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HomeMy WebLinkAboutUPLANDS PH 3 LT 6Onsite File 3 -,,lands Ph" Y�> Municipality of Anchorage On-Site Water and Wastewater Section • (907) 343-7904 Page 2 of 2 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP201480 PID Number: 050-474-69 Dwelling: ❑ Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: W New ❑ Upgrade Name tom} ;_So� ABSORPTION FIELD ❑ Deep Trench FMI Wide Trench ❑ Bed ❑ Mound Site Address 'at «d \ 20925 Upper Lowland Avenue ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 4 1.2 GPD/SF •�_ Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 2.5 Ft. Gravel depth beneath pipe 4.0 Subdivision Block Lot Uplands #3 6 Ft. Fill added above original grade 2.2 Ft, Gravel length 50.0 Ft. Township Range Section Gravel width 5.0 Ft. Beds: Number of Lines N/A Distance between lines N/A Ft. SEPARATION DISTANCES To Septic Absorption I Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field ! I III Tank Line 500 Ftz 1 N/A Ft. Well ( N/A N/A i NA I NA N/A TANK Septic F-1S.T.E.P. El Holding ❑ Other Manufactu er Greer Capacity 1250 Gal. Surface Water 100'+ 1001+ NA NA Material Number of compartments Lot Line I 51+ 10'+ j NA NA NA Plastic 2 Foundation 10'+ 101+ NA NA LIFT STATION Manufacturer Capacity Remarks Gal. Alarm location Electrical installed by Installer PIPE MATERIAL House to tank 3034 Tank to 3034 drainfield Pomraning Excavation Drainfield 3034 COIMT3034 Inspector Pannone Engineering BENCH MARK (Assumed elevation)100 ft Inspection ection v 5/08/2021 5/10/2021 Location and description 2"d 3'd 5/12/2021 4t Daylight Basement Foundation Footing ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional Approval: DateOFA A � . Z�,�� 9TH�� Septic System Approved Date 1.2 j pZ� _9-. CE 81,19 > �� sT `o ���,' m �F Note: this does /rOrESSO-Al. approval not include well permit requirements. in ., natnota Q� -I K ' l n -rt 0 ^ ^ '-1 <-,"'m"ov�=� z CC) �;O o -i P X x m< -00 rO Z z 0 2 A Z O O m 0 o o rr) O c D > Z cc) rpz {n z m z o m: Rt D O� �m In A mp D r -i - Z 7 cm 'D N < fill, z m 7, m (ti NOTES: RECORD DRAWINC DRAWN LJC SITE PLAN - cn 00 c cn K x cn D cn -0 -i z cn -0 m-[ XO mD0 <� � -i DD m p Z O cn m - z • rc' Dr C7� cn mD - N m.. (N N - 00 n � vcp Z -Jrn.P --1 z m � ACD r?t-x U-rt D0 N� A N Q�m (-n cn 'D CI 0 - ,P0 m 00 y 0) -. O W W J -P -. rn 0) 00 0) 00 W N W - n P N N N Cf) �1 m Ii ! Gr :r, J -P N J (ti NOTES: RECORD DRAWINC DRAWN LJC SITE PLAN - cn 00 c cn K x cn D cn -0 -i z cn -0 m-[ XO mD0 <� -i DD m p Z O cn m - z • rc' Dr C7� cn mD - Irl (J} m.. mn� DJm> -<G7 — �Op 00-DiJDDN0 � Z D O --1 z m � r?t-x U-rt D0 N� A N Q�m (-n FF, \\ �e Do O N.. m p0� n�G m D U) I .0-0 rn m m m - O ~ 'S o Z 0 O cl) rn T' O C-) C-) rn -� 0 0 o m- n Z7 0 Cf) OD_� Jp 2ODC)z c,)mZ00 D=pOlm D \rm;vc o c� ` ;0 m �? D < 0moo m �Cr)o� D O MZ ;0 m -*) D D 0r --0M C) p ;0 -rI 'u-IZK m O D r_ ! z' CD ::j n m0D Z;0 ZZ C O t p cn n �'6Z• A m t t ✓ -t O O z 00 j J t ? m D —O" N c7 m p S t -� C) 07 it l '" \r \ \ _ \•� If � // Orn r/ O \ \ _z 0 l P=ONE ENG SVC LLC. (Ci.'. 1088) REVISIONS DATE P.O. BOX 1807 PALVIER, AK 99645 , �E OF gCgs l 20210622 PHONE 907) 745-8200 FAX (907) 745-8201 r�P' SCALE UPLANDS PHASE 3 LOT 6` vi el 17-01 1" 50' �... ... � P.I.D. NO SITE: 20925 UPPER LOWLAND AVE 050-474-69 _ SMITH FAMILY IRREVOC TRUST . s°° R. °°°°°' c ce-alas : PERMIT NO. 10441 STEWART DRIVE E SNOEP201480 EAGLE RIVER, AK 99577 °',« 1 of 2 m Z U) O cn'-, F— CFi cn ONm r \ � FT1 r?t-x D nity oJm FF, \\ Ut D CD (n m mOOZ00 on o�� Oma ~ - m > �N mcn ` 0OoO rDDm(n f� O C-) C-) mmo Pi z f� o m pcf) C) m- ` \i ON mm 0-D OD_� Jp ! Gr DO / V / mU > pZ �) s� 7 _ N . M> �7 D Z ! o r 2ODC)z c,)mZ00 D=pOlm D \rm;vc o c� ` ;0 m �? D < 0moo m �Cr)o� D O MZ ;0 m -*) D D 0r --0M C) p ;0 -rI 'u-IZK m O D r_ ! z' CD ::j n m0D Z;0 ZZ C O t p cn n �'6Z• A m t t ✓ -t O O z 00 j J t ? m D —O" N c7 m p S t -� C) 07 it l '" \r \ \ _ \•� If � // Orn r/ O \ \ _z 0 l P=ONE ENG SVC LLC. (Ci.'. 1088) REVISIONS DATE P.O. BOX 1807 PALVIER, AK 99645 , �E OF gCgs l 20210622 PHONE 907) 745-8200 FAX (907) 745-8201 r�P' SCALE UPLANDS PHASE 3 LOT 6` vi el 17-01 1" 50' �... ... � P.I.D. NO SITE: 20925 UPPER LOWLAND AVE 050-474-69 _ SMITH FAMILY IRREVOC TRUST . s°° R. °°°°°' c ce-alas : PERMIT NO. 10441 STEWART DRIVE E SNOEP201480 EAGLE RIVER, AK 99577 °',« 1 of 2 40.0' A in 7.0' m�N 17.0' N N O 4.0' 23.0' N O 27.0' N O W in 2.0' cri r v N 00007'25"E 114.25' 39.0' v 3111-4 £°4� S xs, N cn N rn c_Q ^ 64 m 5; Z C) 0 g O to rn rn � a 0 � N 00007'25"E 276.45' K Fol v OD A OD CO -u N W 0 O rn N V 'T� cy) r tL7 W a K 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: OSP201480 Work Type: Septic Initial Tax Code Number: 05047469000 Site Legal Address: UPLANDS PH 3 LT 6 G:0057 Site Mailing Address: 20925 UPPER LOWLAND AVE, Eagle River Owner: SMITH PHYLLIS FAMILY IRREVOC Design Engineer: PANNONE ENGINEERING SERVICES This permit is for the construction of: Effective Date Expiration Date �1»erl( 61 V r J. DeI)artill ell t Lot Size in Sq Ft: Total Bedrooms: 12/1/2020 12/1/2021 43066 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 '/ql2, Co .4c 1�l� mo✓-�- Received By: Issued By: Date: Date: S Z E IVI"UNICIPALITY OF ANCHORAGE Community Development Department_w 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. 050-474-69 Property owner(s) SMITH FAMILY IRREVOC TRUST Day phone Mailinq address 10441 STEWART DR, EAGLE RIVER, AK 99577 Site address NHN UPPER LOWLAND AVE, EAGLE RIVER AK 99577 Legal description (Sub'd., Block & Lot) UPLANDS PH3 L6 Legal description (Township, Range & Section) Lot Size 43,066 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑X Initial N Single Family (SF) ❑X (w/wo ADU) Septic Tank IRUpgrade ❑ Duplex (D) F-1Holding Tank ❑ Renewal El 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: 446. 25 Waiver Fees: Date of Payment: 1 1 I I 1 I a o) -C) Date of Payment: Receipt Number: O `i 313 6 Receipt Number: Permit No. OJ1 019 $O Waiver No. Permit App_:- :- :' ., c G-4- 1 Steven R. Pannone, Principal Registered Professional Engineer E-mail: steve@panengak.com May 3, 2021 Subject: UPLANDS PH3 L6 Septic System Permit Request Design Narrative This is a design narrative for a permit to install an initial septic system to be issued for this property. The proposed system will serve a proposed four-bedroom (4) bedroom house. Currently the lot is undeveloped. A 1250G septic tank will be installed with a conventional absorption field. This lot and the surrounding developed lots will be served by a public water system. Required separation distances to any wells will be maintained. I. Soils. One test holes was performed in the vicinity of the firld by PES and groundwater monitoring was performed. Groundwater was observed at a depth of 10.5 -feet in May 2021. Based on the results of the percolation tests and overall soils appearance; an application rate of 1.2 gallon/day/square feet was used for a conventional wastewater system in the area of the test hole. 2. Soil Absorption System Design. a. See Sheet 1 of the design package. 3. Surface Water: There is no surface water within 100 feet of the proposed septic tank and drain field. The proposed drain field upgrade will maintain at least 100 feet from all surface water. The mapped drainageway on the lot is dry and remained dry with no surface water through the snowmelt in April 2021. 4. Topography: The existing topography generally slopes from the south to the north in the area surrounding the septic system of approximately 5%-35%. The proposed field will be located in the toe of the slope. 5. Drawing Markings: The Drawings are marked "For MoA Review Only". When written notification that the review is complete and that there are no further comments is received from MoA On -Site Department, the note will be removed and "Issued for Construction" drawings will be issued. The proposed installation will not affect the future development of this or the surrounding lots. Steven R. Pannone, P.E. Anchorage Mailing: P.O. Box 100217, Anchorage, Al; 99510-0217 Palmer ivIailing: P.O. Box 1807, Palmer, AK 99645 Telephone: (907) 745-8200 FAX: (907) 745-8201 C m ma � m D In A d D mp y C m — O Z n cm U)\ n � r \ ( 01 N F ./ \ Xo Jj . � r / r 0 O O O D m -i (-" IC 0m D 111) m -O z -i Z Oom OU)mm' m �OFq�,_ P• ' �`��+ •• * ".. •'tlevei, A. anrioae CE 8149 , Dr -x D U% r f- W N mq ��7 Nm O \ -I,- Ln — m�OizOm0zmrNT10� REV: 20201201 Z D x = G).. O ;U DON u' O ND- O_ 'N.. o CA D v 0mo�J O��rr1 o�cq m Z -i U) U) _1C7om Ul 0 D l m �- rn 0Z CD ON <O >o Zo O o , M m n m O N `' , . W > �l O � � � (n �'- NOTES: PANNONE ENG SVC LLC (C.I. 1OHH) P.O. BOX 1807 PALTER, AIC 99645 PHONE (907) 745-8200 FAX (907) 745-8201 �OFq�,_ P• ' �`��+ •• * ".. •'tlevei, A. anrioae CE 8149 , REVISIONS DATE 20210504 ` REV: 20201130 \ -I,- Ln SCALE 1" = 50' UPLANDS PH3 L6 SITE: NHN UPPER LOWLAND AVE SMITH FAMILY IRREVOC TRUST 10441 STEWART DRIVE EAGLE RIVER, AK 99577 REV: 20201201 Ln I C O DON om I \ m m F- Z -{ O N \\. Ul 0 ` <O >o Zo > z, z , r- m ` , . W > �l , D o o 0 mow m , �'- \ \ O * x N m 70 / C .p r < / I 1 O\ C7 ` m N m \ ` Z D W r ' N gzoo r m -I Gn - J i m -0 n t= m of T,Nr� �l ' 1 < Z-j�-1 \ 7 XO (n Z i r \\ `� O 7 m xcn 1 r Z I I W ' 1 r O x> D o I N (r Om o= N o o NOTES: PANNONE ENG SVC LLC (C.I. 1OHH) P.O. BOX 1807 PALTER, AIC 99645 PHONE (907) 745-8200 FAX (907) 745-8201 �OFq�,_ P• ' �`��+ •• * ".. •'tlevei, A. anrioae CE 8149 , REVISIONS DATE 20210504 CHANGE ORDER REV: 20201130 SCALE 1" = 50' UPLANDS PH3 L6 SITE: NHN UPPER LOWLAND AVE SMITH FAMILY IRREVOC TRUST 10441 STEWART DRIVE EAGLE RIVER, AK 99577 REV: 20201201 REV: 20210504 C O i•I I m I \ PERMIT PERMIT N0. OSPNO. Z -{ O N SHEET 1 of 2 ` <O \, \\ z, z , r- m ` \\ , , OZ -uO 0-1 1 I N gzoo Iy�oz,m 1 \ r=DO" mm;uC , , \\ `� O 7 m xcn 1 r \ N 1 r O x> D o N (r Om o= N o o LWn \ O m z , 1 mm D M7 r 1 O m m m 0�m , r / ' cnm -qI Cn �O , n ,- (n O mo -o- .' J \` zK mODco , " I 1 r mo> NOTES: PANNONE ENG SVC LLC (C.I. 1OHH) P.O. BOX 1807 PALTER, AIC 99645 PHONE (907) 745-8200 FAX (907) 745-8201 �OFq�,_ P• ' �`��+ •• * ".. •'tlevei, A. anrioae CE 8149 , REVISIONS DATE 20210504 CHANGE ORDER REV: 20201130 SCALE 1" = 50' UPLANDS PH3 L6 SITE: NHN UPPER LOWLAND AVE SMITH FAMILY IRREVOC TRUST 10441 STEWART DRIVE EAGLE RIVER, AK 99577 REV: 20201201 REV: 20210504 P050 -474-69 DRAWN JRL SITE PLAN PERMIT PERMIT N0. OSPNO. SHEET 1 of 2 D m A Z m m O m N tl z m G z m O z � I U z i0 I Z( V v7 G r m 4� m A m y O 0 N _ < m 0 0 0 Gl 0 O A O 0 0 tt+<+<11 m co w C m O 0 0 0 0 m Z I O tDi, ''� m m C1 _ = O co v Z LnTm m --I O ZO y mOC N Z�� Oo y 0 Z O m j .�➢ 00 m m D A ZE ;o -t D iia ODn Gi an A n V ;D D Z m m a 0 D m Q M Z r)T=i 0- r D-1-i"D=�- O m -a '� N trail trail X- a -I -1 -I C) a O p S SIn =CC �� V'Dm 7� D p O n mZZma _;u m'lm Z �D Z DA{Do'�-I _.I r) OZ �� a 0 O m -I mz D 2mZmo �c 0 -i c tnAw ^+D D m� oz� _ 3 U) \ c n o=a T`- O z !l _ O z (n _. 0 0 C) O C n Z mu �y a n �' NOTES: Plat! NONE ENG SVC, LLC (C.I. 1088) P.O. BOX 102954 ANCHORAGE, AK 99510 PHONE (907) 272-8218 FAX 907) 272-8211 `"""'11j '�E �F q�qS =��� ' !ry , REVISIONS DATE 20210503 CHANGE ORDER SCALE UPLANDS PH3 L6 SITE: NHN UPPER LOWLAND AVE SMITH FAMILY IRREVOC TRUST ...... ...... % '.. St—v R. Po-- S is CE-8149 ��_ NTS P050 Na74-69 DRAWN XXX PERMIT NO. SOIL LOG 10441 STEWART DRIVE s, moo......... OSP201480 SHEET EAGLE RIVER, AK 99577 ,ES51�' """"' 2 OF 2 A n N mA z m G z m 4 z � I U z i0 I Z( V v7 G z tp 4� m A m y 4 0 N O m 0 0 0 Gl 0 0 0 0 tt+<+<11 m w I I nrA z rmi v o 0 o o 9 A DEPTH (feet) I 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 MUNICIPAL OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT 4700 ELMORE ROAD ANCHORAGE, AK 99519-6650 SOILS LOG AND PERCOLATION TEST LEGAL DESCRIPTION: UPLANDS S/D - LOT 6 PERFORMED FOR: THE BOUTET COMPANY DATE: 11/13/17 PROJECT No.: PARCEL ID#: TECHNICIAN: TEST HOLE #1 is SAND SANDY GRAVEL W/ SOME SILT HARD PAN @ 8.5' J. MILLETTE SLOPE WAS GROUND WATER ENCOUNTERED? No IF YES @i WHAT DEPTH? DEPTH OF WATER AFTER MONITORING: NONE DATE OF MONITORING: 11/22/17 70/31/19 COMMENTS: PERK TEST WAS RUN 6 T SITE PLAN SEE SITE PLAN DATE READING GROSS TIME (MINUTES) NET TIME (MINUTES) DEPTH TO WATER (INCHES) NET DROP (INCHES) 11/14 TEST HOLE PRESOAKED PRIOR TO TESTING: 1 9:54 0 2 9:44 10 4 4 9 10:18 0 10 10:28 10 4 4 11 10:29 0 12 10:39 10 4 4 PERCOLATION RATE: 2.5 (MIN/INCH) PERC. HOLE DIA. 6—(INCHES) TEST RUN BETWEEN: 2 FT. and 3 FT. INTERMEDIATE RESULTS ARE NOT SHOWN FOR CLARITY BUT WERE SIMILAR. MUNICIPAL OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT 4700 ELMORE ROAD ANCHORAGE, AK 99519-6650 SOILS LOG AND PERCOLATION TEST LEGAL DESCRIPTION: UPLANDS S/D - LOT 6 PERFORMED FOR: THE BOUTET COMPANY DATE: 11/13/17 PROJECT No.: PARCEL ID#: TECHNICIAN: ©"IEPTIH TEST HOLE 42 (feet) I- 2 J 4 5 6 7 8 -- 9 - 10- 11- 12- 13- 14- 15- 16- 17 18 W J. MILLETTE NO, CE -4381 �` PERCOLATION RATE: 5.7 (MINANC 3) FERC. HOLE DIA. 6 (INCH TEST RUN BETWEEN: 2 FT. and SLOPE OB TIGHT SANDY GRAVEL SEE SITE PLAN ` `-*:-'%!�; W/ SOME SILT w4 HARD PAN @ 8.5 WAS GROUND WATER ENCOUNTERED? No — S IF YES a, WHAT DEPTH'? OF WATER AFTER MONITORING: —_____ _ LQ NONE.— DEPTH DATE OF MONITORING: 11/22/17 _— t E 10/31/19 GROSS (1MINUTES) DEPTH TO NET DROF (INCHES) DATE READING ESME (IJNCHE) TEST HOLE PRESOAKED PRIOR TO TESTING: II/14 1 5:45 0 2 6:15 30 3 6:16 0 4 6:46 30 5 %4 5 %4 5 6:47 0 6 7:17 30 514 5%4 PERCOLATION RATE: 5.7 (MINANC 3) FERC. HOLE DIA. 6 (INCH TEST RUN BETWEEN: 2 FT. and MUNICIPALITY OF ANCHORAGE Development Services Department t Phone. 907-343-7904 On -Site Water & Wastewater Section --'/ Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 050-474-69 1. GENERAL INFORMATION Expiration Date: _ffld _ �O a� - VnV_ Complete legal description Uplands #3 Lot 6 Location (site address) 20925 Upper Lowland Avenue, Eagle River 99577 Current property owner(s) Smith Phyillis Family IrrevoC Day phone Mailing address Real estate agent Day phone 2. TYPE OF DWELLING: R Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF. WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ❑ Private Septic 0 Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System n Public Sewer ❑ Waiver request for: Distance: MEMMEMMMEEMM Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. 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. In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA COSA guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed above. Reliance on this report by another person is at their own risk. Pannone Engineering Services LLC highly recommends buyers hire their own engineer to evaluate this report. Name of Firm Pannone Engineering Services Phone (907) 745-8200 Address P.O. Box 1807 Palmer, AK 99645 Engineer's Printed Name Steven R. Pannone P.E. Date 2�®� OF AL�s���� 6. DSD SIGNATURE 4.9 p ` _/ System #1 Approved for bedrooms'ever System #2 Approved for bedrooms annce' nCE 8149 Disapproved Conditional approval for bedrooms, with the following stipulations: i AN pR0(',h By:ce&Original Certificate Date:_941 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: Uplands #3 Lot 6 If more than 1 septic system on lot: COSA Checklist # 1 of 1 A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled N/A Total depth ft Cased to ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) in. Date of flow test for COSA Static water level at beginning of test ft. Comments Lot Served By Public Water B. TANK DATA Age of tank(s) <1 years Tank type/material 5`°°`MOPE Measured operating fluid level in septic tank N/A ❑ Standpipes/foundation cleanout per record drawing Date of pumping New D. ABSORPTION FIELD DATA Wide Trench Which system tested (date installed) °``°g'z°?' ❑ ALL standpipes present per record drawing Total measured depth from grade 8.7 ft (max) Measured depth to pipe invert from grade 4.7 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: NEW COSA Checklist yellow sheet Parcel ID: Structure served by this system 1 Well production at time of test NIA gpm Water storage tank volume N/A gallons , Well disinfected for coliform test? ❑ Yeses No ❑ Coliform bacteria is Negative Nitrate mg/L ❑Nitrate 1096than MRL (ND) �.a Arsenic ug/L ❑Arsdi is less than MRL (ND) Collected by Date of Sample,/ C. LIFT STATION ❑ Required maintenance completed Age of lift station N/A years Lift station material N/A Comments: Adequacy test date N/A Results E Pass For 4 bedrooms Fluid depth prior to test in Water added gal New depth in Elapsed time min Final fluid depth in Absorption rate 600+ gpd Any rejuvenation treatment (past 12 months) . N/A 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' 0 Community Sewer M I o[06leanout > 100' ❑ Yes if No ft r Yes if No ft Neighboring Tank > 100' ❑ Yes if No ft P ' to Sewer/Septic Line > 25' ❑ Yes if No ft Absorption Field on Lot > 100' F-1Yesif No Holding Tank > 100' ❑ Yes if No ft Neighboring Absorption Fields > 100' Yes Animal Containment > 50' ❑ Yes if No ft ❑ if No ft Water Main > 10' Q Yes if No Manure/Animal Excreta Storage > 100' Community Wells > 200' Community Sewer Main > ❑ Yes if No ft ❑ 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' ❑✓ Yes if No ft Property Line > 5' F/1 Yes if No ft Wells on Adjacent Lots: El Absorption Field > 5' if No Yes if No ft Private Wells > 100'✓❑ Yes if No ft Water Main > 10' Q 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' El 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 ft Water Service Line > 10' Yes if No ft Community Wells > 200' Q Yes if No ft Surface Water > 100' Q 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 e GF Std `+'''