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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N_' 3 5 7 5
Assessor's Parcel No.
109 8th Street Suite 303
Glenwood Springs, Colorado 81601
Phone (303) 946.8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY `, ,/y'
O ner's Name Y(%J`il \\L )-�-LILA-Gi• Present Address to ISI?) L2 1; ( Citi r L1 1 A1111 Phone L J 107-) 3-74.S
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System Location L25( ( C7 C Ca \1G'v C,C XP
This does not constitute
a building or use permit.
Legal Description of Assessor's Parcel No.
SYSTEM DESIGN
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7 D Q 4 Septic Tank Capacity (gallon) Other
ISPercolation Rate (minutes/inch) number of Bedrooms (or other) 2
98$ s.;-"7- Foca Lac 5413
Required Absorption Area - See Attached 21(4� A 6 13 cm/75 4I:0G/4
Special Setback Requirements: 273 • I) /6 y^y75 aro 3 , (o
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*Mai i Ui, 1r5 .Bzo 2. 3'
Date 9:I'-1' ai Inspector .. �� _Z_ '^_'��
PWL.i
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer 1 Tom / S rZ-� ( 4 U 6 /uc-(
Septic Tank Capacity
SO
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Septic Tank Manufacturer prLTrr* Name
CL4'- ‘--
Septic Tank Access 2'
within8"8" of surface
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Absorption Area ' / c, - i{ "' 2'1 1 3� -" 3C (L. -.) f. F{ --l)
Absorption Area Type and/or Manufacturer or Trade Name
Adequate compliance with County and State regulations/requirements -011 S
Other C\
Date y' ��, 0 f Inspector • J\
)«L
c5fkZL4,419
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
•CONDITIONS:
1. All installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chapter
25, Article 10 C.R.S. 1973, Revised 1984.
2. This permit is valid only for connection to structures which have fully complied with County zoning and building requirements. Con-
nection to or use with any dwelling or structures not approved by the Building and Zoning office shall automatically be a violation or a
requirement of the permit and cause for both legal action and revocation of the permit.
3. Any person who constructs,alters, or installs an individual sewage disposal system in a manner which involves a knowing and material
variation from the terms or specifications contained In the application of permit commits a Class I. Petty Offense ($500.00 tine —6
months in jail or both).
White - APPLICANT Yellow - DEPARTMENT
AUG -22-2001 09:31A FROM:BLDGPLANGARCO 9703843470 TO:9P9635844 P:2/9
)WNER
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
Laura Van Dyne
6283 County Road 300
Carbondale, CO 81623-8815
ADDRESS PHONE 9 I03' 3 LIS
:ONTRACTOR P\ S 0 OW Ce\ ✓\C
ADDRESS (0 h IS udi j� C 1 rr.tlt PHONE ?(03 ' 076 71)
'ERMIT REQUEST FOR (YrNNEW INSTALLATION ( ) ALTERATION ( ) REPAIR
Witch separate sheets or report showing entire area with respect to surrounding areas, topography of area, habitable
wilding, location of potable water wells, soil percolation test holes, soil profiles in test holes (See page 4).
.00ATION OF PROPOSED FACILITY. 1 f -
Dear what City of Town \ Ct/\hDrj Q '4 Size of Lot 3 -G / aL' Lk.o
..egal Description or Address CT, TWN, RN0119-7 -87 »ESC 1 TR IN THE
Bx10457 PG:0121
WASTES TYPE: (v(DWELLLNG ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER - DESCRIBE
3UILDING OR SERVICE TYPE: 4 -Um
number of Bedrooms tuber of Persons 7
10 Garbage Grinder Automatic Washer Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: (X) WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: AV 61 -
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: !1i I 1 es
Was an effort made to connect to the Community System? /1)O
4 site plan is required to be submitted that indicates the following MINIMUM distances:
Leach Field to Well: 100 feet — /35 Feet
Septic Tank to Well: 50 feet
Leach Field to Irrigation Ditches, Stream or Water Course: 50 feet
Septic System to Property Lines: 10 feet
YOUR INDIVIDUAL SEWAGEDISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT
4 SITE PLAN.
GROUND CONDITIONS:
Depth to first Ground Water Table V)QA. t S a,001 ae,e
Percent Ground Slope t
2
RUG -22-2001 09:32R FROM:BLDGPLRNGRRCO 9703043470 T0:9P9635844 P:3'9
ImYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(✓ SEPTIC TANK ( ) AERATION PLANT ( ) VAULT
VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POTABLE USE
NT PRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
CHEMICAL TOILET ( ) OTHER - DESCRIBE
FINAL DISPOSAL BY:
VI ABSORPTION TRENCH, BED OR PIT ( ) EVAPOTRANSPIRATION
( ) UNDERGROUND DISPERSAL ( ) SAND FILTER
ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
( ) OTHER - DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? NO
PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer, if the Engineer does the
Percolation Test)
Minutes per inch in hole No. 1 Minutes per inch in hole NO. 3
Minutes per inch in hole No. 2 Minutes per inch in hole NO. _
Name, address and telephone of RPE who made soil absorption tests:
Name, address and telephone of RPE responsible for design of the system:
Applicant acknowledges that the completeness of the application is conditional upon such further mandatory and
additional tests and reports as may be required by the local health department to be made and furnished by the applicant
or by the local health department for purposed of the evaluation of the application; and the issuance of the permit is
subject to such terms and conditions as deemed necessary to insure compliance with rules and regulations made.
information and reports submitted herewith and required to be submitted by the applicant are or will be represented to
be true and correct to the best of my knowledge and belief and are designed to be relied on by the local department of
health in evaluating the same for purposes of issuing the permit applied for herein. 1 further understand that any
falsification or misrepresentation may result in the denial of the application or revocation of any permit wanted based
upon said applic tion and in legal action for perjury as provided by law. 1
Signed aite/C(i /l�V:? 1� Date 6, as l
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY?!
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RUG -22-2001 09:32A FROM:BLDGPLANGARCO 9703843470
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