HomeMy WebLinkAboutEVANSON LT 2
FHA Form 2573
Re~ Ju~y 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.
2nci ~'~.;~,~ ~]~a~k~ Pouch 70]2~Anohorage~ Alaska ~-/:084~
C~n ~i~ or othe~ ~reo be mede into
TOTAL NUMBER: ~ASEMENT ~ New ins[al[aLien additional bedrooms?
_ - (If Yes, how many~)
~ Yes ~ No ~ Yes ~ No
~TER SUPPLY BY: SYSTEM DESIGNED FOR
~ Public system ~ CommuniW system I1__ Indivktual uo.
S[W~OE DISPOSAL
]Public system ~ Community syste~n ~ Individual Z ~ Yes [~ No
PART II.~TO BE COMPLETED BY HEALTH DEPARTMENT
HEALTH DEPARTMENT INSPECTOR'S SKETCH
It is the opinion of the ~ State ~ County ~ I.ocal Department of Health that this individual water-supply system
~ is ~ is uot sadshctory as a domestic water supply n)r~he subiecSproperty.
It is the opinion or the ~ StaEe ~ County ~ Local Department of Health that this iodividual sewage-disposal sys-
tem with proper maintenauce:
Can be cxpected to function satisGctorily, and ~ Cammt be expected to fimction satisfactorily
~ is not likely to create an insanitary condition
DATE SIGNATURE TITLE
NOI[: lbo healih ~uthority should comple*e the opprop~a~e opinion s~o*ement obove ond offix dote, s,~n~*ure ond t,~le m lhe
sp~ce~ provided,
Use of the above grid for Health Department Inspector's sk~tc~ as well as use of the bock of this form is at the option of the
health authority.
PART III.~FOR USE OF FHA OFFICE
TO THE CHIEF UNDERWRITER:
[ h~ve ~evie~cd the ~oregoh~g m~d thc ~erdnent F~ CompJi~n(e Inspection Report, ~nd ~ecommcnd dmt'thc
D~TE SIGNATURE
[~CHIEFARCHITECT
~ DEPUTYFOR CHIEFARCH,TECT
HEALTH AUTHORITY APPROVAL FHA Form
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM R~v, ~ul¥ ~9~
REPORT OF INSPECTION--INDIVIDUAL SEWAGE-DISPOSAL SYSTEM
PRIMARY TREATMENT consists nf,,~ Septic tank. [] Cesspool.
Septic Tank:
Distance from well, __feet.
Total liquid capacity, / '-
Inside length,_ .feet.
Cesspooh
1)istance from: Well,
lnskfe diameter,_ feet.
Material . r ,'. ~ ' . 42 .v. Number of comparunents
'~' · * .~ gallons. Capacity inlet compartment, ~ ....... gallons.
,. · ~iq ~uid depth, .feet
Inskfe width, .
feet; foundation, t~et; nearest lot line at [] front, [] side, [] rear, 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 line& feet. Number of lines,_ . Distance between lines, __ feet.
Trench width laches. 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 materiah [] Graveh [] Broken stone. Other
Depth of filter material beneath tileq inches. Depth of filter material over tile, inches.
5eepage Pits:
Number of pits_f_ . Outside d+azneter,." *;( '~' feet. Depth, '~:' - feet. Lining material .... ~L_ ;:
Distance from: Well, '~ feet; building foundation,~'~' ~, feet; nearest lot line at [] front, ~] side, [] rear, ~';
Inspection made by: [] State. [] County. /~ Local Health Authority.
/ Inspected by
Date of inspection ....... ~'~!.~ 19! ' /
REPORT OF INSPECTION--INDIVIDUAL WATER-SUPPLY SYSTEM
feet.
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 linc, feet.
Individual water supply ii'om: [] Drilled well. [] Driven well. [] Dog well. [] Bored well.
Distance of well from:
Building fonndation, _ __feet; nearest lot line at [] frnnt, [] side, [] rear,
cast iron sewer,_ feet; tile sewer ........ feet; septic tank,_ feet; disposal field,
seepage pit, feet; cesspool,, feet; other sources of possible pollution, ~et.
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.
Exterior space around casing sealed with: [] Cement grout. [] Puddled clay. [] Ordinary backfill.
Well cover: [] Concrete. [] Wood. [] Metal. Openings iii well cover watertight: [] Yes. [] No.
Pampi [] Shallow well. [] Deep well. Length nf drop pipe,_ feet. Pump capacity,
Located in: [] Basement. [] lhmiproom off basement. [] Pnmphouse above ground. [] Pump pit.
Pumproom properly drained: [] Yes. [] No. Pump mounting watertight: [] Yes. [] No.
Type of storage: [] Pressure. [] Gravity. Capacity, gallons.
tias bacteriological examination of water been made? [] Yes. [] No. If answer is "yes," give date__
Quality of water [] is [] is not satis~ictory fi~r 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__
(TITLE)
Depth of casing,
_gallons per minute.
.gallons per minute.
feet~
.feet;
feet.