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Gift COUNTY BUILDING AND SANITATION DEPARTMENT Permit N° J 413
109 8th Street Suite 303 Assessor's Parcel No,
Glenwood Springs, Colorado 81801
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
Phone (303) 945-8212
This does not constitute
a building or use permit
Owner's NameIThUU €II�1�St7!T Present Address 133 i'T4 fli In-An.b2 Q5 Phone 9f l 99T3-5ASS
System Location 't1�/� -e�3 LIDAA) i[ l 1 b
Legal Description of Assessor's Parrgel No a l [�Qi -' Q S'r O ® 015-0
SYSTEM DESIGN
Septic Tank Capacity (gallon) Other
Percolation Rate (minutes/inch) Number of Bedrooms (or other)
Required Absorption Area • See Attached
Special Setback Requirements:
Date Inspector
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for 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 --` Xn ,Q J \11gN\ (ICA -C i
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 ($500.00 fine — 6
months in jail or both).
White - APPLICANT Yellow - DEPARTMENT
1.n INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER lN1AQA_ r bLettN--(C__
ADDRESS 13 �T. r"1-9 \�
CONTRACTOR
ADDRESS
PHONE 1qr *4 t\ C
PHONE
PERMIT REQUEST FOR (i(j NEW INSTALLATION ( ) ALTERATION ( ) 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 CILITT�Y:�
Near what City of Town et3C 1SIC.Cs Size of Lot Lic-;. A 1C Q t -;S
Legal Description or Address 3-1\t,,4L`�4ey C=r•(► `l0 Vv
WASTES TYPE: ( ) DWELLING ( ) TRANSIENT USE
(A COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) O - DESCRIBE
BUILDING OR SERVICE TYPE: \ G\2a r -r
Number of Bedrooms Number of Persons
( ) Garbage Grinder ( ) Automatic Washer ( ) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: `o 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 she 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 Ditches, Stream or Water Course: 50 feet
Septic System 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
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
SEPTIC TANK
VAULT PRIVY
PIT PRIVY
CHEMICAL TOILET
AERATION PLANT ( ) VAULT
COMPOSTING TOILET ( ) RECYCLING, POTABLE USE
INCINERATION TOILET ( ) RECYCLING, OTHER USE
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?
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 tore 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. I further understand that any
falsification or misrepresentation may r, the denial of the application or revocation of any permit granted based
upon said appfll4bAtdtt
' 2 legal : ' ' n r 'ury as provided by law.
Signed Date Z C�`
PLEASE DRAW AN AC ' TE MAP TO YOUR PROPERTY!!
3
January 24, 2001
Garfield County Building & Planning
109 Eighth Su+eet, Third Floor
Glenwood Springs, CO 81601
Re: Scott Miller ISDS -. HCE No. 2000004.32
Tract 3 -Adair Rippy Exemption
To Whom It May Concern:
RECEIVED JAN 2 5 2011
On January 23, 2001, High Country Engineering (HCE) personnel inspected the construction of the
ISDS located at Tract 3 of the Adair Rippy Exemption in Garfield County, Colorado. HCE's
original design called for a 4000 devapotranspiradon system with one 1000 -gallon septic tank. At
the time of inspection, the contractor had consttuctod a4200 sf(60'x70') system and installed a
1000 -gallon concrete septic tank and the necessary inspection wells and cleanouts. No backfilling
had taken place. The installation of the syslemvas in conformance with the intent of the design.
If you have any questions, or need additional information, please contact us.
Sincerely,
HIGH COUNTRY ENGINEERING, INC.
Roger D. Neal, P.E.
Project Engineer
RDN/djw
Cc: Scott Miller
923 Cooper Mess.
Samoed $b. CO sidMM
Ugh= 070)9454676 - (919)!{52555
14 ureas Drive Fps[ Su= 0-144
Food, CD 80112
TJ4.— (303) 9250544 - Fax (303) 925-0547
Scott Miller
'
Scott Miller ISDS - 2000004.32
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SCOTT MILLER
GARFIELD COUNTY, CO
INDIVIDUAL SEWAGE DISPOSAL SYSTEM
TRACT 3 - ADAIR AIPPY EXEMPTION
ASH
,MIref>B
HCH COUMIAV ENGINE
923 COOPER AV
GLE WOOD 9WldOE
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