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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N. 214
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109 8th Street Suite 303 Assessor's Parcel No.
Glenwood Springs, Colorado 81601
Phone (303) 945 -8212 i
This does not constitute x
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. if
PROPERTY .1
Owner's Name Leonard E. EeAROtt Present Address 3080 Highway 13, Rifle Phone
4
s.
3080 State Highway 13. Rif is `
System Location . !
Legal Description of Assessor's Parcel No.
SYSTEM DESIGN 4
Septic Tank Capacity (gallon) Other �,� 7 p R ' _ U �- l7 `
a.e ? 2 0 "!e Fly, C.-ee p GQ c.A r !g I s"
� 2 a t 4i'9 ! Percolation Rate (minutes/inch) Ntimber of Bedrooms (or other) 3 4 r
40 i5 —te ' /3 k 4, I� eac 8 -eek tx! X3'
Required Absorption Area •See Attachad 4 0; re = N *� ? r R 4 'r R� '' ,2 r f f G e S ,( /°`/° p I 1
I J p1 e „ c r
'
Special Setback Requir G, d !�' Q �p 7t x' p c'J - O Y —. 34 ,
Date._/ w /3 Inspector 4ern (0.....-0.4‘..0
FINAL SYSTEM INSPECTION AND APPROVAL (as installed) It
Call for Inspection (24 hours s/ notice) Before Covering IInst�allllatiioon k
System Installer /(/�!'ti^Q �� ('�r'T�'"`�'$ "! ,
r 1 ,
Septic Tank Capacity §41%/2 L k
Septic Tank Manufacturer or TC Trade Name I/ ^I
.11
Septic Tank Access within 8" of surface �j / [/9
Absorption Area 4,_/3,
/ GiArv y -• � e[� ' J p
Absorption Area Type and /or Manufacturer or Trade Name f " iV! ? * 8 4 r n Y p
t Adequate compliance with County and State regulations /requlrement
I
Other
Date ` ? ? Inspecto (1:;:}' owl 62,40. Q44.
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
*CONDITIONS: i
1. All Installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chapter f
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 q
requirement of the permit and cause for both legal action and revocation of the permit.
3. Any person who constructs, alters, of Installs an individual sewage disposal system In a manner which involves a knowing and material I
variation from the terms or specifications contained In the application of permit commits a Class I, Petty Offense ($500.00 fine —8 §13
months In )all or both).
Applicant: Green Copy Department: Pink Copy 1
Application
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION Approval by
• _ p
County Official:
OWNER I ry v► e r � C, f f3 . Te »Teat (� et�rac � 0 .e Q", , "�_
ADDRESS 3D WV t'i h'..y /3 R1 fIc PHONE _ /"" nn
CONTRACTOR Dews To Lhs0'1 i5 V�
ADDRESS PHONE
PERMIT REQUEST FOR: ( ) New Installation ( ) Alteration (✓j 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 Gs'grFitiA
Near what City of Town 'RI Fi Lot Size 3, Q
Legal Description
WASTES TYPE: ( ✓) Dwelling ( ) Transient Use
( ) Commercial or Institutional ( ) Non- domestic Wastes
( ) Other - Describe
BUILDING OR SERVICE TYPE:
Number of bedrooms 3 Number of persons
( .Garbage grinder (✓f Automatic washer ( .-'1Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: ( well ( ) spring ( ) stream or creek
Give depth of all wells within 180 feet of system:
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: / �yti�t
Was an effort made to connect to community system? Ait
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(I 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 (t) Evapotranspiration
( ) Underground Dispersal ( ) Sand Filter
( ) Above Ground Dispersal ( ) Wastewater Pond
( ) Other - Describe:
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF TIIE STATE? �o
Paae 2
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 Mo._
Nance, 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 permft.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 sane 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. /J
Date Q..1 // / 993' Signed - �� e
PLEASE DRAW AND ACCURATE MAP TO YOUR PROPERTY
•
•
Page 3
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 arid 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
conini tmen is
Page 4
Aug.11 '93 10 :38 SANYU FAX +303- 625 -2888 P. 3
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Book 447
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Page 103
E lla sto hens
ItoMpBau No 754119 A Recorder.
LEON 3, BERNARD and
ANTOINETTE U. BERNARD
whouo address 1s Rif le 91Ai! tOCUMBPIIY Ill
County of Garf. fold , and elate of
JUL 1 I Inn
Colorado ,for Ilw cmmldernl{ou o1 Ten Doling and
Othor Valuable Consideration IlolktW Iri lmnrl paid,
hcrebr ocll(a) and quit clnfn(e) to VERNB r. ALBERTSON
and BETTY J. ALBERTSON
• whosoaddrnuab Rifle
Conuly of Garfield , and State of Colorado , tbn follewing real
properly, in the Couuly of Garfield , and $tat. of Colorado, to wits
An easement and right of way for the construction and
continued maintenance, improvement, repair or upkeep of
a water or nowngo waste disposal syctom over, under or
across a portion of the NE SEk Section 36, Tp. 5 S.,
R. 93 W. 6th P.M. described na follows:
angilnning at a point in the Westerly right of way
fence of Colorado State Highway No. 13, whence the
:southeast Corner of said Section 36 bears S. 11 ° 46'55"
E. 2426.75 feet; thenco N. 89 °36'00" W. 50.94 feel;
thence N. O1 °25'53" E. 60.00 feet: thence 5. 89 °16
U. 50.60 fent to a point on the Westerly right of way
fence of said highway; thence E. 01 °07'00" W. 60.00
foot along the Westerly right of way fence of said
highway, to the point of beginning, containing 0.0699
acros, more or less,
•
NO STATE DOCUMENTARY VEE REQUIRED — Consideration less than $100.00.
with all its epputicnancca. //'')
•
Bigued ilia r day of June , 19 73
'eeta
BTATl9 OF COLORADO,
County of Gat £Lela
The foregoing instrument was Dclmoteledged bofora ma this 1.1
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day of June , 10 73 , by LEON J. BERNARD and ANTOINETTE
D. BERNARD.
' ,, 4f,r. oolntnitaion expires
V rwas Any band and official Beal
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Aug 11 '93 10:37 SRNYU FAX +303- 625 -2888 P. 1
JOHNSON CONSTRUCTION INC .
1920 STATE HWY. 13
RIFLE, COLORADO 81650
• �LS7 i Office • 626.2251 i
tb Mit p61k • 626.2888
Facsimile Transmission Date :R- ./t• No. Pages W /Cover Sheet-E
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