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GARFIELD, COULITY DEPARTYVINT or ELivi.
2014 Blake Avntio
Glenwood Sprin.47s, ColcrEeo
PERTUT ft; 0 1
ic"1
fo:c a/41../.—ic,
0:70 %3.1::11.
3?.:: ::Jifl.cL
X .R,173 sq. fe
4w49. e 4,9474
r
App:vcval of Syt,-:-c:
shall -ba dc,..r2olo.d to in cc;;T:;..1 with the
Lays until the asnmatl.ed rystrl pr!,r
aay pal:t thereof.
'i7" septic cic:;Anout with 44e15
.....„/,‘.____P•rop_er...itlat.C: a: :1 a 1 3. J,..1,1,.1. ...z2., s SrtrthIy___________
4--- Pieluate abIorption armn
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Covenants siqned
RETAIN WITH PERMIT REOGRDS AT CONSTRUCTI9N SITE.
I t}NRADO DEPARTMENT OF HEALTH
Water Pollution Control Division
' 421Q East i l th Avenue
Denver, Colorado 80220
/r% Building Offidia1
NOTIFICATION OF PROPOSED DISCHARGE TO WATERS OF THE STATE*
INDIVIDUAL HOME SEWAGE TREATMENT SYSTEM**
Owner :/7 E,l a 17/ 14/1 11/ e 6/1'
Mai l Address:/:3/ (2,,, ex ad) C1 ty C.d.c41i ' 0 Se i p P//O(0/ Phone 9y 235e
A. INFORMATION REGARDING PROJECT SUBMITTED FOR REVIEW:
Attach separate sheets or report showing entire area with respect to surrounding
areas, top)graphy of area, habitable buildings, location of potable water wells,
soil percolation test holes, soil profiles to test holes.
1. Location of facility: County Gi?gFiE4.1) C1 ty or town/Ay, . F 4140/0,0040.5-124.5:
Legal description i C.S 'N`OFLot size .2- ACe&
2. No. of bedrooms
Septic tank capaclty14Q_Aeratlon unit capecity__.
3. Source of domestic water: Public (name) vorcHti,c-- codwgx Gv/fiEle
Private: Well Depth Other Depth to first ground water table
4. Is facility within boundaries of a city/town or sanitation district?
ApoPPDX •
5
Distance to nearest sewer system:
Have you attempted to arrange a connection with the system? — s R �VC'
If rejected, what was the reason?
6. Rate of absorption in test holes shown on.the location map, in minutes per inch
of drop in water level after holes have been soaked for 24 hours
%. Name, address,.and telephone of person who made soil absorption tests:
_fie 2M 1 i
8. Name, address, and telephone of person responsible for design of the system:
37 y
n-ture of Owner
*Rewired by Article 66-28-12(CRS, 1963, 1967 Perm. Sum. Supp.)
**Required it areas which have been identified as areas in which danger of pollution
of waters of the State may occur (Art. 66-28-8(5), CRS) and/or areas in which there
IS no local septic tank ordinance.
B. SIGNATURES OF LOCAL OFFICIALS: The undersigned have reviewed the notification
described on the front of this sheet and recommend approval or disapproval of
the discharge as shown below:
Date
Comments:
Approval Disapproval
0111.141.11411 r
Signature for Local Health Department
Signature for City/Town Of`ici�i tTltl�
Signature for County Official
Signature and Title
Note: The Noti'.`Icr (front cf this sheet) must obtain comments and signature of at
least one of the above.
C. FOLLOWING FOR STATE HEALTH DEPARTMENT USE: Recommendations of the District Engineer:
D. ACTION BY THE COLORADO WATER POLLUTION CONTROL COMMISSION:
r'P133(10-j2-2�) -
iminna
d• 1.
GARFIELD COUNTY DEPARTMENT OF ENVIRONMENTAL HEALTH
2014; lake Avenue
Glenwood Springs, Colorado 81601
PERMIT # S 10
Owner C. kItA1'Nifi`1 LC } cer CQ
(this does not constitute
a building or use permit)
System Location VAN CD( )r (1. -?C~ L.
Licensed
Contractor
* Conditional Construction approval is hereby granted for a gallon
Septic Tank or Aerated treatment unit.
Absorption area (or dispersal area) computed as follows:
Pere rate inches inminutes sq. ft.
absorption area per bedroom
of bedrooms x sq. ft. minimum requirement
May we suggest
Date , Inspector
FINAL APPROVAL OF SYSTEM:
No system shall be deemed to be in compliance with the Sewage Disposal Laws until the assembled system
is approved prior to covering any part.
Septic Tank cleanout to within 12" of final grade or aerated access ports above grade.
Proper materials and assembly.
Adequate absorption (or dispersal) 'area.
Adequate compliance with permit requirements.
Adequate compliance with County and State regulations/requirements.
Date ;,Inspector
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
*CONDITIONS:
1. All installation must comply with all requirements of the County Individual Sewage Disposal Regulations,
adopted pursuant to authority granted in 88.444, CRS 1985, amended 68.8.14, CRS 1983.
2. This permit is valid only for connection to structures which have fully complied with County Zoning and
building requirements. Connection to or use with any dwelling or structures not approved by the building
and Zoning office shall automatically be a violation of a requirement of the permit and cause for both
legal action and revocation of the permit.
3. Section 1I1, 3.24 requires 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 con-
tained in the application of permit commits a Class I. Petty Offense (8500.00 fine - 6 months in jail or
both.