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HomeMy WebLinkAboutTHIBODEAU LT 3 N U -n, tau U It, Municipality of Anchorage FEB 2. On -Site Water and Wastewater Section • (907) 343-7904 Page of ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP201106 PID Number: 008-032-20 Dwelling: ® Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ® Upgrade Name ROBERT & AUDREY KIRN ABSORPTION FIELD - EXISTING ❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 2825 KIMBERLIE COURT, ANCHORAGE ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 4 GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot THIBODEAU 3 Fill added above original grade Ft. Gravel length Ft. Township Range Section Gravel width Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line Ft' Ft. Well 200'+ __ 25'+ TANK ® Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer GREER Capacity 1250 Gal. Surface Water 100'+ -- Material HDPE Number of compartments 2 Lot Line 10'+ -- NA Foundation 8'+ __ LIFT STATION Manufacturer Capacity Gal. Remarks Tank insulated & outside soil bearing prism. Alarm location Electrical installed by Installer NORTHERN EXCAVATION Tank to PIPE MATERIAL House to tank 3034. dra meld 3034 Drainfield CO/MT 3034 Inspector FWCS BENCH MARK (Assumed elevation) 100 ft Inspection Vt 5/11/2020 Znd 5/11/2020 Location and description 3`d 4'" BOTTOM OF SIDING ON-SITE WATER AND WASTEWATER SECTION APPROVAL ..+OF Conditional Approval: DateTH ��Q '•:t�,��� ........ i w �� �i.l• Curtis Huffman System Approvd [#�F� . CE128991 rj Date •�.�.Septic PROFESQA.:� ,, 0/F1/29/21l;�O.�AMW Note: t approval does not include well permit requirements. kRCv UJ/UL/ 1 Of PID: 008-032-32 PERMIT: OSP201106 SHED 10' UTILITY ESMT - - - - - - - - - EXISTING - - 9683 - - - - 95.68 MT• FIELD INSUL DECOMMISSIONED EXISTING 4.93 I S.T. & INSTALLED NEW 1250 -GAL HDPE SEPTIC TANK D n kMHC011.61 M I C LOT 1 LOT 4 B 36.v Ed A LOT 3 LOT 2 Jr4.0 4.0 I EXISTING o 0 v 4 -BR DUPLEX u.6 ID o to o o z o z 515.0' 15.0' z.o' 6 60 W APPROX. N WATERLINE A -C=14 2' B -C=29 2' A -D=18.7' B -D=31.1' A -E=23,0' B -E=33,1' N89 59'00"W 60.00' FCOH DCO co 9683 FINAL GRADE 95.68 INSUL 95.10 1,250 -GALLON 4.93 HDPE TANK TANK OUTSIDE SOIL BEARING PRISM SEPTIC SECTION SCALE: NTS THIBODEAU LOT 3 PREPARED FOR: ROBERT & AUDREY KIRN 2825 KIMBERLIE COURT ANCHORAGE, AK 99508 FIRST WATER CONSULTING 13030 SUES WAY ANCHORAGE, AK 99516 907-350-9566 firstwaterAK©gmail.com SCAT F: 1'' = 30 EXISTING FIELD SUPPORTsSERVICES: —�_� A7"k OF AL4 cJ g TH* DATE: 1/29/2021 , �� rtis Huffman wx SURVEY: JLS 1 ✓ CE 128991'' DRAWN: FWCS ' 1 /29/2021 ,�v SCALE: 1" = 30' \ P'oFESS1oo" -dw N89*59'00"W 6.00' x—x—X0—X—X—X 00 i -n SHED 10' UTILITY ESMT 9,5 SEP TIC • VENT (typ) LOT 1 ADM* • co co X MH NO 1X_X 11.6' 36.0' LOT 4 LOT 3 4.0' 4. 0' c) 0 EXISTING Lo z z < < 0 BUILDING LO 0 0 o 0 0 LOT 2 15.0 15.0 12.0' < fl; 6.0' U' < C) 0 0 z z 0 C,4 0 0 Lj N89*59'00"W 60.00 KIMBERLIE LANE 0 ANCHORAGE RECORDING DISTRIC ALASKA AS -BUILT OF: THIBODEAU SUBDIVISION LOT 3 PLAT P-446 John L. Schuller Have conducted a 0 F NX SURVEY CERTIFICATE: 1.., 4,4 tL LAND physical survey of this property as shown on this drawing and that the improvements situated hereon are within the property lines and no••. �� Y7"A enchroachments exist other than noted, Under no circumstance should•. �'' ,, o'c�► / C� Of � --* 49TH any information on this drawing be used for construction of fences, ;-• • • • • • • • • • y� ❑ - ..... ........ structures,, improvements, or for establishing 'boundary lines. F FA EXCLUSION NOTES: It is the owners responsibility to determine ?j •-A ..... .................... :..0 HN L. SCHULLER.- o 10 the existence of any easements, covenants, or restrictions which 7's do not appear on the recorded subdivision plat. LS -10408 e0e) i831 Talkeetna Street WORK ORDER NUMBER: DATE: SCALE:E-MAIL- JAN 9, 2021 1"=20' 0101 6 Anchorage, Alaska 99508 21-010 DRAWN BY. CHECKED BY. GRID NUMBER: BOOK/PAGE: ofessiono\ �1 A01P (907) 227-1455 office JLS SW1 734 210110 (907) 274-4992 fax A+ UNI IPALITY OF ANCHORAGE. On -Site Water & wastawa ter Program PQ EM lWill bbk: }UL) Elr-Dre koao AnChofagLl-, Pdatka 99519-15651) Phone: '2207) ti4:�-7{]G4 Fax. (907) 343.7997 Ori -Site Wastewater Disposal System Permit Permit Number: 05P201106 WDrk Type: SepticTank Upgrade Tax Caste Number: 00803232000 Site Legal Address-, THIBODEAU LT 3 0:1734 Site Mailing Address: 282 KIMBERLIE CT, Anchorage Owner KI R14 R013F-RT L & AUDREY E Design Engineer' F?R T WATER CONSULTING This permit is for the construction of= ❑ Disposal Field Q SepticTank Q Holding Tank ❑ Privy rp� r tlnent Effective Date: 511112020 Expiration Date: 6f1 V2021 Lot Size in Sq Ft; 9090 Total Bedrooms: 4 ❑ Private Well 71 Water Storage AJI construction shall be in accordance with: 1. The attached approved dr~sign, 2. All requirements specified irk Anchwaye Municipal code hap6ers 15.55 and 15.65 and the Mate of Alaska Wastewater Disposal Regulations (18AAC72} and Drinking Water Regulations {18AA BQ) 3. The wastewater code requires inspections during the installation, The engineershall no#ifir the Deveiopment arvir,es Depaftment per AMC 15.65. Provide notiFlcatlon by Calling (91)7} 343-79D4 (2417). 4- From October 15 to April 15, a subsurface sail absarp9an systerrk under construction during freezing weaftr shall be E=ither: a. Opened and Closed -on the same day, or b. Covered, sealed, and heat to pruvent freezing Received By,. Date: 5/11120 Issued By N MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 008-032-32 Property owner(s) ROBERT & AUDREY KIRN Day phone 9077275059 Mailing address PO BOX 111156 ANCHORAGE, AK 99511 Site address 2825 KIMBERLIE COURT, ANCHORAGE, AK 99508. Legal description (Sub'd., Block & Lot) THIBODEAU LOT 3 Legal description (Township, Range & Section) Lot Size 8090 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (N all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) ❑ (w/wo AD U) Septic Tank El Upgrade FxJ Duplex Q (D) Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: Date of Payment: 5yx) U Receipt Number: '51*3 ni Permit No. (33pabI/ ()(� Waiver Fees: Date of Payment: Receipt Number: Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client FormsTermit Application.doc COVID-1 9 255'0 DISCOUNT APPLIED 13030 Sues Way, Anchorage, AK 99516 907-350-9566 / firstwaterAK@gmail.com May 9, 2020 Municipalities of Anchorage On-Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 RE: EMERGENCY SEPTIC TANK UPGRADE PERMIT LEGAL: THIBODEAU LOT 3 The existing septic tank has collapsed and poses a public health and safety issue. The owner has requested that we obtain a septic permit to upgrade the existing collapsed steel septic tank on the above referenced lot. We propose to install a 1250-gallon HDPE tank to serve the existing 4- bedroom duplex. The lot and area are served by public water. The design will not impact any of the neighboring properties. Please contact us if you have any questions. Sincerely, Curtis Huffman, P.E. DESIGN CRITERIA: DECOMMISSION EXISTING SEPTIC TANK & INSTALL NEW 1250 -GAL HDPE SEPTIC TANK MAINTAIN 10'+ FROM FOUNDATION, 200' TO WELL, 5' TO FIELD & DECK SUPPORTS WITH 4' OF COVER OR INSULAIT❑N. NOTES: LOCATE WATERLINE PRI❑R TO CONSTRUCTION - INSTALL FCO & DCO N89 59'00"W 60.00' X- X- X- X- X- X- X- X- X- X- X SHED SHED 10' UTILITY ESMT 1 STORY 4 -BR LjDUPLEX O X N N X O O Lo Lo LD 0 0 0 LOCATE 6 WATERLINE 6.2' PRIOR TO LOT 3 CONST. N •� XIIIIIIIIIIIIIIIII oM. •• •e 1 0 NO SEWER n KIMBERLIE COURT W 0 0 o LOTS SERVED BY PUBLIC WATER THIBODEAU LOT 3 SUPPORT@SERVICES: ' OF '4Z4 \ PREPARED FOR: ROBERT & AUDREY KIRN W. AONCBOX 11156 ORAGE1 AK 99511 C � � * 9TH * I FIRST WATER CONSULTING DATE: 5/9/2020 0, rt Huffman % SURVEY: FH 1993 1 "I CE 128991 �� DRAWN: FWCS c� 13030 SUES WAY 1 5/9/2020 e � ANCHORAGE, AK 99516 SCALE: 1" = 30' \ FESS100, "w 907-350-9566 firstwaterAK®gmoil. com � EXISTING 12 X 12 • CRIB DCO DECOMMISSION EXISTING Do SEPTIC TANK & INSTAL CO • NEW 1250 -GAL HDPE -5 - TANK W/ DCO & FCO MH 17 & CONNECT TO CRIB. 0 12.0' FCO I 11.8' 36.2' 1 STORY 4 -BR LjDUPLEX O X N N X O O Lo Lo LD 0 0 0 LOCATE 6 WATERLINE 6.2' PRIOR TO LOT 3 CONST. N •� XIIIIIIIIIIIIIIIII oM. •• •e 1 0 NO SEWER n KIMBERLIE COURT W 0 0 o LOTS SERVED BY PUBLIC WATER THIBODEAU LOT 3 SUPPORT@SERVICES: ' OF '4Z4 \ PREPARED FOR: ROBERT & AUDREY KIRN W. AONCBOX 11156 ORAGE1 AK 99511 C � � * 9TH * I FIRST WATER CONSULTING DATE: 5/9/2020 0, rt Huffman % SURVEY: FH 1993 1 "I CE 128991 �� DRAWN: FWCS c� 13030 SUES WAY 1 5/9/2020 e � ANCHORAGE, AK 99516 SCALE: 1" = 30' \ FESS100, "w 907-350-9566 firstwaterAK®gmoil. com � AUG -16-01 THU 10!46 A1, FAX N0. 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M�1-w sa+�r. se a 1064 Pon" t$so ii. 11 l f r Nof AA&Wood + u GRr"TER ANCHORAGE AREA BOROUr'H DL..,.RTMENT 0F ENVIRONMENTAL OUALh 3500 TUDOR ROAD ANCHORAGE, ALASKA 99507 279-8686 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM ...... '; ' ~"' ,:"' '~' ' ''- LOCATION~/('/~/~/~// ~->/, ~/~ ,/~,>c./~/~ / LEGAL DESCRIPTION ~'/- SEPTIC TANK: DISTANCE FROM WELL .... LIQUID CAPACITY GALLONS. -? .... NUMBER OF MATERIAL ,c>//~/:~ .COMPARTMENTS INSIDE LENGTH INSIDE WIDTH -- LIQUID DEPTH SEEPAGE SYSTEM: SEEPAGE PIT: NUMBER OF PITS / OUTSIDE DIAMETER_ OB WIDTH__/'~' / LINING MATERIAL_~ ~.~]/~:~r~' ~ ,'~/~ '~-__/~'~ . DISTANCE FROM WELL ~t/.// NEAREST LOT LINE. ~,/ ~/'~2) /t/~, TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) / , BUILDING FOUNDATION .~.~ · ;'~ sq. FT. ~TLL~E DRAIN FIELD: DISTANCE FROM WELl ~ ..... FOUNDATION NUMBER OF LINES__ DISTAN~c~-BEYWEEN LINES ABSORPTION AREA ....... SQ. FT, __, NEAREST LOT lINE TRENCU WIDTH LENGTH OF EACH LI~E~zz::=~_ DEPTH: TOP OF TILE TO FINISH GRADE TOTAL LENGTH , OF LINES _IN. TOTAL EFFECTIVE DEPTH OF FILTER MATERIAL BENEATH TILE ~-~'- ' -IN,_ABOVE [ILE WELL: TYPE ('/7~//)1 ___, DEPTH. t/ DISTANCE FROM k.__._~ WATER -,BUILDING FOUNDATION. SAMPLE_ ~' , NEAREST SEPTIC SEEPAGE OTHER , TANK ~-~ , SYSTEM .... ~-- , CESSPOOl ~.-~ , SOURCESo''-- DIAGRAM OF SYSTEM G.A.A.B. GREA,ER ANCHORAGE AREA BOR,,.,UGH PERMIT NO, SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT MA'L'N~ ^DDRE S ~ '¢' '~ ~ .~x-/7/~ , OTHER INSTALLATION OF: S[PT[C TANK SEEPAGE PIT , BELIN FIELD SOIL TEST RESULTS - COMPLETiONDATEANTiCiPATED~I~/~ ~'~ NOTE= THIS PERMIT IS NOT VALID WITHOUT SOIL TEST FINAL INSPECTION: 24 HOUR NOTICE REQUIRED, BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE HEALTH DEPARTMENT AUTHORITY WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCES, REQUIREM~:NTS FOUNDATION TO SEPTIC TANK FOUNDATION TO SEEPAGE PI'r '4.~ , DRAIN FIELD SEPTIC TANK TO SEEPAGE Pit WALL · , SEEPAGE PIT ., DRAIN FIELD TO NEAREST LOT LINE.c "~ / WELL TO SEPTIC TANK / ~ , SEEPAG E PIT DRAIN FIELD ALSO CONSIDER AREA WELLS. DIAGRAM OF SYSTEM WATER MAIN TO SEPTIC TANK SEEPAGE PIT DRAIN FIELD . SEPTIC TANK, ., SEEPAGE PIT D~AIN FIELD TO RIVER, LAKE, STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOfL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHt REMOVABLE CAPS. GRAVEL SACKPILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. - /'/ ~ HEALTH AUTHORITY OR LICENSEE) DESIGNER I CERT]FY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE DESCRIB SYSTEM IS IN ACCORDANCE WITH SAID CODE. gReAT)iR A~CI{ORAGE AP, EA BOBOUGH HEALT}~ ~7 I:AGLE STREET ANCHOgAGD~ ALASKA' 99501 . ~ : ,, j~ '~al Dcscrip;ion: Lot This Form Roper'cs a: So~ls Log__~ Fact Soil Characteristics Loca'¢ion Sketch i-~ CF~q ' 2:5I ...... - 'u j~u_, Pro~sed Ins~alia~%~n:~eepage Pi% ~ Drain Field Depth Of Inlet Dep'~h To Bottom Of Pi% Or Tpench DaTa Certified By: ...... Da'ce: \.. -- . GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3330 "C" Street, Anchorage, Alaska 99503 274-4561 Date Received April 12, 1976 Time of Inspection Date of Inspection REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR 1. Approval requested by: Mailing Address: 2. Property Owner: Mailing Address: Spokane Mortgage Company 3201 C Street, Suite 250 Phone: Albert & Cynthia Sawyer Phone: 2825 Kimberly Court 277-0543 Legal Description: Lot 3 Thibodeau Subdivision Location: On Kimberly off of Wright street 5. Type of facility to be inspected 6. Well Data: Public Utility A. Type C. Construction 7. Sewage Disposal A. Installed C. Septic Tank: D. Seepage Pit: E. Disposal 8. Distances: A. Well to: System: 1972 1. Field: Total Septic tank Duplex No. of bedrooms 4 B. Depth D. Bacterial Analysis On-site system B. Installer Size 2. Manufacturer Absorption Area 2. Material length of lines __ Nearest lot line B. Foundation to septic tank , Absorption area , Other contamination , Absorption area , Sewer Lines C. Absorption area to nearest lot line EQ-034 (1/74) Page 1 of two pages Page 2 of two pages - Re ~t for Approval of Individual ~ ~r & Water Facilities Legal Description Lot 3 9. hlbodeau Subdivision Comments Disapproved Ap~r.e'val~Valid for one year from date signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM 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) MUNIC)PALITY OF ANCHORAGE DEP'L OF H~ALqH & [N¥1RONM~NI'AL MUNICIPALITY OF ANCHORAGE DEPARTMENT OF ENVIRONMENTAL QUALITY 2510 g. Tedor Road, Anchorage, Alaska REQUEST FOR APPROVAL OF INDIVIDUAL SEWER and WATER FACILITIES 276-2221 X 283 1. Type o'f Inspection: CMRO VA _ Y/ FHA 2. Property Owner: Albert & Cynthia Sawyer Mailing Address: 2825 Kimberly Court 3. Name of Buyer: Joseph Will:Lam Plahetka III Mailing Address: 822 North Bragaw, Anch. ~ Ak ____ Day Phone 4. Name of Lending Institution: _ Spokane Mortgage Co. Mailing Address: 3201 "C" Street. Suite 250 5. Name of Realtor or Agent: Jack White Co. - Ken Wardwell Mailing Address: 3201 "C" Street, Suite 100 __ CONV Day Phone_ unknown _ 278-4459 Phone 277-0543 Phone _~77-.1553 6. Legal Description: Lot 3. Thibodeau Subdivision~ AnchoraEa: Alaska Location: on Kimberly off of Wright Street, Anchorage, Alaska 7. Type of Facility to be inspected: duplex 8. Water Supply Type of Supply: Public Utility XX If Individual, number of dwellings presently served If Individual, depth of well 9. Sewage Disposal System Type of System: Public Utility If Individual, date of installation 1972 Individual Individual (on-site) No. Bdrms. 4 (total) XX EQ-037 (I/74) GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3500 Tudor Read, Anchorage, Alaska 99507 279~8686 REQUEST FOR APPROVAL OF INDIVIDUAL SBWER & WATBR FACILITIBS FOR , 1. Aoproval Requested By:~.~__~~ . ..... ~ ~' -~ . . 2 Pro.,ert,/ ~ner, ~3~ ~~____ Phone, ~3-~ '~J' z~, Leqa] Description: ~ ~ ~' f/~~~~f 4. Location, ~L 5. ype of Factl o be Ins cted._ ............ Number of Bedrooms~ 6. Well Data: A. Type B, Depth C, Construction D, Bacterial Analysis 7. Sewaqe Disoosa]. Sy ~em~ D. Seepage Ptt~ 1. S~ze 2, E, Disposal Fleld: Total Length of Linas 8. Dzotances, A, Well To: Septic 'rank--"-' Absorption Area '--' , Sewer Lines ..... , Nearest Lot Line__ :'-'-,, .__' Other Contamination~ Foundation to Septic Tank ~ "~ Absorption Area ,Absorption Area to Nearest Lot Line_._ ~, ~) !'/-6_ Req~iost ~or Approval or Ir Page Two 9. Commo~lts: Ao~roved ~)Y, 75 Disapproved Date · Aporoval Valid :for One Year From Date Siqned / ]¥eater A~chor~ge ~rea Borough, Department of ~nviro~menta] Quality-- DIAGRAM OF SYSTE~ 'I certify that the information contained in this request for approval to be a true and accurate reprosenhat~on of tho subject sewer and water facilities located at: Signed Date R 0 M ~[~iFOR~,, ~,S 47~ SIGNED SEND PARTS 1 AND 3 WITt4 CARBON INTACT - PART 3 WILL BE RETURNED WITH REPLY. DETACH AND FILE FOR FOLLOW-UP DATE / // THE FIB,ST July 23, 1973 Nt~TIONtlL, BriNK OF flNGttOFIFIGE Greater Anchorage Area Borough 3500 Tudor Park Anchorage, Alaska Attn: Health Department Re: VA .- LH 204 680 SAWYER, Allen L. Gentlemen: Please execute attached forms and return same to sender. Sincerely, (Mrs,) Marian E. Lampert Mortgage Loan Processor Encl. HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM PART I.--TO BE COMPLETED BY FHA Anchorage, A ska First Nat'l. Bank of Anchorag LH 204 680 MORTGAGOR OR SPONSOR ~ PROPERTY ADDRESS Alfred Lanz (seller) 274-3808 J 2825 Kimberlie Ct. ~aAq~e45-~&o~y-e~r--(-bu~y~--22-2- 0975 SUBDIVISION NAME T / BLOCK NO. J LOT NO. __.~{li bodeau J J 3 TOTAL NUMBERI ~] Vu.blic system BASEMENT OYes [].o Community system [~] New installation additional bedrooml? (If Yes, how martyr) .[[]Yes []No ~_~YSTiM DBSIGNEO FOR Individual ~'~ Yes [] No SJWRGE DISPOSAl, BY: [~] Public system ~] Com~nunity system PART II..mTO BE COMPLETED BY HEAL'rH DEPARTMENT HEALTH DEPARTMENT INSPECTOR'S SKETCIt It is the opinion of the [] State [] County [~1 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 tern with proper maintenance: [~Can be expected to function satisfactorily, and is not likely to create an insanitary condition [~ County [] Local Department of Health that this individual sewage-disposal sys- Cannot be expected to function satisfactorily DATE J SIGNATURE J TITLE NOTEI The health authority should complete the appropriate opinion statement above and affix date, signature c~nd tttle in the 0pa¢®~ provided, U~o of the above grid for HeaDh Department Inspector's sketch as well os use of the back of this form Is at the option of the health authority, PART III.~FOR USE OF FHA OFFICE TO THE C~IIEF UNDERWRITERI 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, HEALTH AUTI'IORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM ] CHIEF ARCHITECT FHA Form 2575