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Rev. July 1958 FEDERAL HOUSING ADMINISTRATION Budget Bureau No. 63-R296.8
HEALTH AUTHORITY APPROVAL
IIND VIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
PART I.---TO BE COMPLETED BY FHA
INSURING OFFICE MORTGAGEE ~ ,j~RIAL NO.
NATIONAI, BANK OF ALASKA IN ANC IOR 60-006579
A~CHOt~AGE AIASKA P 0 BOX 600 - ANCH0~AGE
--[
MORTGAGOR OR SPONSOR PROPERTY ADDRESS
LOT 1~ Telequ~na lite, Subd., Anchorage
Joim L. Stophl See o~ner at~ 1219 "I" St.
;USDiViS,ON~gi:~ANANAMEHEiGHTS . ' BLOCK NO. LO~.j~ O.
OTAL NUMBER~
:L
BASEMENT
J--l o
] New installation
additional bedrooms?
(If Yes, how ma.y~)
WATER SUPPLY BY:
---~'Public system [] Commnnity system [] Individual
~SYSTEM DESIGNED FOR
~ Individual .o. OF BDR~AS. OAReAOE DISPOSAL
FlYeB
PART II.--TO BE coMpLETED BY HEAl.TH DEPARTMENT
HEALTH DEPARTMENT INSPECTOR'S SKETCH
It is the opinion of [] State [] C [] Local Department of Health that this indiv
[] is [] is not satisfactory as a domestic water supply for the subject property.
water-supply system
It is the opinion of the
tern with proper maintenance:
~X~] Can be expected to function satisfactorily, and
is not likely to create an insanitary condition
[] State r-] County [~ Local DeparmleDt of Health that this individual sewage-disposal sys-
L-~ Cannot be expected to function satisfactorily
NOTE: The health authorDy should complete the approprlato opinion statement above and affix dater signature and title in tho
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 OFF~CE
TO THE CHIEF UNDr..RWRITER:
I have reviewed the foregoiDg and the pertinent FHA Compliance Inspection Report, and recom~nend that'the
Individual water-supply system be considered J-~ 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 CHIEP ARCHITECT
FtlA Form 2S73
Rev, July 1958
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ADH-HSE-6 71
(6-58
Z",~ ..// INDIVIDUAL WATER SUPPLY
i/:( ALASKA DEPARTMENT OF HEALTH
/z//'"~"n5"J~'~¢ Section of Sanitation and llngineerlng om, lea
ACTION ON REQUEST FOR BACTERIOLOGICAL WATER ANALYSIS
Your recent request for all analysis of a sample
from the Iudividnal Private XWater Supply
serving~30'g, i'}h't 11 ~
,'~ponar~ Alaska
examination has been completed.
Jo 8teph
230? Ohilligon
Spenard, gla~ka
Lab. 'No__ f~0.~ __
Soughcemgeral Regional
Records in this office indicate this Individual Private Water Supply to be of__Satisfactory~"" Questionable____Unsatlsfactory
sanitary status.
Aualysis shows this SAMPLE to be_.~//_~Satisfactory Qnestionable UnsatisfactoW.
If an "Unsatisfactory" or "Questionable" stares is indicated above, you shonld take im~nediate action as recommended below.
1. Boil or chemically treat yonr water supply to protect your family from water-borne diseases as outlined ia en-
closed leaflet, "Drink It Pure."
2. Improve your spring--See bulletin HSE-6-2
3. hnprove your cistern--See bulletin HSE-6-3
4. hnprove your dug well ~ See bulletin HSE-6-4
5. Improve your driven well~ See bulletin HSE-6-5
6. hnprove your drilled well ~ See bulletin HSE-6-6
7. Relocate your well to a safe location in relationship to your sewage disposal system--See bnlletin 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 offtce for
bulletins, consultation, and assistance.
~ 11. This is a sorface water source and subject to pollutiou by man aud animals. Au approved water supply source
shonld be de~ped. / ~ , . ~ .. ~
SANITARIAN'S I EMARKS~--,. q .~. ,. ..... "-'?--.--~ . ' --
-- ,, / z . '-- '5/4( '
IiThls Form Must Be Filled
Out Completely,
INDIVIDUAL W~TliR SUPPLY
AI,ASKA DF, PAItTMENT OF m]ALTH
Section o! Sanitation and Engineering
Pirate Look on lttevem og]
Sh~t for S~ple Collection
Request for Bacteriolog~l Analysis
/..q~.~//___.~..,~. ~/ ~,. . ~b,~o .......................................... ~,.~.
Water salnpl~ collected Dy ............................... ~.. ~~~'~5.....f~2.Tf.d?e.,Z ............... ~:...~...
(Date) (Time)
(Name~ person collecttn~ ssmple)
Water sample collected from~ Kitchen tap; ~ Bathroom tap; ~ Basement tap;
,'~[] Other (list) ...... 5' ............................ =--x- ........................ ~ ...........................................................
~ (~a~ / :Box No. or street addresS' ' (City) ~"
Please plae~ an "X" In the box before l~ms which b~t describe your water supply:
SOURCE: Well -- ~ Dug, ~ Driven, ~ Drilled, [~ Bored /
[~ Spring, [] Cistern, ~ Other (list) ........................................................................................... '. ...................
~ Creek, ~ River, ~ Lake, ~ Pond ...............................................................................................................
DUG ~LL
OR CISTERN CONSTRUCTION: Walls ~ ~ Wood, ~ Concrete, ~ ~tal, ~ ~ie, ~ Brick or Concrete Block
Top -- ~ Wood,~ Concrete, {~ Metal, ~Open Top
LOCA~ON: ~ In basement, [] Basement offset,/*~'Under house, ~ In yard
Other ....................................................................................................................................................................................
DIST~OE TO: Building sewer or other dralnag9 pipe .............. feet, Septic tank .............. feet, Tile field
feet. Seepage pit .............. ~eet, Cesspool .............. feet, Privy ..............feet. Other p~sible sources
of contamination (1Nt) .............................................................................................................................................
~TEBI~,:Building sewer -- ~ Cast ffon, ~ 'Wood, ~ Trio, ~ ~bre pipe, ~ Asbestos cement
Joint material -- Type ~ .............................................................................................................
GE~B~ INFOR~'~ON': Does water become muddy or dlscolored9 [~ yes,J~no
When?
............................... "7~"'77 ..................................................... 5"~"7 ......................................
Diameter of well ............. ~..~ .............. ~.. ~ epth . .g.~-,~. ............................. feet
Well casing materlal.~.~.~ dia note ~. ~Z depth ........ ~..~.[ .............
Length of drop pipe ~" . ..............
Water depth fro~ bot~m / ........................................ feet
Pump location: ~ ~ well, [j Offset In basement, ~ In basement
[] In utility room, ~ On top of well
[] Other (IMt) ........................................................................................................
Do you susp~tllnea~ from this supply? ~ ye~ '~ no . _ ,, / __ /
PLEASE DRAW A SK~CH ~ ~E SPAOE BELOW. THIS 8KETOlt SHOULD SHOW LOCATION OF HOUSE,
SUPPLY SOURCE, SEPTIC TANK, SE~R, DRAIN LI~8 OR O~g SOURCES OF POLLU~ON AND DIST~CES
· S~N WATF~ SUPPLY SOURC~ AND ~_~OVE FAC~IT~S.
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