HomeMy WebLinkAboutpitkin.eh.272904300008 (1978)Q4a* 043-6ffs
IN COUNTY HEALTH DEPARTMENT %
PERMIT NUMBER �C)Ct
PI RECEIPT NUMBER (`�'n q l
Owner ex., n °, e t, er, v Phone No. C74,5 — 73 �1d
Owner's Mailing Address 2,4Z �(.�/(��1LCT P,
Contractor
Address
System's Contractor's Name
R
Phone No.
Address /� ,
Legal Description -5F y Sw -See � mid N15 1 Yklxg{ 5eCp. 7, T^lOS_ RV)w
Lot Size 2'3 =. Type of Building by Use �e 5 1 Q /
� ��� j1 /
Number of Bedrooms Type of Water Supply'
Owner's Signature 13AA,1AA,A A �W, XIIA2"
Date ----x� T. // . 1 9 % e
PLOT PLAN: ATTACHED AS REQUIRED
Type of Individual Sewage Disposal System — 107-A-1
Type of Soil or Soil Classification :A V 0CeZ9 1,G�
Proximal Location of Bedrock 4'T- ��j�������� 's��� ����/ P //7
Proximal Location of Ground Water Table / X�'T 1 T� /U��[/ "
Percolation Test Date Minutes Per Inch
Minimum Recommended Absorptioi
Minimum Recommended Tank Size
S ecial Condi ions of Issue:
p When properly signed for issuance, this application
e�-`y / �— /%C� becomes your permit. Application valid one year from
/ date. If an individual sewage disposal permit Is issued
_ �i for property on which no building permit has been
OF L �� �J// �/ 'w / _ �T issued, the individual sewage disposal permit shall
�D� expire 120 dame after its issuance if construction has
/�j ,� 7/--/
% / / . y G //� not been commenced. Any thenen in plans or idatspoci-
/�� ✓/l�/ J L �_ Gi c� fications after the permit hes been issued invalidates
the permit, unless approval is secured from the Health
Officer for such /changes.
Approved for Issuance By
Date 13 129
FINAL INSPECTION APPROVAL ate `o ,D }2
(Drawing of System on Back)
PITKIN COUNTY ENVIRONMENTAL HEALTH
Field Test Data Sheet on Percolation Test
a
PROPERTY OWNER PHONE
MAILING ADDRESS _
LEGAL DESCRIPTION OF PROPERTY
LOCATION OF TEST HOLES
Three (3) test holes required per system
Test Hole Depths (24 minimum)
Diameter of Test Holes
r1 t/ Il
Water remaining after 8 hour soak
TEST HOLE No.1 TEST HOLE No. 2
TEST HOLE No. 3
Drop Time Drop Time
97
Drop Time
Percolation Rate Each Hole
Average Rate
Comments on soil or site:
Signature
Date A/za
F
K / /
:ate plan was prepared for B. W. f ilherry
•vey that :has been morrimented by others,
).dins site is entirely with, the
there are no encroachments on the
cents an any ad joKina premises, except
s no evidence or sign of any easement
of saia parcel, except as noted,
Aeg �s erect a.rsra �,u; v�yo
Aagust 26, 1078