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' GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit Nr 2 219 i
109 8th Street Suite 303 Assessor's Parcel No.
Glenwood Springs, Colorado 81601
1 �. Phone (303) 945-8212
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This does not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT; a building or use permit.
PROPERTY
Owner's Name Jacqueline MOROr Present Address P.O. BOY 44 9 e New Caatta Phone_ R76 -9(143
System Location Lot 16, Sierra Vieta /LC ratter)! Retail 991 , R11 r
Legal Description of Assessor's Parcel No. r
SYSTEM DESIGN
h n (1 0 Septic Tank Capacity (ga Other. 7 ✓ J7
/ -4..2 O 0 4 tr✓ a & Ar, ‘ 421213 - =
/ . I ^1 �A1 l ry P ercolation Rate (minutes/inch) Number of Bedrooms (or, o her) 3 (? / 4:4 f l
C �l [� � ..
p .`.. / G p X l� /' / / y / '/) �1, r �� r
/! J " I - ` ��-4— .1. . Q . / L k r � l i / l . � k` i: f :.J
Required Absorption Area - See Attached ` r
5,2 // u . , Xy,f.R7)- tom-.- tr Z S' C., 4A /
Special Setback Requirements: 1 j /t � C0 to ^ tic en / / / a., /.*. f.4
Date G " 1 r."_ 7 Inspector C 3-,_, a? A-41 cn1.k ,r
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FINAL SYSTEM INSPECTION AND APPROVAL (as installed) Y
Cali for Inspection (24 hours notice) Before Covering Installation F
System Installer
Septic Tank Capacity 4 ace j
a
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Septic Tank Manufacturer or Trade Name .
Septic Tank Access within 8" of surface X 945
Absorption Area 5 9 4L
Absorption Area Type and /or Manufacturer or Trade Name 1,() Fi ) /-rt%
Adequate compliance witthQounty and State regulations /requirements ?XS
Other '"`'.
Date 70 'n7A ^Ci, ' Inspector` -0.:.
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SI
*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.
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
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!, Petty Offense ($500.00 line — 8
months in )ail or both).
Applicant: Green Copy Department: Pink Copy
Application
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INDIVIDUAL SEWAGE DISPOSAL SYS1IIl AI'I'LICAIION Approval by
I - -- County Official:
OWNER j n . .c5iue)tAe, oaP�
- - --
ADDRESS FO x. y3 t /lbl(7_PI1011E 19la Guys' �
CONTRACTOR ke,r,,, (a es --i'n � �,� /
ADDRESS 3 1 0 y G „ , _ ' J 3 31 0 S' I f Ca R/65._ �1>11o1N. 8�6 X30 --
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PERMIT REQUEST FOR: p) New Installation ( ) Alleralion ( ) 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 r; I -L -- ___. - --
Near what City of Town S' 1.01 . Size 3(o q 5as .
Legal Description aK 33/ �� - , _ - - /21,a tit-2
WASTES TYPE: ( Dwelling ( ) Mansion'. Use -
( ) Conxnercial or Institutional ( ) Iron- domestic Wastes
( ) Other - Describe _� - - -- -- __________ — _ - - - - --
BUILDING OR SERVICE TYPEPr■cnosy Kie cleAce
Number of bedrooms 3 / - • Plumber of persons A,
(-k) Garbage grinder ("() Automatic washer (X) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: , (A) well ( ) spring ( ) stream or creek
Give depth of all wells within 180 feet of system: NohtE ___________
If supplied by community water, give name or supplier:_ -Ea
GROUND CONDITIONS:
Depth to bedrock: — - -- -- - - - _A. — -- --
Deptlr to first Ground Water Table: _ __._ �__—
Percent ground slope: - ,-------- __ -- -_ -- __ - ---
DISTANCE 10 NEAREST COMIIUIIl1Y SEWER SYSILM: __ _ - - __
Was an effort tirade to connect Lo community system? - _
TYPE OF INDAY4DUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(//) Septic Tank ( ) Aeration Plant ( ) Vault
( ) Vault Privy ( ) Composting Toilet ( ) Recycling, potable use
( ) P11 Privy ( ) Incineration toilet ( ) Recycling, other use
( ) Chemical Toilet ( ) Other - Describe: _
FINAL DISPOSAL BY:
(! Absorption Trench Bed r Pit ( ) Evapotranspiration
( ) Underground Dispersal ( ) Sand Filter
( ) Above Ground Dispersal ( ) Wastewater fond
( ) Other - Describe: --- ------
WILL LEFLUEUT BE DISCHARGED DII(EC1LY 11110 WATERS OF 1111 S1ATG7 N _
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•501. PERCOLATION ZEST RESULTS: (lo be completed by Registered Professional Engineer.)
Minutes per inch in hole Iio. 1 Minutes _per inch in hole Ilu. 3
Minutes per inch in hole No. 2 Minutes _ per inch in hole Ito. ,
Name, address and telephone of PPE who made soil absorption tests:_
Name, address and telephone of PPE responsible for design of Lite 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 periaft.ls subject to
such terms and conditions as deemed necessary to insure compliance w11.11 rules and regulations
adopted under Article 1U, Title 25, C.R.S. 1973, as amender. the undersigned hereby certifies
that all statements made, information and repots submitted herewith and required to be
submitted by the applicant are or will be represented Lo be true and correct to the best
of my knowledge and belief and are designed to be relied on by the 1ocal.deparlmen1 of health
in evaluating the same for purposes of issuing the permit applied for herein. 1 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 o2 a / Signed triaLS/11„ir
PLEASE DRAU AND ACCURATE MAP 10 YOUR PROPERTY
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PLOT PLAN AND DESIGN rtmullla:
Include by measured distance location or 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
comnitments.
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