HomeMy WebLinkAboutpitkin.eh.264322211015 (1978)No
—]Q J j PITKIN COUNTY HEALTH DEPARTMENT
r_ t3 iV11 T NU�PJI E3 E R
/ O / / RECEIPT NUMBcR
Owner t`r Afjc 4Phone No. 9-5--7-
Owners Mailing Address _ Q� As�f�—
ftif
Contractor __ Phone No. E
Address
System's Contractor's Name
--o
Address DO L /e/,
Legal Description
Lot Size
Number of Bedrooms
Owner's Signature
PLOT PLAN
ape of Individual Sewage Disposal System
Type of Soil or Soil Classification
Type of Building by Use
Type of Water Supply
Date z
�y
Proximal Location of Bedrock/ %�� ��� E'e /T�'�' 77-64 N )457F,
Proximal Location of Ground Water Table A' �ETE�/�'//i/E� C /�/ T o f
Percolation Test Date J d Minutes Per Inch —
Minimum Recommended Absorption System Size 1117OQ ` �r
Minimum Recommended Tank Size, CAt1—Z'OA1S
NorlcE
Special Conditions of Issue:
When properly signed for issuance, this application
becomes your permit. Application valid one year from
date. If an individual sewage dispose' permit Is issued
('N for property on which no building permit has been
issued, the individual sewage disposal permit shall
expire 120 days after its issuance If construction hes
not been commenced. Any change in plans or speci-
fications after the permit has been issued invalidates
the permit, unless approval is secured from the Health
Officer for such changes.
Apl.,,ed for Issuance By Date//2
FINAL INSPECTION APPROVAL' Date / /
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Waler.Pollution Control Div
42 0 fast 11th Avenue
Denver, Colorado 80220 „p o.
�. APPLICATION FOR APPROVAL OF LOCATION FOR SEPTIC TANK SYSTEMS
Applicant (Owner) : 1/
Mail Address: '7 L f- City:— Phorib: f�;
A. INFORMATION REGARDING PROJECT SUBMITTED FOR REVIEW: J
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
L 74" e
Legal Description Lot Size:
2. Type of area and facility - Numb r of persons served:
Subdivision Motel Restaurant Trailer Court
.�"
Other:
3. Source of domestic water: Public (naive):
Private: Well 11 Depth ;c'; 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: b/ Cy
If rejected, give reason:
6. Rate of absorption in test holes in minute"er finch of drop in water level after
holes have been soaked for 24 hours:vJ
7. Name, address and telephone of person who made soil a sorption tests:
8. Name, address and telephone of person responsible for design of the system:
9. Est. bid opening date: Est. Completion Date: Est. Project Cost:
Date:
S gnature of Owner
.•
i
Section
FILE REFERENCE:
INDIVIDUAL OR
ESTABLISHMENT:
k'OLORADO DEPARTMENT OF HEALTH
DIVISION OF ENGINEERING AND SANITATION
A C T I V I T Y R E P O R T
ADDRESS: e -a zz
NARRATIVE:
Code �p'f
County
LETTER TO FOLLOW: ( ) OTHER RECOMMENDATIONS:
DATE: /0—/0 , 19 P.
ES: 7 (Rev. 6-70-100)
REPRESENTATIVE:
2
B.SIG�;ATURES FOR LOCAL GOVEP""fc"''f OFFICIALS: The unders i gne,' ',ave reviewed the
proposal for the location . .ne above-described septic tan., stem and
iAECOMMEND APPROVAL or DISAPPROVAL. in the space provided below:
DATE APPROVAL DISAPPROVAL
Signature for Local Kea th Department
Signature for Mayor or City Manager
Signature for County Commissioners
Comments:
Signature and Title
Note: The applicant must obtain the comm,:nts and signature of at least one of the above.
C. FOLLOWING FOR STATE HEALTH V.PA RTMENT USE: Recommendations of the District Engineer
D. ACTION By THE COLORADO WATER POLLUTION CONTROL COMMISSION:
WP -10 (Rev. 5-70-100)
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