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HEALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
PART L--TO BE COMPLETED BY FHA
INSURING OFFICE ERIAL NO.
MORTGAGOR OR SPONSOR
Bolles, Mark O. & Mary C.
SUBDIVISION NAME
MORTGAGEE
National Bauk of Alaska
BLOC~O. LOT NO.
5 9
b~br~G~d
TOTAL NUMRER: EASEMENT
LIVING UNITS BEDROOMS BATHS
s rqYe8 VINo
WATER SUPPLY BY:
[] Public system
SEWAGE DISPOSAL BY:
[] Public system
]New installation
--]Community system
]Community system
additional bedrooms?
Of Yes, how manyFJ
[] Individual
[] Individual
SYSTEM DESIGNED FOR
NO, OF ~DRM$. GARBAGE DISPOSA~.
PART IL--TO BE COMPLETED BY HEALTH DEPARTMENT
4EARTH DEPARTMENT INSPECTOR'S SKETCH
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II IIIII] II IIIIII
II Illll II IIIII I
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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. PUBLIC WATER
It is the opinion of the [] State [] 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 insanitary condition
DATE IS'ON"ORE . !TM
~an. 22, i97i I ~ ~~Z~. ,Environmental Health Supervisor
spaces provided, ~ ~1~ eho .
PART Ill.--FOR USE OF FHA OFFICE
TO THE CHIEF UNDERWRITER:
I have reviewed the foregoing and the pertinent FHA Compliea~ce Inspection Report, and recommend that the
Individual water-supply system be considered [] Acceptable [] Not Acceptable
Sewage disposal be considered [] Acceptable [] Not Acceptable.
SIGNATURE
] CHIEF ARCHITECT
] DEPUTY FOR CHIEF ARCHITECT
DATE
HEALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
FHA Form
R~v. July 1958
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
q. Number.~£.~bed~ooms in house,
5. I4ater~aa%alysis:
a. Ba~ri~
b. Dept~ , i '
c. C~sing Size, is~d~'
d. Distance from well to closest ex~stlng or prop .
1. Sewer line .
2. Septic tank .
3. Seepage Area
q, Cesspool'
5. Property Line
houses~ barn, drainage ditch, etc. ._ .,
Sevrag~ d~posal system, j~/___~ ~f/~ .~
b. Septic tank capacity~ in gallons, ~"-~
Other sources of possible contamination, i.e., creeks, lakes,
c. Name of septic tank manufacturer
1. If "home made" show diafram on reverse side of this form.
al.
Disposal field or seepagefl~it size and 'type
I/ ,
1. Distance to propeI~cy, e to house foundation
e. Pemcol~tio~ Te~t h-esults
f. Percolation Test performed by ....
Use th~ ~ePse,side of this fomm to show diagram. Diafram should include
.... .~he fo~ow~ng inf?rmation: ~opePty lines;.well location, house l?cation,
t~pt~e tank locatzon, disposal area locatlon~ locatzon of percolatzon
an~ direetlon of ground slope.
9. The ~r~ati~ on this form is rPue and correct to the best of my knowledge.
StKnatuPe of Applicant
TO BE FILLED OUT BY HEALTH DEPARTt4ENT PERSONNEL
Date Slgned
~e above described sanitary facilities are hereby approved, subject ,to the
......... '~61t~owing con~ons:
The above descPibed sanitaPy facilities are dissppmoved for the following
'g , , ~'f~ ~:'.'"-l.~; '-'".': ." .',. ¢ ' ~)ate ::,' -~t,
'-'- Aptn'oval ls valid for one year following~he date of approval.
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