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Home My WebLink AboutFAIRMOUNT LT 4 ? ? FHA Form 2573 Form Approved Rev, July 1958 FEDERAL HOUSING ADMINISTRATION Budget Bureau No. 63-R296.B HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM PART I.--TO BE COMPLETED BY FHA ~NSUmNO GE.CE k0"TR~OEE ..... SERIAL NO, MORTGAGOR OR SPONSOR PROPERTY ADDRESS Can a.lc or other area bo made into TOTAL NUMBER: ..... BASEmEnT ~ ~S~I]~ additional bedrooms? WATER SUPPLY BY: _~ SYSTEM DESIGNED FOR ~ Public system SEWAGE DISPOSAL BY~ ~ ~bli~ sy,t~m ~ Community ,y,t~m ~ I,di~ia~l ~~ Ye, ~No HEALTH DEPARTMENT INSPECTOR'S SKETCH ZZZZZ Z ...... ~ -~ ~L-L ~ ...... ....... ~_..~ -~ -~-~ -b--k~ .... -L-L _LL_LL~L-L .... ~ .... ZZZ Z Z ZZ ZZZ ZZZZ k is Ibc opinion of [he ~ Slate ~ Coun[y ~ Zoca] Depar[men[ of ~eakh [ha[ Ibis individual wa[er-supply sys[em ~ is ~ is not satisfactory as a domestic water supply for the subject propers. 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 insanita~ condition DATE SI~NAT~/ TITL[ ' ~ Sanitarian ,.~ Ule of the above grid for Health Department Inspector's sketch as well as use of the back of this form Il 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 pe~inent FHA Compliance Ins~ction Report, and recommend that'the Individual water-supply system be considered ~ Acceptable ~ Not Acceptable ~wage dis~sal ~ considered ~ Acceptable ~ Not Acceptable. DAfE SlGNA~UEE ~ CHIEF ARCHITECT DEPUTY FOR CHIEF ARCHITECT HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM FHA Form 2573 Rev. July 1958 REPORT OF INSPECTIONmlNDIVIDUAL SEWAGE-DISPOSAL SYSTEM PRIMARY TREATMENT consists of [] Septic tank. [] Cesspool. __.feet. Material Septic Tank: Distance from well, Total liquid capacity, Inside length, Cesspooh Distance from: Well, Inside diameter, Number of compartments gallons. Capacity inlet compartment, feet, Inside width,, feet. Liquid depth, .feet. 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_ gallons. Tile Disposal Field: 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. Number of lines, Distance between lines, inches. Total eff&tive absorption area in bottom of trenches feet. Depth, top of tile to finish grade, Type of filter material: [] Gravel. [] Broken stone. Other. Depth of filter material beneath tile,, inches. Depth of filter material over tile, Seepage Pits: Number of pits__. Outside diameter, feet. Depth,. Distance from: Well, __ feet; building foundation,_ Inspection made by: [] State. feet. .feet. square feet. __.inches. Date of inspection_ inches, feet. Lining material feet; nearest lot line at [] front, [] side, [] rear, [] County. [] Local Health Authority. Inspected by 19__ (TITLB) feet. 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 fram: Building foundation, cast iron sewer,, feet; tile sewer,. seepage pit, -feet; cesspool~ Well construction: 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__ .feet; nearest lot line at [] front, [] side, [] rear, feet; septic tank. feet; disposal field, feet; other sources of possible pollution, .feet. Depth of casing, .gallons per minute. .gallons per minute. feet, feet; feet, 19__ ~ ~ . REQUEST FOR APPROVAL OF ~j~ INDIVIDUAL SEWAGE AND WATER FACILITIES (Fill out in Triplicate) Numt,~, n,£ bedr~oms in house b. Dete~ent ~1 1 data: a. 'lype ~~ c. Casing Size well to closest existing or proposed: P. w~r,x'?'~"?___~'"/?' Distance from ., ~, ~ u,'~., 5. Property Line 6. Other sources of possible contaminetion, i.e., creeks, lake~, houses, barn, drainage ditch, etc. .~~ a. Age of system (O~J~-~, .:. ~'~' ! .. ~. Septic ta~k oapacity in ~allons ....... . C?) /'~ -' c. Name of septic tank manufactum~r 1. If "home made" show diagram on reverse side of this form. d.' Disposal field or seepage pit size and type .__~" I ~ ~)/. 1, Distance to property line ~ to house foundation . Percolation Test ~esults f. Percolation Test performed by Use the reverse .side of this form to show diagram. Diagram should include ~',{he fo]lowing Jnformation: p.~operty lines ~ .well location, house location, r~u~{c tank location, disposal area location, location of percolation test~ an~, di~,ection of ground slope. The l~£o~t~on on %his form is true and correct ~co the best of my knowledge. Signature 'of Applicant Date Si?ned ~0 BE FILLED OUT BY HEALTH DEPAP, T~,~ENT PERSONNEL ~--~e above described sanitary facilities are hereby approved, subject to the ~611owin? cond~tions: ......... Conditions: The above described sanitary facilities are disapproved for the following reasons: 'Signature of ~ffi'¢l:~ ....... '' ' Approval is valid for one year following, the date of ~pprovat. CPJ:cw REQUEST FOR APPROVAL OF INDIVIDUAL SEWAGE AND WATER FACILITIES (Fill out in Triplicate) 5. Water Analysis: . 6. W~]~ d. Distance from well to closest existing, or proposed: 8ewe~, line Septic tank /'/rfC'/, · . Seepage ~ 78' Cesspool' ~ - "" Property Line ~.~ Other sources of possible contaminetion, i.e., creeks, lakes, houses, barn, drainaEe dltch~ etc. . a. Age of system .... ~qF$ . I b. Septic tank capacity in gallons J(~(~ c. Name of septic tank manufactu.R~l.~,/~ r~,- r~¢l . 1. If "home made" show diagram on reverse side of this form. Disposal field or seepage pit size and type 1. Distance to property line ~l to house foundation Percolation Test results f. ercolatzon Test perfermed by p . Use the reverse side of this form to show diagram. Diagram should include the fo]lowing information: p~operty lihes~.well location, house location, ~i,t~c tank location, disposal area location, location of percolation test, and direction of ground slope. The Info~f.ation on this form is true an(] correct to the best of my knowledge. 'Slgna~ure of Applicant Date Si?ned TO BE FILLED OUT BY HEALTH DEPART~.~ENT PERSONNEL The above described sanitary facilities are hereby approved, subject to the ?6'llowin~ conair'ions: ' . ._ . Conditions: ~The above described sanitary facilities are dis~pproved for the following reasons: A~:oval is valid for one year followin~ the date of approvel. CPJ:cw 2. 3. q. 5. REQUEST FOR APPROVAL OF INDIVIDUAL SEWAGE AND WATER FB¢ILITIES (Fill out in Tripl~.6ate) ~- . ~',n,,,q of property owne. k_~~-~L-~~ 6. We]] data: c. ' Casing Size ~ . d' Distance from well to ctosest e×isting or proposed: 2. Septic tank 3, Seepage Area " . 4. Cesspool' 5, Property Line_~__ 6. Other sources of possible contamination, i.e., creeks, lakes, houses, ba~,n, drainage ditch, etc. 7, Sewage disposal system. a. ~ge of system ; ~. Septic tan~ c~p~cizy, i gsll ~ /~ ~ .' c. N~me of septic ~nk manufactum~= ........ 1. If "home m~de" show diagram on reverse side of ~his fo~m. Disposal field o~ seepsqe pit size ~nd ~ype 1. Distance to property ]lne .... to house foundation Percolation Test f. Percolation Test performed by Use the reverse side of this form to show diagram. Diagram should include the fo]lowing information: property lineal.well location, house location, n'~I,~e tank location, disposal area location, location of percolation test, and d~rection of ground slope. 9. The Information on this form is true an¢] correct to the best of my knowledge. $iFnature of Applicant Date Si?ned TO BE FILLED OUT BY HEALTH DEPARTMENT PERSONNEL The above described sanitary facilities are hereby approved, subject to the ....... [#6'l].owin~ conditions: Conditions: The above described sanitary facilities are disspproved for the following re as oils ~ Apl;~o,,al ~s valid for one year following the date of approval. CPJ: cw