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'FHA Form 2573 · Form Approved
Rev, July 195B 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
l~m~z~gee l~ambl
MORTGAGOR OR SPONSOR
MORTGAGEE
Nntanuska ¥a22~' hnk
?oueh ~ ~e~ A~s~
PROPERTY ADDRESS
SERIAL NO.
SUBDIVISION NAME
tOTAL NUMBER:
LIVING UNITS BEDROOMS
WATER SUPPLY BY:
[] Public system
BATHS BASEMENT
'l [i-]Yes [-'-[No
[] New installation
~-] Community system
BLO~N~. LO~j~O. / 7
Can attic or other area bo midi Irate
additional bldrooms?
(If Yes, how many?)
SYSTEM DESIGNED FOR
[~] Individual NO. F BDRM$. OAKBAGE OISPOSAL
~-~ Individual ~ N Yes [] No
SEWAGE DISPOSAL BY:
--]Public system
'-]Community system
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.
It is the opinion of the ~. State N County
tern with proper maintenance:
J Can be expected to function satisfactorily, and
is not likely to create an insanitary condition
OLocal Department of Health that this individual sewage-disposal sys-
MCannot be expected to function satisfactorily
NOTE: The health authority should complete the appropriate opinion statemen i
spaces provided.
Use of the above grid for Health Department Inspector's sketch as well as use if 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 fo~m 25:Y3
Rev. July 1958
REPORT OF INSPECTION--INDIVIDUAL SEWAGE-DISPOSAL SYSTEM
PRIMARY TREATMENT consists of XSeptic tank. [] Cesspool.
Septic Tank: ~
Distance from well, ~ feet. Material
Total liquid capacity. {~ ~ gallons. Capacity inlet compartment,
feet. Insi~ w-idth'7 feet. Liquid depth,
Inside length.
Cesspool:
Distance from: Well,
Inside diameter,
Number of compartments
~- gallons.
feet.
feet; foundation feet; nearest lot line at [] front, [] side, [] rear, feet.
feet. Depth,_ feet. Liquid capacity, gallons. Lining material
,~¢ONDARY TREAT~' 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.
Number of pits . Outside diameter _ et. Depth, ~ feet. Lining material
Distance from: Well: ~ feet; building foundation,~.~feet; nearest lot line at [] front,~ side, [] rear,~}__feet.
County. Local Health Authority.
,ns..lon mado by:~ State. [] [] ~~6
Date of inspection 5/,-~ ~ 19 J
REPORT OF INSPECTI
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 weft 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.
Depth of casing, .feet.
.gallons per minute.
.gallons per minute.
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.
Pun~proom 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
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