HomeMy WebLinkAboutpitkin.eh.264321308003 (1974)PERMIT NUMBER
Owner
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7202
'~ PITKIN COUNTY HEALTH DEPARTMENT
' RECEIPT NUMBER 17,�
Phone #�
Owner's Mailing Address -) e) X{�
Contractor
Address
Systems Contractor's Name
Address
Legal Description i
Lot Size
Number of Bedrooms
Type of Individual Sewage Disposal
Type of Soil or Soil Classification
Proximal Location of Bedrock
Proximal Location of
Owner's Signature
PLOT PLAN:
er
Phone #
Type of Building b,,KUse �u-
Type of Water Supply <Z�
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In
Date
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4 (4 a .
rq/z9/71
Percolation Test Data ;[ 7 IN -p / Minutes per inch
Minimum Recommended Absorption System Size f�
M7.n p
Minimum Recommended Tank Size /000
Permit application valid one year from Date. Applkation to become permit and final only
after lower portion is completed and signed by the Sanitarian. RETAIN THIS FORM AT THE
CONSTRUCITPN M/"-
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Date4 Sanitarian 'e
(Drawing of system on back)
1�2,So G-AUN s �-
CottiAAO " �WRf
OPTIC TA OK o
9.21
.CU QRA.rQ DFPAR"(MENT OF HEALTH''
.Watt,!' Poliuti'or) Control Division
4210Ea — filth Avenue
Denver, Colorado 80220
NOTIFICATION OF PROPOSED DISCHARGE TO WATERS OF THE STATE*
INDIVIDUAL HOME SEWAGE TREATMENT SYSTEM**
Owner:—/) d p'e f//
►ia i 1 Add res s: 4 C i ty_6- + -� Z i p Phone
t� 4EVIEW:
A. I P:FORI� : i I ON REGARDING PROJECT SUBMITTED ._FOR
Attach separate sheets or report showing entire area with respect to surrounding
alrluo, lGrCi✓IriaN;"+°7` Of ui"cel, is iL.�..ic LUIIGis"i�,, °,LL. ICi'i GI WG1lS,
soil percolation test holes, soil rofiles in test holes.
1. Location of facility: CountyM//I) City o/rr town
1./
44
Legal description �� t aci
unit ration Lot ize�Ae-yes -
ca
2. No. of bedrooms Septic tank capacity �10- Aeration capacity
3. Source of domestic water: Public (name): _
Private: Well i Depth;W Other Depth to first ground water table
4. Is facility within boundaries of a city/town or sanitation district?_ k' e)
5. Distance to nearest sewer system: ------
Have you attempted to arrange a connection with the system?
If rejected, what was the reason?
6. Rate of absorption in test holes shown on the location map, in minutes rner iron
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 telephone of person responsible for design of the system:
Dat. Signature o
*Reciu i r ed my Article 66-28-12(CRS, 1963, 1967 Perm. Sum. Supp.)
**Required in areas which have been identified as areas in which danger of pollution
of waters of the State may occur (Art. 66-28-8(5), CRS) and/or areas in which there
is no local septic tank ordinance.
C V .
B. SLOP;ATURES OF LOCAL, OFFICIALS: The undersigned have reviewed the notification
described on the front of this sheet and recommend approval or disapproval of
th- discharge as shown below:
Date Ap �roval Disapproval
Signature for LocE 1 Ilea l th Depa-ti--int -
7 --
Signature for City/Town Ofrrc;ar fit1(t)
Signature for County Dffic`sz)l (.i7J
Comments:
Signature and Title
!vote: The Notifier (front of this sheet) must obtain comments and signature of at
least one of the above.
C. FOLLOWING FOR STATE HEALTH DEPARTMENT USE: Recommendations of the District Enuineer:
D. ACTION BY THE COLORADO WATER POLLUTION CONTROL COMMISSION:
WP -•33 (10-72-2)