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Home My WebLink Aboutpitkin.eh.264326201007 (1973)w • L •+oQLA3 -- a1-00 �- . _. + PITKIN COUNTY HEALTH DEPARTMENT rr ?? PERMIT NUMBER RECEIPT NUMBER V94 Owner �.1 �(' 1 �►Y' `�O Phone Address >+-� y�► �3 1�-iSl��'` Contractors �� C 1Ne+�)�1� Phone Address Location of system. ",; 0tY _ ! q Lot Size S Legal description Date _ Siganture of .owner i/ i 1�trC Percolation test data minutes per inch Minimum recommended absorption system size Minimim ecommended tank size Permit application valid One y from date.' Application to be final only after low�`� nhis completed and signed. Retain the construction si e permit and is form at DRA NG OF SYSTER. , to n ��, Date Sanitarian COLORADO DEPARTMENT OF HEAL TK 'nater Pollution Control Di ,ion 4210 East 11th Avenue ` Denver, Colorado 80220 f APPLICATION FOR APPROVAL OF LOCATION FOR SEPTIC TANK SYSTEMS Applicant (Owner):Jr -,- Mail Address: [ <<�� City. 'Phow. 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 �,'{-�� i LN' City or Town Legal Description 1T j t�,t�.)0644 st: L10, Lot Size: AC V 2. Type of area and facility - Number of persons served: Subdivision ° Motel Restaurant Trailer Court Other: 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: Lr 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 telephone of person responsible for design of the system: 9. Est. bid opening date: Est. Completion Date: Est. Project Cost: Date : a Signature of Owner B. � S IG�IF,TURES FOR LOCAL GOVT" JOIENT OFFICIALS: The undersign* +ave reviewed the proposal for the locationf the above-described septic teW system and RECOMMEND APPROVAL or DISAPPROVAL in the space provided below: DATE APPROVAL DISAPPROVAL. ` /_..� / .. _7. Signature or t,ocal Health Department / Signature for Mayor or City Manager /-7 /--� Signature for County Commissioners Comments: Signature and Title Note: The applicant must obtain the comments and signature of at least one of the above. C. FOLLOWING FOR STATE HEALTH DEPARTMENT USE: Recommendations of the District Engineer D. ACTION BY THE COLORADO WATER POLLUTION CONTROL COMMISSION: 10-10 (Rev. 5-70-100) x PERCOLATION TEST FIELD SHEET COMPLETE IN DUPLICATE (Check person responsible for or performing tests) NAME OF OWNER � <<ONJ� ADDRESS �; PHONE — NAME OF CONTRACTOR OR EXCAVATOR, GN 0, �aLr-e_ ADDRESS PHONE LEGAL DESCRIPTION OF PROPERTY 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/installer/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. oaking is to be erformed in the 24-hourperiod between A.M. and g,30 A.M. on the 1 �?�l, 1\ and �� rdays of w_p_ 1-9 The actual percolation ests are to be performed at '3�.M. and 9'3� A .M. on 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 othe proposed system, generally 2.5 to 3 feet deep and 12 to 16 i cies in iameter. ok�L kA(.a At �� &\'L a- C9.4, 00& , 0'--k Aib-tkr- b The holes are to be soaked for a 24-hour period prior to running the test. f TEST HOLE I 0ko�t�- &Vo - TEST HOLE II Reading Drop Time Reading Drop Time r, 30 / Y F <r a f PERCOLATION TEST RESULTS: HOLE I �S�Minutes per inch I HOLE II Z Y Minutes per inch Average percolation rate: 30,S Minutes per inch Comm nts on soil and/or site: f ��QQ_tQ�t OAS w �� o< Address: �c3�L y(�Q6 /tS��,, Signature: TEST FEE $25.00, payable in Advance ( )Ul-V-. A -- AFFIDAVIT (Percolation -Test) uUmly � , being first duly sworn upon his oath under penalty or perjury, states, avers and certifies as follows: 1. That he is the person who performed the percolation tests as required on the reverse hereof. 2. That the tests were performed in accordance with the time schedules and specifications as set forth on the reverse hereof. 3. That the test results of the said percolation tests were as set forth on the reverse hereof. 4. (In paragraph 4, affiant shall insert additional statement(s) which may be properly and reasonably required by the Pitkin County Control Officer or the affiant may wish to insert.) DATED: �3 , 19 r w i ature of Per unni g Test STATE OF �-�'`-•-•�c ) COUNTY OF ) SS A—SUBSCRIBED AND SWORN to before me this day of 19-r:z . My Commission Expires: o ry Public NOTE: This affidavit must be returned to the Pitkin County Pollution Control Department within 24 hours of the time the percolation tests are completed (Saturdays and Sundays excepted). t pop -MR m tN im 0