HomeMy WebLinkAboutpitkin.eh.264328202006 (1976)PITKIN COUNTY HEALTH DEPARTMENT
76069 RECEIPT NUMBER /��
PERMIT NUMBER
01\1 _ Phone No.
Owner
Owner's Mailing Address
Contractor
�L� Phone No.
Address
System's Contractor's Name
Address
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Legal Description
A' 'S T e of Building by Use
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Lot Size �•0 yp /l/
Number of Bedroo!4!t2f=
ter Supply
Date
Owner's Signature
PLOT PLAN: ATTACHED AS REQUIRED
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Type of Individual Sewage Disposal System
Type of Soil or Soil Classification
Proximal Location of Bedrock
Proximal Location of Ground Water Table
Minutes Per Inch o / 9 %_
Percolation Test Date
Minimum Recommended Absorptlor
Minimum Recommended Tank Size
Special Conditions of Issue: p when properly signed for issuance, this application
� ��� ��� ^ l ,� / 77 j 0 becomes your permit. Application valid one is issued J /�/ / (•�L„d V' date. If an individual sewage disposal permit is issued
P/ 19 �� , ) for property on which no building permit has been
r57 D I 6 u �/7 %A i'�f issued, the individual sewage disposal permit shall
Lfy/S�! �r [_/ /c d expire 120 days after its issuance if construction has
notbeen 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.
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Date
Approved for Issuance By
Date
FINAL INSPECTION APPROVAL
(Drawing of System on Back)
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