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Home My WebLink AboutWENTWORTH Block 5 Lot 20 FH~A Torm2573 ~r ~/ Form Approved Rev. July 1958 FEDERAL HOUSING ADMINISTRATION Budget Bureau No. 63-R296,$ HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM PART I.--TO BE COMPLETED BY FHA INSURING O/:FICE MORTGAGEE ~irst National Bank of Anchorage Anchorage, Alaska MORTGAGOR OR SPONSOR PROPERTY ADDRESS Lot 20~ Block 5~ Wentworth Subdivision Viola Urbanek TOTAL NUMBER: WATER SUPPLY BY~ [~ Public system BASEMENT BATHS VlYes ] New installation , [] Community system additional bedrooms? (if Yes, how many~) SYSTEM DESIGNED FOR [] Individual ,o~or BDRh~S. GARBAGE OISPOSAL [] Individual [] Yes [] No ;EWAGE DISPOSAL BY: '--]Public system ] Community system PART II.JTO BE COMPLETED BY HEALTH DEPARTMENT IEALTH 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 [] Local Deparnnent of Health that this individual sewage,disposal sys- tem with proper maintenance: [~Can be expected to function satisfactorily, and [] Cannot be expected to function satisfactorily is not likely to create an insanitary condition DATE SI~Gi~TUR~ ,,~ SI TUR ~ TITLE NOTE, The health authority sh;uld complete thLpp~Jate opinion statement abov;Znd .ffix date, sign~ure and ~,'e in the spaces provided. Use of the above grid for Nealth Department Inspector's sketch as well as use of the back of this form is at the option of the ' 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 ~ystem be considered [] Acceptable .[] N6't Acceptable Sewage disposal be considered [] Acceptable [] Not ~,cceptable. ~, SIGNATURE ~j~ CHIEF ARCHITECT DEPUTY FOR CHIEF ARCHITECT DATE HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM FHA Form 257~ Rev. July 1958 REPORT OF INSPECTION~iNDIVIDUAL,SE. WA~GE-DISPOSAL SYSTEM PRIMARY TREATMENT consi~s o,f ~ Septic tank. [] Cesspool. Septic Tank: ~,.5 '~/' ~ 7 Distance from well ~ ~ ~et. Mater a. ~ ~ e ~/ Number of comp~ments / Inside leng~,~ ~ feet. Inside wld~, f~t. Liquid depth, ~ feet. Dismnce from: Well, feet; fuundation~ feet; n~est lot line at ~ front, ~ side, ~ re~, .feet· Inside diameter,_ f~t. Depth, feet. Liquid capaci~, gallons. Lining'material SECONDARY TREATMENT consists of ~ Tile disposal field. ~epage pits. Other' Total length of tile lines. Trench width, Length of each line, feet; foundation, feet; nearest lot line at [] front, [] side, [] rear, feet. feet. Number of lines,_ Distance between line& feet. inches. Total effective absorption area in bottom of trenches, square feet· feet. Depth, top of tile to finish grad~: inches. [] Broken stone. Other Depth of filter rg~aterial ~eneath tile,~ inches· Depth of filter material over tile. inches. Seepage Pits: /~) '~ X e~ / ( ~. ~ ti.)/ / / / Number of '-ts / ..... :-~' feet. Depth,~feet. Lining material '/~' Distance from: Well, /0 g~ feet; building foundanon~ fi O feet; nearest lot hne at [] front. [~ side, ~rear, Ins~Ion made by: [] State. [] County. {~ Local Health Author'ty. ~ ~ ~ .-./-~ ~, d ,. · · Inspected by ,~'~//~ ~)>-~'~'~' ~'rc-~' ;~'4~7~ D te of inspection_ ¥ - / ,e , o 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 ~g] are [] ate not being developed with both individual water-supply and sewage-disposal systems. Lot size: ff.O 0 feet wide, / -~ /~ feet deep. Dwelling set back from front property line. ~*~ ,'~ feet. Individual water supply from: I~ Drilled well. [] Driven well. [] Dug well. [] Bored well. Distance of well from: Building foundation, ~ ~ / feet nearest lot line at ~i~ front, [] side, [] rear, cast iron sewer. -'~0 feet; tile sewer, ~7 0 feet; septic tank, ~ ~ feet; disposal field, seepage pit,- / 0 e~ feet; cesspool,, feet; other sources of possible pollution, ~ feet. Well construction: feet; Diameter, (// inches. Tota depth, ZJ~ feet. Type of casing, .5~L~/ Depth of casing, /,J~ feet. Approximate depth to pumping level of water i~ well. ~ ~ f~t. Approximate yield, ~ gallons per minute. ~led wate~i~t to depth of ~ feet. Exterior space around casing sealed with: ~ Cement grout. ~ ~ddled clay. ~Ordina~ backfill. Well cover: ~ ~ncrete. ~ Wood. ~ Metal. Openings in well cover wate~ight: ~ Yes. ~ No. ~um~: ~ Shallow well. ~ Deep well. Len~h of drop pipe,_ ~ ~ feet. ~mp ~paci~. ~ gallons per minute. ~ted in: ~ Basement. ~ ~mproom off basement, ~ ~mphouse above ~ound. ~mproom pro~rly &ained: ~ Yes. ~ No. ~mp mounting w~tenight: ~ Yes. Ty~ of storage: ~ Pressure. ~ Gravis. Capacity,~gallons. Has bacteriologi~l examination of water been made? ~ Yes. ~ No. If answer is "yes," give date Qualiw of water ~ is ~ is not satisfa~oty for human consumption. Ins~llation ~ does ~ does not comply with approved exhibits, if any. .~ Insp~ion made by: ~ State. ~ ~un~. ~c~ Health Au~ori~. ~ lns~e~ed bv /~,~,~ Date of inspection - / R 19 ~ O ~'~"~4~ , (x[x~) C 0 P Y Certz~e Well For Emil Urbanek Location Lot 20, Block 5, Wentworth Subdivision - Tudor Road Date completed Depth of Wetl Size of casing August 31, 1959 46 feet 6 inch Distance to water 5 feet Distance to water while pumping of 480 gallons per hour. 40 feet at rate Description of Formation Brown clay and Rock Sand and Gravel Blue Sand and Gravel Sand and Gravel Sand and Gravel w/h2o from to 0 8 8 17 17 38 38 44 44 46 certify above true and correct /s/ W. E. Clemenson Driller SWAFFORD DRILLING 3401 Spenard Rd. Spenard, Alaska We advise you to attach this certificate to your deed. 6782 ~ Lab. No INDIVIDUAL WATER SUPPLY ALASKA DEPARTM~ENT OF HE~TH ~ ~ion of Sanim~on and En~neering ACTION ON :REQUEST FOR BRCTE OLOGIC WATER YSIS Your recent request for an an~ysi~ of a ~ple from ~e lndividual Private Water Supply ~. ~1 ~O~k se~mg ~t ~, Block 5, $,Ie~h Sp~a~ A~ka gub~vts~on ex~ination has been completed. ~ecords ia this o~ce indicate this Individual Private Water Supply to be of ~ Satisfacto~ Questionable Unsatisfacto~ S~K~ sta~. A~ysis shows this S~PLE to b~ ~/' , Satisfacto~ .Questionable. .Unsatisfa~o~. If an "Umafisfacto~" or "Questionable" smms is indicated abovq you shouM take i~ediate action ~ mco~ended below. 1. Boil or &emically treat your water supply to protect your f~ily from water-brahe dishes ~ outlined in en- closed leafleh '~Dri~ It Pure." 2. Improve yo~ spring~ S~ bu~etin HS~-6-2 3. ~prove yo~ cismm~See bu~etin HSE-6-3 4. Improve your dug we~ See bu~eti~ HSE-6-4 5. Improve your driven we~ ~ See bu~etin HSE-6-5 6. ~prove your dri~ed we~ ~ See bu~etin HSE-6-6 7. Relocate your we~ to a safe location in rdationship to yo~ sewage disposal system~ See b~etln HSE-15 8. Botde broken in transih plebe send new staple. 9. Staple mo Bng in transit; staple shouM not be over 48 hours dd at ex~inafion m indicate ze~able resets. Ple~e scm new staple. 10. ~nmgt your nearest ~ Local Health Department or ~ Alaska Heakh Depamenh Sanitation o~ce for buHerinh cons~tation, and ~sismnce. 11. This is a surface water source and subject to po~ufion by man aM animaN. An approved water supply so,ce shouM be developed. S~ITA~'S REMUS. A DIi--I"IgP~6-,P'! (e) I'llfl~ Form Mus~ Be l~llled [ Out Completely. INDIVIDUAL ~TER~UPPLY ALASKA DEPAI~TMENT OF ~E,41,,x,~ , Section o! Sanit~t/on and Engineering Please Look on Reverse of Sheet for Sample ColleCtion Inst..orions. 6 ?82 RexBmst fo~ Baetcdologieal Atmlyala ~. ~o ........................................... W~er ~mple collected b~....C.~.L.L~LA~..:L....~.~--~.:.-.-~(Name of person ,colleetl~ ................. a. ampl~)~'""~'"~' ......... : .......................................................... (Date) (Time) ' ~er ~mple eollee~d from ~' Kl~hen ~p; ~ B~hr~m ~P; ~ B~emen~ ~p; ~ O[her (1~)......~ ............. ; .................................. : .................... :5"/ ......... v: ....................... ~.-~' ...... Afld~s Dremlse where 8oure~ m l~a~a ............................................. ._ .. /- / -,~ ~ ~ repo~ to (~-.-....~.,..~..~.-~.~--.-.p ......... ~m...x.----=.--~ ....................................... ~'"'"" ...... (Name) (Box ~. or street ad,ess) .. Please place an "X" In the box before l~ms which b~t desc~be your water supply: ~U~E: Well ~ ~ Dug, ~ Driven, ~D~Hed, ~ Bored ~ Spring, ~ C~te~, ~ Other (list) ............................................................................................................... ~ CreeK, ~ River, ~ Lake, ~ Pond .................... L ............................................................................................ DUG ~LL OR C~TERN CONS~UOTION: Walls ~ ~ Wood, ~ Concrete, ~ ~tal, ~ ~e, ~ Brick or Concrete Block Top ~ ~ Wood, ~ Concrete,<~ Metal, ~en Top LOCA~ON: ~ In basement, ~ Basement offset, ~ Under ~o~, ~ In yard Other ..................................................................................................................................................................................... D~T~CE TO: Buil~g sewer or o~her drainage pl~ ...... ::......feet, Septic ~nk ...![.'~qL.:.feet, ~le field feet, Seepage pit ....~.feet, Cesspool .............. feet, Pri~ .............. feet. Other ~sible sources of con~am~ation (1~) ............................................................................................................................................. ~: Building sewer ~ ~ Cast ~on, ~ Wood, ~ T~e, ~ ~bre pipe, ~ ~bestos cement Jolt material ~ ~pe ........................................................................................................................................................ GE~R~ ~OR~ON: Does water become muddy or d~colored? ~ yes, ~ no ~e~? ........................................... ;- ...................................................... :--.----;:?----; ............................... Diameter of well ..................... Z.;~..:.~ ...................... depth .................... ~.~,......, .......................... fee~ Well casing material ........................................ diameter .................... dep~ .................................. Length of drop pipe ................................................................................................... : ........................... Water depth from bot~m ............................................................................................................ feet Prop location: ~ ~ well, ~ Offset ~ basement, ~ In b~ement ~ ~ utl~ty r~m, ~ On top of well ~ Other (t~t) ........................................................................................................ Do you s~ct i~ fr~ t~ supply? ~ yes, ~ no ........... ....................................................................................................................................................................... ' PLEBE DRAW A S~TCH ~ ~ SPACE BELOW, ~IS SK~CH SHOED SHOW ~CATION OF HOUSE, WA~ SWPLY 80~CE, SE~IC T~, SE~R, DRA~ ~S OR O~ SOURCES OF PO~U~ON ~ DZST~CES BE~N WAT~ SUPPLY SO,CE A~ ~ OF ~0~ gAMPLES MUST BE SUBMITTED IN CONTAINEitS PItOVID~ED BY,TI~; ALASKA DEPAItTMENT OF HEA/LTH ~ DIRECTIONS FOR COLLECTING SAMPL~q OF ~WA~F3/ FOR BACTERIOLOGICAL EXAM~A~J{ON Read Carefully and Follow,Instructions Exactly DO NOT COr.r.~T SAMPLES' FROM FIRE HYDRANTS, YARD HYDR4k_NTS. DRINKING FOUNTAIIqS OR SIMILAR OUTLETS WHIOH ARE DIFFiOULT TO D I S I N F E C T PROPERLY ? Bear in mind that water analysis deals with materials present In very minute quantities. carelassness in collecting and handling may give rise to result~ which are misleading. The least Arrangements should be made to have water samples reach the laboratory as quickly as possible. After 48 hours .the significance of the bacteriological analysis is impaired. For obvious reasons the laboratory prefers to receive samples in the early part of the week, but is willing to accept sa~nples at any time. In collecting samples from TAPS or PUMPS proceed as follows: (a) Thoroughly flush tap or pump by allowing Water to run freely for five minutes. (b) Shut off water and flame the outlet with torch or burning paper. The flame should not be merely passed over the outlet, but should be applied until fixture shows indication of b~ing hot. Flame should be directed against inside edge. (c) Open fixture so that a small stream flows. (d) Remove bottle from mailing tube. Hold bottle by the lower half in one hand and with the other remove the screw cap with the fingers, leaving paper protecting cover in place. Fill the bottle to the shoulder. Replace cap with paper cover, screwing firmly into place but do not apply pressure which will split cap. (e) Pack bottle carefully in mailing tube enclosing this completed information sheet, being sure that a simple sketch is included. In collecting samples from STREAMS and RESERVOIRS proceed as follows: (a) Remove cap and hold bottle as described under (d) above. (b) Collect sample by holding bottle in a slanting position and sweeping it below the surface in such a manner t~hat water that has been in contact with the hand is not introduced into the bottle. Avoid collecting surface scum and bottom ~ediment. SAMI'LES MUST BE SUBMITTED IN CONTAINERS PROVIDED BY THE ALASKA DEPARTMENT OF