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4 x PITKIN COUNTY HEALTH DEPARTMENT
PERMIT NUMBER _ RECEIPT NUMBER 27511
Owner ROME") NnM I=LCET/rZ Phone No. %27- qZ6 5t
Owner's Mailing Address 1C S�� $� 14 S Pt N f CO G C) el d, � (
Contractor S t t (' Phone No. SA ME
Address S A M F
System's Contractor's Name SE< �= y� M 0 u NTA /V PL u nt_8 1A,(,.
U-71=7
Legal DE
Lot Size .1' )�1,ey AC. Type of Building by Use S/N(;LE FAMILY
Number of Bedrooms -> Type of Water Supply CO M I"1 u .y 7 SJ S HA r6
Owner's Signature 51" 2__412`^- Date �' ; 7
PLOT PLAN: ATTACHED AS REQUIRED
*****#****N*******N****************************#**#*******************************a f******
Type of Individual Sewage Disposal
Type of Soil or Soil Classification
Proximal Location of Bedrock
S'E PT � c TANt' -SEEPAGE ,BES
Proximal Location of Ground Water Table /-foT �E��N�'�EHT TN,4�J 8 GT
Percolation Test Date Z*79
MinuPer Inch —
Minimum Recommended Absorption System Size -J 7Q 5y"n y• Z Ttes
Minimum Recommended Tank Size mm G� ZZe)11_S
Special Conditions of Issue: NOTICE
p When properly signed for issuance, this application
becomes your permit. Application valid one year from
D.IC data. If an individual seweps disposal permit is Issued
/�/ C� for property an which no building permit hes been
Issued, the Individual sewage, disposal permit shall
expire 120 days after Its issuance If construction has
not been commenced. Any change In plans or spocl-
fications afar the permit has been issued Invalidates
the permit, unless approval is secured from the Health
Officer for such chh s.
4 Approved for Issuance By Date /7
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FINAL INSPECTION APPROVAL
(Drawing of System on Back)
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H I C H WAY 32---
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PITKIN COUNTY ENVIRONMENTAL HEALTH
Field Test Data Sheet on Percolation Test
PROPERTY OWNER 47-Al—`0 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
/❑
TEST HOLE No.1
TEST HOLE No. 2
TEST HOLE No. 3
Drop Time
Drop Time
Drop Time
Sy o
51
53� o
`l
6 r
y
7/4 S
Percolation Rate Each Hole
Average Rate 3
Comments on soil or site: /
lLee' X
Signature
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1.
-t, ,jz C e�" ' a
Date
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