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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N2 2188
109 8th Street Suite 303 Assessor's Parcel No.
Glenwood Springs, Colorado 81801 r
Phone (309) 945 -8212 I
This does not constitute 1
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. 4
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PROPERTY
Owner's Name Mountain Pat Control Present Address 3758 Highway 82, Glenwood phone 945 -5942 $
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System Location 3758 Highway 82, Glenwood Springs
Legal Description of Assessor's Parcel No. e
SYSTEM DESIGN I.
11 1
/(0 0 Septic Tank Capacity (gallon) Other )
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Businesses Percolation Rate (minutes /inch) Number of Bedrooms (or other) 4 Bus 3
1 Bath
Required Absorption Area - See Attached 8 Toilets *
8 -9 Sinks
Special Setback Requirements:
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Date Inspector
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FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation )
System Installer .�, i . C.. t.'''t" \ ,r i � ' a
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Septic Tank Capacity Ur (. (- t
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Septic Tank Manufacturer or Trade Name C f`''' N-- 4
Septic Tank Access within 8" of surface
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Absorption Area ✓ , • ' 1 '. ^ 1 2. ( , , A ,v C: CL L L ' 4 / / t: I }
A bsorption Area Type and /or Manufacturer or Trade Name (` (",-. , ": - 1 e
I Adequate compliance with County and State regulations /requirements
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Other
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Date / / "' � � /-" `/ 2 Inspector'7i (1.1%1 C d
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE 4 f
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•CONDITIONS:
i 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.
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 aviolation 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 )ail or both).
Applicant: Green Copy Department: Pink Copy
Application
iNIIIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION Approval by
— -- - -- —
County Official:
OWNER Oix „ J 7Ps{ (dff-a/ ' P_Uiwts
ADDRESS 37.01 Agy V. _ (Cc PHONE gyS-Syye 0o
CONTRACTOR eyy,QfrRQ,r/ Co.�ri, _
ADDRESS (.-c ' PHONE
PERMIT REQUEST FOR: - ( ) New Installation ( ) Alteration X) Repair
Attach separate sheets or report showing entire area with respec o surrounding areas,
topography of area, habitable building, location of potable water wells, soil percolation
test holes, soil profiles in test holes. (See ,page 1.)
LOCATION OF PROPOSED FACILITY: County CrAP._412 —_
Near what City of Town W o., �___ __ Lot Size
Legal DescriptionS(r / r $e • e•ti T 6S R 89u{ 6i Pm
WASTES TYPE: ( ) Dwelling ( ) Transient Use
(X) Commercial or Lnstitu11onal ( ) Non - domestic Wastes
( ) Other - Describe
BUILDING OR SERVICE TYPE: (vrt e -j sµ<ssaS _ 8-a - his ^ _ fr' wrr.Jzs
Number of bedrooms • r Number of persons
( ) Garbage grinder ( ) Automatic washer ( ) Dishwasher
SOURCE AIID 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:
Was an effort made to connect to community system?!
TYPE 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:
() Absorption Trench, Bed or Pit ( ) Evapotranspiration
( ) Underground Dispersal ( ) Sand Filter
( ) Above Ground Dispersal ( ) Wastewater Pond
( ) Other - Describe:
WILL EFFLUENT BE DISCHARGED DIRECTLY IIITO WATERS OF TIIE STATE? __ —_—
, 1
!Thor
•5011 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.
Nance, address and telephone of RPE who made soil absorption tes Ls: _
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 perrirft.is'sub,iect 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 0 ' 57) Signed afrA,X _
PLEASE DRAW AND ACCURATE MAP TO YOUR PROPERTY ar1
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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
comni Unen is .
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