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• GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
i
109 8th Street Suite 303
Glenwood Springs, Colorado 81801
Phone (303) 945 -8212
This does not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT � ' 1980 R}PAIift a building or use permit.
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Owner ') .' 1 C �� 'LA „ I,,,, 4 -
System Location (/ /(2 1 ,. � (.. /1/ ^ ✓1 (-- L(- le.)— "J �� / _ ( LA 1 I C ( . '- , /, /)( //
Licensed Installer _— .__ \\`` ♦ - _ �y _ ^�1
Conditional Construction approval is hereby granted1 A 1('. -' C. ..'_icial bri
L. 9” Tank or Aerated treatment unit.
Absorption area (or dispersal area) computed as follows: \Q\
Perc rate of one inch in � " _ minu)es requires apiinknum of / - sa. ft. of absorption area per bedroom.
l)1, S13(.�-).) 111'CxJ'V 0
Therefore the no. of bedrooms • x 1"'/ / sq. ft. mikimum requi Gent = a total of / f'ir sq. ft. of absorption area.
May we suggest / 1 : t / -: i , . l ; "/ , . i c c. v `'��
Date - I l ,QA l Inspector
FINAL APPROVAL Of SYST — - __T 1 T ��_ T -- __--
No system shall be d erred to be in ompliance 'th the Sewage Dispos I Laws until the assem led syste is approve. prior to cover•
ing an pprt. j
.L" - Se tic Tank acces for inspecti and clearing within 2" of grou id surface r aerated ccess ports -bove ground
su ace.
V Pr er materials a d assembly.
.! ,'r e name of se is tank or ae ated treatment unit..
v Ad aabsorpt' n_locdisper:s 11 area. .. _,.,._ 1 _ :.. ' .1s..:.;., ):__c,J
s!) lc �i - i A dequa t e compliance with permit requirement .
Z I�t I � . :AMA Adequate compliance with County and State regulations /requirements.
CI.1 ) C5 lx�� Other - - / _...
), ate) .Ill Ac
Date f7j± ��� Inspector s . AMY, /_ t 7 /7 -/
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 9,11S Revised 1984. ,
2. This permit Il valid only for ton action to structures which have fully complied with County zoning and building
requiremept4. Connection to or use any dwelling or structures not approved by the Building and Zoning office shall
automatically be a violation of a requlrem t of the permit and cause for both legal action and revocation of the permit.
3. Any peon who constructs, alters, or Installs n Individual sewage disposal system in a manner which involves a knowing
and material variation from the terms or specific ions contained in the application of permit commits a Class 1, Petty Offense
($500.00 fine — 6 mores in-lall�ol;
71 _1 - 1 l yV
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I . Applicant: Green opy Department: Pink Copy
Application
• ' INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION Approval by
��11 County Official:
OWNER,.I�IY\-SZ - /1 A
ADDRESS ((1 q diti a.4ll PHONE
CONTRACTOR
ADDRESS PHONE
PERMIT REQUEST FOR: ( ) New Installation ( ) Alteration fx) 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
Lest hoes, soil profiles in test holes. (See page 4.)
LOCATION OF PROPOSED FACILITY: Coun y ,S 1
Near what City of Town .. � � Ail ! , Lot Size 3 a 00 %(t.
Legal Description _ 1 1 ! ► � � `��: j� , Rh l.(
WASTES TYPE: J Dwelling ( ) Transient Use
( ) Commercial or Institutional ( ) Non- domestic Wastes
( ) Other - Describe
BUILDING OR SERVICE TYP
Number of bedrooms Number of persons rill)/ Q t
( ) Garbage grinder (4 Automatic washer ( ) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: ()d well ( ) spring ( ) stream or creek
Give depth of all wells within 180 feet of system: M .
If supplied by community water, give name or supplier: .cx.z k ¥ iL' , � h 9.Q'
GROUND CONDITIONS:
Depth to bedrock: _
Depth to first Ground Water Table:
Percent ground slope:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: n uyb "'CY1 ■ k 0
Was an effort made to connect to community system? 'p
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? 1 , Q
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Paae 2
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;OIL PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer.)
lljnutes per inch in hole No. 1 Minutes per inch in hole No. 3
M nutes per inch in hole No. 2 Minutes per inch in hole No.
lance, address and telephone of RPE who made soil absorption tests:
lame, address and telephone of RPE responsible for design of the system:
1pplicant 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
Iepartment 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 is'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 Signed
PLEASE DRAW AND ACCURATE MAP TO YOUR PROPERTY
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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
connitments.
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