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Home My WebLink AboutCREEKSIDE PARK #1 LT 51 FII~A Fot, h 2573 Form Approved Rev. July I958 ~ FEDERAL HOUSING ADMINISTRATION ~-~ Budget Bureau No. 63-R296.8 HEALTH AUTHORITY APPROVAL iNDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM PART I.mTO BE COMPLETED BY FHA INSURING OFFICE MORTGAGEE SERIAL NO. MORTGAGOR OR SPONSOR PROPERTY ADDRESS SUBDIVISI'~N NAME v J BLOCK NO. LOT NO. -] Can attic or other area be made Into TOTAL NUMBER: BASEMENT ~%~ew iflstaJlation additional bedrooms? "' LIVING UNITS BEDROOMS BATHS (if Yes, how many~) WATER SUPPLY BY: SYSTEM DESIGNED FOR ~] Public system ~-] Community system ~ Individual NO. OF BDRMS. GARBAGE DISPOSAL SEWAGE DISPOSAL BY: [~] Public system ['--] Community system [-~ Individual 5 [~] Yes ~-] No PART II.--TO BE COMPLETED BY HEALTH DEPARTMENT HEALTH DEPARTMENT INSPECTOR'S SKETCH I I I i I j It is the opinion of the D State N County O 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 ~l County [~ Local Department of Health that this individual sewage-disposal sys- tem with proper maintenance: [~Can be expected to function satisfactorily, and [-'] Cannot be satisfactorily expected to function is not likely to create an insanitary condition he health authority should complete the nt 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 III.~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 O Acceptable [-] Not AcCeptable. HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM DEPUTY I:OR CHIEF ARCHITECT FHA Form 2573 Rev. July 1958 Septic Tank: Distance from well, Total liquid capacity, Inside length,. Cesspool: Distance from: Well, Inside diameter, REPORT OF INSPECTION--INDIVIDUA~ SEWAGE-DISPOSAL SYSTEM PRIMARY TREATMENT consists of~ Septic tank. [] Ccssl:")°]'~g'X i S / a~// ~'7 3 Y ~ ~ feet.~ g~llons. Cal~dry inlet compartment. .feet. Insid~ width, lk~t. Liquid depth, .feet. Number of compartments . feet; foundation, fqet; nearest lot line at [] front, [] side, [] rear, feet. Depth,. feet. Liquid capacity, gallons. Lining material $~CONDARY TREATMEt~' 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; foundation, feet; nearest lo~ line at [] front, [] side, [] rear, f~t. feet. Number of lines,. Distance between lines, feet. .inches. Total effective absorption area in bottom of trenches .square fee~. 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 Pit~: / Number of pits , Outside di~n~er, ,-v feet. ~pth,. __ .feet. Lining material Distance from: Well, ~'~ feet; building foundation, ~ ~a~ feet; nearest lot line at [] front, ~ side_lTl.sear, /~ feet. Ink.ion made by: [] State. [] County. [] Local Health Authority. Date of inspection 19 ~ ~ -.~'~ (nTLE) REPO. I SPECnO --I D V DUAL WA.R-SUPPLY SVS. 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, Wall construction: Diameter, inches. Total depth, .feet; nearest lot line at [] front, [] side, [] rear, feet; septic tank,, feet; disposal field, feet; other sources of possible pollution, feet. Approximate depth to pumping level of water in well,. 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 feet. Type of casing, Depth of casing, feet. Approximate yield, .gallons per minute. gallons per minute. feet, 19 ( TITLE ) ~ u. s. GOVERNMENT PRINTING OFFICE : lES70-F--4ETO$8 REQUEST FOR A?PROVAL OF INDIVIDUAL SEWAGE AND WATER FACILITIES (Fill out in Triplicate ~. ~ of prope~y, owner ~ ~. Numb~,-'of ,bedrooms in house ~ . 5. Water Analysis: a. Bacte~ia]_ b. Detergent Well data: a. Type b. Depth c. Casing Size de Distance from well to closest existing or proposed: 1. Sewer line . 2. Sept ~.c tank . 3. Seepage Area Cesspool' 5. Property Line 6. Other sources of possible contamination, i.e., creeks, lakes, houses, barn, drainage ditch, etc. . Sewage disposal system. a. Age of system V~~ b. Septic tank capacity in gallons, c. Name of septic tank manufactu~e..r 1. If "home made" show diagram on reverse side of this form. d.' Disposal field or seepage pit size and type 1. Distance to property line to house foundation e, PeY'co] ation, Test ~esults f. Percolation Test performed by Use the reverse side of this form to show diagram. Diagram should include the foJlowing information: p~operty lines~.well location, house location, n~?tlc tank location, disposal area location, location of percolation test, a~ direction of ground slope. The ~for~tJon on this form is true and cormect to the best of my knowledge. Signature of Applicant Date Signed TO BE FILLED OUT BY HEALTH DEPAP, T~,~ENT PERSONNEL ~T~e above described sanitary facilities ape hereby approved, subject to the .......... ~6~ll°wing con~i~.~ons: Condi tion~: q~zy%3.- The above described sanitary facilities are disapproved for the following me asons: , "~'g at of ~:f,~i¢.f~.~l_~ ~:'. ~':.: ~'i. ~?,~,~ - Date' :~,: ~.b ...~ .~.'. '~ - Approval i~//valid for one year followin~ the date of approval. CPJ: cw .ANC 62 I certify that the individual S~,~GE DISPOSAL SYSTEM installed at the above location complies with the plans and modifications attached hereto and that the sub-surface disposal system area is adeque, te for the absorotion of the normal volu~s of domestic wastes. ~/4~ ~/~ / ~ ~ ~C~ ~nstaller ..... DATE , __ 19 .__... CASE NO. , - LOCATION l ti~ that the individual ~&TER SUPPLY SYSTEM in. st~.~.led at Icer fY _. t nlans and as-built ~rawmngs tho ~bove location complies w~th the plo ~ ' s.~ecifications attached hereto. / ' ~"-' Ins~aller 147