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`.., GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N: 3651
109 Sth Street Suite 303 Assessor's Parcel No.
Glenwood Springs, Colorado 81801
Phone (303) 945.8212
`{ This does not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit.
PROPERTY
Owner's Name �c- fX�/1/'�/7�rcVC'4
1— [UrAesent Address a/O RIYtQ &6y /hues Phone
System Locatii Do', Pa ('a cl ude Co 8 635
Legal Description of Assessor's Parcel No.
,
SYSTEM DESIGN
i
I l ooQ Septic Tank Capacity (gallon) Other
Percolation Rate (minutes/inch) Number of Sedroo (or other)
Required Absorption Area •See Attached
/3�93 1
i Special Setback Requirements: "7 %2+� LIP.-Gt', or o1 (0 rix S f
^ 30
Date �• �S �27Z Inspector /Ow, Cl Ina" -e,
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
p Call for Inspection (24 hours notice) Before Covering Installation
jItl
{ System Installer
Septic Tank Capacityd� O
Septic Tank Manufacturer or Trade Name
t
Septic Tank Access within 8" of surface
Absorption Area 22-
Absorption Area Type and/or Manufacturer or Trade Name
4
I Adequate compliance with County and State regulations/requirements
N
Other
Date S 1� Z Inspector
f
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
*CONDITIONS:
1. All Installation must complywith all requirementsof 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 QCee not approved by the Building and Zoning office shall automatically be a violation Ora
requirement of the permit and da a h49gal action and revocation of the permit.
( 3. Any person who constructs, al(,Ors,orlt�gOean Individual sewage disposal system in a mannerwhich involves a knowing and material
variation from the terms or specifications contained In the application of permit commits a Class I, Petty Offense ($500.00 fine — 8
months In )ail or both).
White - APPLICANT Yellow - DEPARTMENT
t
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OWNER _
ADDRESS
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
rN �3�i.�.�
CONTRACTOR
ADDRESS
PERMIT REQUEST FOR tYNEW INSTALLATION ( ) ALTERATION ( ) REPAIR
Attach separate sheets or report/sh'owing entire area with respect to surrounding areas, topography of area, habitable
building, location of potable water wells, soil percolation test holes, soil profiles in test holes (See page 4).
Near what City of Town V e77a mt p 7 /r/70S Ot Size of Lot .S /r .� ACA
Legal Description or Address /V C ��i S` y`/ e C /5—,; �rf/I''1 %S /P p
WASTES TYPE: ( DWELLING 2O � ��� )� RANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE
Number of Bedrooms
Number of Persons
Yq Garbage Grinder P6 Automatic Washer O6 Dishwasher
SOURCE AND TYPE OF WATER TPP Y• (>$ WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:? mt les
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 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 4 Y
Percent Ground Slone / 5- °10
SEWAGE DISPOSAL SYSTEM PROPOSED:
( SEP1 jC �TANK ; ( ) AERATION PLANT
( ) • VAULT PRIVY ( ) COMPOSTING TOILET
( )'' PIT�PRIVY
( ) CHEMICAL TOILET
FINAL DISPOSAL BY:
) VAULT
) RECYCLING, POTABLE USE
( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
( ) OTHER - DESCRIBE
) ABSORPTION TRENCH, BED OR PIT
00 UNDERGROUND DISPERSAL
) ABOVE GROUND DISPERSAL
( ) EVAPOTRANSPIRATION
( ) SAND FILTER
( ) WASTEWATER POND
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE?_ /2 a
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. I further understand that any
falsification or misrepresentation may result in the denial of the application or revocation of any permit granted based
upon said application and in legal action for perjury as provided by law.
_� -� /1.. ✓ � tel/ '. '� i
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTYI!
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