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FHA Form 2573 \~. ~/' %,~ /' Form -~pproved
Rev, lul¥ 1958 x FEDBRAL HOUSING ADMINISTRATION
Budget Bureau No. 63-R296.S
HEALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
PART L--TO BE COMPLETED BY FHA
INSURING OFFICE MORTGAGEE SERIAL NO.
Anchor~ge~ ~le~k~ The Ft~'~% ~etionel B~k 111-002078-203
MORTGAGOR
SUBDIVISION NAME
~ ~0~ ~O~ BLOCK NO. ~ LOT NO.
TOTAL NU~BER~ I '
J BATHS additional bedrooms?
(if Yes, how
WATER SUPPLY BY:
[] Public system
SEWAGE DISPOSAL BY:
-]New installation
I,~ tarn 1 ye~. old
[~] Community system
[] Individual
SYST, EM DESIGNED FORd
/'-]Yes [~] No
]Public system
[~ Community system
[] Individual
PART fl.--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 [] State [] County .[] Local Department of Health that this individual sewage-disposal sys-
tem with proper maintenance:
N Can be expected to function satisfactorily, and [] Cannot be expected to function satisfactorily
is not likely to create an insanitary condition
NOTE: The health ~uthority should complete the appropriate opinion statement above and 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 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.
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
TREATMENT consists of ~ Septic tank.
PRIMARY
Septic Tank:
Distance from well,__
Total liquid capacity,
lnside length.
Cesspool:
Distance from: Well,~
Inside diameter,__
[] Cesspool.
Material.;'~'-./~ {/t~L'q~/~ .[- g/
??/
d?~ 0 gallons. Capacity inlet compartment,.
feet. Inside width~ feet. Liquid depth,
gallons.
_feet.
feet; foundation, feet; nearest lot line at [] front, [] side, [] rear,_
_feet. Depth. feet. Liquid capacity, -- gallons. Lining material
_feet.
feet.
square feet.
.inches.
inches.
feet; building foundation, ~,9 .W feet; nearest lot line at }~ front, [~side, [] rear,~/-~feet.
[] County. [] Local Health Authority. ~ /r~ j/~, ~ ~
(Tl'rLg)
SECONDARY TREATMENT consists of [] Tile disposal field. ~ Seepage pits. Other
Distance from: Well,_ feet; foundation, feet; nearest lot line atq~Cfont,:5~ide, [] rear,~-~
Total length of tile lines, feet. Nmnber of lines, Distance between lines,
Length of each line feet. Depth, top of tile to finish grade,
Type of filter material: [] Gravel. [] Broken stone. Other_
Depth of filter material beneath tile4 inches. Depth of filter material over tile,.
Number of pits I . Outside diameter, etf ff~/feet. Depth, ff~. feet. Lining material- /-~°t.-~Q~
Distance from: Well,
Date of inspection__
REPORT OF INSPECTION~INDIVIDUAL WATER-SUPPLY SYSTEM
Distance to nearest public water main ..... feet, Size of main, __-inches.
Individual wells [] are [] are not customap/ 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 s~ze:, feet w de _ 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,.
feet; tile sewer,
feet; cesspool,_
feet; nearest lot line at [] front, [] side, [] rear,
feet; septic tank,_ feet; disposal field,
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 gtound. [] 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~
feet;
..feet.
, 19__
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