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FHA FGrm 2573 ; Form Approved
Rev. July 1958 FEDERAL NOUSING ADMINISTRATION Budget Bureau No. J-R296.8
HEALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
PART I.--TO BE COMPLETED BY FHA
INSURING OFFICE MORTGAGEE SERIAL NO.
aneborase, Alaeka L~Lu$C Nac~ona:L Bank o£ Aneho~a$i 60-00775~
MORTGAGOR OR SPONSOR PROPERTY ADDRESS
lv~n ~L, & Pacr~ef~mAnn OToSS ..... ~S00 G~r~f~ld Avenue
SUBDIVISION NAME BLOCK NO. LOT NO.
B~.rchwood Subd~.v~.$ ~.on , j
~ Can attic or other area be made into
TOTAL NUMBER:_ BASEMENTI I New installation additional bedrooms?
Iii Yes, how
WATER SUPPLY BY: SYSTEM DESIGNED FOR
[-~ Public system [ [ Community system Il Individual .o. oF ~DUMB. O^U~^OE
SEWAGE DISPOSAL BY:
l~l Public system [] Community system [-~ Individual [] Yes ~ No
PART II,--lO BE COMPLETED BY HEALTH DEPARTMENT
HEALTH DEPARTMENT iNSPECTOR'S SKETCH ' , ~ ~ ~
_ _-ZZZXZZ_ZZZ zzzz~_-Xzz~zzzzz_-zz
is the opinion of the [] State [-"] County [] Local Department of Health that this individual water-supply
It
system
[] is N is not satisfactory as a domestic water supply for the subject property.
It is the opinion of the ~ State N County [--1 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
DATE SIGNATURE .//'~ TITLE
' ' '""': >/x- .....
NOTE~ Th~ h~llh aulhorlt¥ should cempl~t~ lhe approE~iat~ oplnlon ~tat~m~nt aboYe and affi~ date, ~lgna~'ur~ ~nd lille In
spaces pro¥1d~d.
D~e of lhe ~ba¥~ grld Jot Nealth D~p~rlment In*p*¢ler'~ sketch as w. II a~ u~ of the back o{ this {orm is ~t the option oE the
health ~ut½oril¥.
PART III.~FOR USE OF FHA OFFICE
I have 'reviewed the foregoing and the pertinent FHA Compliance Inspection Report, and recommend that'the
Individual water-supply system be considered [--1 Acceptable [--1 Not Acceptable
Sewage disposal be considered [~ Acceptable [] Not Acceptable.
DATE SIGNATURE [] CHIEF ARCHITECT
1 DEPUTY FOR CHIEF ARCHITECT
HEALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
FHA Form 2573
R~Y. July 1958
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