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HomeMy WebLinkAboutCREEKSIDE PARK #3 LT 26, D, kl° L ,,,! 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 Federal Housing_ A43Lt~st,~t, Lcm MORTGAGOR OR SPONSOR SUBDIVISION NAME MORTGAGEE llational ~ank of A~s]m Anchorme~m, Alaska PROPERTY ADDRESS lSERIAL NO. 6O-O0784.'7 BLOCK NO. J LOT NO. I 26 ,[ Con attic or ~ area 'il4 made into · l oddiflonal bedrooms? , ]/[--] Yes [] $° {ffYes, howmany~} SYSTEM DESIGNED FOR ~] Individual ~, OF BDRk~. GARBAGE DISPOSAL r~ Individual 3 O Yes r~l No 2~.~nltn~d~ I~n~k ~athd~.~rln TOTAL NUMBER: Lon. ~:~ BASEMENT ~]Yes [~ No ~'~ New installation WATER SUPPLY BY: 0 Public system N Community system SEWAGE DISPOSAL BY: ,, [--] Public system O Community systei~ PART II.mTO BE COMPLETED BY HEALTH DEPARTMENT HEALTH DEPARTMENT INSPECTOR'S SKETCH It is the opinion of the ]~ State O County ~ Kocal Department of Health that this individual water-supply system ~is ~1 is not satisfactory as a domestic water supply for the subject property. It is the opinion of the ]~ State N County ~] Local Department 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 ins~itary condition DATE / I SIGNATURr~ ~ I TITLE / NOTE(The heolth outhorttY should complete the approprlate~opinion statemen~.~qSovo and SEcONDAR'~ TREATME~IT consists °f'~Tile dispOsal fiel~d. ~ Seepage.pits. Other Tile Disposal Field: Distance from: Well, /t~ (~ feet; foundation, ~ .-~ feet; nearest lot line at [] front, []g~ side, [] rear, ,~-~ feet. Total length of tile lines '~ ~ feet. Number of lines, / Distance between Ii .... feet. Trench width, 30 inches. Total effective absorption area in bottom of trenches, ~' ' square feet. Length of each line, ~ ~- feet. Depth, top of tile to finish grade, ~"~ inches. Type of filter material: [~Gravel. 1-1 Broken stone. Other Depth of filter material beneath tile~ ~ inches. Depth of filter material over tile, ? inches. Number of pits ~ Outside~,~o ~d~. Depth,~.,~,~. feet. Liningmaterial~'~/-%.~ Distance from: Well, ///~ feet; building foundation, 7~'~ feet; nearest lot line at [] front, [l~ side, [] rear, 31 ~ feet. In.cfi. rode by: ~ State. [-] County. ~Local Health Authority.(.~ / , Inspected. '~ .: :bY- Date of inspection ~ t'~ii?i'9 ~/ : " (vm.~)' REPORT OF INSPECTION--INDIVIDUAL WATER-SUPPLY SYSTEM Distance to nearest public water main, ~ feet. slz~"of main, - - , inches. Individual wells J~are [] are not customary in neighborho~d'.:/'. Give most recent record of failure of wells in immediate vicinity to furnish'adequate supply~0fT~iater ", Properties in neighboghood ~eare [] are not being developed with both individual water-supply and sewage-~osal systems. Lot size: / ~ q feet wide, ,~O ~',.~ deep. Dwelling set back from front proper~y line, t~ feet. Individual water supply from: ]~Drilled well. [] Driven well. [] Dug well. [] Bored well., Distance of well from: Building foundation, ~) + feet; nearest lot line .at ]~l front, ~[§id_e, ~ / feet, sewer ¥ feet; tile sew , rear, ~ feet; septic tank, feet; dispOsal field, /~O feet; seepage pit, '/Id.~ feet; cesspool,. "--'-' feet; other sources of possible pOllution, ~ feet. Diameter, ~ inches. Total depth, ~ ~" feet. ~vpe of Casln~,~ ~ 1~ ~, ~,L Depth of casing-'" feet. Approximate depth to pumping level of water in well, / ~. feet Approximate yiel~i / ~' gallons per'min-~. Sealed watertight to 4~pth of ~P~'-- feet. i.. Exterior space around casing sealed with: [] Cement grout, [] Puddle&?~:lay. [] Ordinary backfill. Well cover: [] Concrete. [] Wood. {~ Metal. Openings in well cover watertight: ~Yes. [] No. ~ ~ r~ , ~. $ t Pump: [] Shallow well. '~Deep well. Length of drop pipe, '"" feet. Pump capacity, ' ~ {~ .gallons per minute. '°/'~{ Located in: [] Basement. [] Pumproom off basement. [] tKimph0u's~ above ground. [] ~PUmp pit. Pumproom properly drained: [] Yes. [] No. Pump m~qti~, watertight: [] Yes. [] Type of storage: {~ Pressure. [] Gravity. Capacity, "ir 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. Date of inspection ///1 ~,,./ , 19~O Inspected U. S* GOVERNMENT PRINTING OFFICE: I~57 O-P--4~7038 " TAKE WA'I:ER SAMPLE ~R~.. ~J~ 'AD~S~PI {~ ~ Lsborato~, 945 Sixth Ave. ~ FOra M~ b m~ ~~U~W~R S~PLY I ~ut for ~e ,Out Cmpletely. R~u~t for Ba~e~l~ ~al~ ~ ~. so.....o~c/ ................. ' z& l w~, ~ ~oa~ ~ ............. ~: ~..~..~Z~ ............. ~ .................. : ~ 6 ~ ~: ~ . (Na~e' of ~r~n mn;Eib, ~mple) ' T}~;~' ..................... (~;; ............ Water s~Ple coHec~d from '~hen tap; ~ Bathr~m ~p; ~ B~ement't~; ...................................................... ~ ~ ~o~ ~ .................... : .................. , ........ ~ ~ .................................. ( ............... ~.~. ....... ~: ............ ~ ~.g ~~~ ................. ~:.:..~...~. ...... d~..~...r.~ .~.~.~.~... ~fl repo~ ~o ~ .......... ..... ~ ......... ~'~ ......................... {~o~ ~. o~ ~t~t ~a~ Please place an "X" ~ ~e box before l~ms which b~t desc~be your ~r supply: ~E: Well -- ~ Dug, ~ Driven, ~ed, ~ Bored ~ Sp~g, ~ C~tem, ~ Other (Hst) ............................................................................................................... ~ ~ek, ~ River, ~ Lake, ~ Pond ................................................................................................ ~ ................ DUG ~ OR C~N CONS~UCTION: Walls- ~ Wood, ~ Conc~te, ~ ~tal, ~ ~e, ~ Brick or Concrete Block Top -- ~ Wood, ~ Concrete, ~ Me~l, ~ ~en Top LOCA~ON: ~ ~ b~ment, ~ B~ement offset, ~ Under ~o~e, ~ ~ y~d ~er .................................................................................................................. ~ ................................................................. D~T~CE ~: B~g sewer or o~er dra~ge pl~ ......... ,....feet, ~ptic ~nk .............. feet, ~e field .............. feet, Seepage pit .............. feet, Cesspool .............. feet, ~i~ .............. feet. Other ~ible so~c~ of con~m~tion (~t) ............................................................................................................................................. ~~: Bufl~ ~wer -- ~ Cast ~on, ~ Wood, ~ ~e, ~ ~b~ pipe, ~ ~bes~s cement Jolt mate~ -- ~e ...................................................................................................................................................... G~R~ ~~ON: Does water become muddy or ~colored? ~ yes, ~ no ~? ....................................................................................................................................................... ~e~r of well ...................................................... dep~ .......................................................... feet Well c~ng mate~al ........................................ ~meter .................... dep~ .................................. Len~h of drop pl~ ............................................................................................................................... Water depth from ~tWm ............................................................................................................ feet ~p location: ~ ~ well, ~ Offset ~ basement, ~ ~ b~ement ~ ~ ut~ty r~, ~ On Wp of we~ ~ Other (~t) ........................................................................................................ P~Pos~ o~ ~XA~mA~ON: n~n~ ~c~d* ~ ~, ~N~ ~ou~c~ o~ ~pp~ ~ ~ no ~pairs to ex~ting system? ~ yes, ~ no ~E D~W A S~ ~ ~ SPACE B~. ~. SK~CH SHOED ~OW ~CA~ON OF HOUSE, WA~ S~PLY SO,CE, SE~iC T~, ~, D~ ~S OR ~ SO~CES OF ~~ON ~ D~T~C~ BE~ WA~ S~PLY ~CE ~ ~ OF ~O~~ F~~. i SAMPLES MUST BE S~~ m CONTAnqEBS PRoVXDED BY THE ALAS~ DE~ARTMmer OF HE&LTH AI~H.HSE-6-FI (f) 10-55 o 5M ACTION INDIVIDUAL WATER SUPPLY ALASKA DEPARTMENT OF HEALTH OFFICE Section of Sanitation and Engineering ON REQUEST FOR BACTERIOLOGICAL WATER ANALYSIS Your recent request for an analysis of a sample from tho Individual Private Water Supply examInation has been completed, Satisfactory ~ C~uesflonablo Unsatisfactory Questionable Unsatisfactory. Records in this office indicate this individual Private Water Supply to be of sanitary status. - AnalySis shows this SAMPLE to bo, ~ Satisfactory If an "Unsatisfactory" or "(~uestionablo" status is indicated above, you should take immediate action as recommended below. 1. Boll or chemically treat your water supply to protect your family from water-borne diseases as outlined in en- closed leaflet, "Drink It Pure*" 2. Improve your spring- Soo bulletin HSE,-6-2 3. Improve your cistern- 800 b~t~iletin HSE-6-3 4. Improve your dug well- See bulletin HSE-6-4 $. Improve your driven well ~ See bulletin HSE-6-5 6. Improve your drilled well m See bulletin HSE-6-6 7. Relocate your well to a safe location in relationship to your sewage disposal system- See bulletin HSE-15 8. Bottle broken in transit, please send new sample. 9. SamPle too long in transit; sample should not be over 48 hours old at examination to indicate reliable results. PleaSe send new sample. 10. Contact your nearest [] Local Health Department or [] Alaska Health Department, Sanitation office for bulletins, consultation, and assistance. 11. This is a surfaco water source an~ subject to pollution and animals. An approved water supply source SANITARIAH'S REMARKS N,. ~..~ ~~ ~,~ N}\i~ . ADH~HSJ~Fi (e) This .Forin Must Be Filled Out Completely. INDIVIDUAL WATER' SUPPLY ALASI~t DEPAaTMEN~ OF Section of Sanitation and Enfineerlng Request for Bacteriological Anal)si.. Please Look on Reverse of Sheet for Sample Collection Ink, ructions. (Name of person collecting sample) (Date) (Time) Water sample collected from [] Kitchen tap; [] Bathroom tap; J~ Basement tap; [] Other (list)~ ........................... ..~......~-...;;..~---.---~~ ............................. Address premise where source is located...~...~-~..L~...~.....;y'"~-- ......................................................../_ff/~/~/~-~~/../..! ............................. (Mr.) (Mrs,) Mail report to (MJse) ............................................................................................................................................................................ (Name) (Box No. or street addreas) (City) Please place an "X" tn the box before items which best describe ),our water supply: SOURCe.: Well -- [] Dug, [] Drlven,~Drilled, [] Bored [] Spring, [] Cistern, [] Other (iisi) ............................................................................................................... [] Creek, [] River, [] Lake, [] Pond .................................................................................................................. DUC} WELL OR CISTERN CONSTRUCTION: Walls- [] Wood, [] Concrete, [] Metal, [] Tile, [] Brick or Concrete Block Top -- [] Wood, [] Concrete, [] Metal, [] Open Top LOCATION: [] In basement, [] Ba.~ement offset, [] Under Aouse, J~ Tn yard Other ..................................................................................................................................................................................... DIS'lANCE TO: Building sewer or other drainage pipe .............. feet, Septic tank .~..~......feet, Tile field .............. feet, Seepage pit .............. feet, Cesspool .............. feet, Privy ............... feet. Other possible sources of contamination (list) ............................................................................................................................................. MATERIAL: Building sewer ~ [] Cast iron, [] Wood, [] Tile, [] Fibre pipe, [] Asbestos cement Joint material -- Type ....................................................................................................................................................... C}ENERAL INFORMATION: Does water become muddy or. discolOred9 [] yes, J~ ~o Whe~? ....................................................................................................................................................... Diameter of well.. ................... .' ................................ depth .......................................................... feet Well easing material ........................................ diameter .................... depth .................................. Length of drop pipe ............................................................................................................ .. ................. W~ter depth from bottom ............................................................................................................ feet Pump location: [] In well, [] Offaet~ in b,,sement, [] In basement [] In utLLtW room, [] O~ top o! well [] Other (l~t) ........................................................................................................ PURPOSE OF I~.~RMI~AT]ON: Illness suspected? [] yes, [] no New source of supply?~ yes, [] no Repairs to existing systen~? [] yes, [] no Remarks: ................................................. ~ ....................................................................................................................................................... PLEASE DRAW A SKETCH IN THE SPACE BELOW. THIS SKETCH SHOULD SHOW LOCATION OF HOUSE, WATER SUPPLY SOURCE, SEPTIC TANK, SEWER, DRAIN LINES OR OTHER SOURCES OP POLLUTION AND DISTANCES BETWEEN WATER SUPPLY SOURCE AND ANY OF ABOVE, PAC~. S~LES MUST BE SUBMITTED IN CONTAINERS PROVIDED BY THE ALASKA DEPARTMENT OF w~LTI! ADH-H,~II-6-F1 (f) (4M) · IND~IDU~ WATER SUPPLY ACTION ON Your recent request for an analysis of a sample from the Individual Private Water Supply ALASKA DEPARTMF2WT OF HEALTH Section of S~tfitation and llo~ineerins o~nc~ REQUEST'~FOR"BACrERIOLOGICAL WATER ANALYSIS examination has been completed. Records in this office indicate this Individual Private Water Supply to be of sanitary sratm. ~aOry Analysis shows this S.A_IVfPI.{:{. to be ct If an "Unsatisfactory" 1. ~actory Questionable Unsatisfactory Questionable Unsatisfactory. or "Questionable" status is indicated above, you should take immediate action as recommended below. Boil or chemically treat your water supply to protect your family from water-borne diseases as outlined in eh- dosed leaflet, "Drink It Pure." 2. Improve your spring--See bulletin HSB-6-2 5. Improve your dstem--See bulletin HSE-6~3 4. Improve your dug well a, See bulletin HSE-64 5. Improve your driven well--See bulletin HSE-6-5 6. Improve your drilled well--See bulletin HSE-6-6 7. Relocate your'Well to a safe location in relationship to your sewage disposal system-- See bulletin HSE-15 8. Bottle broken in transit, please send new sample. 9. Sample too long in transit; sample should not be over 48 hours old at examination w indicate reliable results. Please send new sample. 10. Contact your nearest '[~ Local Health Department or [] Alaska Health Department, Sanitation office for bulletins, consultation, and assistance. 11. This is a surface water source and subject to pollution by man and animals. An approved water supply source should be developed. SANITARIA_N'S REMARK~q ' TAKE WAqEI{ SAMPLE TO= 5, ".; -2 ~ ~ AD~'I'---I'~SI~-FI (e) -~ Laborat~v, 945 Sixth Ave. ~ O · ~ {.' '~ , ~ ,~om Must ~ ~ ~~U~ WA~R S~PLY ,~ ~ ~ m~ of 'Out Completely. [ ~t for ~e ~~n ~SKA D~~ OF ~Aw,~ / wn~e~ Request for Bacteriological Analysis Z~b. ~o ........................................... ' ¢'~ K~' ~ -g '-~ ."x...,., t~ ..... Water sample collected oy ..... /.Z.:....Z.J .................. .¢:..2...~..~. .......................................... "...~./..[.~..??~' ~' .... (Name of person collecting sample) (Time) Water sample collected from ~tchen tap; [] Bathroom tap; [] Basement tap; ................................................, , ................. Addres~ premise where source .l--........)7. ff--..e...~-..,.5-:..:L.~-,--~.,- ........ =...~..~....:.=..:.L.(...s../.:..~L~m-. ..... (Mr.) .... . tX Mall report to ~ ........... ~. ...... (~i'~')"'"7 ....................................... '('~;i"g:'"o';"~t';;;["ii~'~'i'~'" (City) Please place an ',X" in the bo~ before tte~s 'which best describe your water supply: SOUI~E: Well -- [] Dug, [] Driven, ~Driiled, [] Bored [] Spring, [] Cistern, [] Other (list) ............................................................................................................... [] Creek, [] River, [] Lake, [] Pond ................................................................................ ~ ............... ~ ..... : .......... DUO WELL OR CL~TI~lq COlqSTRUCTIOI~I: Walls ~ [] Wood, [] Concrete, [] l~etal, [] Tile, [] Brick or Concrete Block Top -- [] Wood, [] Coacrete, [] l~etal, [] Open Top LOCATION: [] In basement, [] Basement offset, [] Under house, ~l~yard Other .................................................................................................................. ~ .................................................................. DI~qTA/qCE TO: Building sewer or other drainage pipe..~'.~.....L~f, eet, Septic tank ..~...P...?~..'fee~, Tile field .............. feet, seepage pit .).~...P...~..feet, Cesspool .............. feet, Privy ..............feet. Other possible ~ouree~ of contamination (Rst) ............................................................................................................................................. MATERIAL: Building sewer -- ~Cast iron, [] Wood, [] Tile, [] ~lbre pipe, [] A~bestos cement Joint material -- Type ....................................................................................................................................................... GENERAL II~rFORMATION: Does water become muddy or dlscolored? [] yes, When? ....................................................................................................................................................... Diameter of well ..... ~'-~ .............................................. depth ....... ...~.....~... ....................................... feet Well casing material....~...~..%../:?.. .................. diameter ..... Length of drop pipe ........ ~ ................................................................................................................... Water depth from bottom ............................................................................................................ feet Pump location: ~ In well, [] Offse~ in basement, [] In basement [] In utility room, [] On top of well [] Other (ll~t) ........................................................................................................ PURPOSE OF EXAMINATION: Illness suspected? [] yes, ~-~¥o New so~urce of supply? [] yes, [] no Repairs to existing system? [] yes, [~no Remarks: (z.~).2! A '~ ~ "~.... ~ /.~ ~ Z/.,., '~ .,,t ~c, ~" ," x ,~ q, L; ~ .,, ~, :,-- ,~ ,) ~.-, ¢,~ PLEASE DRAW A SKETCH IN TIlE SPACE BELOW. THIS SKETCH SHOULD SHOW LOCATION OF HOUSE, WATER SUPPLY SOURCE, SEPTIC TANK, SEWER, DRAIN LINES OR OTHER SOURCES OF POLLUTION AND DISTANOES BETWEEN WATER SUPPLY SOURCE AND ANY OF ABOVE FACILITIF~o SAMPLES MUST BE S~]BMITTED IN CONTAINERS PROVIDED BY THE ALASI~A DEPARTMENT OF HEALTH - MEMORANDUM FROM~ Angle la Tentative appointment for inspection of septic tank system and water well set for 10 A.H., Hondaymorning. Call Hr. Stigum at National Bank of Alaska, and he will accompany you. DATL 2~ August 1960 A.M . FHA InspeCt ion SUBJECT__~arl Eberline (Buyer)~ Roy Stigum - Contractor & Builder NBA BR 6-5401 Lot 26, Creekside Park Old Harbor Road WATER SAHPLE NEEDS TO BE TAI~N. Directions: Out Huldoon Road to 01~ Harbor Road; 4th house from far end of street on right; tan house w/~rk bro~ trim.