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HomeMy WebLinkAboutCOLEMAN Block 2 Lot 9 FHA Form 2573 Form Approved Rev. July 1958 FEDERAL HOUSING ADMINISTRATION Bu*dget Bureau No. 63-R296.8 HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM PART I.--TO BE COMPLETED BY FHA INSURING OFFICE MORTGAGEE SERIAL NO. SUBDI~JJjI~JJJ~M~'~'JI~ ~l,'~r'/ ',m.,~,~-l. ~,I/1.. A~ .... ,m, BLOCK NO. J ~.~-~ a~a~v ~-,~ ~,-~- LOT NO. ~l~ll~ql~l~ NUMBER.. Can attic or ether area be made inte BASEMENT ~ New installation oddJtJenaJ bedroems? LIVING UNITS BED,OOMS BATHS (If Yes. how many~.) SYSTEM DESIGNED FOR [-'] .Public system ['~ Community system [~ Individual NO. ~fWAGE DISPOSAL BY.' ~ ~blir system I--1 ~ommunity system ~ Individual ~[--1 Yes ~ ~o PART fl.--TO liE COMPLETED li¥ HEALTH DEPARTMENT HEALTH DEPARTMENT INSPECTOR'S SKETCH ....... - .... ~- ~ ~ , t'" .... ~ -½ ..... .__~. .... ~ ..... : .... ! , ~~ ~ .._. :... '~ .... ----- ~-~- ~ ' 2___~ ----- .... 2, It is the opinion of the [--I State [""] County [~1 Local Department of Health that this individual water-supply system [~ is ['-] is not satisfactory as a domestic water supply for the subiect property. PUBI~IC W^TER It is the opinion of the [~ State ~-~ County ~] Local Department of Health that this individual sewage-disposal sys- tem with proper maintenance: [~ Can be expected to function satisfactorily, and [~ Cannot be expected to function satisfactorily is not likely to create an insanitary condition. /) __ DATE SIGNATURE /////,,,.,_._.~~/// TITLE NOTE: The health auth~ity sho~d~comp/ete 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 well es use of 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 J--1 Acceptable J--J Not Acceptable Sewage disposal be considered [-'] Acceptable ~] Not Acceptable. DATE SIGNATURE [--] C~IE~ ~C~ITECT r --1 DEPUTY FOR CHIEF ARCHITECT HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM FHA Form 2S73 Rev. July 1958 REPORT OF INSPECTION--INDIVIDUAL SEWAGE-DISPOSAL SYSTEM PRIMARY TREATMENT consists of [] Septic tank. [] Cesspool. Septic Tank: Distance from well feet. Material Total liquid capacity, Inside length, feet. Inside width, Cesspool: Distance from: Well, feet; foundation, Inside diameter, feet. Depth,. SECONDARY ?REATMENT consists of [] Tile disposal field. [] Seepage pits. gallons. Capacity inlet compartment, feet. Liquid depth, Tile Disposal Field: Distance from: Well, Total length of tile lines Trench width Length of each line Type of filter material: [] Gravel, Depth of filter material beneath tile, Seepage Pits: Number of pits . Outside diameter,. Distance from: Well, Inspection made by: [] State. Number of compartments .feet. gallons. feet; nearest lot line at [] front, [] side, [] rear,. feet. Liquid capacity, gallons. Lining material Date of inspection Other feet. feet. square feet. inches. 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, [] Broken stone. Other inches. feet. Depth,. Depth of filter material over tile feet. Lining material inches. feet; building foundation, feet; nearest lot line at [] front, [] side, [] rear, [] County. [] Local Health Authority. Inspected by 19 (TITLB) 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: .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. (TITLE) ~r u. S. GOVERNMENT PRINTING OFFICE: 1957 O-F--4Z7038 feet, feet; .feet. 19 5. ~late~3knalT~is: a. Bactre~ial b. Detergent .......... ...... 5, .Well data: b. Deptl%. ...... ' c. Casin~ Size dm Distance from well to closest existin~ or proposed: 1. Bewer line Septic tank Seepage Area.__..___.. ~. Cesspool~. ,_. ,, . 5. Property Line . 6. Other sources of p. ossible, contamination, i.e., creeks, lakes, houses, barn~ draznage dztch, etc. ., · ,~ ~ ~.._ .~. ~ ~,~.T/~/ b. SePtic tank capacity in gallons c. %~ame of septic tank manufactu~ ~.. ~ ..... 1. If "home made" show diagram on reverse side of this form. d.' Disposal field or seepage pit size a~d type ~~~~ .... .. / ~ .... Percolation f, Percolation Test performed by .............. ~ ........ , ~ Use the ~everse.side of this form to show dia£ram. Diagram should include ...~he following., infoPmation: ~operty ltnes;.weti location, house location, ~p~ic tank location, disposal area location, location of percolation a~, direction of Kround slope. \ 9. The ~nfox~a~ion on this form is true and correct to the best of my knowledge. Applzcant SiEnature 'of ' " ' ' TO .... BE FILLED OUT BY ,H, EALTH DE?ART!.~ENT PE~SO.NNEL ~he ab.eve described sanitary facilities are hereby approved, subject to the Conditions: The above described sanitary facilities are disapproved for the following reasons: