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HomeMy WebLinkAboutHIGHLAND PARK BLK 1 LT 8ffl ighla, nd 1 FHA Form 2~.73. Form Approved Re¥. July 19{'~ ' FEDERAL HOUSING ADMINISTRATION Budget Bureau No. 63-R296.1 HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM PART I.MTO BE COMPLETED BY FHA INSURING OFFICE F MORTGAGEE J SERIAL NO. l Ha)?].ene lle~old MORTGAGOR OR SPONSOR PROPERTY ADDRESS ~01 Chev~gny SUBDIVISION NAME I'OTAL NUMBERI BASEMENT [---] New installation E-I Yes [-1 o WATER SUPPLY DYE [-'] Public system ~ Commuuity system SEWAGE DISPOSAL BY: ['--] Public system Eg Community system BLOCK NO..i, LOT NO.0 C.n etflc or other area be made Into additional bedrooms? Iff Yes, how many?) J SYSTEM DESIGNED FOR ~ Individual NO.O, [~_~;;. ~; ~ Individual o 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 J'~ is not satisfactory asa domestic water supply for the subject property. It is the opinion of the [--'] State [] County tern with proper maintenance: [-~ Can be expected to function satisfactorily, and is not likely to create an insanitary condition Local Department of Health that this individual sewage-disposal sys- E] Cannot be expected to function satisfactorily DATE July 23t 1969 SIGNATURE TITLE 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 PART IIh~FOR USE OF FHA OFFICE TO THE CHIEF UNDERWRITER: I have reviewed the foregoing and the pertinent FHA Compliance Inst)ecdon Report, and recommend that'the Individual water-supply system be considered ~l Acceptable E] Not Acceptable Sewage disposal be considered [-'] Acceptable [] Not Acceptable. DATE j SIGNATURE -- HEALTH AUTH~J~ITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM ] CHIEF ARCHITECT [~J DEPUTY FOR CHIEF ARCHITECT FHA Form 2573 Rev. July 1958 2, 3. 4. 5. REQUEST FOR APPROVAL OF INDIVIDUAL SEWAGE AND WATER FACILITIES (Fill out in Triplicate) uam~. of person requesting approval ~-2~ !!,nm~ oi~ pr©perty~owner NumLer. c-~F bedrooms in house Wate~ Anslysis: ao Bacterial b. Detergent 6, Well data: a, b. Depth c. Casing Size de Distance from well to closest existing or propose~: 1. Sewer line 2. Septic tank 3, Seepage Area 4, 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 ' b. Septic tank capacity in ~ . c. Name of septic tank manufacturer 1. If "home made" show diagram on reverse side of this form. d,' Disposal field or seepase pit size and type 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 diagra~n. Diayram should include .',l~he following information: p.roperty lines; .well location, house location, ~ptic tank location, disposal area location, location of percolation tests and, direction of ground slope. 9. The in'fo~'mation on this form is true and corpect to the best of my knowledge. S~Fnature of Applicant Date Signed T__O__. BE FILLED OUT BY HEALTH DEPARTI-IENT PERSOI,INEL he above described sanitary facilities are hereby approved s__ubje, ct to the ........ ~611owing conditions i ' The above described sanitary facilities are dis~pproved for the following reasons: ! ate Approval is valid for one year following the date of approval. CPJ:cw