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(fl Jt.` GARFIELD CQUNTY BUILDING AND SANITATION DEPARTMENT
109 8th Street Suite 303
} Glenwood Springs, Colorado 81801
([ Phone (303) 945.8212
S
-INDIVIDUAL SEWAQE DISPOSAL PERMIT
_4 PROPERTY
' I{r
r F Owner's Name
e
System Location_
q
730/ 0
*36009,
Permit N° 3689
Assessor's Parcel No.
This does not constitute
a building or use permit. P
�C
Preesseslnt Address� l� . a 1` \� iC O' L oni J -_d4j Z
Legal Description of Assessor's Parcel No.
>s-SYSTEMDESIGN jl;I4e,A ahathboed iN 4
x t
Y
w
r
44 ews-
yy Septic Tank Capacity (gallon) Other
11
!JD km(lkrcolation Rete (minutes/inch) Number of Bedrooms (or other)
3
Required Absorption Area - See Attached
Special Setback Requirements:
I?
. .. O
Date ` / 02� Inspector
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installs
System Installer '' LL,, ��V/ ) v o
Septic Tank CapacllyJ�
Septic Tank Manufacturer or Trade Name
Septic Tank Access within 8" of surface .
1VV
Absorption Area
Absorption Area Type and/or Manufacturer or Trade Name
Adequate compliance with County and State
M
i
Other
- b�
Date /� ]
Inspector
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
*CONDITIONS:
1. tion,''00
plywith all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chapter
25, Article C.R.V. 19 3, Revised 1984.
2. Thispermitis Iidwnl
or connection to structures which have fully complied with County zoning and building requirements. Con-
nectlontoorus(tw(tha
dwelling or structures not approved by the Building and Zoning office Shall automatically be a violation ora
requirement of the per'
t and cause for both legal action and revocation of the permit.
3. Any person whoconstru
Is, alters. orinstallsan Individual sewagedisposal system In a mannerwhich involvesa knowing and material
variation from the term
r 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
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER 05F. 'q- _5htAP-0AJ 0&)0i6ttE7
DD PHONE
CONTRACTOR i� 4i�i�s_iilh�ry�i9�r��r-ice ��� ,0jQAt6+r44r,4;0tJ
PERMIT REQUEST FOR ()4 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 F /A�CILITY•
Near what City of Ti' ct2 ES t
Legal Description or Address Lot 6 . 1--, L ; AJ 6 2 4'( j - t c C vc ),! ES
WASTES TYPE:
BUILDING OR SERVICE
0 DWELLING
( ) COMMERCIAL OR INDUSTRIAL
( ) OTHER - DESCRIBE
( ) TRANSIENT USE
( ) NON-DOMESTIC WASTES
Number of Bedrooms 5 Number of Persons
0 Garbage Grinder Automatic Washer (>0 Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: ( ) WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: Art -C �s c6C
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: �i n sic S
Was an effort made to connect to the Community System? /UCAIE /-)-ol it -A8 t C7
A site plan is reauired to be submitted that indicates the followine 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: (septic tank &leach field)10 feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT
A SITE PLAN.
GROUND CONDITIONS:
Depth to fust Ground Water Table
Percent Ground Slope
TYPE OF INDIVIDUAL: SEWAGE DISPOSAL SYSTEM PROPOSED:
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:
( ) 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?/VL
PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer, if the Engineer does the
Percolation Test)
Minutes --------per inch in hole No. I Minutes
_per
inch in hole NO. 3
Minutesper inch in hole No. 2 Minutes
oer 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.
Signed( /CLQ eI' & TIt 0tVP1C-UQ7 s Date-'" 2clo�
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTYI .
�-�M IS NDi2TM
�Grt LGT
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mEsq na,ur
sr �
y gibs m �sA r7a, ✓F
65-ctr�g-
Designate North Arrow
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Lb'r CZAIr7kUC5 Ovel2,fr
Your Plot - Shape to Fit
(No
�D
Your Neighbor's
Name & Address
TK*1 K
iC Sof IN '5"rcSrMEM
Le*clt FIeLD
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Your Neighbor's
Name & Address
OPEA1DACE
W-E'SA
Locate well, all streams, irrigation ditchs, and any water courses. Drawin your ous
septic tank & system, detached garages, and driveway.
If a change of location is necessary, you must submit a corrected drawing, before a
Certificate of Occupation will be issued.
County Road (Note the Road Number and Name)
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