HomeMy WebLinkAboutSOUTH HILLS BLK 6 LT 8
MUNICIPALITY OF ANCHORAGE
· DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL. INSPECTION REPORT
LOCATIONA '~ r~/') '} I ' ,F~ t
Manufacturer Material
Liq. capacity in gallons I IF HOMEMADE: I Inside length Width
NO. OFBEDROOMS~_~
PERMIT NO.
No. of compartments
Liquid depth
)ERMIT NO.
Well
DISTANCE TO:
Length of each line
PERMIT NC
No. of lines Total length of lines Trench width Distance between lines
inches
Top of tile to finish grade Material beneath die Total effective absorption area
inches
Length ¢idth Depth PEHMIT NO.
Type of crib :rib diameter Crib depth Total effective absorption area
Welt Building foundation Nearest lot line
DISTANCE TO:
Class Depth Driller Distance to lot line ]PERMIT NO.
DISTANCE TO: Bu~ldin9 foundation Sewer line Septic tank LAbs°rpt]°n area(s)
OTHER
PIPE MA~, ~
SOIL TEST RATING
REMARKS
7~-013 (~tv, 3/78)
LEGAL
May 29~ 1979
gubJect~ Lot 8 Block 6 South Hills Subdivision
This department will require a holding tank of 2,000 gallons
capacity be installed for the upgrading or erection of a
new str%~ct%~re.
The existing sewage system is inadeq~late ~or expansion and
has a water table problem along ~-;ith sewer placement problems.
The existing sewer mu~t be physically abandoned upon
installation of 'thc; holding tank by removing ten(10) feet of
connectio~g line between the tank ~ud the absorption field.
If there are any further question~, please contact this office
at 264. ~720~
Sincerely~
Les N~ ~uchholz~ R~S~
senior ~nvironmental Specialist
DEP~RTi"IEN. OF HERLTH RI'ID EN,~IF. Or.g.IENTHL PROTEcTiON i G/'/7'~
~25 STREET,
RNCHORFiGE., RK.
~.~4-4,
C~-.I--S I TE SEi~JER,
LQT ' S 17E
PERMIT NO. <
LOC:re'mN
TYPE OF SOIL ~BSORBTIC, N SYSTEM I~:
M~I~;IMUM NUMBER OF BEDROOMS = SOIL RBTING
THE REQUIRED SIZE OF THE SOIL 8BSORPTION SYSTEM IS:
F'EF~:~'-I I T
< SO ' ' '
FT~ BR..'=
SQURRE FEET.
THE LENGTH DIMENSION ~5 THE LENGTH (IN FEET) OF THE TRENCH OR 'DR~INFIEED.
THE DEPTH OF ~ TRENCH, OR PIT IS THE DISTANCE BETWEEN ~HE SI_IRF~E:E OF THE
~ROLIND RND THE BOTTOM, OF THE EXCR'v'RTION <IN FEET).
THERE I~ NO ~ET WIDTH, FOR TRENCHE~.
THE GRRVEL DEPTH I~ THE HINIMUM DEPTH OF GR~'v'EL BETWEEN THE OUTFRLL PIPE
RND THE BOTTOH OF THE,EXCRVRTION <IN FEET). ,
PERMIT RPPLICRNT HRS THE RESPONSIBILITY TO INFORM THIS DEPRRTMENT DURING THE
INSTBLLRTION INSPECTIONS OF RNY HELLS RDJBCENT TO THIS PROPERTY' 8ND THE
NUMBER OF RESIDENCES THRT THE HELL WILL SERVE.
TWO ( 2 ) ii ~4SPECT I ilmr-4S RF~'E F~' E ~l LI I F~'ED
BBCKFILLING OF RNY SYSTEM WITHOUT FINRL INSPECTION RND RF'PROVRL B'Y THIS
DEPRRTMENT WILE BE SUBJECT TO PROSECUTION.
MINIMUM DISTRNCE BETWEEN'R WELL RND RNY ON-SITE SEWRGE DISPOSRL SYSTEM IS
100 FEET FOR 8 PRIVRTE WELL; OR
150 TO 200 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL.
WELL LOGS RRE REQUIRED RND MUST BE RETURNED TO THE DEPRRTMENT WITHIN ~0 DRYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MBS' RPPLY. SPECIFICRTIONS RND CANSTRUCTION DIRGRRMS RRE
B',/RILRBLE TO INSURE PROPER INSTRLLRTION.
F'ERr.11 T EXP I F;ES D. EL--:E I--1E:EF~-: 2:1.. 19 ,-'~'"-='-
I
1:
FORTH 8¥ THE MUNICIPRLITY OF RNCHORRGE.
2: I WILL INSTRLL THE SYSTEM IN RCCORDRNCE WITH THE CODES.
z<: I UNDERSTRND THRT THE ON-SITE SEWER SYSTEM MRY REQUIRE ENLBRGEMENT
RESIDENCE IS REMODELED TO INCLUDE MORE THRN 8 BEDROOMS.
-, I uNED, . .._~ ,,
Applicant -
I=.:,_ ED B"r'
CERTIFY THRT
IRM FRMILIRR WITH THE REL-]LIIREMENTS FOR ON-SITE SEWERS RN[:, WELLS RS SET
IF THE
GRE/
'-iR ANCHORAGE AREA BOR ,GH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME /// (. /~/'],~- '~/~'-/.( MAILING ADDRESS /-/~-'.-,¢//~/~',,~2 /k/~//X'"/~'/ /~/~:~/~HONE LEGAL DESCRIPTION _ ' ' ~ ' '
SEPTIC TANK:
DISTANCE
PROM WELL ~
INSIDE LENGTH
NUMBER OF
MAN U FACTU R E R ~.'~ MATE RIAL 4' ~.~X Z~"/~.~ ~q= C _ _ _ COMPARTMENTS /
INSIDE WIDTH ~ LIQUID DEPTH LIQUID CAPACITY /J)L/ GALLONS.
TILE DRAIN FIELD:
,' , / TOTAL LENGTH ,,
DISTANCE FROM WELL &</ FOUNDATION /~//~ '~ /
NEAREST LOT LINE /_/ OF LINES _/-/
. 'n// /-~-J,~ / WIDTH
NUMBER OF LINES ~)/~ DISTANCE BETWEEN LINES ,~Z,~ / ,)~* TRENCH __ . TOTAL EFFECTIVE
ABSORPTION AREA __ ¢~'~;/'~ SQ. FT. LENGTH OF EACH LINE ~mY / ~ /~'~/'/ //~"/~z~ /
· 1~/ DEPTH OF FILTER
DEPTH: TOP OFTILE TO FINISH GRADE~-"" MATERIAL BENEATH TILE_ ~IN. ABOVE TILE '-~_?/ IN,
WELL:
TYPE. ?/.//~2_/////~/~'~{/· ___ CONSTRUCT ON
BUILDING t/- NEAREST / j NEAREST SEPTIC t/-
FOUNDATION ~ , LOT LINE //~, , SEWER LINE ('c')'//' TANK
CESSPOO[ -- OTHER SOURCES
APPROVED '~/// _DISAPPROVED
REMARKS
DEPTH ~'~'~2z~ / DISTANCE FROM:
SEEPAGE
SYSTEM
DISTANCES:
DIAGRAM OF SYSTEM
INSTALLED BY: -~;~
SEWER LINE DEPTH:
PIPE MATERIAL-
LOT SLOPE:
REMARKS:
Janua~'y 20~ 1[)71
GREATEL ANCHORAGE AREA ,~ )ROUGH ~seSo. ~??
HEALTH DEPARTMENT
327 Eagle St.f) i?~ r,;~b'i~ , Anchorage, Alaska 99501~¢~l>~7'~-2511/?/_
SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT (?Iq,,CT;L,,~
API:iLICANT i~ ~ .o,~ v,.. ~4/.'-,
NAME 0
RES, ID. ENCB/ADD RES8
LEGAL
DESCRIPTION
APPLICATION TO INSTALL: SEPTIC TANK
~,.t.~ MAILING ADDRESS
LOCAT,ON OF ,NSTALLAT, 0N
~' ,SEEPAGE PIT ~ ,DRAIN FIELD ._,OTHER
TO BE INSTALLED BY
ANTICIPATED DATE OF COMPLETION
TO SERVE THE FOLLOWING FACILITY
EINANCEO T~.R0UG.__
_ ~ ~ -
qar: RqSqg~d~, TEST R ESU LTS
BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT
THIS IS TO SERVE AS /¥~L~:3 {~,'~--,,~ ~. ,
PERMIT TO INSTALL A ,
AS DESCRIBED 8ELOW. SIZE OFUNITTO ~SERVED ,'~
.SE~T~CTAU~S~ZE ]0::'~ TrPE ~ ...... , SEE~AG~AREA
" ~ DIAGRAM OF SYSTEM
] certify that I am fa,niliar with the requirements of Greater Anc~horage,Area Borot>gh Ordina~c~_/~N~,~ 28-68 gnd tidal the,
above described system is in accordance with said code. ~--L~c, ~&~ ~-~ &~,z../~=~-~'
~"-'REATER ANCHORAGE AREA BOROUC~H
HEALTH DEPARTMENT CASE
327 EAGLE STREET
ANCHORAGE, ALA,,KA 99501
Legal Description: Lot
This ~orm Reports a: So~ls Log_~
Depth
Feet
Was Ground Water Encountered?___~
if Yes~ At What Dept:h
Location Sketch
Reading Date
Gross Time Net Time Depth To H20 Net Drop
Proposed Installat~on: Seepage Pit Drain F~eld
D}pth Of Inlet ~ l)ep~~it Or '!'renc~7 /
Test Performed B~:~A~~? ,~, ,~ )
Data Certifled~ By.~~~ ./~ ~. , /~L>~>~---
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPRO~/AL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date _/(~
1. GENERAL INFORMATION
I?B8 _
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name
Applicant Address
Telephone: Home :~z/~"-ZSOL Business
(c) Applicant is (check one): Lending Institution []; Owner/buil,der El"; Buyer []; Other [] (explain);
(d) Lending Institution Telephone
Address
(e)
Real Estate Company',and Agent
Address
Telephone
(f) Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family ~ Multi-Family []
Number of Bedrooms ~
Other
WATER SUPPLY
Individual Well I~1/ Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite [] Public [] Community [] Holding Tank ~
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72~°25(11/84)
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation,date shown below, i verify that my investigation of this Health
Authority Approvar shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verily that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect
the date of this inspection.
.ameofFirm ~Or~ ~ ~6~5 Telephone
J. Co~..,¥1. : ::.?i~~
CE-S283 o ..::, ~x
Engineer's Seal
Approved for /~'~6¢.,/~ bedrooms'~
Approved DisapproveU
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their [ending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
72 025 (11/84)
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOAj
MUNICIPALI~I(E~[.TI~'~tR~RITY APPROVAL (HAA)
D~PT OF H
' * FEBRUARY 1984
MAR S L ga, Description:
RECEIVIED
Well Classification -~'N b I ~/t ~0/~[--. If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) /~ (~ Date Completed C{ r~ ~,,~wP~ Yield
Total Depth ~ ~ I Cased to
Static Water Level J ~.- ~
Casing Height Above Ground ~.~
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
f
To Septic/Holding Tank on Lot
Depth of Grouting
Pump Set At _ ~"~
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
+
; On Adjoining Lots
A!/~, ; On Adjoining Lots
7..OO
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
SEPTIC/HOLDING TANK DATA
Date Installed ~o- 4./_ ,'/? Size ~ O ('~/% No. of Compartments _ ff~ I(~obJ N
Standpipes (Y/N) 0~ ~5 Air-tight Caps (Y/N) o/~._~ Foundation Cleanout (Y/N)
Depression over Tank (Y/N) N¢~ Date Last Pumped /8 ¢~b¢t4. o._r.,~
Pumping/Maintenance Contract on File (Y/N) d ~.~ ;for
Holding Tank High-Water Alarm (Y/N) U ~..~ ¢¢¢ J Temporary Holding Tank Permit (Y/N)
£
Separation Distances from Septic/Holding Tank:
To Water-Supply Well /~O¢ To Building Foundation Z'~'i
To Property Line ~'~'l To Disposal Field
To Water Main/Service Line ~/~ To Stream, Pond, Lake, or Major Drainage
Course J ~0 ~
U ~
Page 1 of 2
72-026(1~/84)
/
ABSORPTION FIELD DATA /~/~
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~-~-,f~ (~0J'~ Date / ~ /~,¢'(~'~ / ~
1
ReceiptNo. %3355
Date of Payment ~ ~ &5~ - ~ ~
Ameunt: $ ~ ,0~ / Engineer's Seal
Page 2 of 2
APPLI FILLS OUT UPPER HA :ONLY
Phone
Property Owner ' ~
Madm ddress ; Zip Code
Buyer (~, ~ ~ / ( '
Address (4 Zip Code
Lending Institution Phone
Address ' ~ '
Realty Co, & Agent Phone
Address Zip Code
Type of Residence .
E}
Single
Family
[] Multiple Family NO. of Bedrooms~
[] Other
Water ~upply
E~¢ fndividual ~ A3TACH WELL LOG. A well Icg is required for all wells drilled since June 1975,
i~ For wells drilled prior to that date, give well depth (attach Icg if available),
[]
Public
Utility
Sewer Disposal /
E~ Individual Year Individual Installed;
L~ Public Utility When Connected to Public Utility:
~ ¢~{olding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Date
Inspector
Time
Date
Inspector
Time I/I Time
Inspector
Inspector
MUNICIpALI'rY OF ANCHORAGE
PEPT, OF HC>,LYt[ &
~NVIRONM2NI'At- pRO [ECTION.
RECEIVED
*CONDITIONS OF APPROVAL
Log Received
Soils Rating
Date Sewer Installed Well TO Absorption Area
....... ~' ' ' ' ENVIRONMENTAL p[b: :i ECTION
OEO 7 1978
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C" Street, Anchorage, Alaska 99503 274-4561
Date Received
Time of Insnection
Date of Inspection_
3.
4.
5.
REQUEST FOR APPROVAL OF
INDIVIDUAI, SEWER & WATER FACILITI£S
FOR
VgA.
AoDroval Requested By: C..!~%e~calf Co. (Ron Va:l Sick]e) ,
Address~ ESE. East 5th Avenue Phone: ~72-250l
Prooertv Owner: Victor Si{ifs .L Phone:
" .... ills Sut~.
Legal Description: Lot ,~, u.l ~. ,.'~ SO. ,'~
Location: /,ill~ide/{;,~bbi.~ Cre~;k
Tv~e of Facility to be Inspectedt si~!
Number of Bedrooms:
6. Well Data:
A. Type dri ! ] ~,-),] B,
C. Construction '" ca$1n5 D.
7. Sewage Dfsoosal System: [nc!iv.
A. Installed
Depth
Bacterial Analysis
Installer [] 5orado Construction
C. Septic Tank: 1.
O. Seepage Pit: .1.
Disposal Field:
Size 2. Material
Total Length of Lines
Distances:
A. Well To: Septic Tank_ ~__~ ~'_, Absorption Area/~// / , Sewer Lines
Foundation to Septic Tank ~ / -~ Absorption Area /~ /~
C. Absorotion Area to Nearest Lot Line ~/
Request for Approval of ~ndivi~ual Sewer ~ Wate~ Faoiltties
,--P~ge Two
9. Comments~
Lot ~
o, Block 6, South ~tills Sub.
Aporoved ~. ~____~fsappr oved Date
Approva! Valid for One Year From Date Signed
9/6/73
Greater Anchorage Area Borough, Department of Envtronmenta! Quality
DIAGRAM OF SYSTEM
I certify that the information contained in this request for appreval to be a true
and accurate representation of the sub'ect sewer and water facilities located at:
Signed . Date
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3500 Tudor Road, Anchorage, Alaska 99507 279-8686
Tt e ns ectio.
Date of Insmection ,~--~/'--~-~
REq!.,EST FOP APPROVAL OF
IND!VIDUAI ..... I~R & /~AT~R FACILITIES
FO9
3. Legal Description: /--~2~-~,~ ~/----~. _~'~,
5. Type of F~c]lity te be IDs'mcted:
Number of Bedrooms:
Well Date:
Phone:
A. Tyne //~/~//~;~¢~/-- B.
Constructz or,~~-~ D.
7. Sewage Disoosal System:
C. Septic Tank: l. Size, 2. Manufacturer,S- ~
D. Seepage Pit: h Size - 2. Mat.rxal
E. Dispose] Field: Total Lenoth of Lines
A. Well TO~ Seotic Tank ~ Absorption Are~ . Sewer Lines
B. Foundation to S.ntic Tank
----'> Absorotion Area
C. Absorotion Area to bJearest Lot Line ..... ·
,, Re,quest for Anoroval of Individual Sewer & Water Facilitle~
-. Page Two
Aooroved
Approval V~lid for One Year From Date Signed
Greater Anchorage Area 8orouah, 9enarfment of Environmentml Quality
~IA~,~A['~ 0,' SESTEk
I
I
I certify that the information cont~ine~ tn thi~ recuest for ~pprov~l to be a true
and acc:~rat, reDresentat]o-, of the gu~q~ct sewer and wrater facilities located
Aug~: 2> 1~73
Hr. Victor Sims
Chief of Police
6ox 1075
No~le, Alaska
0[~ J~ly 31~ 1573~ at th~? reo~;~st of ~,ietcalf ~eall;y~ tills
~i~,c ~l~t~ Block 6 -.Sout'I~ ~ilts ~uoa;lws~oa.
Ti)( 6~' i~divi~(u~t w~,ll is of a!)prow;(~ construction
sh;);~l<~ ~royid(; ad~qumte~ ~otable watcr~
lh~ o~-.siC~,~ sew[:r system is believed ~ haw~ b~en i~st~lled
~ tL~t.~, 197~ or 1971~ how{~ver, was noL insy~ct~d hy
~]~or~h.~ I-~ is for t',his reason, we ~:annot a?~row
l]~o~.~ ~;a~:'ia~ with ferment proper~y owner, Joanae Jones.
r~si~lenc~ ji~on~: 34$-,;.157, sh(~ advised an (~xcavating
l;he s'~a~ of Alasi~.a. ~,~rs. Jon~s ha~ a soils cost rur~ on
tI~, lot ~J',d obtained a F, srF~i't from this depart)~nt for
~)ini~Y~um 7!~0 gal. se)~tic Caulk and 187~ of <irai~)'~i~ld w{~uld
have to h~ve be~n installco for this
~roval and il~stall,~.d a i~inlmum 4' abov~ the wat(~r table
of 7'. (see a'~tachc'.;t soils
In or~er for this department's (~)))~roval to be f~iven, the
existing sysber~) wilt bare to be dug u~ so t~a/; we c~n see
tho se2tic tank and a new drainfield in~talled, If Caere
Is asepcic ta)~k the size should be adequate as ,~ 7t~O gal.
se(~tic tank is the smallest manufactured tn this area. To
dip u~) t;~e exis~l~g drainfield would damage it so greatly
~t would ~robably not be a wor~a&~e system.
Victor Sims
August 2, 1973
Page 2
worked closely with f4r. Roll Van Stckle of Net-
~ealty o~ [hls p~oblem. Please advise ~m ~ha~
~uul~ 11k~ Lo do. According ~o the First National
Anchorage. there ts a prospective buyer for
l:~'~closed, please find a copy of our regulations govern~
· i~'tg ~uc;i i,lstalla~ions. If you have any questions,
~,)eask~ do no~ hesitate to contact us.
~,,ViI~,,~:,E~TAL COi~TROL DFFICER
,',ETC~L F RLALTY
HEALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
INSURING OFFICE
PART L--TO BE COMPLETED BY FHA
MORTGAGEE
SERIAL NO.
MORTGAGOR OR ONSOR
TOTAL NUMBER:
BASEMENT
/ /
WATEI~ SUPPLY BY:
Public system
SEWAGE DISPOSAL BY:
~E] Public system
PROPERTY ADDRESS
I BLOCK NO. LO,NO.
"-]New installation
additional bedrooms?
(If Yes. how manyF)
E] Community system
El Community system
Individual [] Yes [] No
PART II.--TO BE COMPLETED BY HEALTH DEPARTMENT
HEALTH DEPARTMENT INSPECTOR'S SKETCH
,'Ill
It is the opinion of the [] State [] County [~Local Department of Health that this individual water-supply system
~]is [] is not satisfactory as a domestic water supply for the subject property.
is the opinion of the [] State [] County
tom with proper maintenance:
[5~'Can be function satisfactorily, and
expected
to
_~'-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
NOTE: The health authori~ should complete the appropriate opinion statement above and a~x date, signature end title in the
spaces provided.
Uso of the above grid for Health Deportment Inspector's sketch as well os use of the back of this form is at the option of the
heal~ authority,
PART III.mFOR 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 SEWAGE DISPOSAL SYSTEM
REPORT OF INSPECTION--INDIVIDUAL SEWAGE-DISPOSAL SYSTEM
Total liquid capacity,
Inside length,
Distance from: Well,
Inside diameter,
feet. Material
gallons. Capacity inlet compartment,
fret. Inside width, teet. Liquid depth, fret.
gallons.
feet; foundation, feet; nearest lot line at [~ front, [] side, [] rear,__
feet. Depth, feet. Liquid capacity, gallons. Lining material
SECONDARY TREATMENT consists of [] Tile disposal Iield. [] Seepage pits. Other
Distance from: We!l,
Total length of tile lines.
Trench width,
Length of each line,
Type of filter material: [] Gravel.
_inches.
feet; toundation, _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
Depth of filter material beneath til% .inches. Depth of filter material over tile
Distance from: Well ........ feet; building foundation,
feet. Lining material
feet; nearest lot line at [] front, [] side, [] rear _
[] Local Health Authority.
Inspected by
inches.
REPORT Of INSPECTIONmlNDIVIDUAL 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 furnisi~ 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, teet deep. Dwelling set back from front property line, .feet.
Individual water supply from: [] Drilled well [] Driven well. [] Dug well. [] Bored well.
D~stance of well from:
Building foundation
seepage pit,
Well construction:
feet; tile sewer,
feet; cesspool,
feet; nearest lot line at [] front, [] side, [] rear,
.fleet; septic tank, feet; disposal field,_
feet; other sources o£ possible pollution, feet.
Diameter, inches. Total depth, feet Type of casing,
Approximate depth to pumping level of water in well, feet. Approximate yield,
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.
~um~: [] 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. [] I~xal Health Authority.
Inspected by
Date of inspection 19
Depth of casing,
gallons per minute.
gallons per minute.
feet;
fret.
. ' Gpo 889-088