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PITKIN COUNTY HEALTH DEPARTMENT
PERMITNUMBER RECEIPT NUMBER
Owner /�/ �/ C �, JU J Phone No.,�---
Owner's Mailing Address
Contractor VPhone No.
Address
System's Contractor's Name —c,— -I— -,-� Z /�,_
Address
Legal Description `� 7 -
Lot
Lot Size e-, - Type of Building by Use %! ' zC� F -s' ��Y ��"����j"✓�
Number of Bedrooms - Type of Water Supply
Owner's Signature /` ll�- Date
PLOT PLAN: ATTACHED AS REQUIRED
Type of Individual Sewage Disposal System _�)EmIAtill(t5co
Type of Soil or Soil Classification S7rC PEx?ml T 7201
Proximal Location of Bedrock
Proximal Location of Ground Water Table
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Percolation Test Date IVIA Minutes Per Inch
Minimum Recommended Absorption System Size 7`Sc FJ Z-'—,y/S % IAJ C
Minimum Recommended Tank Size /t/)00 C' A t Z 01(1E L Z 6(110A1P X1--17111 1�
Special Conditions of Issue: NOTICE
p When properly signed for issuance, this application
becomes your permit. Application valid one year from
date. If an individual sewage disposal permit is issued
for property on which no building permit has been
issued, the individual sewage disposal permit shall
1"A L Fr AJ /� , FTA L �A A e W / / f� q expire n days after its issuance if construction has
11 � � / /-T /v I^� not been commenced. Any change in plans or speci-
/ fications after the permit has been issued invalidates
/ LO Al 0—eA10j /JC-7-� T,4 /I //� the permit, unless approval is secured from the Health
L> C� l�/� / ��,VVV L Officer for such changes.
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Approved for Issuance By
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FINAL
INSPECTION APPROVAL Date
(Drawing of System on Back)
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PITKIN COUNTY HEALTH DEPARTMENT
i` HERMIT NUMBER 720186 RECEIPT NUMBER /sem oC�
Owner _ r, +� r' CLQ rd r Phone #
Address i -11D -
Contractor
Address
Phone #
Location of system a u,qh
/ c't=
(/�Idt p P
Lot size.
Legal description
Number of bedrooms
Signature of owner
Percolation test data
�.. L :--
—
Minimum recommended absorption system size
Minimum recommended tank size
Date
minutes per inch
Permit application valid one year from date. Application to become permit and final
only after lower portion is completed and signed. Retain this form at the construction
site.
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tDRAWING OF SYSTEM
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