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HomeMy WebLinkAboutEVANSON LT 12 Form Approved FHA Form 25Z3 k.~,,,~ FEDERAL HOUSING ADMINISTRATION ~'~"/' Budget Bureau No. 63-R296.8 Rev. July 1958 HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM SERIAL NO. MORTGAGOR-OR SPONSOR PART I.--TO BE COMPLETED BY FHA MORTGAGEE I~URING OFFICE Ilat~nu~ka ?alley Bank I~ROPERI~Y XD"~ R ~'s s Care7 Wt, Eddene 4210 ~eedle D~ive S~D,V,S,ON NAM~ aLOCK NO. ~OT NO. E~ran~ Subdi~ialon ~2 TOTAL NUMBER: : BASEMENT LIVING UNITS BI~DROOMS BATHS WATER SUPPLY BY: --] Public system SEWAGE DISPOSAL BY: J--]Public system ] New installation Can attic or other area be made Into additional bedrooms? (If Yes, how many~) Iii Community system '-] Yes [~] No SYSTEM DESIGNED FOR [~] Individual .o. OF BDRMS. GARBAG[ D}SPOSAL ~-~ Yes [] No --']Community system [] Individual pART II.--TO BE COMPLETED BY HEALTH DEPARTMENT 2 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 ~s not likely to create an insanitary condition  , Local Department of Health that this individual sewage-disposal sys- -']Cannot be expected to function satisfactorily DATE SIGNATURE TITLE / /NOTE: The Jalth authority should fo~p;ete the appropriate o~n statement above and~x date, sJ~natureandtJtleln he spaces provided. ~ ~ / Use of the above grid for Health Department Inspector's s~ch as weft ~s use of the back of this form is at the option of the health authority. / PART Ill.--FOR USE OF FH.,~ OFFICE TO THE CHIEF UNDERWRITER: ~--..~ · I have reviewed the foregoing and the pertinent FHA Cdmplianc~--'Inspection Report, and recommend that 'the Individual water-supply system be considered [~] Acceptable [--] Not Acceptable Sewage disposal be considered [-'] Acceptable [~ Not Acceptable. DATE ~IGNATURE HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM ] CHIEF ARCHITECT [ DEPUTY FOR CHIEF ARCHITECT FHA Form 2573 Rev. July 1958 REPORT OF INSPECTION--INDIVIDUAL SEWAGE-DISPOSAL SYSTEM PRIMARY TREATMENT consists of XSeptic tank. [] Cesspool. Septic Tank: Distance from well, Total liquid capacity, ] t~ ~ /~ gallons. Capacity inlet compartment, Inside length, ~ feet. Inside width t ~ f~t. ~iquid depth, .feet. Dis~nce ~om: ~ell, ~ee~ ~ouod~don, ~ee~ neares~ lm line ~ g ~on~, g side, ~ rear, inside ~i~mece~, ' ~. Depth,. ~eer. ~iqgid cap~ci~, JICOgDARY TRJATJIgT cofisis~s oE ~ Tile disposal field. ~ Seepage pks. Ocher Tile Disposal Field: Distance from: Well, Total length of tile lines,. Trench width,. Length of each line Date of inspection / Number of compartments ~r ~ .gallons. feet. feet. square feet. inches. inches, '~ feet. Lining material feet; building foundation,~L_ feet; nearest~;;:);j fT~e~fee;~ [] County. [] Local Health Authority. OF INSPECTION--INDIVIDUAL WATER-SUPPLY SY~'EM feet; foundation, feet; nearest lot line at [] front, [] side, [] rear, feet. Number of lines, Distance between lines, inches. Total effective absorption area in bottom of trenches, .feet. Depth, top of tile to finish grade, Type of filter material: [] Gravel. [] Broken stone. Other Depth of filter material beneath tile,~ inches. Depth of filter material over tile, Seepage Pltst Number of pits [ . Outside di:.:.:z:.~r~ ? ~ ~ feet. Depth, Distance from: Well, Inspection made by: [] State. 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 fromt Building foundation, cast iron sewer, seepage pit, Well construction: feet; tile sewer,. feet; cesspool, .feet; nearest lot line at [] front, [] side, [] rear, feet; septic tank. feet; disposal field, 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 (TITLE) feet~ .feet.