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FHA Form 2573
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FEDERAL HOUSING ADMINISTRATION ~
HEALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
Form Approved
Budget Bureau No, 63-R296.8
PART I.--TO BE COMPLETED BY FHA
INSURING OFFICE
MORTGAGOR OR SPONSOR
SUBDIVISION NAME
TOTAL NUMBER: BASEMENT
LIVING UNIT~ BEDROOM5 BATHS
WATER SUPPLY BY~
~ Public system
· MORTGAGEE SERIAL NO.
PROPERTY ADDRESS
BLOCK NO. LOT NO.
[~] New installation
Can attic or Other area be made into
additional bedrooms?
(if Yes, how many~)
No
SYSTEM DESIGNED FOR
l~-] Community system ~] Individual NO. OF eDRMS. GARBAGE DISPOSAL
SEWAGE DISPOSAL BY: ~
[] Public system [] Community system [] Individual ~ [] Yes [] No
PART fl.--TO BE COMPLETED BY HEALTH DEPARTMENT
%
It is the opinion of the ~ State [] County [--] Local DeSar~ment of Health that this individual, water-supply system
[] is [] is not satisfactory asa domestic water supply for the subject property..
It is the opinion of the [~ State N County [] Local Department of Health that this individual sewage-disposal sys-
tem with proper maintenance:
[] Can be expected to function satisfactorily, and ,[--] Cagnot be expected to function satisfactorily
is not likely to create an insanitary condition
DATE
J TITLE
NOTE: The health authority should complete the appropriate opinion statement above and affix date, signature and title in the
spaces provided.
Use of the above grid for Health Department Inspector's sketch as weft as uso of the buck of this form is at the option of the
health authority. '
PART Ill.--FOR USE OF FH,I( 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 [--] Acceptagle' ~ Not Acceptable
Sewage disposal be considered [] Acceptable [--] Not Acceptable.
)ATE SIGNATURE
HEALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
[] CHIEF ARCHITECT
-~ DEPUTY FOR CHIEF ARCHITECT
FHA Form 2573
Rev, July ~958
REPORT OF INSPECTION--INDIVIDUAL SEWAGE-DISPOSAL SYSTEM
PRIMARY TREATMENT consists of ~ Septic tank. [] Cesspool.
Distance from well, ~ feet. Material, -_ Number of compartments
Total liquid capacity, f~:~ gallons. Capacity inlet compartment, !~a~ t~ gallons.
Inside length, ~-- feet. Inside width, ~ feet. Liquid depth, .feet.
Cea~pooh
Distance from: Well,
Inside diameter,
SECONDARY TREATMENT consists of [] Tile disposal field. ~Seepage pits. Other
TIb Disposal Fieldt
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. Depth, feet. Liquid capacity, gallons. Lining material
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,~ inche~: Depth of filter material over tile, inches.
Seepage Pits~
Number of pits / Outside diameter,-e~t~,~feet..Depth ~' feet. Lining material ~O'~,~-
Distance from: Well ~ feet building foundation. ~ ~ ~ feet; nearest lot line at [] front, l~kside, [] rear,~t~_feet
,ns,~loo made by* [] State. [] County. {~Local Hcal~h~Authority.
Date of inspection , 190/
REPORT OF INSPECTION--INDIVIDUAL W~TER-SUPPLY SYSTEM
Distance to nearest public water main, feet. Size of main, inches.
Individual wells [] are [] are riot 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,
Individual water supply from: [] Drilled well.
'Distance of well from*
Building foundation.
cast iron sewer,, feet; tile sewer,
seepage pit, .feet; cesspool,
Well construction:
Diameter, inches. Total depth,
.feet deep. Dwelling set back from front property line,
[] Driven well. [] Dug well. [] Bored well.
feet.
.feet; nearest lot line at [] front, [] side, [] rear, feet,
feet; septic tank, feet; disposal field, .feet;
.feet; other sources of possible pollution, feet.
Approximate depth to pumping level of water in well.
Sealed watertight to ~e, pth of feet.
Exterior space around casing sealed with: [] Cement grout. [] Puddled clay. [] Ord{nary backfill.
Well cover: [] Concrete. [] Wood. [] Metal. Openings in well cover watertight: [] Yes. [] No.
~ump* [] 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. Opacity, .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
feet. Type of casing, Depth of casing,
feet, Approximate yield, _gallons per minute.
.gallons per minute.
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