HomeMy WebLinkAboutpitkin.eh.264929101010 (1975)..—Ato41-1191— "1 —010 ��y,�l � �r �suD,!;
w PITKIN COUNTY HEALTH DEPARTMENT
Pll.unlT NUMBERS 7203 c % RECEIPT NUMBER
Owner l , (� ) @,1,L} �/ Phone # 176 —1313 8 1
Owner's Mailing Address
Contractor
Address
Systems Contractor's Name
Address
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Phone # ! Z15- Aa tlo) l(,p
Legal Description
Lot Size Y., Q _ Type of Building by Use
Number of Bedrooms `, Type of Water Supply
Type of Individual Sewage Disposal System fly a -nn<
Type of Soil or Soil Classification
Proximal Location of Bedrock
Proximal Location of Ground Water Table
Owner's Signature
PLOT PLAN:
Dat'e10
It
=inutes
Percolation Test Data per inch
Cj
Minimum Recommended Absorption System Size n 0
f (1400
Minimum Recommended Tank Size 10 C d
Permit application valid one year from Date. Application to become permit and final only
after lower portion is completed and signed by the Sanitarian. RETAIN THIS FORM AT THE
CONSTRUCTTON SITZ, /
Date Sanitarian
(Dr i g of syste n back)
3
PITKIN COUNTY ENVIRONMENTAL HEALTH
. Field Test Data Sheet on Percolation Test
PROPERTY OWNER P a i SC, uj & LL PHONE
MAILING ADDRESS
LEGAL DESCRIPTIO
LOCATION OF TEST HOLES
Three (3) test holes required per system
Test Hole Depths (24" minimum)
Diameter of Test Holes
Water Remaining after 24 hour soak
Percolation Rate Each Hole
Average Rate ' /� JA)
NAME OF RESPONSIBLE PARTY RUNNING TEST PHONE
SIG1,1ATURE PHONE
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• COLORADO DEPARTMENT OF HEALTH
iCOUNTY ti a REQUEST FOR SERVICE
PROGRAM % RECEIVED BY �oark DATE
LOCATION NAME
REPORTED BY ADDRESS TELEPHONE
SERVICE REQUESTED(//2G7/
InC vv
ACTION
DISPOSITION
DATE
SH -M-71 (4-71-50)