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Home My WebLink AboutCOLEMAN #1 BLK 1 LT 8 FHA form 2573 Form Approved Rev. Juiy 1958 FEDERAL HOUSING ADMINISTRATION Budget 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. Anehe~&ge~ Alaska F~wt ht~onal MORTGAGOR OR SPONSOR PROPERTY ADDRESS SUBDIVISION NAME J BLOCK NO. [ LOT NO. Coleman 8ubd:Lv:ialonj 1J 8 TOTAL NUMBER: Con attic or other area be made into BASEMENT J~] New installation additional bedrooms? LIVING UNITS BEDROOMS BATHS -- (if Yes, how many'.) ..X ~ 1 [-']Yes [~'] No ['-]Yes [-~No WATER SUPPLY BY: SYSTEM DESIGNED FOR [-']SEWAGEPUbliCDIsPOsALsystemBy: [-~ Community system ~'] Individual NO. OF BDRMS, GARBAGE DISPOSAL [~] Public system [--] Community system ~-1 Individual ~ [--] Yes [ii No PART fl.--TO BE COMPLETED BY HEALTH DEPARTMENT HEALTH DEPARTMENT INSPECTOR'S SKETCH .....-= ..... !', _~ ~ ~--.-, _ _ ~ .... -~-__ -~ ~:-~ .... _~._~_~- .... --_?-_ __,- --- :- --:-:- ---~- --~-~_ ~ --=-~_ --~'j__ ~'--- ij I ~- I ---~--~_ -- ___~. ~.. It is the opinion of the [] State [--] County [] Local Department of Health that this individual water-supply system ~ is ['-1 is not satisfactory as a domestic water supply for the subject property. It is the opinion of the [-'] State [-"] County ~t] 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 mean 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 as 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 ['-'] Acceptable [--] Not Acceptable Sewage disposal be considered ['-'] Acceptable [~] Not Acceptable. DATE SIGNATURE J--J C~IEF ,~RC~ITECT [ "~ DEPUTY FOR CHIEF ARCHITECT HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM FHA Form 2573 Rev. July 1958 REPORT OF INSPECTIONwlNDIVIDUAL SEWAGE-DISPOSAL SYSTEM PRIMARY TREATMENT consists of [] Septic tank. Septic Tank: Distance from well, ~ ~ Material, Total liquid capacity, 0 Inside length, ' Cesspool: Distance from: Well, Inside diameter, [] Cesspool. gallons. Capacity inlet compartment, feet. Inside width,. ' feet. Liquid depth, '~ feet. Number of compartments -- gallons. feet; foundation, feet; 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, Total length of tile lines~ Trench width, Length of each line, Type of filter material: [] Gravel. feet. 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. [] Broken stone. Other. Depth of filter material beneath tile,~ inches. Depth of filter material over tile, inches. Seepage Pits: SCi · -,~/'~' '>*~ Number of pits $ . Outs,de ~a~t~r, $ ~[{~ feet. Depth. ~ .feet Lining material <: ~.~., ........... Distance from Well, feet' building foundation feet nearest lot line at ~ front ~lit e ~ rear Ins,~ion made by: = State. = Count. = ==1 Heal~ AuthoriW. * CO~THgL~ ,:~,t~,, Date of insp=tion O,;tob~r =4 19 ~l ~ ~. ~~1.~,, '~':' "'~ % ". / REPORT OF INSPECTION--INDIVIDUAL WATER-SUPPLY SYSI M,'~.~57:,, Distance to nearest public water main, ~ n k 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 N~Ill41 Properties in ~n.~ighborhood [~1 are &~re not being developed with both individual water-supply and sew~l~-disposal systems. Lot size: . O~} feet wide~ ' ~"~ feet deep. Dwelling set back from front property line, ,~,t feet. Individual water supply from: ~ Drilled well. ~ Driven well. ~ Dug well. ~ Bored well. Distance of well from: Building foundation, I 8 feet; nearest lot line at ~ front. ~ side, ~ rear, t 7 . ,~044 feet; tile sewer, feet; septic tank, ~ feet; disposal field, feet; n~we[ feet; cesspool,, feet; other sources of possible pollution, ' feet. Well construction: Diameter, 6 inches. Toml depth, 2~ .f~ Type of casin~I ici i ro. Depth of casing, 2~ feet. Approximate depth to pumping l~l of water in well, f~t. Approximate yield, [ ~ gallons per minute. ~aled wate~ight to depth of feet. Exterior space around casing sealed with: ~ Cement grout. ~ ~ddled clay. ~ Ordina~ backfill. Or [ ~{~ ~ i ~ Wellcover: ~ncrete. ~Wo~. ~Metal. Openings in well cover watertight: ~Yes. ~No. $}~. $~}}~r~ ~um~ ~ Shallow well. ~ Deep well. Len~h of drop pipe, [ ~ feet. ~mp capacity, [ ~ _~llons per minute. ~cat~ in: ~ Basement. ~ ~mproom off basement. ~ Pumphouse above ~ound. ~ ~mp pit. ~r~ [ ~mproom properly &ained: ~ Yes. ~ No. ~mp~unting wateffight: ~ Yes.. ~ No. Type of storage: ~ Pressure. ~ Graviw. Capacity, -'' gallons. Has bacteriologi~l examination of water been made? ~ Yes. ~ No. If answer is "yes,'~. give ~te OC ~'~' :/~¢~1 ~ ~,~ U~ '" ~.~ Ouali~ of water ~ is ~ is not satisfa~o~ for human consumption S~{ t $b r~por f s ~ ~. 4/. Installation ~ does ~ does not comply w~th a~roved exhibits, tf any ...... ~ % ~ . t '. ~c~77ns~o~y ~t~t~· ~un~ ~ ~o~l~alth A~thorl~s~eT~~~~~~7~} inform,Lion 'reg,rdlng Items not visible-a, obt,lned 4v4114~iC sources. Anc, 6~ 4nd exhibits 4tt.chcd. -'~'~. ~proxlm4tclv 300 gellons of w4fer fed Info dlspos,l system with no evidence of b4ck-up. C.O~'~ T, CO,i ANC 62 DATE O c.-r 2. ~" ~, 19 ~ I LOCATION I certify that the individual SE~GE DISPOSAL SYSTEM installed at the above location complies wi'~'.t the plans and modifications a.ttacLed hereto and that the sub--surface disposal ssrstem area is adequate for the absorption of the normal volumms of domestic wastes. CASE NO. ~.O._O.,q3 I certify that the Zndividual ?~TER SUPPLY"SYST~"i~stalI6~"~2'~J the above location co~plies ~ith the Plot plans and as-built drawings and specifications attached hereto. ~ Installer INDIVIDUAL WATER SUPPLY 8eetion of 8anlt~tion and ~n_-ineeFm~ Request for Bacteriological Analysis. Sh~t for ~e; C~on (Name of person collecting sample) (Date) (Time) Water sample collected from [] Kitchen tap; [] Bathroom tap; [] Basement tap; [] Other (list) ...................................................................................................................................... (Mr.) Mail report to (Miss) .............................. (Name) (Box Bio. or street address) (City)- Please place an .X" in the ,box before items-which be~t describe your water supply: SOURCE: Well ~ [] Dug, [] Driven, [] Drilled, [] Bored ,.) [] Sprin~, [] Cistern, [] Other (list) ............................................................................................................... , [] CreelS, [] River, [] Lake, [] POnd ................................................................................................................. DUO WELL OR CISTERN CONSTRUCTION: Walis ~ [~Wood, [] Concrete,.~] 'Metal, ~ Tile, [] Brick or Concrete 'Block Top ~-i~] Wood, [] Concrete, ~] Metal, [] Open-Top LOCATION: [] In basement, []-Ba~n~ent offset, [] Under house, [] In yard Other ..................................................... · ........................................ , .................................................................................... DISTANCE TO: Building sewer or other drainage pipe.....eL.Z.....feet, Septic tank ....7...~......feet, Tile field .............. feet, Seepage pit ...t..~....O...feet, Cesspool .............. feet, Privy .............. feet, Other possible sources of contamination (list) ................ ~.aiIK .............................................................................................................. MATERIAL: Buildin~ sewer ~ [] Cast iron, [] Wood, [] Tlle~ [] Fibre pipe, [] Asbestos cement ~opp~ Joint material ~ Type ........ .~.O..~.O.J//..R, ....................... ; .............................................................................................. GENERAL INFORMATION: Does water ' become muddy or discolored? [] yes, ~ no When? ................................................ ~r ..................... , .............................................................................. Diameter of well ........................ ..~...:. ....................... depth ........................ ..~.....~... ....... ................ feet Length of drop pipe .......................... /...~...f. ............... i. ........................................................................ Water depth from bottom .......... ~ ...................... [..~. ................................. · ........ :: ................. ..... feet Pump location: [] In well, [] Offsel~ in basement, [] In basement [] In utility room, [] On top of well [] Other (list) ....................................................................................................... PURPOSE OF EXAMINATION: Illness suspected? [-]'yes, ~ no New source of supply? l[~ yes, [] no Repairs to existing system? [] yes, [] no Remarks: ............................................ : ........................................................................................................................................................... PLEASE DRAW A SKETCH IN TIlE SPACE BELOW. THIS SKETCH SHOULD SHOW LOCATION OF HOUSE, WATER SUPPLY SOURCE, SEPTIC TANK, SEWER, DRAIN LINES 'OR OTHER SOURCES OF POLLUTION AND DISTANCES BETWEEN WATER SUPPLY SOURCE AND ANY OF ABOVE 'PACILI'I'iF~t. " - SAMPLEs MUST BE SUBMITTED IN CONTAINERS PitOVIDEDBYTHE ~8K/t 'DEPARTlV~A'T-OF,~'t~tt