1958, 04-04 Permit 14219 Sewage Disposal FacilityFEE-26- ' 92 10: AR I LT HEALTH EFO TEL HO: 94583243
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.atAir. — A
TY EALT DEPARTMNT
ARTHUR R. UN, M.D.M.P.H., Hahn Officer ,.
Division of Sanitation
N. 819 Jefferson• ; DATE
(el°
AT° 1.4219
APPL CAT ON F PERMIT TO INSTALL OR RECONSTRUCT SEWAGE DISPOSAL FACILITI
Name a Add„„./ 7‘,0 r Phone N
Address of Props
Type of Use Other
Number of Bedrooms
Ise of Property / 0 2> Jr JD 0
ulicling Capacity Camp Capacity Other
Is property below grade of streets or alleys? Are streets graded in?
Is basement tor bOng planned ,....eatlerstr, How much excavation or fill proposed/
(.....
Water Supply.......... (City, Well, Spring) Drywell
Sk CD eptic tancapacity gals. Style of tank
Length of disposal field .1 0 0 Leaching Bed Diet, BOX
— .
(1) Draw in property area to scale.
(2) Show relative location of: Proposed house, septic tank,
disposal field, well, garage, and other out buildings,
(2) Make note of any heavy slope or swampy area or any
other important topogrephie details.
Date when test hole will be ready for
inspection
Date Installation will be ready for final inspection (that is,
before backiillingi
6.1
SANITARtAN'S REPORT AND RECOMMENDATIONS: Date of Inspection
Topography
Ground Water
Soil Condition Percolation tests: Minutes
SpeClal Recommendations
Final Inspection Date Ppleo#4ft(1-4-1-0-fs-P
Remarks:
CONTRACTOR RECOMMENDED PERMIT BE
Sanitarian
Marra 84a—ges1th—ell-24ti) By