Company: Hefty Drilling, Inc.
Mailing Address: P.O. Box 112130 Anch AK 99511
Attention: The well driller shall provide a well log to the
On-site Water and Wastewater Section within 30 days of
completion.
w
s
0
- I
30' i —O—W Easement
O
M
,/
m
( -
—
W U N Q
VL--
N
o
D x
I
E
QJ N
bA O
O
o
0)
N'
UE
C t C
3 U
D C sem-.
V7N
x
W,--oGo
O
i
-N a
Q
(:�3
w
N
iii
S?
E
c
n
(1 J
T
=
•in
i
:
I
�.
u
v
v
W
O
a
Grove/
�
I
v
`p at
0LO
o Y
< e
_
C> -C
c N 2 C
I
z
,L
O O
..
Rood
}y
00
a'
a
p
Lu E
U
v'
u
e>
a
Q
L Q1
F C
O C
i
?
4 N
a
z
RIDGECREST DRIVE
S 00'00'09" E
10' T&E Easement
O
50' Front Setback
S� 39.2'
I
O
M
165.46'
O C
d- Z3 C
O 0
x v
O :3 o
N I— W
Z ,6'PZ
Ic
o¢
—
W U N Q
VL--
N
o
D x
I
E
QJ N
bA O
O
o
0)
N'
UE
C t C
3 U
D C sem-.
V7N
x
W,--oGo
O
i
-N a
N a
(:�3
w
N
I
S?
c
n
(1 J
O
=
•in
W
a)
�I
I
�.
U
v
W
O
�
I
v
`p at
0LO
W
< e
_
C> -C
c N 2 C
I
z
,L
O O
sz �
E
}y
00
a'
E
p
U
v'
u
e>
a
Q
L Q1
F C
O C
i
?
m
z
((,�.�1�
LJ
z Y
I
h
I
O
M
165.46'
O C
d- Z3 C
O 0
x v
O :3 o
N I— W
Z ,6'PZ
I
E
i
I
50' Rear Se -back
N 00'00'09" W
165.42'
Ic
o¢
—
W U N Q
ul c
CC I ru
N
Q.
D x
N U OC
O
E
QJ N
bA O
Ford�• �'Aw
o
0)
N'
UE
C t C
3 U
D C sem-.
V7N
x
W,--oGo
O
i
-N a
N a
(:�3
w
U
E
S?
J
n
(1 J
O
=
•in
s -+c
O 'U W O
O
u p 3
U
O,^^
o
�
U
0 E 3
v
`p at
< e
_
C> -C
c N 2 C
z
,L
O O
6
E
}y
a'
E
p
N
v'
u
z
Q
L Q1
F C
O C
i
?
m
z
((,�.�1�
LJ
z Y
N O O p
v s
Q
"
O +N-� a ro N
U
Q-�'a
cr
c + n
'p C
L
LE
LL OL
E N ro p
73
y i-+ a SZ
oma
v O
Q
O
z Q v
N C O
o a @
a)
z
=•
LD —C)-
_
Y>- a-
c
N 0-
�f O
Q .24.c
W me p N
ff}
�
U C
—
w U
Z N
@ v
p C
Ut
—
O
cra
w Y °'
z
z c Q c v
"J
N
m a C
U v- lu
O N
�^+�
Os
z
N
w >O
Ui N
DO
LO
I
E
i
I
50' Rear Se -back
N 00'00'09" W
165.42'
Ic
o¢
—
W U N Q
—
N
Q.
D x
0
E
QJ N
bA O
Ford�• �'Aw
o
0)
N'
L
D C sem-.
V7N
x
W,--oGo
O
i
Nj
(:�3
w
w
O
a v c
O
u p 3
N
o
< e
C\2
'
QJ (? N
T
6
E
}y
a'
]C �
Ow
N
v'
u
Z
u p
?
m
c
o
z
co
U
Q-�'a
oma
0 W
3 LU
f
L/
c
o
"To
m
ff}
�
U C
—
w U
Z N
"J
N
m a C
U
lJ`
`
DO
LO
u N uO
'i
UL
bl)r\j
O
ice-+ ro
ly_,
R2
O
LU
U
00
'6 O
C� \9
h�-�--11
o z
m
U
Z
a
c -0-0
I
E
i
I
50' Rear Se -back
N 00'00'09" W
165.42'
Ic
o¢
+
W U N Q
oQ
a¢
Q.
� �oq. a
T
b
�'
QJ N
bA O
Ford�• �'Aw
o
N'
m v�
N
rn
z°
Nj
(:�3
w
p
KC)
C\2
Q.
� �oq. a
cd:)
Q'•
Ford�• �'Aw
o
• S��Qcvo
MUNICIPALITY OF ANCHORAGE renr
Onsite Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 n
http://www.muni.orglonsite
epall rtment n
On -Site Water & Wastewater System Permit
Permit Number: OSP211390 Effective Date: 9/29/2021
Work Type: WellSeptic Initial Expiration Date: 9/29/2022
Tax Code Number: 01549104000
Site Legal Address: T12N R3W SEC 23 S2NE4SE4NW4 PARCEL 25A G:2638
Site Mailing Address: 11361 MAEL ST, Anchorage
Owner: HOME RENEWAL COMPANY LLC Lot Size in Sq Ft: 217800
Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING Total Bedrooms: 4
This permit is for the construction of:
0 Disposal Field 0 Septic Tank ❑ Holding Tank ❑ Privy CSI 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
Received By: "
Issued By:
Date: 2 Z
Date: Z I
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax. 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 015-491-04
Property owner(s) TARAS ILNITSKIY
Mailing address 1120 HUFFMAN RD STE 2, ANCH AK
Site address 11361 MAEL ST, ANCH AK
Day phone
Legal description (Sub'd., Block & Lot) TI 2N R3W SEC 23 S2NE4SE4NW4 PARCEL 25A
Legal description (Township, Range & Section) (PROPOSED RIDGE CREST LOT2)
Lot Size 217,800 Sq. Ft. Number of Bedrooms 4
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
0
Initial 0
Single Family (SF)
0
ADU)
Septic Tank
0
Upgrade El(w/wo
Duplex
❑
(D)
Holding Tank
ElRenewal
❑
Multiple 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: R 20 Waiver Fees:
Date of Payment: c1 q /Z k Date of Payment:
Receipt Number: OI LI70 3 Receipt Number:
Permit No. 0 S P 211 3 9 0 Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
Sept 15, 2021
Municipalities of Anchorage
Departments of Health and Human Services
P.O. Box 196650
Anchorage, Alaska 99519-6650
Fax 249-7847
Re: New septic & well permit
Legal: T12N R3W SEC 23 S2NE4SE4NW4 PARCEL 25A (Proposed Ridge
Crest Subd. Lot 2)
To Whom it may concern:
This is a request for a septic/well permit on the above referenced lot. One test hole
was excavated and found silty gravels (GM) for the entire depth with no water after
the 7 day monitoring period. The perc rate was 10 minutes per inch. The lot has
slope of approximately 10 percent to the west, see site plan. This new system and
well will not impact any of the surrounding neighbors.
Sincerely
Michael N. Anderson, P.E.
4661 Natrona
Anch, Ak 99516
Ph 727-8864
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211390, Deb Wockenfuss, 09/29/21
1"=100'
PROPERTY LINE
PROPOSED
DRAINAGE FIELD
PROPOSED HOUSE
PROPOSED WELL
100' RADIUS
SCALE:
DJRDRAWN:
DATE:
T12N R3W SEC 23 S2NE4SE4NW4 PARCEL 25A
(PROPOSED LOT 2 RIDGE CREST SUBD)
Anchorage, Alaska
TARAS ILNITSKIY
9/15/2021
TEST HOLE
RADIUS
SEPTIC FIELD SECTION
DESIGN CRITERIA:
7.0' EFFECTIVE
4 BDRM X 150 = 600 GPD
SOILS = 600/0.8 = 750 GPD
750 GA/14 = 54'
2.0' WIDE
54' LONG
(1) TRENCH
10.0' DEEP
17
(TH#1)
1.0
GM
ORG 1.0'2.0'
-10.0
-3.0
MOUND OVER
FILTER FABRIC &
SEWER ROCK
3,3(
GRADE
NO WATER MAY 2021
2" INSULATION
SEPTIC
WELL
WELL
WELL
WELL
WELL
WELL
WELL
WELL
WELL
PROPOSED WELL
100' RADIUS
SEPTIC
SEPTIC
SEPTIC
SEPTIC
SEPTIC
SEPTIC
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211390, Deb Wockenfuss, 09/29/21
1"=50'
FCO
PROPERTY LINE
DRIV
E
W
A
Y
PROPOSED WELL
100' RADIUS
SCALE:
DJRDRAWN:
DATE:
T12N R3W SEC 23 S2NE4SE4NW4 PARCEL 25A
(PROPOSED LOT 2 RIDGE CREST SUBD)
Anchorage, Alaska
TARAS ILNITSKIY
9/15/2021
MT
DCO
SLOPE 10%
TCOTH#1
CO
SLOPE 10%
OLD SYSTEM TO
BE
DECOMMMISSIONED
FOR A NEW
SYSTEM
10 UTILITY
EASEMENT
NEW 1250 GALLON
PLASTIC TANK W/
20" RISER, 10'
FROM
FOUNDATION
WELL
CO
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211390, Deb Wockenfuss, 09/29/21
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211390, Deb Wockenfuss, 09/29/21
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. 015-491-13
1. GENERAL INFORMATION
Expiration Date: 1 2 ^ Z3 - Z Z
Complete legal description RIDGECREST HEIGHTS LT 2
Location (site address) 1#346 F _ D0M RD, ANCHORAGE AK
Current property owner(s)
Mailing address
Real estate agent
HOME RENEWAL CO LLC
Day phone
11330 RIDGECREST DR, ANCH AK
2. TYPE OF DWELLING:
E 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
0
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 $ Waiver Fee $
Date of Payment /� (�� Z Date of Payment
Receipt Number 0 d (9 C( Z r Receipt Number
COSA # O SC 2_2 1 q c(L2 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 MIKE N ANDERSON, P.E. Phone 727-8864
Address 4661 NATRONA AVE ANCH AK
Engineer's Printed Name MIKE N ANDERSON, P.E. Date 9-12-22
0
6. DSD SIGNATURE ; 49TH
System #1 Approved for 4 bedrooms..:• .. , „ , _ , • , ,
��• MICHAEL N. ANDERSCNs I�
System #2 Approved for bedrooms ,� �'.
r . CE 945
Disapproved � !} fig'• �.�7 7
N_
Conditional approval for bedrooms, with the following stipulal�����
X PALIT)/
I
mT� ATF "ATF
�O 4, It
i
�i)�'NCES
B &Q -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
Legal Description: RIDGECREST HEIGHTS LT 2
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled 9130121
Total depth 210 ft
Cased to 210 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 155 ft.
Comments
B. TANK DATA
Age of tank(s) NEW years
Tank type/material eB UMOPE
Measured operating fluid level in septic tank 48
❑ Standpipes/foundation cleanout per record drawing
Date of pumping NEW TANK
D. ABSORPTION FIELD DATA new system
Which system tested (date installed) 9126122
❑ ALL standpipes present per record drawing
Total measured depth from grade 10.5 ft (max)
Measured depth to pipe invert from grade 3.5 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 0 gallons
Comments/Deficiencies:
COSA Checklist yellow sheet
Parcel ID: 015-491-13
Structure served by this system
Well production at time of test 5+ gpm
Water storage tank volume 0 gallons
Well disinfected for coliform test? ❑ Yes ❑ No
❑ 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 8/22122
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments.-
Adequacy
omments:
Adequacy test date NEW
Results Q✓ Pass For 4 bedrooms
Fluid depth prior to test 0 in
Water added gal
New depth in
Elapsed time min
Final fluid depth Jn
Absorption rate gpd
Any rejuvenation treatment (past 12 months)
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'
n✓ Yes
if No
ft
M Yes
if No ft
Neighboring Tank > 100'[7✓ Yes
if No
ft
Private Sewer/Septic Line > 25' Yes
if No ft
Absorption Field on Lot > 100' Q Yes
if No
ft
Holding Tank > 100' Q Yes
if No ft
Neighboring Absorption Fields > 100'
0 Yes if No ft
Water Main > 10'✓Q
Animal Containment > 50' 0 Yes
if No ft
M Yes
if No
ft
M Yes if No ft
Water Service Line > 10'
✓V
Yes
if No
ManurelAnimal Excreta Storage > 100'
if septic tank is under driveway
Community Sewer Main > 75' Yes
if No
ft
M 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'
Q✓ Yes if No ft
Property Line > 5'
Yes
Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
Q✓
Yes
if No
ft
Private Wells > 100'
0 Yes if No ft
Water Main > 10'✓Q
ft
Yes
if No
ft
Community Wells > 200'
M Yes if No ft
Water Service Line > 10'
✓V
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'✓Q
Yes
if No
ft
Private Wells > 100' Yes if No ft
Water Service Line > 10'
F71
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
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
gas OF 41 '
00 ,49TH • Y` ',
. F
Py y^• MICHAEL N. ANDERSCN
%• CE 945 ?•`
�::r'.