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Home My WebLink AboutLAMPERT #3 FIRST ADDITION BLK 3 LT 52ol II FHA~Form 2573 Form Approved Rev, July 1958 FEDERAL HOUSING ADMINISTRATION Budgel Bureau No. 63-R296.~ HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM PART I.--TO BE COMPLETED BY FHA INSURING OFFICE Anchora~o~ MORTGAGEE ]-SERIAL NO. ~ira% Na%iom~! .~ank o~ /Lne&ora~o J 60-00029~ MORTGAGOR OR SPONSOR PROPERTY ADDRESS 2390 ~,'a~lmr~s~ Ancho~.~¢,s .~.l~a SUltDIVISION NAMI: , TOTAL NUMBER~ BASEMENT ¥es l-1 o New installation [--~ Yes WATER SUPPLY BY: [] Public system [] Community system J~ Individual SEWAGE DISPOSAL BY: J-'-J Public system [] Community system ~3£{,2I --~Ij~Indiviclual Can attic or other area be made Into additional bedrooms? (If Yes, how rnany~) J SYSTEM DESIGNED FOR NO. OF BDRMS. GAR§AGE DISPOSAL [5]Yes PART II.~TO BE COMPLETED BY HEALTH DEPARTMENT HEALTH DEPARTMENT INSPECTOR'S SKETCH [ )eO ~t~h~ D~",,ir~,-~'~}) It is the opinion of the [] State J~ County j-"] Local Department of Health that this individual water-snpply system ["--] is J-'-J is not satisfactory as a domestic water supply for the subject property. It is the opinion of the [--] State [] County tern with proper maintenance: El 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- [~] Cannot be expected to function satisfactorily DATE l SIGNATURE TITLE NOTEJ The hoalfh autl~orily should complete the appi op,iote oplnlon st~fement above and ~ffix date, slgn~ture and title in 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 III.~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 S~WAGE DISPOSAL SYSTEM CHIEF ARCHITECT DEPUTY FOR CHII:F ARCHITECT FHA Form '2573 Rev. Joly 1958 '*~nu!m Jod SUOlF~' 'dP[O, )l.0. ~ [: (~0.' 'a~nu!uJ ~ad SUOllU~- ,', IT '~'ulsu:> jo q~dac[ · 1aaj (..(-, "omI. X~Jado~d :~uoJj tuoJj :guq ~as ~'Uilla,~o. 'daap 3a*j -.(;~ 'apya 1~*j (1¥ L:°z~s. 'stua~s,~s l~sods!p:a~ru,~0s puu Xlddns-Ja~u~ lunp[~!pu! q~oq q~!~ podop^ap ~upq ~ou aJu oJU [] pooq~oqq,%au m sauJadoJd Z*r 01. pi1'(I Ja~U~ jo Xlddns munb*pu q$!uJrtJ o1 ~I!~:)!A o~*[pamm! u! Sllam jo olnl!~J jo pJoDaJ luo:>aJ lsom oA!r0 'pooqJoqq~'!au u! ~JeuJolsrt~ lou oJU [] ol~ [] slla~ lunp!~!pul · saq~u! 'u!em jo az!s '~*aj .... :u!utu Ja~u~ ~!iqnd ~sa~uou m a~ums!G WIISA$ A1ddI'lS-i131VA~ 1vflalAlaNl~NOIIDldSNI IO l~lOdlll '~*j 'saq>u! 'l*aj a~unbs '~aaj 'lgoj ~aq~o :S4ld eBudees %1!1 q~uauaq iqaalum JallIJ jo qzdaQ 'auras ua~o~fl ~ '[a~uJD ~ :l~alu~ aallg jo ~t& 'aU}l qoua jo q~gu~ 'qlp~ q2uaa& 'souH alp Jo q~uaI lmO& 'lla~ :moJj aoums}Q ~PlOlt In*Od*lO oil& 'sl~d o~udaag ~ 'HaD lusods]p al}Z ~ jo s~s}suo> INIWIYIUI A~YONODi~ lUgm~tu gu!uFI 'suoll*g '&pud*a p!nbFI '~aaj 'q~daQ '~aaj 'JuaJ [] 'ap!s [] '~uoJj [] ~u au!! ~oI ~sa~*au ',~aaj 'uo!~upunoj :~aaj 'SUOlN~ 'laaj 'tpdap p!nbFI '~aaj 'qlp!m ap!suI qaaj' '~uam~udtuo> ~o[u! al!yeduD 'SUOllUg sluamlJ~dtuo> jo JaqmnN 'loodssaD [] W:IISAS 1VSOdSICl':IOV/~AtS 1vrlalAIONI~NOIJ.3:IdSNI lO l~lOdt~l ~o.55- ~ ~r~--~' - Lab. No. INDIVIDUAL WATER SUPPLY /2,/- (:i- 6-~ Soughc~entral Begior~l ALASKA DEPARTMENT OF HEALTH OFFICE DA'i~I~ Section of Sanitation and Engineering ACTION ON REQUEST FOR BACTERIOLOGICAL WATER ANALYSIS Your recent recluest/or an analysis of a sample /:~om the Individual Private Water Supply serving was ~ecetved examination has been completed. ~. Hu~h Pfie£er ~05 Eo Fi~eed D~ne 5per~rd, A]~ska Records in this office indicate this Indlvldual Private Water Supply to be oi Satisfactory~Queslionnble~Unsatisfactory sanitary status. /~ Analysis shows this SAMPLE to be i._/- Satisfactory. Questionable..__ Unsatisfactory. If an "Unsatisfac4ory" or "Questionable" etatus is indicated above, you should take immediate actlo~ as recommended below. 1. Boll or chemically t~eat your water supply to protect your fmuily from water-borne diseases as outlined in en- closed leaSet, "Drink R Pure." 2. Improve your spring ~ See bulletin HSE-6-2 3. Improve your cistern ~ See bulletin HSE-6-3 4. Improve your dug well~ See bulletin HSE-64 5. Improve your driven well-- See bulletin HSE-6-5 6. Improve your drilled well~ See bullelin HSE-6-8 7. Relocat~ your well to a safe locution in relationship to your sewage dlspos~l system-- See bulletin tlSE-15 8. Bottle broken in transit, please send new ~ample. 9. ~ample too long in transit: ~ample ~hould not be over 48 hours old at examination to indicate reliable results. Please send new sample. 10. Contact your nearest ~ Local Health Department or ~ Alaska Health Depadment, S~nitcdion office for bulletins, consultation, and assistance. 11. This I~ a sudace wate~ source and subject to pollution by man ~nd ~nimals. An approved water ~upply ~ource ~houldbe developed, ) .' · ' / , . .Z.. , .:,: - ' ::" ..<., SANITARIAN'S REMARKS , ~,~/~ '-" ~ ~ '''~ ~ : ~ '"' Signature,.?/ ~' ~ ~' " ..... ' ;'' '~:~' ~ .ADH--HSE.6-FI '.Phis Form Must Be Filled Out Completely. 0 C ]' ,'~ F INDIVIDUAL WATER SUPPLY ALASKA DEPARTMEN3J OF H~:ALTH Section of Sanitation and gngineering Please Look on Reverse of/ Sheet for Sample Collection ln-utrllctions. Request for Bacteriological Analysis Lab. No ........................................... Water sample collected by ........ ~"~J(IX~me ........... of person: .... collectingS' ' '~"-sample) ................................. /'"'O"':7'"'~)'~'"::"~(Date) ................................. iL3, (Time) ........ Water sample collected from [~f~itehen tap; [] Bathroom tap; [] Basement tap; [j Other (list) .............................................. : ...................................................................................... Address premise where source is located ........ ~2....;~.~..Q.;2 ...... .~!5.,.'~:Uz.~...f*~.~./~.~. ................................................................................ (Mr.) ............. , ........... 3. ................................... t:.f:.~.~..k.. ~ (Name) (Box No. or street address) (City) Please place an "X" in the box before items which bast describe your water supply: SOURCE: Well -- [] Dug, [] Driven, [~,d~tlled, [] Bored [] Spring, [] Cistern, [] Other (list) ............................................................................................................... [] Creek, [] River, [] Lake, [] Pond .................................................................................................................. DUG WELL OR CISTERN CONSTRUCTION: Walls- [] Wood, [] Concrete, [] Metal, [] Tile, [] Brick or Concrete Block Top -- [] Wood, [] Concrete, [] Metal, [] Open Top LOCATION: [] In basement, [] Basement offset, [] Under l~ouse, ~ yard Other ..................................................................................................................... : ............................................................... DISTANCE TO: Building sewer or other drainage pipe...;~..~....feet, Septic tank ..%Z ....... feet, Tile field .%T ......... feet, Seepage pit .... .~.m.....feet, Cesspool ...:~:2 ..... feet, Privy.....:::.~.... feet. Other possible sources of contamination (list) ................................................................................................................................... i ......... MATERIAL: Building sewer -- ~]"Cast iron, [] Wood, [] Tile, [] Fibre pipe, [] Asbestos ce~nent Joint material -- Type ....................................................................................................................................................... GENERAL INFORIVIATION: Does water become muddy or discolored? [] yes, When? ....................................................................................................................................................... Diameter of well ...................................................... depth .......................................................... feet Well casing material ........................................ diameter .................... depth .................................. Length of drop pipe ............................................................................................................................... Water depth from bottom ............................................................................................................ feet Pump location: [k~-'Ih well, [] Offset in basement, [] In basement [] In utility room, [] ,On top of wel~ [~ Other (list) ~ ~.:z-~ i.t:~ :../.~../..~.~..,:, . ....................................... PURPOSE OF EXAMINATION: Illness suspected? [] yes, ~,,~'f5 New source of supply? ~yes, [] no Repairs to existing system? [] yes, Remarks: ~]..i~. ................ .f.....t.Z..gT.~ ................................. :: .............................................................................................................................. PLEASE DRAW A SKETCH IN THE SPACE BELOW. THIS SKETCH SHOULD SHOW LOCATION OF HOUSE, WATER SUPPLY SOURCE, SEPTIC TANK, SEWER, DRAIN LINES OR OTIqdER SOURCES OF POLLUTION AND DISTANCES BETWEEN WATER SUPPLY SOURCE AND ANY OF ABOVE FACILITIES. SAMPLES MUST BE SUBMITTED IN CONTAINERS PROVIDED BY THE ALASKA DEPARTMENT OF HEALTH --