HomeMy WebLinkAboutpitkin.eh.264316401014 (1973)W - 4
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PITKIN COUNTY HEALTH DEPARTMENT
PERMIT NUMBER 6 2 17 "
Phone if , 3 d
Location of system
Legal description
RECEIPT NUMBER /llp
Phone #
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Percolation test data --minutes per inch
Minimum recommended absorption system size kL Qd
Minimum recommended tank size
Permit application valid one year from df(te. Application to become permit and final
only after lower portion is completed and signed. Retain this form at the construct
site. �.�2 17Y - - z
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DRAWING OF SYSTE
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Date I Sanitarian /•
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COLORADO DEPARTMENT OF HEALTH
Water Pollution Control Division
4210 East 11th Avenue
Denver, Colorado 80220
APPLICATION FOR APPROVAL OF LOCATION FOR SEPTIC TANK SYSTEMS
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Applicant (Owner):
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Mai 1 Address:_" �; j City: Phone: 07
A. INFORMATION REGARDING PROJECT SUBMITTED FOR REVIEW:
Attach separate sheets or report showing entire area with respect to surrounding
areas, topography of area, habitable buildings, location of potable water wells,
soil percolation test holes, soil profiles in test holes.
1. Location of Facility: County. City or Town ij
Legal Description /,,11 /`jSr�.���(��� -.Lot Size:lfw/ ilk a"itnA7 ,7A ,
2. Type of area and facility - Number of persons served:
Subdivision Motel Restaurant1 Trailer Court
Other: 1 �C� 1
3. Source of domestic water: Public (name):
Private: Well Depth Other Depth to first ground water table
4. Is facility within boundaries of City or Sanitation District:
If so name:
5. Distance to nearest sewer system:
Have negotiations been attempted with owner to connect:
If rejected, give reason:
6. Rate of absorption in test holes in minutes per inch of drop in water level after
holes have been soaked for 24 hours:
7. Name, address and telephone of person who made soil absorption tests:
8. Name, address and tq e0one of person responsible for design of the system:
,/--704172 -7")-
D. Est. bid opening ate:=/5'Est. Completion Date: TZrEst. Project Cost: -!�-5-Z77
Date:T- -
% Signature of Owner
PERCOLATION TEST FIELD SHEET
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COMPLETE IN DUPLICATE
(Check person responsible for or performing; tests)
( ) NAME OF OWNER
ADDRESS,���L%1�� L�? �QF-
( ) NAME OF CONTRACTOR OR EXCAVATOR
ADDRESS PHON
LEGAL DESCRI ION OF PROPERTY k#f-
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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/insi;aller/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
.M. and M. on the and days of
19 -'rTie actual percolation es s are to be
performed at .M. and .M. on
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 depth of the 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.
Percolation Rate Each Hole 67-1
Average Rate
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NAIL OF RESPONSI PARTY UN IN TEST �i(Jr:-Iyj��549&..PHONE
PHONE
SIGNATURE
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PITKIN
COUNTY ENVIRONMENTAL
HEALTH
Field Test
Data Sheet
on Percolation
Test
PROPERTY OWNER ��
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PHONE
MAILING ADDRESSQ
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LEGAL DESCRIPTION OF PROPERTY
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LOCATION OF TEST HOLES
Three (3) test holes required
per system
Test Hole Depths (24" minimum)
Diameter of Test Holes
Water Remaining after 24 hour
soak
TEST HOLE #1
TEST
HOLE #2
TEST
HOLE #3
Dro � 2 Time
Drop
Time
Dro
Time
7
3
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31
3
+,
+
5
7
'S. 7
7
Percolation Rate Each Hole 67-1
Average Rate
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NAIL OF RESPONSI PARTY UN IN TEST �i(Jr:-Iyj��549&..PHONE
PHONE
SIGNATURE