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HEIGtlTS
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INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
Location ~C f~i~_~Legal Description LOT I~
SEPTIC T~K: Diet.ce from wel~atePial ~, N~er of compartments
Liquid eapacity,,~ gallons. Inside length Inside width .., Liquid depth
SEEPAGE SYSTEM: Seepage Pit: Nu~eP of pits ~ Outside dia~ter
, len~h , depth ~ lining material ~ ,. Diet.ce
well , building fo~dati~ ,3~, newest lot line,,,~; Total effective
~sorption a~a (wall area).,, ~ sq.
TILE DRAIN FIELD: Distance from well , f°~dation , ne~t lot llne .....
Total len~h of lines Nu~er of lines Distan~ between lines T~nch
width ...... in. Total effective ~soPption area sq. ft. Length of each line
Depth: Top of tile to finish grade ..... Depth of filter ~e~ial beneath
WELL: ~e~. depth . diet.ce ~om building fo~datlon .. hearst
.... , nearest sewer line , septic tank , seepage system ,
lot line
cesspool,,
DISTANCES:
other sources
DIAGRAM OF SYSTEM
DATE:
Health Authority
SE~'~E DISPOSAL SYSTEM - APPLICATI0
Name of AppZie~t
Application to Install: Septic t~k, ,, . ~epage
To Serve the F~llowlng
Financed Through
Percolation Test Results
.... ~t~cX~ated Date of
,$
I cez~tify that I am familiar with the ~equi~ements of G~eater Anchorage A~ea Borough
Ordinance No. 28-68 and that the above described system is in a~cordance with said code.
· ~eptic tank size
Type .... Seepage Az~ea
.... DI~ SYSTEM
IL,~J /
This is to serve as_~, l, uss,, lle. , pe , t to install a ~h ~.
~ ;-~ as described below. Size of unit to be set-ced
BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT
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.mTO BE COMPLETED BY FHA
iNSURING OFFICE
MORTGAGOR OR SPONSOR
MORTGAGEE
PROPERTY ADDRESS
SERIAL NO.
SUBDIVISION NAME
BLOCK NO. LOT NO.
TOTAL NUMBER:
EATHS
L~VING UNITS BEDROOMS
WATER SUPPLY BY:
--]Public system
BASEMENT
__ Yes [] No
[~] New installation
Can attic or other area be made Into
additional bedrooms?
(If Yes, how many{:)
[-~ Community system
SEWAGE DISPOSAL BY:
[] Public system [] Community system [-~ Individual
SYSTEM DESIGNED FOR
Individual NO. OF~BDRM$. GARBAGE OIBPOSAL
[-1 Yes
PART fl.--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.
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 health authority should complete the appropriate opinion stateme&dr above and aEfix dote, 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 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
Rev. July 1958
Septic Tank:
Distance from well,
Total liquid capacity,
Inside length,
Cosspool:
Distance from: Well,
Inside diameter,
REPORT OF INSPECTION--INDIVIDUAL SEWAGE-DISPOSAL SYSTEM
PRIMARY TREATMENT consists of~Septic tank. [] Cesspool.
.feet. Inside width~ feet. Liquid depth,. .feet.
Number of compartments
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 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:
Distance from: Well, ""' feet; building foundation,~P_~feet; nearest lot line at [] front, J}4, Side [~/rear,~4l).~-feet.
-- [] Local Health
Inspection made ~
byz ~ State. [] County. Authority.
/
Date of inspection O ~ 19 ¢ f
REPORT OF INSPECTION.-'~NGFV~q~:h~ 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 fi~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.
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
Depth of casing,
gallons per minute.
gallons per minute.
,19
(Tnq~B)
~, u. $. GOVERNMENT PRINTING OFFICE: TgS7 0-F--427038