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HomeMy WebLinkAboutEVANSON LT 11 i FHA F~m 2573 ,Rev. July 1958 Form Approved ~ FEDERAL HOUSING ADMINISTRATION ~ Budget Bureau No. 63-R296.8 HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM INSURING OFFICE MORTGAGEE MORTGAGOR OR SPONSOR PROPERTY ADDRESS PART I.--TO BE COMPLETED BY FHA SERIAL NO. Am~o~e 8LOCmK NO. LOT NO. TOTAL NUMBER:T t BA~SEMENT r~ New installation X ~ / ~j ~Yes ~No WATER SUPPLY BY: ~ Public system ~ Communi~ system ~ Individual ~o.. o~ ~. ~*~, ~,,os*, iEWAGE DISPOSAL BY: Can atgic or other area be made into additional bedrooms? (If Yes, how many~) FI Yes ~--] No SYSTEM DESIGNED FOR PART~II.--TO BE COMPLETED BY HEALTH DEPARTMENT HEALTH DEPARTMENT INSPECTOR'S SKETCH It is the opinion of the [--] State .l--I 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 thex-~ State [~] County [] Local Department of Health that this individual 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 7/'~/~1 ~~"~~~--~~~/") ' ' and title iff he - ..: o.-.,...o.,, co..,.,.. rovlded ''~ spaces p · PART Ill.--FOR USE OF FHA OFFICE TO THE CHIEF UNDERWRITER: ~ I have reviewed the foregoing and the pertinent FHA.~C%mpliance Inspection Report, and recommend that 'the Individual water-supply system be considered [--] Acceptable [--] Not Acceptable Sewage disposal be considered ~] Acceptable [] Not Acceptable. DATE [~__] CHIEF ARCHITECT DEPUTY FOR CHIEF ARCHITECT SIGNATURE HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM FHA Form 2573 Rev. July 1958 REPORT OF INSPECTION--INDIVIDUAL SEWAGE-DISPOSAL SYSTEM PRIMARY TREATMENT consists of ~ Septic tank. Septic Tank: Distance from well, ~ Total liquid capacity; Inside length,. ~ Cesspool: Distance from: Well, Inside diameter, [] Cesspool.Cg feet. Material,C / Number of compartments/ J~5 ~ ~ gallons. Capacity inlet compartment, ' gallons. feet. Inside width, ~". f?t. Liquid depth, .feet. 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. ~l,.Seepage pits. Other Tile Disposal Field: Distance from: Well, Total length of tile lines, Trench width, Length of each line, feet; foundation, feet; nearest lot line at [] front, [] side, [] rear,, feet. feet. Number of lines,. Distance between lines, feet. inches. Total effective absorption area in bottom of trenches .square feet. 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 / ~,~feet.,~ ~t,~Depth~z ~ feet. Lining material~ budding foundation,_~__feet; nearest lot line at [] front, [] side,~ rear,.~..~ feet. Distance from: Well, feet; Inspection made by: [] State. [] County. ~ Local Health Authority. Date of inspection ~19 ~ Inspected hy o, nL't..y REPORT OF INSPECTION--INDIVIDUAL WATER-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, cast iron sewer,, feet; tile sewer, seepage pit, -feet; cesspool Well construction: Diameter, inches. Total depth, Approximate depth to pumping level of water in well, Sealed watertight to depth of feet. _feet; nearest lot line at [] front, [] side, [] rear, feet; septic tank, feet; disposal field,. feet; other sources of possible pollution, feet. feet. Type of casing, Depth of casing, .feet. Approximate yield, _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. .feet.