HomeMy WebLinkAboutpitkin.eh.264327400003 (1973)W -j
PITKIN COUNTY HEALTH DEPARTMENT
PERMIT NUMBER 7 2 ® 1 RECEIPT NUMBER
Owner Phone # O
Address
Contractor
Address
Location of system42 c��¢. •- '
Legal description Y-�
Number of bedrooms
Signature of owner
Phone #- 27 S' - ,
Lot size
s
Date 73
Percolation test data, �- % —�d minutes per inch
Minimum commended absorption system size
imam recomm ed tank size S'U
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.
DRAWING J',��SYSTEM
Lj-L1 M ZLO I
Date Sanitarian
. . '
PITKIN COUNTY HEALTH DEPARTMENT
PERMIT NUMBER 7 �ECEIPT NUMBER
Owner �f% . Phone
Address
Contractori�y_ ,(��� 1� - Phone
Address
Location of system % ) �,� ,�(/� aLot Size � G �--
Legal description
Date x4{� 7 Siganture of owner
Percolation test data minutes per inch
Minimum recommended absorption system size
Minirrjum recommended tank size
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.
DRAWING OF SYSTEM
Date Sanitarian
3
C
TEST HOLE I
TEST HOLE II
Reading
Drop
Time
Reading
Drop
Time
x`00
4: do
cl 3/Y
oo J
14I31y
,/,
/V66 M1
19��
�2
11:aUy
Z
,l<<,,
r z , opyl
1 ti
y',
on PA1
13 '/ i
1
V "
d 0
I3 '/
�.'�
, 0
PERCOLATION TEST RESULTS:
HOLE I Minutes per inch ]HOLE II Minutes per inch
Average percolation rate: Aq0 Minutes per inch
Comments on soil and/or site: y
Address:
Signature:
i'
TEST FEE $25.00, payable in Advance
)n
• � o
AFFIDAVIT
(Percolation Test)
being first duly sworn upon
his o under naltr of 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: v 7 193
(Sig re of P15rson Runfiing Test
STATE OF a� )
COUNTY OF�'� "�� ) SS:
SUBSCRIBED AND SWORN to before me this ,/,'day of,,/ � 19z.
Nay Commission Expires:
Ygeary 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).
PERCOLATION TEST FIELD SHEET
t
COMPLETE IN DUPLICATE
(Check person responsible for or performing tests)
( ) NAME OF OWNER
ADDRESS
( ) NAME OF CONTRACTOR OR EXCAVATOR
ffll�_ Mw_ffi �
ADDRESS , .,� �= G PHONE y -2
LEGAL DESCRIPTION OF PROPERTY �%� ��2 .
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.
Soaking is to beerformed in the 4 -hour period between
c5,'06 P.M. and �c� J/� .M, on the / and IS -'days of
s , 19_2,:�. The actual percolation Tests are to be
perf med at rad .g_.M. and D6 P.M. on t ,
19-2--,A .
At least two (2) test holes per system must be run. They
should be in the area (within 4 1 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.