HomeMy WebLinkAboutpitkin.eh.264916101024 (1978)' sLgel hitt—at-62-
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�0ITKIN COUNTY HEALTH DEPARTMENT
PERMIT NUMBER RECEIPT NUMBER
Ownerc %��N /`?%?C�u� Phone No. 2Q,5--
Owner's
Q,5 Owner's Mailing Address /SSG � � Asnz7V ; /CLU Z/l//
Contractor To///V Phone No.
Address
System'e rnntrar•tnr'c Namo
Address
Legal De
Lot Size f �1 A Type of Building by Use
Number of Bedrooms Type of Water SupplyT���
Owner's Signature Date
PLOT PLAN: ATTACHED AS REQUIRED
Type of Individual Sewage Disposi
Type of Soil or Soil Classification
Proximal Location of Bedrock
Proximal Location of Ground Water Table
Percolation Test Date Q Minutes Per Inch
Minimum Recommended Absorption System Size
Minimum Recommended Tank Size _,. D CXZZ 26-72 9 &)Ij 06e -
S ecial Conditions of Issue: rvo
p When properly signed forr issuance, this application
becomes your permit. Application valid one year from
leA1� / date. If an individual sewage disposal permit is issued
for property onwhich no building permit has been
issued, the individual sewage disposal permit shall
expire 120 days after its issuance If construction has
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 su h changes
Approved for Issuance By Date
FINAL INSPECTION APPROVAL
(Drawing of System on Back)
Date
PITKIN COUNTY ENVIRONMENTAL HEALTH
Field Test Data Sheet on Percolation Test
PROPERTY OWNER - `�''"�� PHONE
MAILING ADDRESS
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LEGAL DESCRIPTION OF PROPERTY
LOCATION OF TEST HOLES 2
Three (3) test holes required per system
Test Hole Depths (24" minimum)
33 rr
Diameter of Test Holes �—
Water remaining after 8 hour soak
d
TEST HOLE No.1 TEST HOLE No. 2
TEST HOLE No. 3
Drop Time Drop Time
Drop Time
b
`'
Percolation Rate Each Hole
Average Rate
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Comments on so i or site.
Signature
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