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FHA F~ornl 257~, · ~ ~/ x~...~/ Form Approved
.Rev. Juo' 195ff ~ FEDERAL HOUSING ADMINISTRATION Budget Bureau No. 6S-R296.8
HEALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
PART L--TO BE COMPLETED BY FHA
INSURING OFFICE MORTGAGEE SERIAL NO.
M~)RTGAGOR OR S~ON$'OR PROPERTY ADDRESS
BLOCK NO. LOT NO.
SUBDIVISION NAME
TOTAL
NUMBER:
Can attic or other area be made into
~ N'ew installation additional bedrooms?
BASEMENT
(if Yes, how rnany~/
/ / r-lYes ( No lqYes
WATER SUPPLY BY: SYSTEM DESIGNED FOR
SEWAGE DISPOSAL BY~
PART II.~TO BE COMPLETED BY HEALTH DEPARTMENT
HEALTH DEPARTMENT INSPECTOR'S SKETCH
IIIIIIII IIIlllllllllllll
REPORT OF INSPECTION~INDIVIDUAL SEWAGE-DISPOSAL SYSTEM
Septic Tank:
Distance from well,
Total liquid capacity,
Inside length,
Cesspool:
Distance from: %Vell,
Inside diameter,
PRIMARY TREATMENT consists of [~I Septic tank. [] Cesspool.
feet. Material. g'bee~J)ElL S¢~/t~:g'[('7~Numberofcompartment$
~7 ~O gallons. Capaci~ inlet comp~tment,
.feet. Inside width, f~t. Liquid depth, feet.
g~lons.
feet.
feet; foundation,, feet; nearest lot line at [] front, [] side, [] rear,
feet. Depth,. feet. Liquid capacity, gallons, Lining material
S[CONDARY IR[ATMRNI consists of [] Tile disposal field. ~ Seepage pits. Other
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