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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit 2978
109 8th Street Suite 303 Assessor's Parcel No.
Glenwood Springs, Colorado 81601
Phone (303) 945-8212
This does not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit.1
PROPERTY
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Owner's Name °N 'Q-Present Address? O• 1 t 3 M1' ` ( L Phone & 26 - 4 i ys
System Location C 12 'Z (o 1 r oA - u
e
Legal Description of Assessor's Parcel No.
t0C t.6 Ac: H— P IC t0 7 1U9YT
SYSTEM DESIGN L 6 AC 41 - C H 4 tit Gen - 060 3 S V til I T S 7 G S9 LY
h,., ///i,,TACMe HC'J Zg r
V v Septic Tank Capacity (gallon)Other 7 r"19
r, 0 Percolation Rate (minutes/inch) Number of Bedrooms (or other)
Required Absorption Area - See Attached
Special Setback Requirements:
Date X _ Z Q Inspector :--
i
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation i
System Installer D • f
Septic Tank Capacity i
Septic Tank Manufacturer or Trade Name 9 ,M ° '{ 41 44
Septic Tank Access within , 8" of surface y"e
Absorption Area J T 9
Absorption Area Type and /or Manufacturer or Trade Name _ i A( r ith 9 .4atit
Adequate compliance with County and State regulations/requirements L0
Other \
Date 9 / q 1 r Inspector L
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 materialvariationfromthetermsorspecificationscontainedintheapplicationofpermitcommitsaClassI, Petty Offense ($500.00 fine — 6
months In )ail or both).
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White - APPLICANT Yellow - DEPARTMENT
2 Jun -02 -98 10:27A Stella Archuleta 970 -945 -7785 P.03
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
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OWNER .6o,20 /Ke/fy Mcte
ADDRESS P O. look 21.? Rifle lo WO PHONE 62S -- 4P9S
CONTRACTOR <to i-/ C 2Ood
ADDRESS San PHONE S4 # fl
PERMIT REQUEST FOR X 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).
J OCATION OF PROPOSFI) FACE ITV
Near what City of Town Siff Co /orA0O Sin of Lot Acre.S
Legal Description or Address /o 2/ Rat--ii 041L£ y rc—lva20 S4b,0r CS iO"CDinfy leciWASTESTYPE:DWELLING TRANSIENT USE Zed
COMMERCIAL OR INDUSTRIAL NON - DOMESTIC WASTES
OTHER - DESCRIBE
BUILDING OR SERVICE TYPE:
Number of Bedrooms 9 Number of Persons Z
Garbage Grinder 5 Automatic Washer Dishwasher
SOURCE d,ND TYPE OF WWA st S iPPL.Y: 00 WELL SPRING STREAM OR CREEK
If supplied by Community Water, give name of supplier:4/7*
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: 8 r J tS
Was an effort made to connect to the Community System? AO
I.l +' t.,' I. I u It. -.'t. J1.1 fir . U 1/ I
Leach Field to Well:100 feet
Septk Tank to Well:50 fat
Leach Field to Irrigation Ditches, Stream or Water Coarse:SO feet
Septk System to Property Limes:10 feet
YOUR INDIVLDIIAI. SEWAGX DISPOSAL SYSTEM PERMIT WILL. NOT BE LSSI IEI)
Wmtotrr A SITE PLAN,
GROLJNDCOND177ONS:
Sit p
Depth to first Ground Water Table wiSit geCA ID Dr9 ropilt• Note, we
Percent Ground Slope Z.
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9O'd 98LL 946 - 0L6 s;oLn4a -4V v1L04S VIZ :Ot 06- ZO -unr
Jun -02 -98 10:28A Stella Archuleta 970 -945 -7785
er
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TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
X) 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:
4 ABSORPTION TRENCH, BED OR PIT(TA/1 lTR*TORS) EVAPOTRANSPIRATION
UNDERGROUND DISPERSAL SAND FILTER
ABOVE GROUND DISPERSAL WASTEWATER POND
OTHER - DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? AA°
pPRCOLATION TRST RESI11.TS (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 bole No. 2 Minutes par inch in hole NO.
Name, address and telephone of APE 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 tents and conditions as deemed necessary to insure compliance with rules and regulations
made, information and reports submitted herewith and required to be aubinitted 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 penult applied for herein, I further
understand that any faisification or misrepresentation may result in the denial of the application or revocation of any
permit granted • said application and in legal action for perjury as provided by law,
Signed fitS i VG- Date 3 /7
P • • SE RAW AN ACCURATE MAP TO YOUR PROPER I1
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