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% INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION Approval by
OWNER County Official:
ADDRESS o 96 4_ �G p,„‘ PHONE Th6- c 26oz.
CONTRACTOR_ Sf_r; A, r
ADDRESS 5 p - PHONE 5,q,,,.,,T
PERMIT REQUEST FOR: ( ) New Installation ( ) Alteration (70) 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 FACILITY: County (I p.e. p ;t d
Near what City of Town 5 j I- T Lot Size . 9. A AR12, 5
Legal Description resrT.2H, See,/,00 4/ 7An.A .sL,i. F .Se,,, '(9, C,aA, 47 4.40-
,0r> .L4 6 a Reining) „c m ardA,g a> CI,n.N eve P /ad j oalb A:..q. es °MIAA Paw. G
WASTES TYPE: ( ) Dwelling ( ) Transient Use
( ) Commercial or Institutional ( ) Non - domestic Wastes
( Other - Describe 1:: A 5i_ mf k „— Cjzft Ma5P • nj4r,,, tA_S A, I44 41.4-ti3
BUILDING OR SERVICE TYPE:
Number of bedrooms n1/ p Number of persons WA
( ) Garbage grinder ( ) Automatic washer ( ) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: ( () well ( ) spring ( ) stream or creek
Give depth of all wells withinag 7 feet of system: , -- ., • 1.0 , :s :inn' Pn/KAti
If supplied by community water, give name or supplier:
GROUND CONDITIONS:
Depth to bedrock:
Depth to first Ground Water Table:
Percent ground slope:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: - i.7,.;IE• s
Was an effort made to connect to community system? ,;h
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
( ,r-) 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
( -F) Other - Describe: 17 iT 4I S .� r.., et1. •n„,,, 5 dr II
•
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE?
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Page 2
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PLOT PLAN AND DESIGN FEATURES:
Include by measured distance location of wells, springs, potable water supply
lines, cisterns, buildings, property lines, subsoil drains, lake, water course,
stream, dry gulch and show location of proposed system by direction and distance
from dwelling or other fixed reference object, and additional submissions in
support of this application such as data, plans, specifications, statements and
commitments.
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Page 4
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SOIL 'PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer.)
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
purposes of the evaluation of the application; and the issuance of the permit i -S subject to
such terms and conditions as deemed necessary to insure compliance with rules and regulations
adopted under Article 10, Title 25, C.R.S. 1973, as amended. The undersigned hereby certifies
that all statements 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 under-
stand 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 per-
jury as provided by law.
Date /1(01.r l Signed C�
lre� /',
PLEASE DRAW AND ACCURATE MAP TO YOUR PROPERTY
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MAR 211988
0 I (3 ,*It.LU COUNTY
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h, U i I ti ti WILL DE ADDED TO ALL ACCOUNT BALANCES THAT EXCEED 30 DAYS.
MARPLE ENTERPRISES - Grand Junction, CO
COPELAND SHIP TO
CONCRETE INCORPORATED
Manufacturers of Precast Concrete Products
Also Distributor of Related Items
28803 U.S. Hwy. 6 Rifle, Colorado 81850
826.1112
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� HARGE I RESALE MDSE. RETD. JOS NO I L O. NUMEER
IrrOMER NO. 'SALESMAN PHONE NO. PERSON CALLING , JOB NAME
% mss X 71,— Gp Z Am
vaONT I ITEM LNi00sa -- oESCRIPT1oN UNIT PRICE EXTENSION
1 61 / /,7 /
/ </ 1 `l = /z-, -. 1
1 _ 3 1 11 iff X G ' i 1 e t.EF.t Ones()
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WARRANTY ON ABOVE - LISTED MATERIAL (INCLUDING NEW MACHINES, PARTS & SUPPLIES) IS LIMITED
TO THAT AS PROVIDED BY THE MANUFACTURER, COPIES OF WHICH ARE AVAILABLE UPON REQUEST.
WER'S SIGNATURE - CUSTOMER'S SIGNATURE
NOTICE STATE TAX
SS IF PAID BY GARFIELD COUNTY TAX
1 DISCOUNT AFTER THIS DATE. THIS IS A CASH DELIVERY CHARGE
3COUNT AND MUST BE PAID ON TIME TO TAKE
SCOUNT.
THANK YOU TOTAL
Please pay on invoice. Statement will be sent on request only.
f A FINANCE CHARGE OF 11% PER MONT�y (WHICH Is AN ANNUAL PERCENTAGE RATE OF 18 %)
N2 U i f n "1 WILL BE ADDEO TO ALL ACCOUNT BALANCES THAT EXCEED 30 DAYS.
MARP LE ENTERPRISES —Grano Junction, CO
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EXTENSION
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In the event of delivery beyond curb line this company will
2 not assurnB habill y pl. da s ', , e
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mo i . t x , ! �f�z:,.�'f „.kft5 I .:Saut'r''. hNd 4 l f , �71
l. $4:4431.... 1 iq �Pi rR+S a ,n, .;
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invoices Due on 10th (1 the Month - q TOTAL COST — ` - --
FINANCE CHARGE OF 2% per Month,
which is an ANNUAL RATE of 24 % - •i • chn {all5 ''? °' ,f nit
' following
lowing bIIIing date
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ARRANTY ON ABOVE - LISTED MATERIAL (INCLUDING NEW MACHINES, PARTS & SUPPLIES) IS LIMITED
TO THAT AS PROVIDED BY THE MANUFACTURER, COPIES OF WHICH ARE AVAILABLE UPON REQUEST.
w[R S SJGhAI LIED I CUSTOMER '5 SIGNATURE
NOTICE S'A'E TAX
SS IF PAID BY °AR "ELD COUNTY TAX
DISCOUNT AFTER THIS DATE. THIS IS A CASH DELIVERY CHARGE
SCOUNT AND MUST BE PAID ON TIME TO TAKE
SCOUNT.
THANK YOU TOTAL
-
Please pay on invoice. Statement will be sent on request only.
N. } �? rl Q A FINANCE CHARGE OF 1 PER MONTH (WHICH IS AN ANNUAL PERCENTAGE RATE OF 18 %) 1
__ WILL BE ADDEO TO ALL ACCOUNT BALANCES THAT [WEED 30 DAYS
MARP LE ENTERPRISES -Grand Junction, CO