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PITKIN COUNTY HEALTH DEPARTMENT
PERMIT NUMBERCEIPT NUMBER
Owner
Owner's Mailing Ad
Contractor
Address
,!Q3;7$3
System's Contractor's Name
Address C�-1 sx�sy0
Legal Description A=4
Lot Size -2 Type of Building by Use I LG
Number of Bedrooms A f Type of Water Supply Z6W` U
Owner's Signature Date
PLOT PLAN: ATTAC DOREQUI tED& e40"�
Type of Individual Sewage Disposal System
Type of Soil or Soil Classification LA y S HA LAE
Proximal Location of Bedrock NOT- D-CrEeM I rJ6 0 C/e647&? %/fAAJ S FT
Proximal Location of Ground Water Table /W®i DCTEk-A* V6d ` 6-)eCh-rGoe, 220Q 6 r '
Percolation Test Date eA Minutes Per Inch
Minimum Recommended A66e4p4+enSystem Size 13.0 S( El -
Minimum Recommended Tank Size 1200 C-ALL00 AE&AMEE) 'IMATAI&AIr OV 17 -
Sial Conditions of Issue: Ivorlcl=
p When properly signed for issuance, this application
becomes your permit. Application valid one year from
YM M"5% a ,f date. If an individual sewage disposal permit is issued
// �' i��jeDJA4C for property on which no building permit has been
&6-
/v—��f o 1 y� issued, the individual sewage disposal permit shall
• '��� &6-XCE:X10G PI -440 .Jdg '^T � � D�" expire 120 days after its issuance if construction has
/��� `� CAN /��� 777 not been commenced. Any thenen in plena va speidates
/// Bj C ®� P� q5_0 7 the
after the permit has been issued invalidates
the permit, unless approval is secured from the Health
Officer for such
changes.
Approved for Issuance By � O Date / 0
FINAL
INSPECTION APPROVAL Date 9 a
(Drawing of System on Back)
0
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