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HomeMy WebLinkAboutBROOKWOOD BLK 4 LT 3 GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3330 "C" Street, Anchorage, Alaska 99503 274-4561 Date Received Time of Inspection Date of Inspection REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR Approval requested by: Mailing Address: 2. Property Owner: . ~'z~{O/< Mailing Address: .~,X~)~ 3. Legal Description: 4. Location: 5. Type of facility to be inspected 6. Well Data: A, Type '~---C,'-~/~~ C. Construction Phone: Phone: ]~/-/-~/~--- No. of bedrooms B. Depth D. Bacterial Analysis Sewage Disposal System: A. Installed~ /~ B. Installer C. Septic Tank~/ 1. Size /d~TOd~) 2. Manufacturer D. Seepage Pit: 1. Absorption Area 2. Material E. Disposal Field: Total length of lines /~r~x3~-- ~77~ Distances: A. Well to: Septi , Absorption area Nearest lot line , Other contamination , Sewer Lines B. Foundation to septic tank , Absorption area C. Absorption area to nearest lot line EQ-034 (1/74) Page 1 of two pages · Page 2 of two pages - Req_..st for Approval of Individual '- ~er & Water Facilities Legal Description ~--'~ ~t.~_ ~/00~ ~00~-~/4 Comments .~~ ~~r~ ~'~ ~~~ -~~ Approve~_?~~ J~i sapproved Date~-o Approval Valid for one year from date signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM I certify that the information contained in this request for approval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating satisfactorily. SIGNED Date EQ-034 (1/74) e .3. 4. 5. GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3500 Tudor Road, Anchorage, Alaska 99507 279?8686 Time of Inspection Date of Inspection 7. Sewage DtsOosal System: A. Installed /.q~ C. --Septic Tank: 1. D. Seepage Pit= 1. E. Disposal Fie]d: Distances: A. REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR O-ncr __. Phone Type of Facility to be Inspected: A, T~e ~, Depth C. Construction, D. Bacterial Analysis ~~. B. Installe~ Size~ / 2. ~,nufacturer Size ~ 2. Materta 1 Total Length of Lines /mm Well To: Septic Tan~~7~bsorption Area , Sewer Lines , Nearest Lot Line --- , Other Contamination B Foundation to Septic Tank . C. Absorption Area to Nearest Lot Line /o / Request for Approval of l,,dividua] Sewer & Water Faciliti~ Page Two / Aooroved ~ ~. ~ Disapproved Date Approval Valid for One Year From Date Signed Greater Anchorage Area Borough, DeF~rtment of Environmental Quality DIAGRAM OF SYSTE~ I certify that the information contained in this request for approval to be a true and accurate representat].on of the subject sewer and water facilities located at: Signed Date June ~, 1973 Federal l-)ousing Administration 344 ~. 5th Avenue Anchorage, Alaska 99501 SUBJECT: Lot 4, Block 3, Brookwood Subdivision Dear Sirs: The subject lot is served by an approved community well system. This office inspected an upgrade of the sewer system on August 16, 1972. The v~rk was begun without a soil test or permit. An additional 60 feet of dratnfteld was added to yield a total of 160 feet of lines. The septic tank is suitable for a three bedroom dwelling only; the absorp- tion area is probably adequate for a three bedroom dwelling only. Slncerely, Susan E. gtckerson Sanitarian I lb FHA FORM NO. 2573 U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Farm Approved ,Rev. 11/71 FEDERAL HOUSING ADMINISTRATION Budget Bureau No. 63-R0296 HEALTH AUTHORITY APPROVAL (o/_~ / 9 ~ INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM PART I"-';TO BE COMPLETED BY HUD/FHA I .... lng O£fice Anchorage F.A Case No. ~j~,,~,~ .~ Mortgagee -'Name~ Address and Zip Code Mortgagor or Sponsor: [--The 1st National Bank of Alaska --] Paul Witteman Property Address: 1915 Dolly Varden Subdivision: Lot No, L_ __] Brookwood Block 3, 4 TOTAL NUMB R CanAttlc or otherAreabe made into additional T.TVTN~ T)NIT~ BEDROOMS BATHS BASEMENT [] New Installation bedrooms? (If yes, how many?) 1 3 2 ~¥es []No ~]¥es ~-~No ~,TER SUPPLY BY: SYSTEM DESIGNED FOR r'"] Public System [] Community System [] Individual No. of ..... ' ' Bedrooms Garbage Disposal SEWAGE DISPOSAL BY: [] Public System [] Community System [] Individual [] Yes [] No. PART II. ~TO BE COMPLETED BY HEALTH DEPARTMENT HEALTH DEPARTMENT INSPECTOR'S SKETCH ~, ~ ~---- It is the opinionof the ~-~ State ~ounty Local Department of Health thatthis individual water-supply system ~__~ is [] is not satisfactory as aannUdomestic water supply for the subject property, It is the opinion of thei ~_-] State ~-~ County [] Local Department of Health that this individual sewage-disposal system with proper maintenance: GAAB ~-~ Can be expected to function satisfactorily, and ~-~ Cannot be expected to function satisfactorily is not likely to create an insanitary condition DATE SIGNATURE TITLE NOTE: The health authority should complete the appropriate opnion 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 opinion of the health authority. · PART III.--- FOR USE OF FIELD OFFICE TO THE CHIEF UNDERWRITER, OR ASSISTANT DIRECTOR SINGLE FAMILY MORTGAGE INSURANCE BRANCH: I have reviewed the foregoing and the pertinent 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 [] CHIEF ARCHITECTURAL SECTION ~]DEPUTY FOR CHIEF ARCHITECT HEALTH AUTHORITY APPROVAL FHA FORM NO. 2573. INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM R.~v. 11/71 REPORT OF INSPECTION - INDIVIDUAL SEWAGE-DISPOSAL SYSTEM PRIMARY TREATMENT consists of [] Septic tank. [] Cesspool. Septic Tank: Distance from well, feet. Material, Total liquid capacity, gallons. Inside length, feet. Inside width, Number of compartments Capacity inlet compartment, feet. Liquid depth, feet. gallons. Cesspool: Distance from well, feet; foundation, . . feet; nearest lot line at Inside diameter, feet. Depth, ~ feet. Liquid capacity, SECONDARY TREATMENT consists of [] Tile disposal field. [] Seepage pits. Other [] front, [] side, [] rear, ~ gallons. Lining material feet. Tile Disposal Field: : ~. Distance from well, f6ii; 'fbundation, ~ feet; nearest lot line at [] front, [] side, [] rear, __ Tot~il length of tile lines, feet. Number of lines, . Distance between lines, Trench width, inches. Total effective absorption area in bottom of trenches, Len~h of each line, feet. Depth,.top of tile to finish grade, Type of filter material: [] Gravel. [] Broken stone. Other Depth of filter miiterial beneath tile, inches. Depth of filter material over tile, Seepage Pits: Number of pits,__. Outside diameter, feet. Depth, ~ feet. Lining material Distance from well, feet; building foundation feet; nearest lot line at [] front, [] side, [] rear, inspection made by: [] State. [] County. [] Local Health Authority. feet. feet. 'square feet. inches. inches. feet Inspected by (Ti tie) Date of inspection , 19 REPORT OF INSPECTION - INDIVIDUAL WATER-SUPPLY SYSTEM Distance to nearest public water main, feet. Size of main, inches. Individual wells [] are [] are not customary in neighborhood. Give most recent record of failure of wells in immediate vicinity to furnish adequate supply of water Properties in neighborhood [] are Lot size: __ feet wide, feet deep. Dwelling set back from front property line, Individual water supply from: [] Drilled well. [] Driven well. [] Dug well. [] Bored well. [] are not being developed with both individual water-supply and sewage-disposal systems. feet feet; nearest lot line at [] front, [] side, [] rear, tile sewer, __ feet; septic tank, feet; disposal field, cesspool, feet~ other sources of possible pollution, feet; feet; fe et. Distance of well from: Building foundation, cast iron sewer, . feet; seepage pit, feet; Well construction: Diameter, inches. Total depth, __ APproximate depth to pumping level of water in well, Sealed watertight to depth of feet. feet. Type of casing, Depth of casing,' feet. feet. Approximate yield, gallons per minute. gallons per minute. ,19 Exterior space around casing sealed with: [] Cement grout. [] Puddled clay. [] Ordinary backfill. Well cover: [] Concrete. [] Wood. [] Metal. Openings in well cover watertight; [] Yes.. [] No. Pump: [] Shallow well. [] Deep well. Length of drop pipe, feet. Pump capacity, Located in: [] Basement. [] Pumproom off basement. [] Pumphouse above ground. [] Pump pit Pumproom properly drained: [] Yes. [] No. Pump mounting watertight: [] Yes. [] No. Type of storage: [] Pressure. [] Gravity. Capacity, gallons. Has bacteriological examination of water been made? [] Yes. [] No. If answer is ~'yes," give date ~)uality of water [] is [] is not satisfactory for human consumption. Installation [] does [] does not comply with approved exhibits, if any. Inspection made by: [] state. [] County. [] Local Health Authority. Date of inspection , 19 ~ (Title) Inspected by GPO 92t.999 FHA F~'m 2573. ~'' DEVELOPMENT ~ ~' : ~::'~v/~='=~::;~~:~" -L" July ~95'~ , ~ ,, FEDERAL HOUSING ADMINISTRATIm : = ~: : ' HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM PART I.~TO BE COMPLETED BY FHA ~H~Ri~G OFFICE MORTGAOEE SERIAl. ~O. ~ORTG*~OR OR S~SOR PROPERTY ADDRESS ~*~; ~ TOTAL NUMAR: Can ~c ~ o~ aNa be mode in~ ~ New installation o~flonal b~mms? BASE~T L~VING UNITS 8EDROOMS lATHS (If Yes, how WA~R SUP~Y lY~ SYSTEM DESIGNED F~ LJ Public system ~ ~uni~ system U Individual .o. o, ...... l,'1 ~blic system ~ ~mmunity system ~ Individual ~ ~ Yes ~ No ~ ~ ~ ~ .............. __ _ ~ " ~--~ ~~ I -- - :--: .......... r__ :_: ..... ' ...... -- ~ .... :2-- ~ ~ .... . - ~ ~ ........ r-~ ~ ~ ' ~- .... ~--- -~ I .... ~ - m ~-- _ ' ...... ... . ................ . .... ~-q-h , - .......... ~ .......... ~ ~ .... ~- ~ ~ ~ ..................... ~ ~--- _ ..... It is the opinion of ~e ~ State ~ Cou.~ ~ ~al Department of Health that this individual water-supply .system ~ is ~ is not satisfactory as a domestic water supply for the subject pro~rW. It is the opinion of the ~ State ~ County ~ Local Department of Health that this individual sewage-disposal sys- tem with proper maintenance: ~ Cm ~ exp<ted to function satisfactorily, and ~ ~nnot be exacted to run.ion satisfa~orily is not likely to c~ate an insanit~ condition DA~ ] SIGNATURE TITLE I  ; gnvl~ntal Health Dl~oto~ NOTE: The health authorJ~ ihould complete the appropriate opinion statement above and a~x date, signature and title In the spaces provided. Us~ of the above g~ 'for Health Depgrtment Inspector's sketch as well as use of the back of this for~ is at the option of heal~ authority. PART III.~FOR USE OF FHA OFFICE TO THE CHIEF UN~RWRI~Rt I have r~iew~ the foregoing and the ~inent FHA Compliance Ins~ion Repo~, and ~commend that the Individual water-supply system ~ considered ~ Acceptable ~ Not Acceptable ~wage dis~sal ~ considered ~ Acceptable ~ Not Accepmble. DATE SIGNATURE ~ c~ x~c~r~cr  DEPU~ F~ CHIEF ARCHITE~ INDIVIDUAL 'IIALTH AUTHORITY APPROVAL .tlr SUPPLY AND SEWAGE DISPOSAL , ,TEM FHA Form 2S73 Rev. July 1958 REPORT OF INSPECTION--INDIVIDUAL SEWAGE-DISPOSAL SYSTEM PRIMARY TREATMENT consists of [--] Septic tank. Septic Tank: Distance from well,~.feet. Material Total liquid capacity, Inside length, Cesspool: Distance from: Well, Inside diameter, [] Cesspool. gallons. Capacity inlet compartment, feet. Inside width, feet. Liquid depth, feet; foundation, feet. Depth, SECONDARY TREATMENT consists of [] Tile disposal field. Tile Disposal Field: Distance from: Well, Total length of tile lines,. Trench width Length of each line Type of filter material: [] Gravel. [] Broken stone. Depth of filter material 'beneath tile.~ Seepage Pits: Number of pits .... Outside diameter, Distance from: Well, Inspection made by: [] State. Number of compartments feet. feet; nearest lot line at [-I front, [] side, [] rear, feet. Liquid'capacity, gallons. Lining material gallons. [] Seepage pits. Other. Date of inspection__._ feet; foundation, feet; nearest lot line at [] front, [] side, [] rear, feet. Number of lines, Distance between lines, inches. Total effective absorption area in bottom of trenches feet. Depth, top of tile to finish grade, Other __ feet. feet. square feet. inches. Depth of filter material over tile inches. inches. feet. Depth, feet. Lining material feet; building foundation, feet; nearest lot line at [] front, [] side, [] rear, [] County. [] Local Health Authority. Inspected by 19__ REPORT OF INSPECTION--INDIVIDUAL WATER-SUPPLY SYSTEM Distance to nearest public water main,__ __ feet. Size of main, inches. Individual wells [] are [] are not customary in neighborhood. Give most recent record of failure of wells in immediate vicinity to furnish adequate supply of water Properties in neighborhood [] are [] are not being developed with both individual water-supply and sewage-disposal systems. Lot size: feet wide .... feet deep. Dwelling set back from front property line,, feet. Individual water supply from: [] Drilled well. [] Driven well. [] Dug well. [] Bored well. Distance of well from: Building foundation cast iron sewer seepage pit, Well construction: Diameter, feet; tile sewer, feet; cesspool, inches. Total depth, .feet; nearest lot line at [] front, [] side, [] rear, feet; septic tank,_ feet; disposal field, feet; other sources or' possible pollution, ~'eet. APproximate depth to pumping level of water in well, Sealed watertight to depth of . feet. Exterior space around casing sealed with: ["1 Cement grout. [] Puddled clay. [] Ordinary backfill. Well cover: [] Concrete. [] Wood. [] Metal. Openings in well cover watertight: [] Yes. [] No. P~mp: [] Shallow well. [] Deep well. Length of drop pipe, feet. Pump capacity, lx~cated in: [] Basement. [] Pumproom off basement. [] Pumphouse above ground. [] Pump pit. Pumproom properly drained: [] Yes. [] No. Pump mounting watertight: [] Yes. [] No. Type of storage: [] Pressure. [] Gravity. Capacity, gallons. Has bacteriological examination of water been made? [] Yes. [] No. If answer is "yes," give date Quality of water [] is [] is not satisfactory for human consumption. Installation [] does [] does not comply with approved exhibits, if any. Inspection made by: [] State. [] County. [] Lot'al Health Authority. Inspected by Date of inspeCtion 19 feet. Type of casing, Depth of casing, feet. Approximate yield, .gallons per minute. .gallons per minute. (TITLE) feet; feet. 14~Jl~Waah., D. C. oAAB-HD-I GREATER ANCHORAGE AREA BOROU¢'H HEALTH DEPARTMENT 327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM SEPTIC TANK: DISTANCE FROM WELL ~ ~' / OA,,O S. A D D RE S.S'~"'r'"~7~'1~-' v LEGAL DESCRIPTIONZ*:~ ,~' MATERIAL C/OMPARTMENTS .... INSIDE WIDTH DEPTH SEEPAGE SYSTEM: SEEPAGE PIT: NUMBER OF PITS LINING MATERIAL NEAREST LOT LINE OUTSIDE DIAMETER OR WIDTH DISTANCE FROM WELL TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) LENGTH , DEPTH BUILDING FOUNDATION__ SQ. FT. TILE DRAIN FIELD: NUMBER OF LINES ABSORPTION AREA DEPTH: TOP OF TILE TO FINISH GRADE / FOUNDATION -~ ,NEAREST LOT LINE .DISTANCE BETWEEN LINES '~ -- TRENCH WIDTH S?Q. FT. LENGTH OF EACH LINE ~'~ ~ TOTAL LENGTH OF LINES L~'~ , IN. TOTAL EFFECTIVE Z 75 / DEPTH OF FILTER MATERIAL BENEATH TILE; IN. ABOVE TILE F~~.,[~.~/~/~/, DISTANCE FROM WATER WELL: TYP . DEPTH , BUILDING FOUNDATION ~ SAMPLE NEAREST NEAREST SEPTIC SEEPAGE OTHER LOT LINE SEWER LINE ., TANK SYSTEM , CESSPOOL , SOURCES__ DISTANCES: DIAGRAM OF SYSTEM DATE APPROVED HEALTH AUTHORITY GAAB-HD-2 GREATEIx 327 Eagle St. ANCHORAGE AREA HEALTH DEPARTMENT Anchorage, Alaska 99501 .OROUGH 279.2511 Case No. / SEWAGE DISPOSAL SYSTEM APPLICATION & PERMIT NAMEOF APPLICANT ~~-t~/ RESIDENCE ADDRESS LEGAL DESCRIPTION ~-~'~ APPLICATION TO INSTALL: SEPTIC TANK TO SERVE THE FOLLOWING FACILITY~ FINANCED THROUGH /~ ~ 7~ TO BE INSTALLED BY PERCOLATION TEST RESULTS ,-~z--,,~'~',',4,'////t/~'~ ANTICIPATED DATE OF COMPLETION ,~ "7'-/_. ~ ~'~,,~ 7~'~ BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT SEEPAGE PIT. DRAIN FIELD ~ OTHER THIS IS TO SERVE AS ~./~, ~~ PERMIT TO INSTALL A ~~~- ~ AS DESCRIBED BELOW. SIZE OF UNIT TO BE SERVED... ~_::;:~ ~ · SEPTIC TANK SIZE'/~)(~(;~) TYPE ~ SEEPAGE AREA 37~-~ ! TYPE DISTANCES: / ~";altli' AuthOritY I certify that I am familiar with the requirements of Greater Anchorage Area Borough Ordinance No. 28-68 and that the above described system is in accordance with said code. DATE , ~ APPLICANTS SIGNATURE ! ';HA Irorm'-25~' form Approved Bev. * Budget Bureau No. 63-R296.8 July 1.~9~L8~ U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FEDERAL HOUSING ADMINISTRATION HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM PART I.~TO BE COMPLIED BY FHA ~NSURING OFFICE MORTGAGEE SERIAL NO. MORTGAGOR OR S~NSOR PROPERTY ADDRESS  Can ~ ~ o~ a~a be made in~ TOTAL NUMBER: ~SEMENT ~C~ ~SC~]G~iO~ o~iflonol b~oms? LIVING UNITS BEDROOMS BATHS (If Yes, how WA~R SUP~Y BY~ SYSTEM DESIGNED FOR SEWAGE DIS~SAL BY: ~ ~blic system ~ ~mmunity system ~ Individual 5;'~ ~ Yes ~ No PART II.--TO BE COMPLETED BY HEALTH DEPARTMENT HEALTH DEPARTME~ INSPE~OR'S SKETCH ..... -- ..... ~ ....... ~ ....... ._ ~_. ~ - ~ .... ¢-' 2 ........................ ~--- ~---~ ~-~, '-'--- ~- --~ ~-I , ................ ....... ~_- ~ ..... ...... ~ - ~ ~_~ ~ ..... ....... ...... ............ ~ ...... ~ ........ ~ ..... ~~ ~ -~ ~ ........ It is the opinion of the ~ State ~ Coun~ ~ Local Department of Health that this individual water-supply ~ is ~ is not satishctory a~ a domestic water supply for the ~ubject propers. It i~ the opinion of the ~ State ~ County ~ Local Department of Health that this individual sewage-disposal gys- tern with proper maintenance: ~ Can ~ expect~ to function ~ati~hctorily, and ~ ~nnot be exacted to function ~ati~hctorily i~ not likely to c~ate an in~anit~ condition ~ATE S GNATURE ' ,' /' /~ ' ~ TITLE 1 ,/ NOTE: The health auth~ should, complete the appropriate opinion statement above and a~x date, signature and title in the spaces provided. Use of the above g~d for Health Depatt~ent-lnspecto~'s sketch as Well as us~ of the hack Of this fornr Is at the optiOn of heal~ authority. PART Ill.--FOR USE OF FHA OFFICE TO TH! CHIEF UN~RWRI~R: I have r~iew~ the foregoing and the ~inent FHA Compile]ce Ins~ion gepo~, and recommend that the Individual water-supply system ~ considered ~ Acceptable ~ Not Accepmble ~wage dis~sal ~ considered ~ Accepmble ~ Not Acceptable. DATE SIGNATURE  DEPU~ FOR CHIEF ARCHITECT HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM FHA Form 2573 RoY. July 1958 REPORT OF INSPECTION--INDIVIDUAL SEWAGE-DISPOSAL SYSTEM PRIMARY TREATMENT consists of [] Septic tank. Septic Tonk: Distance from well,__feet. Material. Total liquid capacity, Inside length, feet. Inside width, Distance from: Well, feet; foundation,__ Inside diameter, feet. Depth,. SECONDARY TREATMENT consists of [] Tile disposal field. gallons. Capacity inlet compartment, {~et. Liquid depth, Tile Disposal Field: Distance from: Well, Total length of tile lines Trench width Length of each line, Type of filter material: [] Gravel. Depth of filter material 'beneath tile,~ Seepage Pits: Number of pits .... Outside diameter,. Distance from: Well, inat:~dion modo by: [] State. [] Cesspool. Number of compartments gallons. .feet. __ feet; nearest lot line at [] front, [] side, [] rear, feet. Liquid'capacity, .gallons. Lining material [] Seepage pits. Other square feet. inches. Date of inspection feet; foundation, feet; nearest lot line at [] front, [] side, [] rear, feet. Number of lines Distance between lines, inches. Total effective absorption area in bottom of trenches feet. Depth, top of tile to finish grade, [] Broken stone. Other. inches. inches. Depth of filter material over tile feet. Depth, feet. Lining material __ feet; building foundation, feet; nearest lot line at [] front, [] side, [] rear, [] County. [] Local Health Authority. Inspected by 19 REPORT OF INSPECTION--INDIVIDUAL WATER-SUPPLY SYSTEM Distance to nearest public water main,__ feet. Size of main, inches. Individual wells [] are [] are not custolnary in neighborhood. Give most recent record of failure of wells in immediate vicin!ty to furnish adequate supply of water Properties in neighborhood [] are [] are not being developed with both individual water-supply and sewage-disposal systems. Lot size: feet wide, ____ feet deep. Dwelling set back from front property line, feet. Individual water supply from: [] Drilled well. [] Driven well. [] Dug well. [] Bored well. Distansa of well from: Building foundation cast iron sewer,. seepage pit, Weft construction: Diameter, feet; tile sewer, feet; cesspool, .inches. Total depth, feet; nearest lot line at [] front, [] side, [] rear, feet; septic tank, feet; disposal field, feet; other sources o£ possible pollution, }'eet. Approximate depth to pumping level of water in well,. Sealed watertight to depth of feet. Exterior space around casing sealed with: [] Cement grout. [] Puddled clay. [] Ordinary backfill. Well cover: [] Concrete. [] Wood. [] Metal. Openings in well cover watertight: [] Yes. [] No. ~mp: [] Shallow well. [] Deep well. Length of drop pipe, feet. Pump capacity, lx~cated in: [] Basement. [] Pumproom off basement. [] Pumphouse above ground. [] Pump pit. Pumproom properly drained: [] Yes. [] No. Pump mounting watertight: [] Yes. [] No. Type of storage: [] Pressure. [] Gravity. Capacity,. .gallons. Has bacteriological examination of water been made? [] Yes. [] No. If answer is "yes," give date Quality of water [] is [] is not satisfactory for human consumption. Installation [] does [] does not comply with approved exhibits, if any. Inspection made by: [] State. [] County. [] Local Health Authority. Inspected by Date of inspection 19__ feet. Type of casing, Depth of casing, feet. Approximate yield, gallons per minute, .gallons per minute. (TITLE) fe~r, feet; HUD-Wash., D. C.