HomeMy WebLinkAboutBENITO BLK 1 LT 6
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES.
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage,'Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
--2.."7'/- ~.,~:~ HAA # H
1. GENERAL INFORMATION
Complete legal description Lot 6; 8£ock 1; Be~o Subdiuision
J
Location (site address or directions)
Property owner, -
Mailing address
Lending agency
10207 Genora Street
Eaqle River, AK
',.Robert & Shannon Law Day phone
-10207 Genora Street Eagle River, AK 99577
Day phone
696-1571 (h)
Mailing address.
Agent Kathi Olmstead/ REMAX OF EAGLE RIVER
Address 16600 Centerfield Drive Eaqle River, AK
Unless otherwise requested, HAA will be.~eld for pickup.
NUMBER OF BEDROOMS: 4
Day phone, 694-4200
99577
TYPE OF WATER SUPPLY:
Individual well XXX
Community well
Public water
NOTE:
lng to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
NOTE:
If community well system, provide written confirmation from State ADEC attest-
Individual on-site
Holding tank
Community on-site
Public sewer XXX ' ?i,) ~
If community wastewater system, provide written confirmation from .State ADEC
attesting to the legality and status of system.
72-025 (Rev, 1/91) Front MOA#21
=
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm ~~ Phone~
Address S & $ EHGIt,IEERING
17034 Eagle River L.~p?_o~___~O. ~ . Dat~e-.~
Engineer's signa~a, deP'ivei~~ ~;?.~,~ .~.:~.5,~' :?~_. ,
SIGNATURE
Approved for d
Disapproved.
Conditional approval for
DHHS
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
By:
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA~¢21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:~--c:~¢ L~ ~¢~- ~ ~¢~\'¢'b~/o
Parcel I.D.
A. Well Data
Well type "~¢--~-~¢.~
Log present (Y/_l~ ~
Total depth ~.~ ! 7~
Sanitary seal ~'~1) ~/
If A, B, or C, attach ADEC letter. ADEC water system number.
Date completed _ /c)~_/~ .... Driller
Cased to _~_~, ~ ~- Casing height
Wires properly protected ~4)
/;Z
FROM WELL LOG AT INSPECTION
Date of test
Static water level
Well flow
Pump levell
SEPARATION DISTANCES FROM WELL TO:
!
Septic/holding tank on lot
Absorption field on lot
Public sewer main
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Sewer service line ¢~ Petroleum tank
g.p.m.
WATER SAMPLE RESULTS:
Coliform ~ Nitrate ~. ¢ LO
Date of sample: ¢ ~/,.Z ~- ~/¢ Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
Date installed Tank size
Compartments
Cleanouts (Y/N)
High water alarm (Y/N)
Foundation cleanout (Y/N)
Depression (Y/N)
Alarm tested ~(YJN}~ ' ......
Date of pumping __~_¢:_~P~r~)er
SEPARATION DISTANCES FROM sF~HOLDING TANK TO:
Well(s) on lot _ _.,.~ On adjacent lots
To propecb]l~ Absorption field
Foundation
Water main/service line
Surface wateddrainage
72-026 (3/93)* Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed Manufacturer
Size in gallons Manhole/Access (Y/N)
Vent (Y/N) "Pump on" level at "Pj~C~ff" Level at
High water alarm level Oycd~s tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE~FJ~E~FT STATION TO:
Well onset~ On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date installed Soil rating (GPD/FF) System type
Length Width
Total absorption area
Date of adequacy test
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Gravel thickness
Cleanout present (Y/N)
Results (pass/fail) for
AfteptES~
~,~.~_t-_ If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD~O~:
__ Total depth _.~---- -
Depression over fiel~f~v-/~
Bedrooms
To building foundation
Well on lot On a~.dja~nt lots Property line
~ To existing or abandoned system on lot
On adjacent lots__
Surfac~
Curtal~ drain
Cutbank
Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
S~gnature .
Engineer's ~~gle J~Jver~,
Date of Payment
Receipt Number
72-026 (3/93)* Back
Waiver Fee $
Date of Payment
Receipt Number
~8./17/94 1~: 24 CT&E ENU I ROI',IHENT~L L~B SERU I CE'3 NO.
Environmental Laboratory Serwces ~
LABORATORY ANALYSIS REPORT
CT&B Kef.# 94,414%3
Client Smnple ID 1,6 BI BBNITO Sfl)
Matrix WATER
Client Nme 8 & S ENGINEERING
Ordered By R, SI iAFER
proj~¢.t Name,
PWSID UA
W OI-LK. O rdez 81341)
printed Da're 08/17/94 (~), 13:01
CollectedDate 08/t2/94 (6! 10:30 hrs.
Receiv cd l?atc 08/12194 (~! 13:50
2'echnical Dir¢c'mr STt2.PHEN C, EDI'.
parameter
Njtratc-N
ROt)TI-NE 8AIv[PI.E £..OJ_,LEC I. I.D BE. KAY.
QC
Re~utts Qual Units
2,80 mg/L
Method
I'";PA 353,2/300.0
Allowable Ext. Anal
Lim].tfl DaZe f)atc
10
UA '-' Un ~,v ail itl) } e
* See Special In stnlctions Abvve NA =Not Ant~tyzc(l
* * See Sample; Remarks Ahoy c
11 = U~&tectcd, gt~ odcdvah~ ia the practical qmat[ficat[on limit,
D = Seoon~y
5633 B Street, Anchorage, AK 99518-1600 --' Tek (907) 562.2343 Fax: (907) 501-5301
F~0v!~ONMFNTAL FAC. If I'r ~-.q. IN ALASKA, COLORADO, FLOI~IDA, ILLINOIS, MARYLAND, NEW JEFISEY, OHIO, UTAH, WEST VIRGINIA
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 6; Bloc~ I; Benito Subdivision
Location (address or directions)
(b) Property owner AHFC
Mailing Address
Telephone: (home)
Business
(c) Lending Institution
Mailing Address
Telephone
(d) Real Estate Company and Agent JACK WHITE COMPANY/Lori Crowder
Address 10928 Eagle River Road, Ea~le River, A~aska 99577
Telephone 694-5,500
(e) Mail the HAA to the following address: (or check here,~, if hold for pick up.)
List contact person and day phone number below:
94-2979
17034 Eagle. Riu¢.~ Lcmp Road; SuZ~¢. 204
EagZ¢_ Rive.4; A2~k~ 99577
TYPE OF RESIDENCE ordered by Lori Crowder
Single-Family,~D[ Number of bedrooms 4
WATER SUPPLY '
Individual Welt iD( Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
SEWAGE DISPOSAL
On-site [] Public [~]X Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmentai
Conservation attesting to the legality and status.
72-025 (Rev. 7/88) Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigatior~ of this
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe,
functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the information obtained from the Municipality of Anchorage files and from my investigation and
inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and
State codes, ordinances, and regulations in effect on the date of this inspection.
Name of Firm
Address
Date
S & S ENGINEERING
17034 Eagle River Loop Road No.
Eagle River, Alaska
Telephone
6. DHHS APPROVAL
Approved for ~'/ bedrooms by
Approved ~_ Disapproved
Terms of Conditional Approval
Conditional
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections
or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work.
72-025 (Rev. 7/88) Back Page 2 of 2
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4744
Legal Description:
A. WELL DATA /
Well Classification ~)/'~///~_¢~_: ..../~ If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y~N)/ Date Completed ..... Yield ~ ~/"/-~/
Total Depth ~/ ~ Cased to ¢O ~ Depth of Grouting ~
Static Water Level ~ / ...... Pump Set At ~~
Casing Height Above Ground
Electrical Wiring in Conduit (~)N) _
SEPARATION DISTANCES FROM WELL:
To Septic/Ho!dh~g Tank on Lot
Sanitary Seal on Casing (~N)
Depression Around Wellhead (YN~/
;On Adjoining Lots __z'"v'/
To Nearest Edge of Absorption Field on Lot _ __/_~.~Z~///¢7 ; On Adjoining Lots ._ "~'/////¢/
To Nearest Public Sewer Line .~__~/;z _ To Nearest Public Sewer Cleanout/Manhole
/
To Nearest Sewer Service Line on Lot
Water Sample Collected by ~_~_ _;--~/d¢ ..... Date_
Water Sample Test Results ~ ¢/~ ~c
Comments
B. SEPTIC/HOLDING TANK DATA
Date'lns~l~ ..... Size _ No. of Compartments
Standpipes (Y/N)'~-..~<__ Air-tight Caps (Y/N) ....... Foundation Cleanout (Y/N)
Depression over Tank (Y/-'~N")'"--~ .............//___/Date Last Pumped
Pumping/Maintenance Contact on File~%/tN¼~///~--/' ~/___/~ .... ; for
Holding Tank High-Water Alarm (Y/N)__~_ ~:--~.~/~T. err~/~ry Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEP~IC/HOLDI?G//C//~TA~Ci, K: ~
To Water-Supply Well ......... ~' To~uilding Fou~a"tl~'Om
To Property Line __ To Disposal Field
To Water Main/Service Line ....
To Stream, Pond, Lake or Major Drainage Course
Comments _ . _
72-026 (Rev. 7/88) Front Page 1 of 2
ABSORPTION FIELD DATA
~" S~s..Rating" in Absorption Strata Type of System Design
Date In'~t~ed ....... Length of Field
Width of Fiel~.~___~ .... Depth of Field
Gravel Bed Thickness
Square Feet of Absortion Are~
---_ ¢;tatndpipes Present (Y/N)
Depression over Field (Y/N)
__~.~ ._.<.._~_ __ te of Last Adequacy Test
Results of Last Adequacy Test /~OO ~j~~
SEPARATION DISTANCE FROM
To Water-Supply Well To P~e
To Building Foundation 'f"o-'~.ting or Abandoned System on
L. ot ; On Adjoining Lots
To Water Main/Service Line To Cutback (if present)
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area '"""--.%
Comments
LIFT ~N
Date Installe~
----.~.
Size in Gallons ~-~_-.~ ~_
"Pump On" Level at .......
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
MaThole/Access (Y/N)
/"Pump Off" Level at
Vent (Y/N) _
/ '-~ --. ........ Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request** · ,
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines ~n effe ~h~s
inspection·
Signed S & S ENGINEERING ~'-~' '~ ~ ''~ ......
Company ~~a 99577
MOANo. ~ ¢~ ~ ......... ~'"'"
Receipt No,__:e¢_/ e / . ~' ,. I/)/~.> Receipt No.
Date of Payment //./z~-. Waiver Fee: $
Amount: $ /~ ) ?t Date of Payment
72-026 (Rev, 7/88) Back Page 2 of 2
~~ CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343
V ~^BO.ATO.,ES ~ FEDERAL TAX ID # 92-0040440
[)ate ~o. po;t Printe~l: [tO? 8, 8g .0. J9:2~I
NOV ~ g¢ ~ 14:00
APPLI( NT FILLS OUT UPPER HA' ONLY
~1~../~'~ Phone
Property Owner
Buyer
Address Zip Code
Lending Institution Phone
Address ~ Zip Code
Realty Co.& A~nt ~) ~"? i ~'~,/) ~,~-~ ~ ~(~ .... ~'/~ Phone
,p ~ , .
~,, ~.~,,~,,on W'.. ~ ,' ,t~:~ . ~ ~:~, '~
1
Street Locati~
~ Single Family Z ~
~ Multiple Family No. of Bedrooms
~ Other
W~e~p~
~lndividual A~ACH WELL LOG. A w~l log is required for all wells drilled since June 1975.
~ Community ~~ For wells drilled prior to that date, give well depth (attach log if available).
~ Public Utility--
Sewer Disposal
~ Individual Year Individual Installed:
~blic Utility When Connected to Public Utility:
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSlNG CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
Field Notes: C_'IL,['to
C [ ~ C°v' ~ ( ~ ~ Jl~~ MUNICIPALITY OF ANCHORAOE
PEPT. OF I'J~/,LT~t
~ ENVIRONM:NTAL P~Oi~C[ION
'~to ~
~YC~l~/ch
~ ) APPROVED BEDROOMS *CONDITIONS OF APPROVAL' ~ ~ % ~ I
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL*
DATE J~- J~
Soils Rating Date ~wer Installed Well To Absorption Area [ ~' Well Log Received
ftp - 2 ~-? ( WelltoTank ~ Septic T~k Size / ~-~ '
72-023 (3182)
~ · ~ ~W ~h DATE RECEIVED
" INSPECTION APPOINTMEI~S (~'" ~'
TIME TIME ~ ' TIME
DATE DATE DATE '
INSPECTOR INSPECTOR INSPECTOR
MUNICIPALITY OF ANCHORAGE MUNICIPALI~ OF ANCHO~GE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIONDEPT. OF HEALTH
~ 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL P~OTE~ION
ENV, RONMENTALSAN,TAT,ON D,V,S,ON 5U~ ~ 0 1981
Telephone 264~720
DIRECTIONS: Complete all parts on page 1. Incomplete reques~ will not be proce~ed. Please allow ten (10) days for processing.
r, P'HONE
MAILING ADDRESS
PROPERTY RESIDENT (If different from~ove) ' PHONE
MA, L,.G AOO.~SS~ TL ' y .
MAI LING ADDRESS
MAI LING ADDRES~
5. LEGAL DESCRIPTION
STREET LOCATION
6. 'TYPE bF RESIDENCE. , NUMBER Oi=~EDROOMS
[] One ~ Four []
' SINGLE FAMILY [] Two [] Five
[] MULTIPLE FAMILY [] Three [] Six
7. WATER SUPPLY
~' INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled
[] COMMUNITY since June t975. For wells drilled prior to that date, give well
[] PUBLIC UTI LITY depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
~ yDIVI DUAL/ON-SITE**
~ [~PUBLIC UTI LITY
Other
.YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY , ·.
TYPE OF RESIDENCE
[] SINGLE FAMILY
[] MULTIPLE FAMILY
2. WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTILITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
[] INDIVI DUAL/ON -SIT.~E.
[]PUBLIC UTILITY
Connection Verified
[]Septic Tank or [] Holding Tank
Size:. If Tank is homemade
give dimensions:
[] ONE
[] TWO
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
SOILS RATING
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
Septic/Holding Tank
NUMBER OF BEDROOMS
[] THREE [] FIVE
[] FOUR [] SiX
Absorption Area ISewer Line
[] OTHER
INearest Lot Line
5. COMMENTS
DATE
~]~-APPROV ED FOR
DISAPPROVED
~ BEDROOMS
CONDITIONAL APPROVAL (letter must accompany certificate)
72-010 (Rev. 6/79)
o,.~ATER ANCHORAGE AREA BOROUG,-,
DEPARTMENT OF ENVIRONMENTAL QUALITY
3500 TUDOR ROAD
ANCHORAGE, ALASKA 99507
279-8686
REQUEST
INDIVIDUAL
FOR APPROVAL
SEWER AND WATER
FOR
DATE RECEIVED:.
INSPECT: / ~
TIME:
OF
FACILITIES
7/
PROPERTY OWNER: ~,/--,~-,-Y~.~ PHONE:
TYPE FACILITY TO BE INSPECTED: 5)h~//~ ,~ STREET:
NUMBER OF BEDROOMS:
WELL
A.
B.
C.
D.
E.
SEWAGE
TYPE
DEPTH
S ZE [.;' _
CONSTRUCTION
BACTERIAL ANALYSI
DISPOSAL SYSTEM:
(IF HOMEMADE, SHOW
SEPTIC TANK
1 . SIZE
2, AGE /'~ 7/'
3. MANUFACTURER
DIAGRAM
ON BACK)
4. INSTALLER
~PPROVAL REQUEst' FOR SEWER & WATER FACILIl~ES
TWO
SEEPAGE PIT
2. LINING Co-mc y'~
DISPOSALX~LD
l. NUMBER 0~I NES
2 TOTAL LENGTH
REQUIRED MEASUREMENTS
B. WELL TO SEEPAGE PIT
C. WELL TO SEWER LINE
D. WELL TO PROPERTY LINE /~'-/-
E. WELL TO OTHER POSSIBLE CONTAMINATION
F. FOUNDATION TO SEPTIC TANK
G. FOUNDATION TO SEEPAGE PIT .~_~
H. SEEPAGE PIT TO PROPERTY LINE
COMMENTS:
APPROVED,
DATE:
APPROVA
~_~j DISAPPROVED:
2...- /V / /~"// DATE:
ALID FOR ONE YEAR FROM DATE SIGNED.
GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALIT~
January 8, 1971
bir. harold L. Carlos
CMR #1
Box 949
Elmendorf Air Force Base
Anchorogo, ^laska 99506
SUBJECT: Lot 6, Block 1, Bonito Subdivision
Dear ~r. Carlos:
This letter is to indicat® that an approved individual
water supply in conjunction with an apl)roved sewer system
can be located on the subject lot. Our files indicate
the well depth will be 'from 80' to 110' deep.
Sincerely,
John R. Lee, R.S.
Sanitarian
Farm Approved
ElNA Form 2S7S U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT
lev..lulv 1958 FEDERAL HOUSING ADMINISTRATION Budget Bureau No. 63-R0296
HEALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
PART I.--TO BE COMPLETED BY FHA
INSURING OFFICE MORTGAGEE SERIAL NO.
Anchorage Alaska State Bank 012186
MORTGAGOR OR SPONSOR PROPERTY ADDRESS
Harold L. Carlos Genora Street,
Con ~c ~ o~ ema be made Into
TOTAL NUM~Rz ~SEMENT New installation a~lflonal
LIVING UNITS BEDROOMS BATHS (If Yes, how mon~)
WA~R IUP~Y lYf SYS~M DESIGNED
~ Public system U ~mmuni~ system ~lndividual
DISPOSA~
~WAOE DIS~SAL BY~
~ ~blic system ~ ~mmUnity system__Individual . 4 ~ Yes ~o
PART II.--TO BE COMPLETED BY HEALTH DEPARTMENT
HEALTH DEPARTME~ INSPE~OR'S SKETCH
X~ iS ~ is not .tis[notary as ~ domestic water supply Ear the subject proart,
it is the opinion o[ the ~ State ~ Coumy ~ Local Department o[ Henkh that ~his individual s~Wn~c.disposd sys-
tem with proper maintennnce:
X~~ Cnn ~ expired to function sn6ffnctorily, nnd ~ ~nnot be exacted to ~unction sntis[actorily
is not lik~y to c~nte nn~ snnitn~ condition'
NOTE: The hlalt~ a~horl~ should complete the appropriate opinion sfafemenf above and .~x dale, sl.nafure and rifle in fhe
Ipocel provlded. / /
U~e of the ab~gHd for Healfh Departmenf Inspector's skefch as well as use of fhe back of fhls form Il at the option of fhe
heal~ authority.
PART III,--FOR USE OF FHA'OFFICE
TO TH! CHIIF UNHRWRI~R:
] h~vc r~i~w~ th~ ~orc~oin~ and th~ ~incnt ~HA Compli~)c~ ]ns~ion R~po~, and r~comm~nd that
Individual w~tcr-supply system ~ considered ~ Acc~ptnbl~ ~ Not Accep~bl~
~wn~ dis~snl ~ consi&red ~ Acceptable ~ Not Acceptnble.
DA~ SIGNATUR~ ~ CHIEF ARCHITECT
D~FU~ F~ CHIef ARCHITECT
HIALTH AUTHORITY APPROVAL
INDIVIDUAL WATIR SUPPLY AND SIWAGI DISPOSAL SYSTEM
FHA Form 2S73
Rev. July 1958
REPORT OF INSPECTION--INDIVIDUAL SEWAGE-DISPOSAL sYSTEM
PRIMARY TREATMENT consists of [] Septic tank.
Septk Teak:
Distance from well, feet. Material
Total liquid capacity,
Inside length, _fcet. Inside width
Distance from: Well. feet; foundation,__
Inside diameter, feet. Depth,
[] Cesspool,
gallons. Capacity inlet (ompartment,
toot. Liquid depth,
Number of compartments
feet.
feet; nearest lot line at [] front, [] side, [] rear, .
feet. Liquid capacity, gallons. Lining material
[] Seepage pits. Other
Depth of filter material over tile,*
gallons.
SICONDARY TREATMENT consists of [] Tile disposal {ield
Tile Disposal Field:
Distance from: Well,
Total lenKth of tile lines,
Trench width
Length of each line
Type of filter material: [] Gravel.
Depth of filter material beneath tile~
bpeR® Pits:
Number of pits .... Outside diameter, f~et,
Distance from: Well, feet; building foundation,__
lalpoctlofl mode by: [] State.
(eot; 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 gra~e,_
[] Broken stone. Other__
inches.
,,feet.
__ square feet.
inches.
. inches,
Date of inspection
Depth, feet. Lining material
feet; nearest lot line at [] front, [] side, [] rear,
[] County. [] Local Health Authority.
[nspected by
lc)__
(TITLE)
REPORT OF INSPECTION--INDIVIDUAL WATER-SUPPLY SYSTEM
Distance to nearest public water main, feet. Size of main, inches.
Individual wells [] are [] are n()t customary in neighborhood.
Give most recent record of failure of wells in immediate vlcimty to furnish adequate supply of water
Properties in neighborh~d [] are [] are not being developed with both individual water, supply and sewage-disposal systems.
Lol~ size: feet wide ....... feet deep. Dwelling set back from front property line, feet.
Individual water supply from: [] Drdled well. [] Driven well. [] Dug well. [] Bored well,
Distance of w®ll from:
Building foundation feet; nearest lot line at [] front, [] side, [] rear,, feet,
cast iron sewer, feet; tile sewer, {eot; septic tank, feet; disposal field, feet;
seepage pit, feet; cesspool, feet; other sources o£ possible pollution, feet.
Well construction:
Diameter, inches. Total depth, feet Type of casing, Depth of casing, feet.
Approximate depth to pumping level of water in well, feet. Approximate yield, gallons per minute.
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.
Pomp: [] Shallow well. [] Deep well. Length of drop pipe, feet. ~m~p capacity, . gallons per minute.
Located in: [] Basement. [] Pumproom off basement. [] Pumphouse aba,ye 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," giv. e date 19
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. [] Loc'al Health Authority.
Inspected by -,.
Date of inspection 19__
(TITLE)
GPO 889-0 88
~U,$. GOVERNMENT PRINTING OFFICE 1975~Jg(l~i6BS 257-7~ ,
