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• ,� form Approv.d <br /> s OMB No.2800-0085 <br /> VETERANS ADMINISTRATION/U.S. DEPARTMENT OF HUD/FHA OR VA CASE NO. <br /> HOUSING AND URBAN DEVELOPMENT • 2 q <br /> HEALTH AUTHORITY APPROVAL Fiuti/FHGORSvR Pd 41e <br /> INDIVIDUAL WATER-SUPPLY AND SEWAGE-DISPOSAL SYSTEM <br /> IMPORTANT—This form should be completed and Mod no required by existU'g law 38 U S.G. 1804 end 1810. <br /> _ PART I — TO BE COMPLETED BY HUD/FHA OR VA <br /> MORTGAGEE NAME AND ADDRESS(Include ZIP Code) MORTGAGOR OR SPONSOR <br /> Metropolitan Financial Mortgage LEVY, David <br /> 6800 France Avenue South #200 • PROPERTY ADDRESS Edina, MN 55435 4505 W. Branch Road <br /> Orono, MN <br /> SUBDIVISION/LUT NO. <br /> Lot 1, Block 1, Gray Lindgren <br /> _ IS*HIVE A IS THIS A NEW CAN THE ATTIC OR OTHER AREA BE MADE INTO - <br /> TOTAL NUMBER . _. BASEMENTS INSTALLATION? ADDITIONAL BEDROOMS?(II 'yea,"how mrnyfl <br /> LIVING UNITS BEDROOMS BATHS <br /> 0 YES 0 NO 0 YES 0 NO 0 YES 0 NO <br /> wnrl:n.$UPPLY BY: SYSTEM DESIGNED FOR <br /> 0 PUBLIC SYSTEM 0 COMMUNITY SYSTEM DI INDIVIDUAL NO OF BEDROOMS GARBAGE DISPOSAL <br /> SEWAGE-DISPOSAL BY: <br /> 0 PUBLIC SYSTEM 0 COMMUNITY SYSTEM INDIVIDUAL 0 YES 0 NO <br /> PART II --TO BE COMPLETED BY HEALTH DEPARTMENT OR COMPLIANCE INSPECTOR <br /> INSI'ECl DRSSKETCH(TO REPORT AS-BUILT DEVIATIONS FROM APPROVED PLAN) _ <br /> 1 , _._ N.q... .- -- <br /> eM.L I s'-3`4 c.4xa"s J <br /> It Is the opinion of the 0 State 0 County WLocal Department of44eefth that thIs individual water-supply system'f(Is O Is not Satisfactory as a domestic water-suppl1 <br /> for the subject property. S /1,..7.7.7„ ..0..&-, L ` <br /> 641.1u' ..-\+�...i--ej <br /> It Is the opinion of the O State 0 County IfICLocal Department of+lentttrlfiat this Individual sewage-disposal system with proper maintenance)(Can be expected to <br /> function satisfactorily,and Is not likely to create unsanitary conditions 0 Cannot be expected to function satisfactorily.Sl`t.477 -/NSP.t7-Ali <br /> DATE 1 SIONA R TITLE <br /> 1'/' - �'/ i P NzA� oNt,3 6..,�c,,1i" <br /> NOTE: The health authority should complete the appro)444.4,- <br /> //—/ - 9/1 <br /> pinion statement above and affix dale,signature and title In the spaces provided. <br /> NOTE: Use of the reverse side of this form Is at the option of the health authority. <br /> PART III — FOR USE OF FIELD OFFICE <br /> I have reviewed the foregoing and the pertinent Compliance Inspection Report and recommend that the Individual water-supply system be <br /> considered 0 acceptable 0 not acceptable end that the sewage-disposal be considered 0 acceptable 0 no acceptable. <br /> DATE SIGNATURE TITLE <br /> 0 HUD ARCHITECTURAL SECTION CHIEF OR DEPUTY CHIEF <br /> 0 VA CHIEF APPRAISAL SECTION OR DESIGNEE <br /> VA rORM 26.6995.APR 1982 SUPERSEDES VA FORM 28.6995,OCT 1910. <br /> M <br /> FIUD FOA92519 WHICH WILL NOT BE USED <br /> EFS 540 (11/06) <br /> RECEIVED FROM 6989616 <br /> __—. ..--_`-___ <br /> 84. 17. 1991 13:40 <br /> P, 2 <br />