HomeMy WebLinkAboutSUNNY SLOPES LT 3
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in T~iplicate)
2,' ~ame Of proper~y.owner ._
g. Nu~er :o~. >~rooms in house, ~
a. Bac~,ial
b. De~emgont " '
Well data:
a, Type
b, Depth.
c. Casing Size
Distance from well to closest existing or proposed:
1. 8ewer llne
2. Septic tank
' _ 3, Seepage Area
4, Cesspool'
5. Property Line
Other soumces of possible contamination~ i.e,~ creeks~ lakes~
houses~ bamn~ drainage ditch~ etc.
7. Sewage disposal system,
a. Age of system
b. Septic tank capacity in gallons .....
c. Name of septic tank manufacture>,,
/~0
If "home made" show diagram on reverse side of this form.
Disposal field om seepage pit size and type,
1, Distanc~ to pmoperty line
df< to house foundation
e. Percolatio~ Test h~esults
f. Percolation Test performed bY
Use the reverse .side of this form to show diagram. Diagram should include
'qbe fo~.owing information: property lines~.well location, house location,
~t~t~c tank location, disposal area location~ location of percolation test~
~ direction of ground slope~
9. The tnfox-,~ation on this form is true and correct tO the best of my knowledge.
'S~gnature of Applicant
TO BE FILLED OUT BY HEALTH DEPARTS~ENT PERSONNEL
Date $ign'ed
~The above described sanitary facilities are hereby approved, subject
~llowing eon~ions: ' '
Conditions:
to the
The above described sanitary facilities are disapproved for the following
reasons:
p~a~ure o[ ~fi~,;~.~ ~ q'~' ~.'~" 'i
' A~9~al ~s valid for one year following the date of approval.
CPJ:cw
/ff 7o
06-1220(a) 'Rev. 1973
DATE
AL~./ DEPARTMENT OF HEALTH AND SOCIAL S~,~ES
DIVISION OF PUBLIC HEALTH LaB No.
INDIVIDUAL AND SEMI-PUBLiC
BACTERIOLOGICAL WATER ANALYSIS
INDIVIDUAL ~] SEMI-PUBLIC [] CHLORINE RESIDUAL PPM
REPORT RESULTS TO
OFFICE
~ . '~,~?_._ } /'/J /~ ~'/(/~',- ZiP CODE
/ XX ~0
Tile Seepage Cess- ,
COMPLETE THIS SECTION ~
ONL WATE..S AN SUPPLY
DATE COLLECTED /~(~'/ ~, ~ TIME COLLECTED ~ 'dj'/
Sample Collected From ./ ~.Kitchen Tap ~ Bathroom Tap ~ Basement Tap
~ Other (List)
~aJysis shows Ibis Water SAMPLE to be:
[~L S'atisfactory
[] UnsatiSfactory
[] Questlonab!e
[] Sample too long in fransil; sample should not be over 48
hours old at e,xamlnafion fo indicate rel~aBIe results. Please
[] Bottle Broken in transit, please send new sample.
SANITARIAN'S REMARKS
PURPOSE OF EXAMINATION: Illness Suspected?
New Source of Supply? ~ Yes
READ NSTRUCTIONS
ON
REVERSE SIDE
BEFORE
COLLECTING SAMPLE
[] Yes
J~]?No Repairs to System?
I~fNo
06-1220 Cb) , ~.C~
Rev. 1973 /BA(~TERIOLOGICAL-WATER ANALYSIS R .ORD
Lactose Broth ' 10cc 10cc 10cc 10cc 10cc 1.0cc 1.0cc
24 Hours
24 Hours
48 Hours .
EMB AGAR
Lactose BrotE, 24 Brs. 48 hrs Oram's stain
Rev. July 1958 FEDERAL HOUSING ADMINISTRATION Budget Bureau No. 63-R296.8
HEALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
PART I.--TO BE COMPLETED BY FHA
INSURING OFFICE
MORTGAGOR OR SPONSOR
MORTGAGEE SERIAL NO.
SUBDIVISION NAME
TOTAL NUMBER:
WATER SUPP~.Y BY:
[] Public system
~ATH$ J BASEMENT
~ []Yes []No
] New installation
[~ Community system
SEWAGE DISPOSAL BY:
--J Public system [] Community system
BLOCK NO. LOT NO. ~
additional bedrooms?
(If Yes, how many~)
SYSTEM DESIGNED FOR
J--J Individual No. oF ~D~MS. G^.~^O~ D~SPOS^r
[] Individual 4 [] Yes [] No
PART II.~TO BE COMPLETED BY HEALTH DEPARTMENT
HEALTH DEPARTMENT INSPECTOR'S SKETCH
It is the opinion of the [] State [] County [] 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 [] 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 insanitary condition
*TE/' / I SIGNAT. W) '
NOTE: The health authority should complete the appropriate opinion 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
HEALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
] CHIEF ARCHITECT
] DEPUTY FOR CHIEF ARCHITECT
FHA Form 2573
Rev. July 1958