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#2463 - 341 - DI --00
PITKIN COUNTY HEALTH DEPARTMENT
PEPnJIIT NUMBER S I RECEIPT NUMBER 22002,
Owner Phone r� /°S�/�Ir% / Phoone No. �-13<
Owner's Mailing Address 1JC�X 9-57 /f2 olunk-A'/F el ell, I
Contractor �^ E/Z Phone No.
Address �� y
System's Contractor's Name
Address ry� / //
Legal Description �� #� Sell-eN L/ 1!2 S Sv,b
Lot Size— Type of Building by Useev � �wB��wy
Number of Bedrooms Type of Water Supply
Owner's Signature Date
PLOT PLAN: ATTACHED AS REQUIRED
********#a********************************a*Nx****xx*x******x***********xxx x******xx******x*
Type of Individual Sewage Disposal System �T,_ _ .
Type of Soil or Soil Classification/�-Sye-�+� LIzv�� "%�'��2i �Q�t�4
Proximal Location of Bedrock z of IV r^ e &I I C'
Proximal Location of Ground Water Table AJ6 l �(�t,c.,,,�_GX/�W"l - C 14- e. , 6
******#**N***a*******x*****x*****************x*xx***N*******x******x*a*a*NNxxN*#axxx N#a#*
Percolation Test Date 5--1 3 �o Minutes Per Inch
Minimum Recommended Absorption System Size 5-2 , /" • Er
Minimum Recommended Tank Size lODD HZ L O/L/
Special Copditions of Issue:
NOTICE
When properly signed for issuance, this application
becomes your permit. Application valid one year from
data. If an individual sewage disposal permit is issued
for property on which no building permit hes been
issued, the individual sewage disposal permit shall
expire 770 days after ite Issuance If construction hes
not been commenced. Any change in plans or specl-
fications after the permit has been Issued invalidates
the permit, unless approval is secured from the Health
Officer for such changes.
Approved for Issuance By Date
NNNxN*#NNNN#***eN*NNN***N****N*xi***x*NN*#NxN #xx*
FINAL INSPECTION APPROVAL 4'pate X-� �V
(Drawing of System
PITKIN COUNTY ENVIRONMENTAL HEALTH
Field T2Z,-?4",--
Data Sheet on Percolation Test
PROPERTY OWNER r -o- PHONE
MAILING ADDRESS
LEGAL DESCRIPTION F PROPE
107- l
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
0 30 3z
TEST HOLE No.1
TEST HOLE No. 2
TEST HOLE No. 3
37 C
Drop
Time
37 L
Drop Time Drop
3 7 `-
Time
rs $
Z
I
5 i
r 17
—� -
4< Svc _
0
Z
.:l 1
V 3 Z>
Percolation Rate Each Hole
Average Rate LL
Comments on soil or site:
i
Signature L
Date
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