HomeMy WebLinkAboutMG LT 3BMG
Lot 3 B
#051-045-02
/ Municipality of Anchorage
Development Services Department,:
Building Safety Division
On-Site Water and Wastewater Program, 4700 Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650 Page/ Of 3
www.ct.anchorage.ak.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number:SWO602cf2 PID Number. OKI— Olt—O2_
Nanw
F 1A/
Wastewater System: New ❑Upgrade
�G K E
ABSORPTION FIELD
/ e
PIW's 90'r Number of •orooma�
T..ih D Sl,, o Trend D lied O Mount D 00w
LEGAL DESCRIPTION
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Inspections performed by: "fAh IP4 Dates: 1" YhfOS
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.....
2n° ! 6
.....
Development Services Department Approval
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Reviewed and approved by: Date: 3 7 — O
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FFOM : MICHREL COJINJ MISTFUCTIDI PrDNE 110. : 307 6344356 Feb. 23 20Y 11:06FiM P1
Certifieb Orirring log
by
Doc co. du
SULLIVAN WATER WELLS
P.O. BOX 670272, CHUGIAK, ALASKA 99687 -TELEPHONE 680.2759
OWNER OFLAND: _M/Kc 0j &J'J
ADDRESS:
LEGAL DESCRIPTION: M A Sy4,0 4-a 7 3
DATE �/ 7 1
PERMitNUMBER-0-SQ e?f'a.fknie of tme&.-Ja -
TAX IDENTIFICATION NUMBER: 01 - o g .
Is well located at approved permit location?� O No
Method of Drilling: 6e_r0tary U cable tool
Depth of well: /04'
Casing Type Ct, Wa'I Thickness inches
/r
Diameter /I inches, depth ��� feet
liner Type: /JJ..Jc
Casing Stickup Above Ground: °�' feet
Static Water Level: S feet
Recover Rate:S�O ggpm
Method of Testing: - A A
Well Intake Opening Type: wJ'tfpen end O open hole
...P SFreened; Startfeet Stepped feet
O Perforations Slant - felt ocoad feet
Grout Type: �c U r J•'J rTa"" VVc!u nn/') rx Wit
Depth: fromy feet, too� 1 J feet
t�
Well Disinfected Upon Completion? 'Z'Yes U No
Mothed of Disinfection: C HA,)Aj , c SDJ / /77
Comments:
/Y�
CrfS..tJc 17-1cF JD _
y c2k.4JS..
}lit t D/A•./ . ...._
'fs SIIvd i_`j.FR J.� L [•tJn i
r
Driller's Name _/3,��-1—�— _
ATTENTION: It is the responsit:ility of the property owner to submit a Copy of line well 4 to the proper author.ty. Municip Jity
of Anchorace: Department of Health & Human Services and'or Department of Env'ronvmental Conservation. MatSu Boroi at
Department of Environmenta: Conservation.
MUNICIPALITY OFANCHORAGE
Development Services Department
On -Site Water 8 Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM / WATER SUPPLY PERMIT
Initial
Permit Number: SWO50282
Legal Description: MG SUBDIVISION LOT 3
Date Issued: Aug 12, 2005
Expiration Date: Aug 12, 2006
Parcel ID: 051-042-23
Design Engineer: 0838 North Rim Engineering Site Address: NHN GRASSER ROAD
Owner Name: MIKE OUINN Lot Size: 189150 SO. FT.
Owner Address: P.O. BOX 772641 Total Bedrooms: 3 Permit Bedrooms: 3
EAGLE RIVER. AK 99577 -
This permit is for the construction of:
❑✓ Disposal Field ❑✓ Septic Tank ❑ Holding Tank ❑ Privy ❑✓ Private Well ❑ Water Storage
All construction must 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 engineer must notify DSD at least 2 hours prior to each Inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By:
Issued By:
Date:
Date: o �2
f of
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907)343-7904
ON-SITE SEWERIWELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. %- 64a a3 Permit Number SW
ZD
A lie
Day phone C%^ 4/%cc
Property owner(s) it:
Mailing addressl o. 772;Y/
t�� Zip Code 9577
1�/
Site address :�ylssm' ('VlaN
Ju Zip Code
Legal description (Lot, Block & Sub'd.)
Legal description (Section, Township & Range)
Lot Size Acre-q.Ft
Number of Bedrooms
THIS APPLICATION IS FOR:
Sewer Only ❑
Well Only ❑
Sewer and Well
Water Storage ❑
Sewer Upgrade ❑
THIS PROPERTY CONTAINS:
Hot Tub ❑
Jacuzzi ❑
Swimming Pool ❑
Water Softening Unit ❑
Therapy Pool ❑
I certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
7
(Signature of property owner or
Receipt Number: 'I (`tS r(,(LAT Receipt Number:
(Rev. 09104)
�ItNMNGING
Northitim Engineering
17237 Bear Paw Circle
Eagle River, AK 99577
907.694-7028
August 9, 2005
MOA On -Site Water & Wastewater Program
4700 Bragaw St
Anchorage, AK 99519
RE: Septic System Design & Nater Well Siting, AIG S/D, Lot 3
The subject lot is being developed. The owners wish to replace immediately. The soil test
was excellent.
Some of the neighboring lots are developed. This site should not negatively impact any of
the other area lots. The slope is relatively flat, sloping to the north.
Please review the wastewater system design for the 3 bedroom single family home. I
have included design plans & specs, design guidelines, & soil tests. If there is need for
additional information or clarification please give me a call.
Steve Eng, PE, PH
Design Enclosures
bTI��Vf _
ENGINEERING
SPECIFICATION'S & DESIGN GUIDELINES
MG S/D, Lot 3
Wastewater System Sizing:
This is a new single family home @ 3 bedrooms. This requires a new 1000 gallon septic tank.
The lot is very large; over 4 acres in size as are neighboring lots. Some of the neighborhood lots
have been developed as shown on drawing. The area subdivisions are served by private water
wells. No adverse impacts are expected from septic system development. A new water well is
also sited. The area of the septic system is relatively flat, and then slopes to the north with a
slope under 25%. No conflicts to any neighbor lots is anticipated. The test hole revealed a sandy
soil with a percolation rate below 1 min./inch; over 50% of the soil is sand. An application rate
of 1.2 GPD/FTz with 0.5 reduction factor for utilizing a 5' wide trench was utilized.
Specification Requirements:
All components and work must comply with the Municipality of Anchorage Specifications
(AMC) & State of Alaska Drinking Water Regulations and Wastewater Regulations.
• Two compartment, 1000 gallon septic tank.
• Watertight couplings on inlet & outlet.
• 5 foot minimum between the tank and bed. 10 foot to property lines.
• 3 feet of cover or insulation is required for trench; an equivalent of I" insulation for each
foot soil cover.
• Tank & solid pipe must be set on well compacted, stable soil.
• 4 inch diameter cleanouts with airtight caps are required 1 to 4 feet from foundation wall,
prior to any 90 degree bend in 4 inch line, in each tank compartment, and two adjacent
opposing cleanouts between the tank and the absorption field, not more than 10 feet from the
tank positioned to provide cleanout access towards the tank and towards the absorption field.
• All cleanouts must extend to at least ground level.
• In solid pipe runs, ASTM D-3034 may be used in lieu of cast iron.
• Trench to be placed level, minimum of 4 feet to groundwater, 6 feet to bedrock from drain -
rock.
• Drain rock to be 1/2 inch to 2 %x inch screened. Drain rock to be distributed uniformly
throughout the trench.
• Perforated pipe to be installed level with perforations down.
• Silt barrier (filter fabric) to be installed above the drain rock.
• Smeared trench sides must be raked or scarified before drain rock placement.
• Backfill over drain rock must not be less than 36".
• The finish grade must be mounded to promote drainage over the trench.
• Insulation must be placed over any pipe installed under driveways or parking areas.
• Approved pipe materials include cast iron, PVC ASTM D3034, PVC ASTM F789, ABS
ASTM D2661,
• Sewer Service Line is minimum 2% slope.
• Septic Tank to be pumped every two years or when required.
• Insulation board to be extruded direct burial polystyrene (Dow Styrofoam III or equal)
DESIGN NOTES:
1.
Total Depth of Trench is 7.5'
from
surface. Terrain slopes
toward the north.
2.
Sewer Service Line minimum
2% slope.
3.
Trench is Minimum 10'
from
Lot Line.
4.
Lots Served by Private
Water
Wells.
A "� I00
•_
GRASSER
,• 330.00IF-
pyyie
11' 49 b+< f+nTR.967 V+SE]
Vacant
m +i
K
NORTHRIM
ENGINEERING
17237 Bear Paw Circle
Eagle Piver, Alaska 99377
907.694.7028
Septic System Construction
Does Not Preclude Adjoining
Lots From Sanitation
Improvements.
1000 Gallon
Septic Tank Proposed
Septic System
.c.a
to +S.e) 1 tpuc 234-18
n�
,♦Ma L
V A 1.L
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M G SUBDIVISION
LOT 3
SUBDIVISION LAYOUT
LOT PLAN
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S❑ILS LOG - PERC❑LATI❑N TEST
TH I� M
ENGINEERING
Performed For: Mike Quinn
Date Performed: 7/27/05
Legal Description: MG Subdivision, Lot 3
DEPTH
(FEET)
Comments:
Organic T.H. Location: See Attached Design
Elevated Bench In Rear of Property
SP
Sand
w/ Gravel Groundwater? No
Depth --
Water Depth
Ar+e,• Mr,r,t+n, lnnNnna flnta: A/3/O9
# jDate
Gross Time
Net Time
Depth
Net Drop
1
8/3
0
3
3'
--
2
8/3
2
4 -
5.5'
2.5'
3
8/3
5
5
3'
--
4
8/3
7
2 min
5.5'
2.5'
5
8/3
1 10
--
3'
--
9
-
'Q ''•'
10
5.5'
2.5'
11
;�r.....
12 -
13 -
:: •.
14 -
15 -
16 -
17 -
18 -
19 -
20
-
21
-
Comments:
Organic T.H. Location: See Attached Design
Elevated Bench In Rear of Property
SP
Sand
w/ Gravel Groundwater? No
Depth --
Water Depth
Ar+e,• Mr,r,t+n, lnnNnna flnta: A/3/O9
# jDate
Gross Time
Net Time
Depth
Net Drop
1
8/3
0
--
3'
--
2
8/3
2
2 min
5.5'
2.5'
3
8/3
5
--
3'
--
4
8/3
7
2 min
5.5'
2.5'
5
8/3
1 10
--
3'
--
6
8/3
1 12
2 min
5.5'
2.5'
Percolation Rate <1 min./Inch Perc Hole Diameter 6'
Test Run Between 3' and 4'
Performed By NorthRim Eng. I C
Performed in Accordance with All
ON THIS DATE. DATE, 8/3/05
NORTHRIM
I ENGINEERING
17237 Becr Pow Circle
Eagle River. Alaska 99377
907.694.7028
_ CERTIFY THAT THIS TEST WAS
to/Municipal Guidelines in Effect
TESTH❑LE
GE❑TECHNICAL
T. H. 1
Dote:
8/3/051 of 1
MUNICIPALITY OF
Development Services Department r
On -Site Water & Wastewater Section
Parcel I.D. 051-045-02
Certificate of On -Site Systems Approval
1. GENERAL INFORMATION
Complete legal description MG LT 313
Location (site address) 21901 Grasser Rd
Current property owner(s) Cindy Wilson
Mailing address
Real estate agent
Cindy Wilson
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
Expiration Date:
Phone: 907-343-7904
Fax: 907-343-7997
.- �k (, - 2-0 2-(
Day phone 244-1930
Day phone 244-1930
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
0
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 $ ( U.5-0 (COV) D ^ 1 1 ) Waiver Fee $
Date of Payment (0-21— 2-0 Date of Payment
Receipt Number 09,3N 7 9 Receipt Number
COSA# O S c a o 153 1 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 NorthRim Eng. Phone 694-7028
Address PO Box 770724, Eagle River
Engineer's Printed Name Stere Eng pate 10119120
OFAr
Ar
:* :49
8. DSD SIGNATURE f
Iwl16l1tjPt7"
System ##t Approved for bedrooms 's� �, steVQkP Q
CE -6256
System #2 Approved for bedrooms
1Q/3'%2Y
Disapproved
Conditional approval for bedrooms, with the following stipulations:
,,t<<t,ttt(trrrr.,.
m VVAST`V'ATER
f'V�n�%
Original Certificate Date:_] 0 eco` ZQ
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations green 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 pfofossional Engineer's work.
7. ATTACH M E NTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisary Other
Legal Description: MG LT 3B
If more than 1 septic system on lot: COSA Checklist #
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled 8119'05
Total depth 104 ft
Cased to 104 ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) 24 in.
Date of flow test for COSA 10/16/20
Static water level at beginning of test 46 ft.
Comments
B. TANK DATA
Age of tank(s) 15 years
Tank type/material sepli,Sl
Measured operating fluid level in septic tank 5
❑ Standpipes/foundation cleanout per record drawing
Date of pumping 10/12/20
D. ABSORPTION FIELD DATA 11/17/05
Which system tested (date installed) same
❑ ALL standpipes present per record drawing
Total measured depth from grade 7.5 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 gallons
Comments/Deficiencies:
COSA Checklist yellow sheet
Parcel ID: 051-045-02
of Structure served by this system
Well production at time of test 6+ gpm
Water storage tank volume 0 gallons
Well disinfected for coliform test? ❑ Yes Al Nc
❑ Coliform bacteria is Negative
Nitrate mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L Al Arsenic less than MRL (ND)
Collected by NRimEng
Date of Sample 10/15/20
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 10/16/20
Results ❑✓ Pass For 3 bedrooms
Fluid depth prior to test 0 in
Water added 450 gal
New depth 28 in
Elapsed time 37 min
Final fluid depth 30 in
Absorption rate 450 gpd
Any rejuvenation treatment (past 12 months) no
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'
[E]
Yes
Community Sewer Manhole/Cleanout > 100'
Q Yes
if No
ft[7,/
Yes
if No ft
Neighboring Tank > 100' Yes
if No
It
Private Sewer/Septic Line > 25' 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
Animal Containment > 50' Q Yes
if No ft
Q Yes
if No
It
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' n-, Yes
if No
It
n Yes
if No It
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' El Yes if No It Surface Water > 100'✓ Yes if No ft
Property Line > 5'
[E]
Yes
if No It
Wells on Adjacent Lots:
Absorption Field > 5'
Q
Yes
if No ft
Private Wells > 100' Yes if No.
Water Main > 10'
Private Wells > 100' Yes if No
Yes
if No ft
Community Wells > 200' Yes if No.
Water Service Line > 10'
ff
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' S 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'
El,
Yes
if No
ft
Private Wells > 100' Yes if No
Water Service Line > 10'
Yes
if No
ff
Community Wells > 200' Yes if No
Surface Water > 100'
Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
/ certify that / 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.
Steve Eng
CE 6256 f
st:: L0 Z 3'Z cr
i-NUNEER S
ft
ft
ft
It
S1710C •eopl
Municipality of Anchorage
Development Services Department
Building Safety Division
Onsite Water and Wastewater Program , • r
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.orglonsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. n S/— D yS- o2 — COSA # O O O 5�
Expiration Date: & — 7— 06
1. GENERAL INFORMATION
Complete legal description /lilr, VfAt //,('W r L a % 35
Location (site address) Gt-Gsser kol
Current Property owner(s) IBI L_, Q t it, Day phone 6 94{-11440f
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Z
Day phone
1�P_e _n,� Day phone
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding Tank
❑
Community On-site
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an Independent professional civil
engineer registered In the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also Issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval
are valid for 90 days from the date of Issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. 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 Onsite 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 Stale codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm Noriq, 1`,,., E..,y Phone !L,/- 7 0 ZP
Address/7d37 a, -l -/e
Engineer's Printed Name s'S i E��e�Af C Date e-7 1Z Z /Oc
44.
5. DSD SIGNATURE v� "c s""`"wA
e� u :••• PE 6156
✓ Approved for bedrooms. `r�9F�'•••....••
Disapproved. G ��ima i
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
B c Original Certificate Date: 3'" 7 - O
(R•V. 11105)
Municipality of Anchorage
• i' Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 19MM
Anchorage, AK 99519.66M
www.muni.orglonslte
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: lNe ZSZ4 L'Of j a Parcel ID: _0 S/_ oMs- 02
A. WELL DATA
Well type
Date completed .,F/l ?/pS
Total depth /dy ft.
If A. B, or C provide PWSID #
Sanitary seal (Y/N) V
Cased to _,10�ft.
FROM WELL LOG
Date of test - /
Static water level
Well production S g.p.m.
WATER SAMPLE RESULTS:
Well Log (YM)
Wires properly protected (Y/N)
Casing height (above ground) n.
AT INSPECTION
AJ 4Z&J
ft.
Coliform --O--colonies/100 mL Nitrate O. mg/L(u j Other bacteria CJ colonies/100 mL
Arsenic: S $ jn cu) Date of sample:,'Z L'* 2/7/0toilected by.Pr n
B. SEPTICMOLDING TANK DATA
Tank Type/Material a 0&406 7401 5; 7"6ej.
Tank size /d O Q gal. Number of Compartments Z_
Foundation cleanout (YM) Depression over tank (YM) 'r
Date of pumping Pumper
Date installed /I 6 7�/J S-
Cleanouts (YM)
High water alarm (YM) At
C. ABSORPTION FIELD DATA
Date installed r, Soil rating (g.p.dR oi�arm) _� System type r _4At/C tV
Length 2 ft. Width S ft. Gravel below pipe_ ft.
Total depth 7.T ft. �E�ff..-a"b"sorption area 310 fe Monitoring tube __Y__ Depression over field
Date of adequacy test — Results (Pass/Fail) /VAJ For 3 bedrooms
Fluid depth in absorption field before test _ in. Water added_ gal. New depth_ in.
Elapsed Time: _ min. Final fluid depth _ in. Absorption rale >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (YM & type) If yes, give date
D. LIFT STATION
Date installed Size In gallons Manhole/Access (Y/N)
'Pump on". level _ in. 'Pump off" level at _ 1 High water alarm level in.
Datum Cycles tested Meets alarm 8 a uiremenis?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic lankAift station on lot Ida rf-
Absorption field on lot /OG .I-
Public
iPublic sewer main A114
Sewer /septic service line 6'01
Animal containment areas
On adjacent lots / d O If
On adjacent lots 10 G
Public sewer manhole/cleanout N�A
Holding tank At f4
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation _?0 rt" Property line /O rf" Absorption field --S J4
Water main N f,4 Water service line d r•f Surface water 00 '+
wells on adjacent lots 0 G r t
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line /0 •f Building foundation 2 O rr Water main
i
Water Service line /Q f Surface water /oorr Dmveway parkinglvehide storage /Q If
I�
Curtain drain � Wells on adjacent lots _baa
F. COMMENTS
G. ENGINEER'S CERTIFICATION
."�1`:' ��,• + '•;.lid
I certify that l have determined though field Inspections and �° r.: ^. '• T a ; r ld
review of Municipal records that the above systems are in • t',
conformance with MOA COSH guidelines in effect on this date.
Engineer's Printed Name l E%F_ l v `� : si`P 6 W. E. ° `''✓
2�(' '•• PE 625 ••: �,: r+
Date 2 12 2- duJ"c. • •• F•
L.. F@5d`
COSA Fee $ -#=JJ:V .5- 7 , S C Waiver Fee $
Date of Payment ,Z - 2 Y- 0 t, Date of Payment
Receipt Number Receipt Number
(Rev. I M) 0 7 % .Z. 0 7 .',i/J
ASBUILT
I HEREBY CERTIFY THAT I HAVE SURVEYED THE SCALEt
FOLLOWING DESCRIBED PROPERTY -'r�� •SOF A(14%
14�7G tUf' LoT3B DATE P� ,:9s
AND THAT NO ENCROACHMENTS EXIST EXCEPT AS �: ' ' '•
INDICATED. IT IS THE RESPONSIBILITY OF THE t I H
OWNER TO DETERMINE TH' EXISTENCE OF ANY GRID ' ••• e
EASEMENTS, COVENANTS, OR RESTRICTIONS .dwss8 i vlssN. riG:f....�
WHICH DO NOT APPEAR ON THE RECORDED SUBDI-•. Omens Merk Ss+erd /
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD FB' t •� 15-6918�+
ANY DATA HEREON BE USED FOR CONSTRUCTION �1 ° c;:'
skxu�
OF FENCE LINES' OR FOR ESTABLISHING BOUND-
ARY LINES.