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3
ASPEN*PITKIN
ENVIRONMENTAL HEALTH "DEPARTMENT
APPLICATTON FOR .AN INn1V IDU: I SEWAGE r)ISPOSArj- PEF.41T
Name of OWNER .�rJ�rlbi5 PHONE 7 S
Address of OWNER ¢35 5 ec i'>
Name o'' f// 5 r APPLICANT 41 E PHONE
E:Iltlr To OES (14Pieked up ( )Railed tot STYPE OF PERM:TI ( )New Installatfon (LAepair
( )Owner ( ;Applicant i lemacgancy use ( )Alteration NOT due to failure
LJ j:t JIDN OF PROPOSED SYSTEMS pe
1clel Description 5 , c= %' .• nG 5 P a ACU, L.+ ' f.{'. /�/
Sat--- Blo'�___ FIllrq_ Sebdiviaion sise of tnt �. r arcs
^.:r"OF STRUCTURE: (�ngle Faadly L-'ellinq ( )Others Do you plan any Lurches�a�J J`tions to the
residence? ( )YE5 (✓'f4a
pa. of bedrooms_ He. of Lofts_ No. of Cartage Disposal• V_(No, of Au`.oastie DSshwsahers
r:c, of automatic Clothes FasnMrs /
K%7FP Sr—' (private X:31. Depth "") or ( iPubl!c, Hame of System,
( )Spring
( )Stream or Creek
TYarS CF INDIVIDUAL SEWACE 01S;3 -AL Si9TEM PP0:-ISEDI'
(()septic Tenk/Absorption Viola ( )Aeration Plant/Absorption field ( )Composting Toilet ( )Incineration Toilet ( )no
unQ
i IFocycling, potable use ( )P.ecycling, other use ( )Vivi[ Privy ( 10ther:
%he initial site inapaction must be arranged with the Aspen/Pitkin `-rviroSvaental Health Department (925-2020. 8:10-9030 e.m.)
i,efore a perr_it can be issued. The individual sewage disposal permit moot be lssucd before a bull dl nq perm![ call S nbtainaa.
TINA: INSPECTION APPROVAL MUST P.E OIVEN LY THE ASPEN/PIPKIN ENVIRONMENTAL 9EALTM OEPARI'MENT PRIOR 70 DA:KEILLINL JVY PORTION
DF 7HE SY'_'TEM.
l.ppIitat!on for an individual sewage poral permit is hereby aubmitted. The crdcralgned acknowledges that the above information
is true and that [alto Sntocmat wn•+ii�l� invalidate the application and any subaequen[ pe rm rlt. cI�
Signature of Applicant =.�� ,,r� DATE �+ J L/
(7t.is application becomes" invalid 1: months free the above data.)
NOTE: PIAT PLAN must be filed with this application.
Please locate the following items by measured distances:
1. Proper.y lines and dimensions.
2. Proposed and existing water wells or. subject property and
adjacent property.
3. 'Domestic water service lines.
<. Proposed and existing buildings, driveways, and other
structures.
5. Streams, takes, ponds, irrigation ditches, and other water
courses.
6. Proposed and existing individual sewage systems on subject
property.
SUBMIT A REVISED PLOT PLAN PRIOR TO CONSTRUCTION IF INSTALLATION IS TO
BE CHANGED FROM ORIGINAL FLAN."
Sten a Q.L
Receipt signed hereby acknovladge.s receipt �of this individual oewegi dtspoaai w^rmii nspit at and permit C in the amount
of : ___, ipt Number o I T Data Fee Received
RFT(J4IED.
REOninistrativg ofticor
000!; of 7
130 South Galena Street
Aspen, Colorado 81611
303/925-2020
ON
ItiY' .9• I V• �.
Inspection Requested By
original Report To Be Sent
Parcel ID Naber/ 2 i—
Legal 1/4, L4, Sec.
Lot , Block - , Filing
check/Receipt NwTber
MAR'IIg1PP RHOORDS:
Permit Number SZUZ l Year Issued % Z No Records ound
Septic Tank Capacity- 0 (Gallons) Septic Tank Mat lid
Leach Field Size (Sq. Ft.) Leach Field Type o
INSPEMaI:��—�
Date Of Inspection—1 cf Z- Inspector
Soil Conditions: Dry Saturated Snow Covered other
Septic System: Functioning Satisfactorily Not Functioning
Camnents•
Water Supply: Public: Name
Private: Well X, Spring , Cistern Surface ,
other
Well Construction And Location: Approved_
Unapproved Because
Bacteriological Water Test: Lab Number 2'7 Date / /
Acceptable X
Other
COMMEMS•
A.P.E.H.D.:4/87
GGOGC2
�. 2 Y6
ASPEN*PITKIN
ENVIRONMENTAL HEALTH DEPARTMENT y
- LXMVIDUAL S dAGE DISPOSAL PERMIT No. Q;C 0.2 1 — Z
I= OF PERMIT;
):n L•f al Construction ( IF.merganey Use �Aepalr work,(Pievlous Permit 1 N. 0067 •) ( lAlteratlon o: an existing aystemp
or instal:a'Lon (P r<v.ous Permit ! .) `
I )Coe e-rmlt as a result of Sala ( )othorl I
ISSUED TO: DATE OF ISSUE 7—A / p iI
0a^er ES FI�EQ2 $Fie Home Phone � Business Phone
Tw,N2(O�O i
wal_ng
lPo• B (AI:S�-Yy [ oLoA�ApO OI%L3 -3 (31 f
Ade ress Ox
agent AlDA1 Phone
Mailzag
Address 01/3S �oHAS /DAB
Sewage Disposal System Work to be performed by GT(JTSMAA/- G"8ACZ �\tp� Ts/\� 1`fI
This permit valid only
for premises location by thn following legal domeription:Al -wero/ LANo i4 k22 I W9
T.bf 512E �C1GG .i MATER SUPPLY WG4LL AVEAALE PERCOOLATIOCN RAATTn
This Individual Sewage Disposal Permit is granted with regard to the following ussr 9/,#slurATY`S�K^M..0
Wu,.a,cr oft Dodr-ems _- Lo CLs f_ Garbage Disposal$ I Dishwashers 1 Clothes Ha¢hors
CALCOLATF.D AVERAGE DAILY WASTE :AAO ISO GALLONS.
THE NATUME OF THE SYSTEM iNCLU'DED UNDER THIS PER-'1IT:
Tyne of Tank or Treatment Units SEPne- 'ASK Tank C•pnelty �Q _Gallon Htnlmus
vcthnd of sinal Disposals SEEPAGE Bev Absorptiop tree 1,266 Square Felt Hln L^,•�a
O_acription (including brand name, if any) of other equipment or appurtnancess
Othar Conditions or Specilicaticnn
WA
STAGES REQUIRING Il;SPF,CT.ION BY THE HEALTH DEPARTMENT:
( )Before Excavation ( )Upon completion of excavation and prior Lo plsDement of gravel )(On Core obsor disc rl ba.ion
system of
absorPcian :Cc1J
($rior to beck:ill of any cosponent ( )other, SLoci Cys . KkWGC
Plans and $proiftcations of the Prorosed sewage dlapn al system have herr-eviewed and are eensidercl :aerofactory. Permlanlor,
,a. hCrChy to thn awrer or has agent to r^rfnrn the work .mqicated at»ve in accordance w1:i: the Pitkin
Sewa^•t Ui.eposal Re-nilations in etfect on the date of i -sue. In a z!d Xtton Ae gtncr4l pravtarons set forth on the reverse herco C,
rm
this PCit is subject to the followtng additional terms and conditlonar ��e
:u PROVED 602 ISSUE(title)
r
Thr afu)vC Cnilvidusl c"go disposal system installed by
hqa e<Cn 1n:gN`et Cd lUr use by a representative cf the Aspen t•ttktn Lnvis cnxnt.
N.:)wDs ibis ity in case of failure Or iaadequacy o'ff thlu ewd')Q JtsPuul aystcm
DATE OF FINAL IN5P `/
C 0:1 n2 /Je—OZ
BY: 4V - A�
11: lth Ocpart.renc. Thu nwnu[ a�-. u::ae n. t, •
Corplece a%–bull[ drawing attachcdpAP
TITLE_
930 South Giplena Street Aspen, Colorado 81611
0G01iUv
303/925-2020
t !'
GENERAL PROVTSIONS OF Ali
INDIVIDUAL SEWAGE DISPOSAL PER -MIT
This Permit must be retained and made available for inspection at the above location upon
request.
This Permit shall not be transferred without approval of the issuing agency.
This Permit shall expire 120 days after its issuance if construction has not commenced and
a valid building permit has not been obtained. Any change in plans or specifications after
the permit has been issued invalidates the permit, unless approval is secured from the
Health Officer for such changes.
This Permit is temporary until final approval. is granted by the issuing agency in writing.'
Final approval cannot be granted until construction, repair and/or operation have occurred
in conformity with the conditions of this permit. This Permit is valid only for the indi-
vidual sewage disposal system and/or equipment specifically identified herein.
Before issuing final approval of this Permit, the issuing agency reserves the right to
impose conditional terms and conditions required to meet its applicable regulations on a
continuing basis. Monitoring and testing requirements may also be imposed. The issuing
officer shall be notified not less than 24 hours prior to backfilling or closing up the
work which would prevent inspection of components installed in places otherwise inaccessible
following such backfilling or closure.
This Permit may be revoked or suspended by the issuing agency for reasons set forth in the
regulations of said agency or of the State Board of Health, as applicable, including failure
to meet any term or condition imposed thereon during temporary approval or upon, final approval.
Each and every condition of this Permit is a material part hereof and is not severable. Any
challenge to, or appeal of, a condition hereof shall constitute a rejection of the entire
permit and upon such occurrence this Permit shall be deemed denied ab initio.
This Permit is issued and accepted with the understanding that a fee in the amount of
$ , plus cents for each mile traveled by a designated inspector from
the principal office of the issuing agency to the location of the system and return, may
be charged for each of no more than two annual effluent samples routinely collected and
tested from subject system as deemed necessary by the issuing agency to monitor said
system for compliance with the Provisions of Article 10, Title 25, C.R.S. 1973, as amended,
and the rules and regulations which implement said Article; and that a like fee may be
charged for each such sampling taken in conjunction with the determination of compliance
of subject system with a cease and desist order issued pursuant to C.R.S. 1973, Section
25-10-107(1)(k).
The issuance of this Permit does not imply compliance with other state or local regulatory
or building requirements, nor shall it act to certify that the subject system will operate
in compliance with applicable state and local regulations adopted pursuant to Article 10
of Title 25, C.R.S. 1973, as amended, except for the purposes of establishing final approval
of an installed system for issuance of a local occupancy permit pursuant to C.R.S. 1973,
25-10-111(2).
APPLICANT'S SIGNATiURE
a
y 3 L
3/y (0 7 3h
319 $S�? 70'WA
3�°► G 87A 71 'l? 68'/W
71
359 69 �� 71
G 1 � 32" 3q" 31��zn
6
MOM
;1>:Iii1�
0
PITKIN COUNTY ENVIRONMENTAL HEALTH
Field Test Data Sheet on Percolation Test
PROPERTY OWNER PHONE
MAILING ADDRESS
LEGAL DESCRIPTION OF PROPERTY
LOCATION OF TEST HOLES
Three (3) test holes required per system
Test Hole Depths (24" minimum)
Diameter of Test Holes
Water remaining after 8 hour soak
l2
v
U e�
TEST HOLE No.1
TEST HOLE No. 2
TEST HOLE No. 3
Drop / Time
Drop Time
Drop Time .
d42
410— z
Percolation Rate Each Hole
Average Rate
Comments on soil or site:
84c4,&
Signature
Date
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