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PITKIN COUNTY HEALTH DEPARTMENT
PERMIT NUMBER �®°RECEIPT NUMBER
Owner
Phone #E vZ �3 —7S-00
Owner's Mailing Address. �?�C> alli C ilii t�)D
Contractor
Address
Systems Contractor's Name V%J-i I Q(a
Address
Legal
Phone
Lot Size
(f���r
iel�i%/VC Type of Building by Use \f?tkkN
AL.
Number of Bedrooms_
Type of Water Supply C ,'-r
f" C �
0EIP )d1 �
/ 7
Type of
Individual
Sewage Disposal System /1-1
Classification 5ANQ
Type of
Soil or Soil
Proximal
Location
of Bedrock A .167- }
Proximal
Location
of Ground Water Table
Owner's
Signature
Date
3 — % I , 711)
PLOT PLAN:
Percolation Test Data R"—Wlnutes per inch
Minimum Recommended Absorption System Size
Minimum Recommended Tank Size /5 'C
Permit application valid one year fromyI)/ate. Application to become permit and final only
after lower portion is completed and signed by the Sanitarian. RETAIN THIS FORM AT THE
CONSTRUCITON SIT
Date Sanitarian
( awing of system on back)
Rjoi-Di4C AT
APppwtoTE /�ATcje L
SvPP1.v1. CA-TioAi
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-- -* QERCOLATION TEST FIELD SHEET
NAME OF OWNER 14 D/IL fI e(W,4W7-10/11 PHONE 2 Y —7 -5—--D
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ADDRESSFip/;2 Je)We�TIe6✓ 6to.&IADo
LEGAL DESCRIPTION OF PROPERTY ATIIWCS7� 0`
At least two (2) test holes per system must be run. They should be in the
area of the proposed leaching system and dug to the depth of the proposed system,
generally 2.5 to 3 feet deep.
The holes are to be soaked for a 24 hour period prior to running the test.
Test Hole I
Test Hole II
Reading Drop Time
'Reading Drop Time
(20)
�i 31—
PERCOLATION TEST RESULTS:
Hole I n Minutes per inch♦ Hole II Minutes per inch
Average percolation rate: 3 Minutes per inch
1
Comments on soil and/or site: J
Vv
Name of person running test:
Address:
Phone: