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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N: 2 0 4 � 4
109 8th Street Suite 303 A is Parcel No.
Glenwood Springs, Colorado 81801 2407-184-01-014 t
Phone (303) 945 -8212
This does not constitute 1
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. t
PROPERTY
t
Owner's Name Fred 8.2covic Present Address P.O. Box 428, Carbondale phone 963 -0420 t
System Location 0617 County Road 113, Carbondale
Legal Description of Assessor's Parcel No.
SYSTEM DESIGN $
/ J POO) Septic Tank Capacity (gallon) r Other '. j K
mi)'Ip re XI-flutes/inch) si r s r 3 S
/....,/6 , a Pereolati Rate mutes /inch) Number of Ballrooms (or other) p q
Required Absorption Area - See Attached 8 i i 5 .a -Q- - fis> CZ -r - at f ,,,./ I
f •)' n cr 8 V - Cd f
Special Setback Requirements: / � 0 r �� , .2 7 r-,,,,
r 0 'N t o A ti - ,�q ,
Date 3 -10-73 Inspector 1Mi L ,
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer fry. ceJ 2i )i't
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Septic Tank Capacity / 4 n n ) i1 - 'a' { yf ,,
Septic Tank Manufacturer or Trade Name ` A { . ,
Septic Tank Access within 8 of surface (!
K Absorption Area / X .9 0 /'
Absorption Area Type and /or Manufacturer or Trade Name eLLtf - , f f.
( 27 . 04-,1 it y/ e - r� i
Adequate compliance with County and State regulations /requirements , r
Other `''- /�(,r1/ t SpI
Date C.. -..di n l - '7 2 Inspector ¶j>tni l_Y� u-f'..N4 R
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. i y
2. This permit Is valid only for connection to structures which have fully complied with County zoning and building requirements. Con - 1$7
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 — 8
months in jail or both).
Applicant: Green Copy Department: Pink Copy
Application
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION Approval by
— — — — County Official:
OWNER _ Q CCU Y
luDltESS _ U 61 7 C o K n Ty rd( / /.S PHONE 963 -a race
:oNT RACTOR - _ - 0 W h c/ _
ADDRESS_-_. pp-- r3 1 �' ra . 0 4 PHONE ,Z al) z
'ERMIT REQUEST FOR: ()< ) New installation ( ) Alteration ( ) Repair .
\ttach 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 holes, soil profiles in test holes. (See page 4.)
'.00ATION OF PROPOSED FACILITY: County 6:4,44,..
.
lear what City or Town ��.,Ljo,a�G�?� - Lot Size ,3, o/ 4Cvc_s
' egal Description _ - -- -- �— -- —
WASTES 1YPE: ( )0 Dwelling ( ) Transient Use
( ) Connnercial or Institutional ( ) Non - domestic Wastes
( ) Other - Describe_,_
BUILDING OR SERVICE TYPE:_____ _
umber of bedrooms _ _ Number of persons 2
(X) Garbage grinder (X) Automatic washer (x) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY_: (x) well ( ) spring ( ) stream or creek
Hive depth of all wells within 180 feet of system: /(o „ s_
IF supplied by community water, give name or supplier:_
GROUND CONDiTI01NS: /
Depth to bedrock: k3 o? hewre- bvk be.* s /ors- tiA)1
liepth to first Ground Water Table: 7J'D' 3""
I'ercent ground slope: J 7, +a Ott kaw«
DISTANCE 10 NEAREST COMMUNITY SEWER SYSTEM: .9 ht; res
Was an effort made to connect to community system? No
fYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(X) 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: •
('x) 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? V i.
•
•
1
d)IL 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 Mo.
lame, address and telephone of RPE who made soil absorption tests:_
!
lame, address and telephone of RPE responsible for design of the system:
\pplicant 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
lepartment to be made and furnished by the applicant or by the local health department for
nrrposes of the evaluation of the application; and the issuance of the pernift. 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
Lhat all statements made, information and reports submitted herewith and required to be
:Omitted by the applicant are or will be represented to be true and correct to the best
if 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
it revocation of any permit granted based upon said application and in legal action for per-
jury as provided by law.
na to - -_ -- /-z — 0 2 2 =� ,� _ Signed 74/1C-ri\e--1 PLEASE DRAW AND ACCURATE MAP TO YOUR PROPERTY
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