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HomeMy WebLinkAboutEVANSON LT 4 FHA Fdrm 2573 Rev. July 1958 FEDERAL HOUSING ADMINISTRATION Budget Bureau No. 63-R296.8 HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM INSURING OFFICE PART I.--TO BE COMPLETED BY FHA MORTGAGEE ~ MORTGAGOR OR SPONSOR SUBDIVISION NAME PROPERTY ADDRESS BLOC NO. O NO. TOTAL NUMBER: BATHS LIVING UNITS BEDROOMS WATER SUPPLY BY: ~ Public system BASEMENT 1[] New installation ~r] Community system Can attic or other area be made Into additional bedrooms? (If Yes, how many?J t-lYcs [--1No ~ SYSTEM DESIGNED FOR r']Individual NO. F BDRM$. GARBAGE DISROSAL SEWAGE DISPOSAL BY: "-] Public system [~] Community system [] Individual Yes ri-j No PART II.--TO BE COMPLETED BY HEALTH DEPARTMENT HEALTH DEPARTMENT INSPECTOR'S SKETCH It is the opinion of the ~] State ~] County ~] Local Department of Health that this individual water-supply system [] is [] is not satisfactory as a domestic water supply for the subject property. It is the opinion of the [5~l~State r-] County [-] Local Department of Health that this individual sewage-disposal sys- tem with proper maintenance: ~San be expected to function satisfactorily, and [--] Cannot be expecte, d to function satisfactorily JS not likely to create an ~nsanitary condition DATE , / J SiGNATUBE , .. J TITLE. £.., /:7 · t ..... ~ / ~. . / / NOTE: The health authority should complete the appropriate opinion statement abo~p'~nd affix date, signature and title in the spaces provided. Use of the abov'e grid for Health Department Inspector's sketch as well as use of the back of this form is at the option of the health authority. PART III.~FOR USE OF FHA OFFICE TO THE CHIEF UNDERWRITER: I have reviewed the foregoing and the pertinent FHA Compliance Inspection Report, and recommend that 'the Individual water-supply system be considered [-'] Acceptable [] Not Acceptable Sewage disposal be considered ]'~ Acceptable [~ Not Acceptable. DATE SIGNATURE HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM C'~IEF ARCHITECT DEPUTY FOR CHIEF ARCHITECT FHA Form 25),$ Rev. July 1958 REPORT OF INSPECTIONmlNDIVIDUAL SEWAGE-DISPOSAL SYSTEM PRIMARY TREATMENT consists of ~Septic tank. [] Cesspool. ~ ~' ~{~' / Number of compartments Distance from well, feet.' Material, Total liquid capacity, / ? (~ (~ gallons. Capacity inlet compartment, '~ .gallons, Inside length,. '~ feet. Inside width, ~" feet. Liquid depth, ~ .feet. Cesspool: Distance from: Well, feet; foundation, feet; nearest lot line at [] front, [] side, [] rear, . feet. Inside diameter, feet. Depth,. feet. Liquid capacity. .gallons. Lining material SECONDARY TREATMENT consists of [] Tile disposal field. ~Seepage pits. Other Tile Disposal Fields Distance from: Well, 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 lines, .feet, inches, Total effective absorption area in bottom of trenches .square feet, feet. Depth, top of tile to finish grade, inches. Type of filter material: [] Gravel. [] Broken stone. Other. Depth of filter material beneath tile4 inches, Depth of filter material over tile, inches. Seepage Pita: Number of pits / ~. !~'X ~feet. Depth,-- ~ .feet. Lining material Distance from: Well, ~-- feet; building foundation, ~ ~t feet; nearest lot line at [] front, ~ side, [] rear~ ~ feet. Ins~ction made by: [-I State. [] County. [] Local Health Authority .... ~ Date of inspection ./'"~ ( 19~ ' ~":~;~ "'"r '~"" 't'4~ ~('nTL~) 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 [] 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. Individual water supply from: [] Drilled well. [] Driven well. [] Dug well. [] Bored well. Distance of well from: Building foundation, 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, feet. feet. Type of casing, Depth of casing, feet. Approximate yield, .gallons per minute, Exterior space around casing sealed with: [] Cement grout. [] Puddled clay. [] Ordinary backfill. Well cover: [] Concrete. [] Wood. [] Metal. Openings in well cover watertight: [] Yes. [] No. Pump: [] 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 .gallons per minute. ,19 (TITLB) ~ U. S, GOVERHMEHT. PRINTING OFFICE: 19570-F--42705B .feet.