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FH~WJorm 2573 '~_. Form Approved
Re','~'July 1958 FEDERAL HOUSING ADMINISTRATION ~ Budget Bureau No. 63-R296,B
HEALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
PART I.--TO BE COMPLETED BY FHA
INSURING OFFICE MORTGAGEE SERIAL NO.
MORTOAOOR OR SPONSOR PRO.mY ADD.SS
SUEDW~S,ON NAME
TOTAL NUMBER:
LIVING UNITS BEDROOMS
BATHS
BASEMENT
] Yes [-~ No
[~] New installation
WATER SUPPLY BY:
[] Public system [] Community system
SEWAGE DISPOSAL BY:
[-'] Public system ~] Community system
Btoc~ NO.
Can attic or other area be mode into
additional bedrooms?
(If Yes, how many?)
NO. SYSTEM DESIGNED FOR
--] Individual OF BDRMS. GARBAGE DISPOSAL
[] Individual S N Yes ~ No
PART II.--TO BE COMPLETED BY HEALTH DEPARTMENT
HEALTH DEPARTMENT INSPECTOR'S SKETCH
It is the opinion of the [] State [-'] County [] Local Department of Health that this individual water-supply system
~] is [~ is not satisfactory as a domestic water supply for the subject property.
of the [~' State N County [] Local Department of Health that this individual
It
is
the
opinion
sewage-disposal
tern with proper maintenance:
~Can be expected to function satisfactorily, and [~] Cannot be expected to function satisfactorily
/ · is not likely to create an insanitary condition
I SlONATURE .,.' J TITLE
' ' ' / - ' ,. ,'.,h-
The health authority should complete the appropriate opinion statement ab?~ve and anix date, signature and ti le ' e
spaces provided.
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
CHIEF ARCHITECT
DEPUTY FOR CHIEF ARCHITECT
FHA Form 2573
R~v. July 1958
Septic Tank:
Distance from well,
Total liquid capacity,
Inside length,_
Cesspool:
Distance from: Well,
Inside diameter,
REPORT OF INSPECTION--INDIVIDUAL SEWAGE-DISPOSAL SYSTEM
PRIMARY TREATMENT consists of ~Septic tank. [] Cesspool.
--' feet. ~e. rial,~-~,~5. / ~_,.~ ~ ~'~ ~/,~ ~Number of compartments
'7 ~ ~ gallons. Capacity inlet compartment, '*"~
.feet. Inside width, feet. Liquid depth, .feet.
/
gallons.
feet; foundation, feet; nearest lot line at [] front, [] side, [] rear, feet.
feet. Depth~ feet. Liquid capacity, .gallons. Lining material
SECONDARY TREATMENT consists of [] Tile disposal field. J~eepage pits. Other Tile Disposal Field:
Distance from: Well, feet; foundation, feet; nearest lot line at [] front, [] side, [] rear, feet.
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.
Length of each line .feet. Depth, top of tile to finish grade, inches.
Type of filter material: [] Gravel. [] Broken stone. Other_
Depth of filter material beneath tile,~ inches. Depth of filter material over tile, inches.
Seepage Pits: ., ~- /~ ~ ~
Number of pits /. Outside diameter ~')~/~feet.~j De~,~ ~ -feet. Lining material ~32
Distance from: Well,_ =__feet; building ~ou;d-ation,_~ feet; nearest lot line at [] front ]~side/[~ar ~ 7
feet.
Insl~eflofl made by: ~tate. [] County. [] Local Health Authority _>/ / t~ /_~W/~ ~r~
Date of inspecrion,~e~--~/, /~ 1~ ~-/~~ ,~=~
REPORT OF INSPECTION~------a%MI}I~{~'~/ATER-SUPPLY SYSTEM
Distance to nearest public water main, feet. Size of main, inches.
Individual wells [] are [] are not customary in neighborhood.
Give most recent record of failure of wells in immediate vicinity to furnish 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,
cast iron sewer, feet; tile sewer,
seepage pit, feet; cesspool
Well construction:
Diameter, inches. Total depth, feet. Type of casing,.
Approximate depth to pumping level of water in well, feet. Approximate yield,
Sealed watertight to depth of feet.
feet; septic tank, feet; disposal field,
feet; other sources of possible pollution, feet.
feet,
Depth of casing, feet.
gallons per minute.
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,
Located in: [] Basement. [] Pumproom off basement. [] Pumphouse above ground. [] Pump pit.
Pumproom properly drained: [] Yes. [] No. Pump mounting watertight: [] Yes. [] No.
Type of storage: [] Pressure. [] Gravity. Capacity, .gallons.
Has bacteriological examination of water been made? [] Yes. [] No. If answer is "yes," give date
Quality of water [] is [] is not satisfactory for human consumption.
Installation [] does [] does not comply with approved exhibits, if any.
Inspection made by: [] State. [] County. [] Local Health Authority.
Inspected by
Date of inspection , 19
gallons per minute.
(TITLE)
19
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