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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
Owner's Name tiS( n1 vel P.aock"° • Present Address
Permit
4415
Assessor's Parcel No.
16(70 Ce-(04yCtceo,
System Location 40((Og Ca, -bo . c(e I
4-1L 343 -� a ('- Oo 37�'
Legal Description of Assessor's Parcel No
SYSTEM DESIGN/4
750 A
Septic Tank Capacity (gallon) e/ Other
30 Percolation Rate (minutes/inch) Number of Bedrooms (or other) .0.072,6r--
®,
Required Absorption Area - See Attached `� 9 4 � 3 egee V 3
Special Setback Requirements: 411 '4'11
1
Date .5 % inspector " :27Zear6.17-T "'I/fee-4~72
This does not constitute
a building or use permit.
Phone G-3 r A 4 V
f j . C lri
f
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before -- Covering installation
System Installer A�.C.G./�,
Septic Tank Capacity /�► 'O
Septic Tank Manufacturer or Trade Name
Septic Tank Access within 8" of surface '(,(X✓
Absorption Area
Absorption Area Type and/or Manufacturer or Trade Name
2,4".141 39'
Adequate compliance with County and State regulations/requirements
Other _/iA
Date 4,A -0o inspector 771Zji4,77
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 I, Petty Offense ($500.00 fine — 6
months in jail or both).
White - APPLICANT Yellow - DEPARTMENT
GARFIELD COUNTY SEPTIC PERMIT APPLICATION
108 81h Street, Suite 401, Glenwood Springs, Co 81601
Phone: 970-945-82121 Fax: 970-384-3470 / Inspection Line: 970-384-5003
www.earfield-county.com
1
Perk Fee: /�
/oc e,d
Parcel No: this information is available at the assessors office 974-945-9134)
Ds '432.1 cit, 3? S
2
Building Permit #:
tO32
Job Address: Of an address has not been assigned, please provide Cr, Hwy or Street Name & City) or and legal description
tA4'1 coy -to -ix CZ -D 1,OF, CA- ar m -Z . co
3
Issue Date:
(2 f
Lot Size: Lot No: Block No: Subd.I Exemption:
4
Owner: (property owner)
CIN 6r l (41 t -)ci--C K C 0
Mailing Address
Vie—u0 CV- Lt7td, CAMPIVOrt*
Ph:
qa - 7ZLt[f
Alt Ph:
5
Contractor:
6 2 vcUvtr lit 45 Gc A'tb—S
Mailing Address
4 tis, CR t , G
Ph:
q4 S —O t 47
Alt Ph:
6
..�—IDvA
Engineer:
co / (o� G�1�!
Mailin Address
Po� rag . (I Ai L Gn
h:
-49- Ce c,31
Alt Ph:
7
PERMIT REQUEST FOR: New Installation ( ) Alteration ( ) Repair
8
WASTE TYPE: 00Dwelling ( )Transient Use ( )Commercial or industrial ( )Non- Domestic wastes
( )Other .- Describe
9
BUILDING OR SERVICE TYPE: Y. the-mce
Number of bedrooms 2, Garbage Grinder ( )Yes KNo
10
SOURCE & TYPE OF WATER SUPPLY: (X)WELL ( )SPRING ( )STREAM OR CREEK ( )CISTERN
If supplied by COMMUNITY WATER, give name of supplier:
11
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to the Community System?
G/'w rxRA-t-f. — Z Mr i e5
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN
12
GROUND CONDITIONS:
Depth to 1,i Ground Water Table Percent Ground Slope
13
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS) PROPOSED:
K}Septic Tank ( )Aeration Plant ( )Vault ( )Vault Privy ( )Composting Toilet
( )Recycling, Potable Use ( )Recycling, other use ( )Pit Privy ( }incineration Toilet ( )Chemical Toilet
( )Other- Describe
14
FINAL DISPOSAL BY:
AxiAbsorplion trench, Bed or Pit ( )Underground
( )Wastewater pond ( }Other-
Dispersal ( )Above Ground Dispersal ( )Evapotranspiration ( )Sand filter
Describe
15
Will effluent be discharged directly into waters of the state? ( )YES ( )NO
16
PERCOLATION TEST RESULT: (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
No,_
Minutes per inch in hole No.2 Minutes per inch in hole
Name, address & telephone of RPE who made soil
Name, address & telephone of RPE responsible
absorption test
for design of the system,
17
Applicant acknowledges that the completeness of
the local health department to be made and furnished
issuance of the permit is subject to such terms and
reports submitted herewith and required to be submitted
and are designed to be relied on by the local department
unie I, - • d'ifitt any falsification or misrepresentation
a ;.4. .,.L.n for perjury as provided by law.
the application is conditional upon such further mandatory and additional test and reports as may be required by
by the applicant or by the focal health department for purposed of the evaluation of the application; and the
conditions as deemed necessary to insure compliance with rules and regulations made, information and
by the applicant are or will be represented to be true and correct to the best of my knowledge and belief
of health in evaluating the same for purposes of issuing the permit applied for herein. I further
may result in the denial of the application or revocation of any permit granted based upon said application
�,Lw..- t tn8
OW ` I 'ATURE DATE
STAFF USE ONLY
Permit Fee:
7,:g
Perk Fee: /�
/oc e,d
Total fees:
f
'30
Building Permit #:
tO32
Septic Permit #:
, ai L4 'IS
j
Issue Date:
(2 f
0`--05 X -
Building & Planning Dept:
yY/
APPRO,i .1
DATE