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FHA Form 2573 Form Approved
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 MORTGAGEE SERIAL NO.
MORTGAGOR OR SPONSOR PROPERTY ADDRESS
-
.oc .o.
~~ ~d~e~on
TOTAL NUMBiRi can affJc or arbor area be made Into
eAS~.m ~ New installation additional bedrooms?
LIVING UNITS BEDROOMS BATHS
(If Yes, how many~)
WATER SUPPLY BY: SYSTEM DESIGNED FOR
~ Public system ~ Communi, system ~ Individual ,o. o, .~'~'.
~ ~blic system ~ ~mmunity system ~ Individual ~ ~ Yes ~ No
PART fl.--TO BE COMPLETED BY HEALTH DEPARTMENT
'~ ~ -
, _
cZ;_ ~ -~-
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It is the opinion of the ~ State ~ CounW ~ L~al Department of Health that this individual water-suPply system
~ is ~ is not satis(actory as a domestic water supply for the subject properW.
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 insanita~ condition
.ATE 0~ ~~ ~. TITLE
NOTf: The health authority ~hould ¢emplete the~pp~te ;¢ ' ~
o~inion I', atement above and a~x date, signature ~d title in t~e
,paCes pro~i~ed~
U~e of the abo~e grid let tealth ~epartment Inspeetor'~ sketch as ~ell a~ use of the baek of this form is at the option of the
health authority,
fO TNE ¢~llF UN~RI~
I have reviewed the [ore~oin~ and the pe~inenc PHA Compli~ce lnst~ion ~epo~, and recommend chat
Individual wa[er-suppty sys[em ~ considered ~ AcceR~ble ~ No~ Accep~ble
~w~e disps~l k considered ~ Accepcable ~ Noc Accep[able.
DATE SIGNATURE ~ CHIEF ARCHITECT
DEPUTY FOR CHIEF ARCHITECT
HEALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
FHA Form 2573
Rev. July 1958
6I
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