HomeMy WebLinkAboutpitkin.eh.264316200020 (1973)Document Layout
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(All relevant older documents in the same order as above)
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•
PITKIN COUNTY HEALTH DEPARTMENT
ry
JJJ PERMIT NUMBER ( 2 6 t_ [ RECEIPT. NUMBER
�` QQ ✓✓ .5
Ilk
Owner '���/' ` 'y`� Phone N 2s F!N�/ —
Address Ac �oX -�9T�f ffspax
Contractor S�%n+� Phone #
Address
01460 L.
Location of system 6000 °
00 (� I��K_ I
MWm5m/p
Legal description 94cZr 8T w4rST &f T&W Sp(TH
Number of bedrooms
size a2 ' 6iQA WJ
Signature of owner
Percolation test data
Minimum recommended absorption system size v
Minimum recommended tank size 9 o o
minutes per inch
Permit application valid one year from dat4�1 Application to become permit and final
only after lower portion is completed and signed. Retain this form at the construction
site.
DRAWING OF SYSTEM
Date 'al aQh-� Sanitarian
/6c el
J
HC) QS c -
1 • •
TEST HOLE I
TEST HOLE II
Reading
Drop
Time
Reading Drop Time
3
I
32
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f
—
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I
(�
C'
C
-3
PERCOLATION TEST RESULTS:
HOLE I Minutes per inch IHOLE II Minutes per inch
Average percolation rate: % Minutes per inch
Comments on soil and/or site:
Address: DCfrTe
Signature: &Zga:nt�
TEST FEE $25.00, payable in Advance
9
0
AFFIDAVIT
(Per coT£ion Test)
0
IE D $ I�IG�h u D being first duly sworn upon
his oath under 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
t13e Pitkin County Control Officer or the affiant may wish to
insert.)
DATED:
STATE OFCpLoQppo ) SS:
COUNTY OF
, 19
ignature of Person unning est
SUBSCRIBED AND SWORN to before me this CjTM day of
AuGrusT ) 1973
Hy Commission Expires: AP,ZiL. Zp )=)No
otaryblic
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).
3
PERCOLATION TEST FIELD SHEET
a
COMPLETE IN DUPLICATE
(Check person responsible for or performing tests)
( )
NAME OF OWNER � EO/�O12�
�I 1Q)CA Hop
ADDRESS P,��GQX q -S.4
PHONE
( )
NAME OF CONTRACTOR OR EXCAVATOR
ADDRESS
PHONE
LEGAL DESCRIPTION OF PROPERTY QTS
T,n.)usti,v 4 sodrw RfIL2sE SriLu€sr erP -ios .Snr
F01A) a i pAh MEM ( O"q A)
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 be performed in the 24-hour period between
3;06 P.M. and g;pp .M, on the & and 7 days of
IT The actual perco1—ation %sem are to be
performed atm. and �. M, on R g6urr- 7
7• ,
19 .
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 dept�he 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.
14