HomeMy WebLinkAboutSOUTH LAKEWOOD HILLS BLK 1 LT 5 E2 a. Bacterial
b. Detergent
Well data:
C. Casing Size ~ ,1.
existing or proposedt:L(
d. Distance f~om well to close t
2. Septic tank,,, -.
3, Seepa[e Area
Cesspool'
5. Property Line
6. Other sources of possible contamination, i.e., creeks, lakes,
houses, barn, drainage ditch, etc.
Sewa~,. disposal system.
b. Septic tank ?apacity in gallons ~/~//~,~"~ ,Td~2 ~ ~
c. Name of septzc tank manufact~ . ~ ~
1. If "home made" show diagram on reverse side of this form.~
d.' Disposal field om seepagez, pit size and type ~~ /
~, Distance to p~ope~y llne to house fo~dafion
e, Percolatlor~ Test
f. Percolation Test performed by
Use the reverse ,side of this form to show diagram.
Diagram should include
"?Ihs foilowing information: p~operty linss~ .well location, hLuse location,
~ut~c tank location, disposal area location, location of percolation test
and direction of ground slope. '
\
9. The i~n-ro~tion on this form is tmue and correct to the best of my knowiedge~
i$~gnature of Applicant
Date Signed
T_qO BE FILLED OUT BY HEALTH D~PART!,~EN~ PERSONNEL
above described sanitary facilitie~ ~re~hereby approved, subject to, the
The above described sanitary facilities are disspproved for the following
''Signature Of ~fi¢~;Ai~,~'.'~.~i bate ~z.p? ..~ ..?. ~-
Approval is valid for.one year following the date of approval.
CPJ:cw
FHA Form 2573
HEALTH AUTHORITY APPROVAl
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
PART L--TO BE COMPLETED BY FHA
INSURING OFFICE
MORTGAGOR OR SPONSOR
0o Evc~r'ty
SURDIVISION NAME
TOTAL NUMBFRz
MORTGAGEE SERIAL NO.
PROPERTY ADDRESS
~,12~ B~O~K ~9' LOT ~o.
[] Yes [] No
WATER SUPPLY BY:
[] Public system [] Community system
SEWAGE DISPOSAL
[] Public system [] Community system
BASEMENT [] New installation additional bedreomsT
[ff Yes, how martyr')
[] Individual :4 [] Yes o,
PART II.--TO BE COMPLETED BY HEALTH DEPARTMENT
HEALTH DEPARTMENT INSPECTOR'S SKETCH
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.
It is the opinion of the [] State [] County
tern with proper maintenance:
~--] 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
--~ATE J SIGNATURE · JTntE
11/7/09 I ', : ,, ~nvironmental Uoolth Supervisor
/ ' ::-C: ,' i
NOTE: The health authority should-complete the appropriate opinion statement above and aff~x date, signature ~nd title in the
spaces provided,
Use of the above grid Jar Health Department nspecl:or's sketch as well as use of the back of this form Is at the option of the
heal~ authority,
PART Ill.--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 cgnsidered [] Acceptable [] Not Acceptable
Sewage disposal be considered [] Acceptable [] Not Acceptable.
DATE
SIGNATURE
HEALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
] cHIEF ARCHITECT
] DEPUTY FOR CHIEF ARCHITECT
FHA Form
Rev. July 1958
Type
sewem line
INSPECTION ~EPORT, ON-SITE SEWAGE DISPOSAL SYSTEM ,5
SEPTIC T~K:
Dist~ee ~om well ~$' Ma~ePial '~ ~C~% Nu~eP of compa~ments MOMf Liquid
· - '0 .
capacity ~O~ gallons. Inside len~h [ ~Insid~ Liquid
SEEPAGE SYSTEM:
Seepage Pi~: Nu~em Of pits ~ 9u~slde d~ame~em, . om width (~ z~f ~
depth ~ lining ma~e~al~nc~_f;~,,~% . Dis~ce f~om well /,~O ~ building
(wall
fo~dation N,~. · nea~es~ lo~ line 2(D' To~al effective ~so~ption aPea ~ea)
TILDE DRAIN· FIELD:
Distance from well , foundation , neares~ lot line
of lines Numbem of lines Distanoe between lines
Total effective absorption a~ea
Depth: Top of tile to finish grade
tile_..._~_.inches, Above tile
WELL:
Distance f~om building foundation
Total length
Trench width
sq. ft. Length of each line
Depth of filter material beneath
septic tank .... , seepage system ,,
, nearest lot line ..... , nearest
· cesspool , other sources,
DIAGRAM OF SYSTEM
Health Auth6rity