HomeMy WebLinkAboutWENTWORTH BLK 2 LT 28Lo '
GR~:ATER ANCHORAGE AREA BOROU~-,H
~ ,, HEALTH DEPARTMENT x, ,
327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511
iNSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME
LOC^T,ON
ADDRESS
LEGAL DESCRIPTION
PHONE____
SEPTIC TANK:
u(~u~D CAPACITY
MATERIAL_
GALLONS. INSIDE LENGTH '~/ /
NUMBER OF c~
COMPARTMENTS
LIQUID
NSIDE WIDTH 5 / DEPTH "~" ~'"/
SEEPAGE SYSTEM:
NUMBER OF PITS. /
LINING MATERIAL_
NEAREST LOT LINE
SEEPAGE PIT:
OUTSIDE DIAMETER
TILE DRAIN FIELD:
DISTANCE FROM WELL
TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA)
D,STANCE PROM WELL /lb, BU,LD,NGFOUNOAT,ON
FOUNDATION.
, NEAREST LOT LINE_
TOTAL LENGTH
, OF LINES_
NUMBER OE LINES
DISTANCE BETWEEN LINES
TRENCH WIDTH
IN. TOTAL EFFECTIVE
ABSORPTION AREA
SQ. FT. LENGTH OF EACH LINE
DEPTH: TOP OF TILE TO FINISH GRADE
WELL: TYPE _'-~)I-,~\~.C~ . DEPTH
LOT LINE c~(~ ( NEAREST
.SEWER L,NE yZ:::'
DEPTH OF FILTER MATERIAL BENEATH TILE WATER .IN. ABOVE.,,~x~TILE__.
DISTANCE FROM · SAMPLE~--~, NEAREST
,BUILDING FOUNDATION. /~ J / ~ ~
F~4 ~ ~//~ ~ o,,~.
SEPTIC ~ ~ ~
. TANK ' , SYSTEM ~ CESSPOOl . SOURCES
DISTANCES:
=;)~ = J~7!
-A->~': ~
DIAGRAM OF SYSTEM
DATE
APPROVED
~HA Form 2~'Y3 Budget Bureau No. 63-R296.E
~,.) U. S. OEPARTMENT OF HOUSING AND URBAN DEVELOPMENT ~/
HEALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
PART I.~TO BE COMPLETED BY FHA
INSURING OFFICE MORTGAGEE SERIAL NO.
PROPER~ ADDRESS
MORTGAGOR OR SPONSOR
SUBDIVISION NAME
TOTAL NUMBER~
WATER SUPPLY BY:
[~] Public system
SEWAGE DISPOSAL
[] Public system
BASEMENT
Yes ~ No
] New installation
'-]Community system
]Community system
Can attic or other oreo be ;;;,e-~ Into
additional bedrooms?
(If Yes, how manyf)
Nam SYSTEM DESIGNED 'O~ ~
~] Individual
~] Individual ~ [] Yes o
PART IL--TO BE COMPLETED BY HEALTH DEPARTMENT
ALTH DEPARTMENT INSPECTOR'S SKETCH
It is the opinion of the [] State [] County [~'I~cal Department of Health that this individual water-supply system
[~4g [] is not satisfactory as a domestic water supply for the subject property.
It is the opinion of the [] State [] County
tern with proper maintenance:
]"Tlc?an be expected to function satisfactorily, and
ts not likely to create an insanitary condition
[~, Local Department of Health that this individual sewage-disposal sys-
]Cannot be expected to function satisfactorily
NOTE: The health authority should complete the appropriate opinion statement above and affix, date, signature rand 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 option of the
health 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 considered [] Acceptable [] Not Acceptable
Sewage disposal be considered [] Acceptable [] Not Acceptable.
SIGNATURE
~r.~_i CHIEF ARCHITECT
DEPUTY FOR CHIEF ARCHITECT
DATE
'qEALTH AUTHORITY APPROVAL
INDIVIDUAL ~.;I'IRSUPPLY AND SEWAGE DISPOSAL L_~TEM
FHA Form 2az,,~
Rev. July 1958r~
REPORT OF INSPECTIONBINDIVIDUAL SEWAGE-DISPOSAL SYSTEM
Number of compartments
gallons. Capacity in]et compartment,
t~et. Liquid depth1 ___feet.
feet; inundation, feet; nearest lot line at [] front, [] side, [] rear,
feet. Depth, feet. Liquid capacity, gallons. Lining material
.gallons,
feet.
[] Seepage pits. Other.
feet; foundation, feet; nearest lot line at [] front, [] side, [] rear,
feet. Number of lilies, Distance between lines,
inches. Total effective absorptfim area in bottom of trenches,
feet. Depth, top of tile to finish grade,
[] Broken stone. Other
.feet.
square feet.
inches.
Depth of filter material over tile,.
Depth of filter material beneath tile,~ inches.
Number of pits .... Outside diameter, feet. Depth, .feet. Lining material
Distance from: Well, feet; building foundation,_ feet; nearest lot line at [] front, [] side, [] rear,.__
In$~eHon meade by: [] State, [] County, [] Local Health Authority.
Inspected by.
REPORT OF INSPECTIONBINDIVIDUAL WATER-SUPPLY SYSTEM
Distam'e to nearest public water main feet. Size of main, inches.
Individual wells [] are [] are llOt customary in neighborhood.
Give most recent record nf failure of wells in immediate vicinity to furnish adequate supply of water
Properties in neighborhood [] are [] are not being developed with both individual water-supply and sewage-disposal systems.
Lot size' feet wide, .feet deep. Dwelling set back from front property line,, feet.
Indivklual water supply t¥om: [] Drilled well. [] Driven well. [] Dug well. [] Bored well.
Distance of well from:
Building fnundation
cast iron sewer, feet; tile sewer,
seepage pit,, feet; cesspool,
Well construction:
Diameter, inches. Total depth,
Approximate depth to pumping level of water in well,
Sealed watertight to depth of feet.
feet; nearest lot line at [] front, [] side, [] rear,
.feet; septic tank, .feet; disposal field,.
feet; other sources of possible pollution, ;/eet.
Depth of casing,
.gallons per minute,
feet;
feet. Type of casing,.
feet. Approximate yield,
Exterior space around casing sealed with: [] Cement grout. [] Puddled clay. [] Ordinary backfill.
Well cover: [] Concrete. [] Wood. [] Metal. Openings in well cover watertight: [] Y&s. [] No.
Pum$:: [] 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_
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.
(TITLE)
.gallons per minute.