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Home My WebLink AboutCREEKSIDE PARK #3 LT 39.D, N L $ ca./~ I FHA Form 2573 Form Approved Lev. July 1958 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. l~rat gational ~a~k of Auehorage Federal I~ouet~g_ ldmi~tratio~ Box 720. Anchorages Alaska 60-008808 MORTGAGOR OR SPONSOR PROPERTY ADDRESS Bernlmz~l T~Lnen no number 01d llarbor Ro~d SUBDIVISION NAME BLOCK NO. LOT NO. Cr~4kaidm Park TOTAL NUMBER: Con attic or 0~h~r area be made into BASEMENT ~1 New installation additional bedrooms? LIVING UNITS BEDROOMS BATHS ~~ (If Yes, how many~.) WATER SUPPLY BY: SYSTEM DESIGNED FOR [~ Public system [--] Community system [~] Individual NO. OF EDBM$. GARBAGE DISPOSAL; SEWAGE DISPOSAL BY: ~l Public system [--I Community system [~ Individual > ~1 Yes [~] No PART II.raTa BE COMPLETED BY HEALTH DEPARTMENT HEALTH DEPARTMENT INSPECTOR'S SKETCH ...... ~-__ -~- ~ ~- ~- -~ _ 2 ' . .-.~..-...--.~- .... -~ . ' It is the opinion of the ~ State N County [~1 Local Department of Health that this individual watef-suppiy system ~' is [-] is not satisfactoryr ', as a domestic water supply fo~: the subiect property. It is the opinion of the ~ State N County ~] Local Departmer:.t of HeAlth that this individual sewage-disposal sys- tem with proper maintenance: ,~fan be expected to function satisfactorily, and [-'] Cannot be expected to function satisfactorily ~s .not likely to create an insanitary condition I / NOTE: The health authority should complete the appropriate opinion statement aba d af~x dote, Lignature and title in the spaces provided. Use of the above grid for Health Department Inspector's sketch as well as use of the back of this form is at the option of the health authority..~ PART Ill.--FOR U$f ~ fl,,l& OIIIC! TO THE CHIEF UNDERWRITER: Individual water-supply system be considered [~ Acceptable N Not Acceptable Sewage disposal be considered [~ Acceptable ~'] Not Acceptable. DATE SIGNATURE ~1 CHIEF ARCHITECT ~-J DEPUTY FOR CHIEF ARCHITECT HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM FHA Form 2573 Rev. July 1958 REPORT OF INSPECTION--INDIVIDUAL SEWAGE-DISPOSAL SYSTEM PRIMARY TREATMENT consists of ~ Septic tank. [] Cesspool. S~pti¢ Tanka (a~ ,~ Distance from well, feet. Material. ~' ~' / Total liquid capacity~._ / 0 0 {~ Inside l~'~geh,- r--~'~' feet. Inside width, Distance from: Well, feet; foundation, Inside diameter, feet. Depth, feet. ~CONDARY TREATMJNT consists of [] Tile disposal field. ~Seepage pits. Tile Disposal Field: Distance from: Well, Total length of rile lines~ Trench width. Length of each line Type of filter material: [] Gravel. gallons. Capacity inlet compartment,.. feet. Liquid depth, Number of compartments / gallons. fe~t; nearestqc~t iine' at [] front, [] side, [] rear, Liquid capacity, gallons. Lining material Other feet; foundation, feet; nearest lot line at I--J' front, [] side, [] rear, feet. feet. Number of lines, Distance between lin~, 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 filte; material over tile, inches. Seepage Pits: Number of pits / O~tside ,rmnt,~r. 8' X. ~ feet' /~ .feet. Lining mareria, ,~ e/.~ Distance from: Well, '/t/ feet; building foundation, /~e~h, feet; nearest lot line at [] front, ~ side, [] rear, Date of inspection Insl~dion made by: [] State. [] County. ]~Local Health Authority. ,~.,j// , 19~.~- Inspected by. ! 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 ne~hborhood ~are [~ not being developed with both individual water-supply and sewa~-d~,~oosal systems. Lot size:. / ~3' ~4, feet wide, ~' feet deep: Dwelling set back from front property line, / feet Individual water supply from: ~ Drilled well. [] Driven well. [] Du~ well. [] Bored well. Distance of well from: foundatio~ ,~ 7 ~,~e~ nearest lot line at [] front, ~ [] rear,. Building cast iron sewer, feet; tile sewe~/g~.$~mr.~_, feet; septic tank, .feet; disposal field, ~ seepage pit, ~ t ~ .feet; cesspool,. ~ feet; other sources of possible pollution, ~ feet. Well construction: Approximate depth to pumping lev~e~ of water in well,, fee~ ~ feet. Approximate yield, ~)C~ .gallons per minute. Sealed watertight to depth of //7' feet. Exterior space around casing sealed with: [] Cement grout. [] Puddled clay. ~ Ordinary backfill. Well cover: [] Concrete. [] Wood. '~4etal. Openings in well cover watertight:~,~,Yes. [] No. Pump: [] Shallow well. ,~4~eep well. Length of drop pipe, '~- feet. Pump capacity, ~ Located in: ~Basement. [] Pumproom off basement. [] Pumphouse above ~onnd. [] Pump pit. 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~proved exhibits, if any. Inspection made by: [] State. [] County. ,~kLocal ~ealth Authority. Inspected by Date of inspection / ~/~'/ ] 9 ~ O //, ~' U. S. GOVERNMENT PRINTING OJfFICE: ItS? O'F--42703~ 10-55 r 5M l// INDIVIDUAL WATER SUPPLY ALASKA DEPARTMENT OF HEALTH Section of Sanitation and 'Engineering OFFICE ACTION ON REQUEST FOR BACTERIOLOGICAL WATER ANALYSIS Your recent request for an analysis of a sample from the Individual Private Water Supply roce,.ed 2M6/60 ana ~xmnination has been completed, Records In this office indicate this Individual Private Water Supply to be of ~sathfactory fsanitary status. ~~Sati Analysis shows this SAMPLE to be siactory Questionable Ire Biub ~ Ba~~ 8tm- ~. B Qusetlonablo Unsatisfactory Unsathfactory. If an "Uasathfactory" or "Questionable" status is indicated above, you should take Immediate action as reco,-,,~,,enclod below. 1. Boll or chemically treat your water supply to protect your family item water-borne diseases as outlined in closed leaflet, "Drink It Pure." 2. Improve your spring- f~ee bulletin HSE.G-2 3. Improve your cistern -- See bulletin I-ISE.6-3 4. Improve your dug well- See bulletin HIE.6-4 5, Improve your driven well- See bulletin 8, Improve your ctrillod well--Soo bulintin HSE-6-6 7. Relocatayour well to a safe location In ralationsldp to your sewage disposal s~stem-- See bulletin HSE-I5 8. Bottle broken in transit, please send new 'sample. 9. f~xmplo too leu9 In transit~ sample should not be over 48 hours old at examination to Indicate reifablo results. Please send now sample. 10~ Contact your neurest ~] Local Health Department or [] Alaska Health Department, Smodtaflen office bulletins, consultation, and assistance. 11. This is a sudaco water source and subject t° pollution by man and ~-nlmals. An approved water supply source should bo developed. SANITARIAN'S ~S 'A DH--HSi~i{'i This Form M~ust !~ Filled Out CompleXly. TAKE WATER SAMPLE TO: Laboratory, 945 Sixth Ave. · Monddy, T~esd,y, VFednesday INDIVIDUAL WATER SUPPLY ALAd~KA D~AB'I~ OF ~tion of ~flon ~d ~~g Please Look on Reverse of Sheet for S~mple Collection ~n~ruetion~ Request [or Bactertological Analysts Water sample' collected uy ....... .~'-d.-.: ..... t.l...&...~...~....~....t...~./- ........................................ -~ ....... t .......................................... (Name of person collecting '~ample) · (Da~e) (Time) Water s~mple collected from _/~K~,~chen tap; [] Bathroom tap; [] Basement tap; ...... ........... ====================================================== (~.) (Name) Please place an "X" ~ ~he box before i~ms which b~ desc~be yo~ wa~er supply: ~E: We~ ~ ~ Dug, ~ Driven, ~ed, ~ Bored ~ Sp~g, ~ C~em, ~ Omer (ns~) .......... ~ ......................................................................................... ~ ~me~, ~ River, ~ Lake, ~ Pond ................................................................................ , ............... : ................ DUG ~ O~ C~N CONS~UC~ON: Wa~ ~ ~ Wood, ~ Concrete, ~ ~ml, ~ ~e, ~ Brick Or Concrete Block' Top ~ ~ W~d, ~ Concre~, ~ Me[al, ~ ~en Top ~A~ON: ~ ~ b~men~, ~ B~emen~ offse[, ~ Under no~e, ~n ~rd ~er ................................................ : ................................................................. ~ ......................... ' ........................................ D~T~CE ~: Bulling sewer or o~her drainage pi~., ............ iee~, Septic ~nk .............. fee~, ~e field .............. fee[, Seepage pl~ .............. lee~, Cesspool .............. fee~, ~i~: ............. fee~. O~her ~sible so~ces of ~nt~maflon (1~) ............................................................................................................................................. ~~: Buffing sewer -- ~ Css~ ~on, ~ Wo~, ~ ~e, ~ ~bre pipe, ~ ~bes~os cemen~ ~om~ ma~e~ -- ~e ....................................................................................................................................................... GE~ ~~ON: Does wa:er become muddF or ~colored? ~ ~es, ~ no ~? ............................. Z"~; ................................... ' ...................... ~"~"57'"~ ..................................... Diameter of well ~ ~ dep~ ~.~ ..................................... fee~ ........................................................... Weu e~mg ma~e~al ...... ~.~e...~...~ ........... ~ame~er ..... ~. .......... dep~...~Z.~ ................... O>il ' t.Ito o, .................... ................................................................................................ ~ t Water depth from ~t~m ...... /...,~"~'v ................................................................................................. feet ~ location: ~ ~ we~, ~ Offset ~ basement, ~ In b~ement ~ ~ ut~ty r~, ~ On top of well u ........................................................ ..................................... PURPOSE OF EXAMINA~ON: Illness sus~cted? ~ yes,~no New source of supply? ~o ~pairs to e~ting syste~? ~ yes, ~o ............................................ ~ ................ ............................ ~ ............................................ PL~E DRAW A S~H ~ ~ SPA~ B~W. ~ SK~CH SHOED SHOW ~CA~ON ~ HOUSE, WA~ S~PLY SO.CE, S~C T~, ~, DRA~ ~S OR O~ SO~CES OF ~~ON ~ DIST~ BE~ WA~ S~PLY SO.CE ~ ~ OF ~O~ F~",~. MUST BE SUB_M~TTED IN 00NTAINF.,KS P~OvIDED BY 't'ttl~ ALASICA DEPARTMENT OF