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HomeMy WebLinkAboutPLEASANT VALLEY BLK 12 LT 8-(?3 HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM INSURING OFFICE PART I.--TO BE COMPLETED BY FHA SERIAL NO. MORTGAGEE ~me~o~e~ a~e~a 6o. o066Eb MORTGAGOR OR SPONSOR PROPERTY ADDRESS SUBDIVISION~1~ ~t~ NAMEv~,~.~ BLOCK ~..NO LOT NO. TOTAL NUMBER: LIVING UNITS BEOROOMS WATER SUPPLY BY: [] Public system BASEMENT 'i [] Yes [] No ] New installation I~0 8 Cdn attic:or other area be made into additional bedrooms? (If Yes, how many~) 171 es SEWAGE DISPOSAL BY: ~]' Public system r-~ Community system [] Individual ]Community system [] Individual SYSTEM DESIGNED FOR []Yes D No PART II.--TO BE COMPLETED BY HEALTH DEPARTMENT HEALTH DEPARTMENT iNSPECTOR'S SKETCH ''"IIII I I1~1 I I I III II I~ IlllJlll ~lJlllll IIII ~ "' I J I I I J i I I I I i I.I I · i'''''JillJ Il J J ' ''""' J I II1~1 IIIIIIII IIIl,lrl ,J,,,,,, ,jill,,, I Illll I I I I I I ,,,,,,,, ,,,jjjji .' IIIIIIII i,,i IIIllllI ' JllJ'll,i II!11 ,il, It is the opinion of the [] State [] County /g~] Local Department of Health that this individual water-supply system [] is [] is eaot satisfactory as a domestic water supply for the subject property. It is the opinion of the [] State [] County tern with proper maintenance: ~] Can be expected to function satisfactorily, and is not likely to create an insanitary, condition ~] Local Department of Health that this individual sewage-disposal sys- * - ~ [] Cannot be expected to function satisfactorily NOTE: The h Ith authority should complete the appropriate opinion statement above and affix date, slgnature and title in the spaces provided, Use~f the above grid for Health Department Inspector's sketch as well as use of the back of this form is at the option of the health autE~orlty. PART Ill.--FOR USE OF FHA OFFICE TO THE CHIEF UNDERWRITER: I have reviewed the foregoing and the pertinent FHA Compliance Inspection Report, and recommend that'the · Individual water-supply system be considered [] Acceptable [] Not Acceptable Sewage disposal be considered [] Acceptable [] Not Acceptable. DATE SIGNATURE HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM __i CHIEF ARCHITECT DEPUTY FOR CHIEF ARCHITECT FHA Form 2S73 Rev. July 19SS REPORT OF INSPECTION~INDIVIDUAL SEWAGE-DISPOSAL SYSTEM Distance from well, fly~D 0 i~t, Material, Total liq!dd capacity. ~,5~') t'D Inside diameter, feet. Depth,. [] Cesspool. gallons. Capacity inlet compartment, feet. Liquid depth, / ~ ~-'~C) 0 gallons. feet. feet. feet; nearest lot line at [] front, [] side, [] rear,__ feet. Liquid capacity, gallons. Lining material SECONDARY TREATMENT consists of [] Tile disposal field. [] Seepage pits. Other Tile Disposal Fleld~ Distance from: Well, ,~'~'4';. ~. / t~et; foundation,~Z~5~ feet; nearest lot line at [] front, [] side, J[~ Total length of tile lines,. ~ feet. Number of lines, Distance between lines, feet. Trench width,, inches. Total effective absorption area in bottom of trenches, .square feet. ~ngth of each line, feet. Depth, top of tile to finish grade, inches. Ty~ of filter material: ~ Gravel. ~ Broken stone. Other Depth of filter material ~neath tile~ inches. Depth of filter material over tile. inches. Seepage Plt~ Numar of pits / . Outside diameter, ff ~ ~ feet. Depth,~ feet. Lining material ~ Dismnce'iiom: Well,~O0/-feet; building foundation,~feet; nearest lot line at D front~ side, D~ar. ~0 feet. Insp. Olon mad. by: ~ State. ~ County. ~Local Health AuthoriW, ~ ~ ~~~~-- Date of inspecdon /O'- /~ 19~F .EPOnT CTIO.--I.DI /m.U X V T -S VSTEM Distance to nearest public water main,__ feet. Size of mail~ ~nch~ Individual wells [] are [] are not customary in neighborhood. Give most recent record of failure of wells in immediate vicinity to filrnish adequate supply of water_ Properties in neighborhood [] are [] are not being developed with both individual water-supply and sewage-disposal systems. Lot size:- feet wide,_ feet deep. Dwelling set back from front property line, .feet. Individual water supply from: [] Drilled well. [] Driven well. [] Dug well. [] Bored well. Distance of well from: Building foundation, feet; nearest lot line at [] front, [] side, [] rear,~ feet, cast iron sewer, feet; tile sewer,, feet; septic tank,_ feet; disposal field, feet; seepage pit, feet; cesspool,, feet; other sources of possible pollution, .feet. Well constructlom Diameter, inches. Total depth, feet. Type of easing,. Depth of casing, feet. Approximate depth to pumping level of water in well,~ feet. Approximate yield, gallons per minute. Sealed watertight to depth of. .feet. Exterior- space around casing sealed with: [] Cement grout. [] Puddled clay. [] Ordinary backfill. Well cover: [] Concrete. [] Wood. [] Metal. Openings in well cover watertight: [] Yes. [] No. Pump: [] Shallow well. [] Deep well. Length of drop pipe, __ feet. Pump capacity, .gallons per minute. Located in: [] Basement. [] Pumproom off basement [] Pumphouse above ground. [] Pump pit. Pumproom properly drained: ~ Yes. ~ No. ~mp mounting watenight: ~ Yes, ~ No. Type of storage: ~ Pressure. ~ Gravis. Capacity, .gallons. Has bacteriological examination of water been made? ~Yes. ~ No, If answer is "yes," give date /-~ / 0 , 1~ Quali~ of water ~ is ~ is not satisfactory for human consumption. Installation ~ does ~ does not comply with approved exlubtts, ff any. Inspection made by: n State. n County. ~ ~cal Health Authority. , / ~/ (TITLE) N Z © 0