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FHA Form 2573 Form Approved
Rev. July 1958 FEDERAL HOUSING ADMINISTRATION Budget Bureau No. 63-R296.8
HEALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
pART I.--TO BE COMPLETED BY FHA
INSURING OFFICE
Anm, tmx,'m~ ** AXmwJm
MORTGAGOR OR SPONSOR
SUBDIVISION NAME
TOTAL NUMBER:
LIVING UNITS BEDROOMS
WATER 5UPPi. Y BY:
[--1 Public system
MORTGAGEE SERIAL NO.
~t~m~im Va~l.e~' ~z~c
PROPERTY AD~RE~S
BLOCK NO.
BATHS 1 BASEMENT
:t I--lYes piNo
New installation
[--~ Community system
LOT NO.
6
Con attic or other area be mode Into
additional bedrooms?
(If Yes, how many~')
[~] Yes [---~ No
SYSTEM DESIGNED FOR
~] Individual No. OF BD~MS. GARB~,GE DISPOSAL
Individual ~ ~] Yes ~-] No
SEWAGE DISPOSAL BY:
[~] Public system
[-~ Community system
PART II.iTO BE COMPLETED BY HEALTH DEPARTMENT
HEALTH DEPARTMEI~ INSPECTOR'S SKETCH
It is the opinion of the [] State [-'] County [--1 Local Department of Health that this individual water-supply system
[--1 is r-] is not satisfactory as a domestic water supply for the subject property.
It is the opinion of the ~iState N County
tem 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
' :' x / E , TITL., : ~ ," i
DATE
SIGNATURE
NOTE: The health authority should complete the appropriate opinion s a e ent abov~nd affix date, signature and title in the ~/
spaces provided.
Use of 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 authority.
PART III.iFOR 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 [-'1 Acceptable [] Not Acceptable.
DATE
SIGNATURE
1CHIEF ARCHITECT
DEPUTY FOR CHIEF ARCHITECT
HEALTH AUTHORITY APPROVAL FHA Form 2573
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM .o,. J~l~ 1958
Septic Tank:
Distance from well,
Total liquid capacity,
Inside length,
Distance from: Well,
Inside diameter,
REPORT OF INSPECTION--INDIVIDUAL SEWAGE-DISPOSAL SYSTEM
PRIMARY TREATMENT consists of ~Septic tank. [] Cesspool.
-- feet. Material:.~,,."fllc3 ~c.~. · {-.~{", } ~Number of compartments
"O gallons. Capacity inlet compa~ment,. ~
feet. Inside width, f~t. 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. ~Seepage pits.
Other
Tile Oisposal 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. Depth, 1~ feet. Lining material
Distance from: Well, ~ feet; building foundation, feet; nearest lot line at [] front, ]l~k. side, t_l Lcar,-~ia~t~
Inspection made by: }~State. [] County. [] Local Health Authority.
Inspected
Date
inspection
'
REPORT OF INSPECTION~~W~TER-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 t~rnish 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.
cast iron sewer,.
seepage pit,
Well construction:
feet; tile sewer,
-feet; cesspool,.
.feet; nearest lot line at [] front, [] side, [] rear,, feet,
feet; septic tank,. .feet; disposal field, feet;
feet; other sources of possible pollution,, feet.
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.
Exterior space around casing sealed with: [] Cement grout. [] Puddled clay. [] Ordinary backfill.
Well cover: [] Concrete. [] Wood. [] Metal. Openings in well cover watertight: [] Yes. [] No.
~m~: [] 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
Depth of casing,
gallons per minute.
gallons per minute.
feet.
-o
,/'~' GR£ATER ANCHOR~.G~ AREA BOR~JG"
/~ ,/// Department of Environmental quality
N ~00 tudor Road, Anchorage, Alaska 99507 279-8686
D~te of %ns~ectton~~_
REQUEST FOR APFROVAI, OF
FOR
Address:
Nu~be~ o~
A, Type B. Deptl._
C. Construction D. Bacterial Analysis
Sewage Disoosal System:
A. Installed /~ ~( B. Installer
C. Septic Tank: 1. Size /~.~,,,/~____ 2. ~anufacturer_
D. Seep,ge Pit: 1. Size ~' 2. Ma,erial
E. Disposal Field: Total Length of Lines
Distances:
A. Well To:
Septic Tank
, Nearest Lo! line
Foundation to S~otic Tank
Abso~tion Area , Sewer Lines
· Other Contamination
AbSorption Area
C. Absorption Area to ~]earest Lot Line
Eequest for Approval of ,,~zvtdUal Sewer & Water Pacilit,
Approved
Disapproved
Date ~"'~ ~)J
/ Ap?rova] Valid for One Year From Date Signed
Greater Anchorage Area ~orouqh, Department of Environmental Quality
DIAGRAM OF SYSTEM
I certify that the information contained in this request for approval to be a true
and accurate represemtm%~on of the subject sewer and water facilities located at:
Signed Date