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HomeMy WebLinkAboutEVANSON LT 5 FHA Form 2573 Form Approved Rev. July 1958 FEDERAL HOUSING ADMINISTRATION Budget Bureau No. 63-R296.8 HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM PART I.mTO BE COMPLETED BY FHA INSURING OFFICE MORTGAGEE SERIAL NO. Ha~al ~ of AXmmlm ~eder,~ Iouin8 Admiato~ra~ea Aaebo~ase, A~aeka 60.oo8~,t7 LOVLR &Mor. BSe~, 7~. Let, $0 Ivanoeu lubdL~LoLe~ SUBDIVISION NAME BLOCK NO. LOTmNO. Evanoeu Subdtvt. otma TOTAL NUMBER: Can attic or other area be mode Into BASEMENT jl~ New installation additional bedrooms? (If Yes, how many~) WATER SUPPLY BY: SYSTEM DESIGNED FOR [] Public system iXl Community system J J Individual NO. OF BDRMB. SEWAGE DISPOSAL BY: [] Public system [] Community system [] Xndividual [] Yes [] No HEALTH DEPARTMENT INSPECTOR'S SKETCH !~:_-z_-7_-zzzz_-_-_-_-_--zzzz_-_-zzc_-_-_-zzz_-_-_-_-zzTzzzzzcrzz: -_-_-zzz: ~_-_-2X~_-7_X_-Z_-Z_-ZZZZ2_-2_-2222222222222222; 22222_-ZzZZ 222222Z :::::::::::::::::::::::::::::::::::::::::::::::::::: fT_ZZZZZT_ZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZXZXZZZ--ZZZE ZZZZZZZ ~. .... . ................................ ~ ................. .L ............................... ' ...... -~ ................. b ................................ ZZ-ZZZZ-~ZZZZZZZZZ~ ZZZZZZZ ~7_ZZZZZT_ZZZZZZ_-ZZZZZ_-ZZZZZZZZZZZZZZZZZZZ~ZZZ--ZZZZ2; Z2_-2222 ::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::: i i------:-_: :-:-~ :-F~ _--_--_:: ~ :-~ ~ ~ :-_--:-~ :-_----_----~ :-:-::::::: i:::::::::: ::::::: hh. 7_ZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZ-_ ZZZZ_Z ........ Z-~ L_-ZZZZZZZZ_-_-_-ZZZZZ_-_-ZZZZZ_-ZZZZZZS_-_-ZZ------; ZZ_-_-_'Z_-_-_-_' _-Z_-Z~_-Z ZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZ- -ZZZ~ZZZZ: ZZZZ~Z~ ............................................. ~ .......... -'t ...................... Ssss2SSSS22SS2S-2S: S222..7S2Ss; It is the opinion of the [] State [mI County r-] Local Department of Health that this individual water-supply system [--] is N is not satisfactory as a domestic water supply for the subject property. It is the opinion of the ~ State r-] County [] Local Department of Health that this individual sewage-disposal sys- tem with proper maintenance:~ ' ~Can be expected to function satisfactorily, and ' r-] Cannot be expected to function satisfactorily is not likely to create an ins54nitary condition /- ./;~ --,---~----~, .. _ .y,~, N The health authority should complete the appropriate opinion stat above d affix date, signature and 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 III.~FOR USE OF FHA OFFICE TO THE CHIEF UNDERWRITER: I have reviewed the foregoing and the pertinent FHA Compliafl'~e In'spection Report, and recommend that'the Individual water-supply system be considered F-1 Acceptable ~] Not Acceptable Sewage disposal be considered [~] Acceptable [] Not Acceptable. DATE SIGNATURE . ~ CHIEF ARCHITECT ] DEPUTY FOR CHIEF ARCHITECT HEALTH AUTHORITY APPROVAL FHA Form 2573 INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM Ke~. July 19S8 REPORT OF INSPECTIONmlNDIVIDUAL SEWAGE-DISPOSAL SYSTEM PRIMARY TREATMENT consists of [~Septic tank. [] Cesspool. Septic Tank: Total liquid capacity, / 0 ~ ~ gallons. Capacity inlet compartment, ~' .gallons. 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 ?REA?MEN? consists of [] Tile disposal field. ~Seepage pits. Other Tile Disposal Field: 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 tile, inches. Depth of filter material over tile, inches. Seepage Pits: Number of pits / Outside d: ......... ~ ~, '~)feet. Distance from: Well, ~ feeti building foundation, Inspection made by: [] State. Date of inspection De tu ~" feet Lining material ~ feet; nearest 1oi line at [] front, [] side, ~rear, ? feet. [] County. ~'Local Health Authority. /~~. 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, seepage pit, Wall construction: feet; tile sewer, -feet; cesspool, feet; nearest lot line at [] front, [] side, [] rear, feet, feet; septic tank, feet; disposal field,, feet; .feet; other sources of possible pollution, feet. Diameter, inches. Total depth, feet. Type of casing, Approximate depth to pumping level of water in well. feet. Approximate yield, Sealed watertight to depth of feet. 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__ Depth of casing, .gallons per minute. .gallons per minute. _feet. 19 (TITLE) FHA Form ~573 Form Approved Rev. July 1958 FEDERAL HOUSING ADMINISTRATION Budget Bureau No. 63-R296.8 HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM PART I.--TO BE COMPLETED BY FHA INSURING OFFICE Fed~a'l Housir~_ ldm~St,~tio MORTGAGOR OR SPONSOR Lewis & Metzger~ Inc. ,UBDIVISION NAME Ev~nson Subdiv~ lol~ TOTAL NUMBER: BASEMENT LIVING UNITS SEDROOM$ BATHS 4 ¥es VINo WATER SUPPLY BY: [~] Public system SEWAGE DISPOSAL BY: [] Public system MORTGAGEE SERIAL NO. ~a~ional Ba~k of Ala~. f 60-008~27 p Pi Ti '~R--S ] ~tm~I~anso~ Subdiv~s~O. ! 4301 NG~dl® Driv® []Community system ]Community system New installation BLOCK NO. LOT NO. Can attic or other area be made Into additional bedrooms?  (If Yes, how many~J N Yes No [] Individual I-X] Individual SYSTEM DESIGNED FOR NO. OF BDRM$,, GARBAGE DISPOSAL 4. [~1 Yes [~] No PART fl.--TO BE COMPLETED BY HEALTH DEPARTMENT HEALTH DEPARTMENT INSPECTOR'S SKETCH It is the opinion of the [--] State N County :rTl,Local Department of Health that this individual wa~er;supply system [--] is [~ is not satisfactory as a domestic water supply for the subject property. It is the opinion of the ~lxState [--] County [] Local Department of Health that this individual sewage-disposal sys- tem with proper maintenance: . Can be expected to function satisfactorily, and ~lk.Cannot be expected to function satisfactorily is not likely to create an insanitary condition DATE ! I SIGNATUR~/' I TITLE NOTE: The health authority should complete the appropriate o~inion statement abov~9~d affix date, signature and t' e in the spaces provided. ~ ' .., Use of the above grid for Health Depart~nent Inspector's sketch as well as use of the back of this farm is at the option of the health authority. ' :'PART ill.--FOR USE OF FHA OFFICE TO THE CHIEF UND~RV4RITER: 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 ] CHIEF ARCHITECT -] DEPUTY FOR CHIEF ARCHITECT FHA Form 2573 Rev. July 1958 REPORT OF INSPECTION--INDIVIDUAL SEWAGE-DISPOSAL SYSTEM Inspection made by: [] State. Date of inspection PRIMARY TREATMENT consists of J~ Septic tank. [] Cesspool. Septic Tank: Distance from well, ~ feet. Material, ~ ''~ ~e. C. / Number of compartments Total liquid capacity~ ,/e') 0 ~ gallons. Capacity inlet compartment, ~ gfllons. Inside leng~,. '~ feet. Inside wid&, '-- .feet. Liquid depth, ~ .feet. Dis~nce from: Well, feet; foundation, ~eet; n~r~st lot line at ~ front, ~ side, ~ rear, f~t. Inside diameter,, f~t. Depth,. feet. Liquid capaciW, .gallons. Lining material ~{O~}l[I l~lll~l~l consists of ~ Tile disposal field. ~Seepage pits. Other TI~ Disposal Field: Dis~nce from: Well, feet; foundation, feet; newest lot line at ~ front, ~ side, ~ rear,, f~t, Total len~h of tile lines, f~t. Number of lines Distance between lines, feet. Trench width, inches. Total eft<tire absorption area in bottom of trenches .square feet. ~ngth of each line. f~t. Depth, top of tile to finish grade, .inches· Ty~ of filter material: ~ Gravel. ~ Broken stone. Other ~pth of filter material ~neath tile.~ inches. Depth of filter material over tile, inches. ~age P~s~ ~ ~ Numar of pits / , Outside ~. X~ feet. Depth,~ feet. Lining material ~ Dis=rice from: Well,. ~ feet; building foundation, ~ ~ feet; nearest lot line at ~ front, ~ side, ~}ear. ~ f~t. ~ ~unW. ~1 Health Authori~ .... '~ .... (x~x~) 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, feet. Type of casing,. Approximate depth to pumping level of water in well,_ feet. Approximate yield, Sealed watertight to 4~pth of feet. 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 feet; nearest lot line at [] front, [] side, [] rear,, feet, feet; septic tank,. -feet; disposal field, feet; feet; other sources of possible pollution, .feet. Depth of casing: feet. .gallons per minute. gallons per minute. 19 (TITLE)