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PITKIN COUNTY HEALTH DEPARTMENT
PERMIT NUMBER .7 ,3� O0 6 17 RECEIPT NUMBER
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Phone u 3 - aa 4 S
Address
Contractor S Phone
AddressQppQ �A/f
Location of system -7 QAk- S �D
. o5, .R. . jot Size 1 Nc .
/ _
Legal description 4c1 F SeCi 3� T. ?Z
DateSiganture of owner . 6 a
.3 ilrm
Percolation test data : e minutes per inch
Miom4iendej absorption system size
Minimum recommended tank size t 000
Permit application valid one year from date. Application to become permit and
final only after lower portion is completed and signed. Retain this form at
the construction site.
DRAWING OF S'.
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Date/��% Sanitarian
151
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PERCOLATION TEST FIELD SHEET
q
COMPLETE IN DUPLICATE
(Check person responsible for or performing tests)
( ) NAME OF OWNER
A
ADDRESS Q-, t
'b A
PHONE
%A a -14S
or
( ) NAME OF CONTRACTOR OR
6. Vt �-
EXCAVATOR
Sg rr.e 0. )
o;Ioyv e
ADDRESS
PHONE
LEGAL DESCRIPTION OF PROPERTY'' -Ty a, f_`Y B tv%
General Information & Instructions
In addition to compliance with all other rules and regula-
tions for sewage systems as promulgated by the County of Pitkin
and State of Colorado, it shall be the responsibility of every
property owner/installer/contractor/excavator (the person running
the tests) installing a sewage system to conduct percolation tests
in accordance with the specifications hereinafter set forth.
Subsequent to the performance of the required test, it
will be necessary for the person responsible for/or person perform-
ing the tests to file, complete and under oath and penalty of
perjury, the affidavit form contained on the reverse hereof.
Warning is hereby given that spot checks and inspections will be
performed by the Pitkin County Pollution Control Officer and his
authorized agents with or without the knowledge of person perform-
ing or responsible for the tests to insure compliance with the
requiements hereof.
Soaking is to beerformed in the 24-hour period between
Z
F.M. and 'CY.M. on the a and 3 days of
, 1�- 'the actual percolation Tests are to be
performed at M. and �_ (�.M. on ,
19�3-
At least two (2) test holes per system must be run. They
should be in the area (within feet) of the proposed leach-
ing system and dug to the depth othe proposed system, generally
2.5 to 3 feet deep and 12 to 16 inches in diameter.
The holes are to be soaked for a 24-hour period prior to
running the test.
K
TEST HOLE I TEST HOLE II
Reading
Drop
Time
Reading
Drop
Time
to
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PERCOLATION TEST RESULTS:
HOLE I IT) Minutes per inch (HOLE II e Minutes per inch
Average percolation rate: Minutes per inch
Comments on soil and/or site: .Q 2,,g
Address:
k
Signaturce
TEST FEE $25.00, payable in Advance
3
C'
01
0
AFFIDAVIT
(Perco a ion est)
M
V -k GIA Z, C Q, , being first duly sworn upon
his oath un er penalty of perjury, states,avers and certifies as
follows:
1. That he is the person who performed the percolation
tests as required on the reverse hereof.
2. That the tests were performed in accordance with the
time schedules and specifications as set forth on the reverse hereof.
3. That the test results of the said percolation tests
were as set forth on the reverse hereof.
4. (In paragraph 4, affiant shall insert additional
statement(s) which may be properly and reasonably required by
the Pitkin County Control Officer or the affiant may wish to
insert.)
DATED : J kx-, x �At 19-L�,
STATE OF � e`fl'��� )
COUNTY O )
SUBSCRIBED AND SWORN
19Z7
My Commission Expires: lb C Wssion expps August 2, l�,i-t
G � i
NotaryPublic
��,
(Signature o son Running Tes 7-
SS:
to before me this "Y`� 4ay of
NOTE: This affidavit must be returned to the Pitkin County
Pollution Control Department within 24 hours of the time
the percolation tests are completed (Saturdays and
Sundays excepted).
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