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r PITKIN COUNTY HEALTH DEPARTMENT Q
PERMIT NUMBER D DQ (� RECEIPT NUMBER v
Owner Us Phone No. 5 L�
Owner's Mailing Address
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Contractor S F- (T Phone No.
Address
System's Contractor's Name
Address 00
Legal Description I 6-� 1573
Lot Size 77 /y Y c2t) 7e 1v Type of Building by Use
Number of R"ar rae s Type of Water Supply _
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Owner's Signature Date 17 7 7
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PLOT PLAN: ATTACHED AS REQUIRED
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Type of Individual Sewage Disposal System – )C=-f'T/C% tHtyr — % ! IC J
Type of Soil or Soil Classifications 10-0 SAWW t1 -1 -AY LOAM E �I NOSTONe G/0 Cf
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Proximal Location of Bedrock T OEM&M;52 — aMMe 7W1141 ? FT
Proximal Location of Ground Water Table
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Percolation Test Date —34_ Minutes Per Inch 5 qb?
Minimum Recommended Absorption System Size / —/J A T r
Minimum Recommended Tank Size /000 4&41:01145— %u%0 &&
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Special Conditions of Issue:
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A MiA'1M11M OF as Gi. rovil
ANO /0 `T AP � N�
Approved for Issuance By
NOTICE
When properly signed for Issuance, this applicatlon
bacames your permit. Application valid one year from
date. If an individual sewage disposal permit N Issued
for property on which no building permit hes bean
issued, the Individual saws" disposal permit shell
expire 120 days after Its Issuance If construction has
not been commenced. Any change in plans or pecl-
ficatlons after the permit has been Issued invalidates
the permit, unless approval is secured from the Heatch
Officer for syph changes.
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FINAL INSPECTION APF
(Drawing of System on Back)
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