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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
108 Eighth Street, Suite 201
Glenwood Springs, Coloradof 81601
Phone (970) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
1t c C' WA\ lC (1
Permit
4346
Assessor's Parcel No.
This does not constitute 1
a building or use permit. 1
Owner's Name )Je Vi-€po`-+' Present Address e
Phon
C11`-11
System Location 11 VTR- ` ` l I UPWC'
Legal Description of Assessor's Parcel No. M.\15— 1
SYSTEM DESIGN
/061 6, 12+4-4c_ r4-5 5 P61- . i2v .4 »ea
Septic Tank Capacity (gallon) Other
Percolation Rate (minuteslinch) Number of Bedrooms (or other)
MCA.71:7 /44-"/"--- Z42/1(
Required Absorption Area - See Attached /14.7.4.1.1.) /9L I //--W-5/5001"----T-,42--V Z4 Z-
/4/57,-7!'
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Inspector
Special Setback Requirements:
Date __
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call tor Inspection (24 hours notice) Before Covering Installation
System Installer
Septic Tank Capacity
Septic Tank Manufacturer or Trade Name
Septic Tank Access within 8" of surface
Absorption Area
Absorption Area Type and/or Manufacturer or Trade Name
Adequate compliance with County and State regulations/requirements
Other
Date Inspector
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 1, Petty Offense (8500.00 fine — 6
months in jail or both).
White - APPLICANT Yellow - DEPARTMENT
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER -7 ,(%v1 -
ADDRESS /1 77
k -
CONTRACTOR F- iFdO' ;� /741 al r, /
ADDRESS 0321/ `'Z1c _ 64;n -41d
PERMIT REQUEST FOR NEW INSTALLATION ( ) ALTERATION 06 REPAIR
Attach separate sheets or report showing entire area with respect to surrounding areas, topography of area, habitable
building, location of potable water wells, soil percolation test holes, soil profiles in test holes (See page 4).
LOCATION OF PROPOSED FACILITY:
Near what City of Town ikoeo, c sk-le, Size of Lot s • 5-3
Legal Description or Address t‘14- Cr
PHONE 770`SSS`33zl
Cd-) Cetitc
PHONE I74 ~ `?4' - 5`$7 y G 85'I-,
WASTES TYPE:
() DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPE:
Number of Bedrooms Number of Persons
( ) 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:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to the Community System?
A site plan is required to be submitted that indicates the following MINIMUM distances:
Leach Field to Well: 100 feet
Septic Tank to Well: 50 feet
Leach Field to Irrigation Ditehes, Stream or Water Course: 50 feet
Septic System (septic tank & disposal field) to Property Lines: 10 feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT
A SITE PLAN.
GROUND CONDITIONS:
Depth to first Ground Water Table
Percent Ground Slope
2
5S4'7
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
SEPTIC TANK ( ) AERATION PLANT ( ) VAULT
( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POTABLE USE
( ) PIT PRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
( ) CHEMICAL TOILET( ) OTHER -DESCRIBE
FINAL DISPOSAL BY:
()�) 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? q
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 ofthc
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 tote and correct to the best of my knowledge and belief and are designed to be relied on by the local department of health in
evatuatin g the same for pu oses of issuing the permit applied for herein. 1 further understand that any falsification or misrepresentation may
result in the denial a app ication or revocation of any permit granted based upon said application and in legal action for perjury as provided
by law.
Signed/
Date
000 7
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
3
Designate North Arrow
Your Neighbor's
Name & Address
Your Plot - Shape to Fit
(No Scale) t.
/J O
Lt2LA
NIJ
Ls4
Locate well, a�Fstreamsirrigation ditchs, and any water courses. Draw in your house,
septic tank & system, detached garages. and driveway.
If a change of location is necessary, you must submit a corrected drawing, before a
Certificate of Occupation wiU be issued
County Road (Note the Road Number and Name
0
Your Neighbors
Narne & Address
roc .Impoaowvpd.mpiatix
'l'at: Garfield County Planning and Building
Re: 1177 CR 241
New Castle, CO 81647
Pleas; allow Roto Rooter Plumbing to pull a permit in regard to the above address. We
will he repairing the system in pine .at present.
1-lome (.Owner
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