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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit il'
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109 8th Street ` Suite 303 Assess
Glenwood Springs, Colorado 81801
Phone (303) 945 -8212
This de
INDIVIDUAL SEWAGE DISPOSAL PERMIT a builit.
PROPERTY
Owner's Name Wayne Coolly Present Address 200 W. 20th, 0328 Rule Phone_
System Location 1116 Mineota Drive, Mineota Estates, Lot 9, Silt
Legal Description of Assessor's Parcel No. (
SYSTEM DESIGN
'. V �� Septic Tank Capacity (gallon) Other
/ i, v C ' Percolation Rate (minutes/inch) Number of Bedrooms (or othe 9 ' a `
Required Absorption Area - See AtteF - / 2 Y2 a' • "' F' 4'944'4 / if %t, 9 ''3' •3 v �Q
7/1r y o /C ee_04
Special Setback Requirements: f
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Date 4 –' 9t Inspector C airn 61.4 i .( in 4, s
FINAL SYSTEM INSPECTION AND APPROVAL (as installed) 1
Call for Inspection (24 hours notice) Before Covering Installation d
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System Installer- (^d6'/ t
f i 9
Septic Tank Capacity J ? SO 6 t y I • !
Septic Tank Manufacturer Or Trade Name ea a 4
Septic Tank Access within 8" of surface _S� j
, i
Absorption Area 6 q
�7 4'
Absorption Area Type and/or Manufacturer or Trade Name /f�4
Adequate compliance with County and State regulations/requirements y¢S /
Other,
Date 1-, -9a 9 ,# In spector aa ` ✓ �t4-
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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
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 8
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 ($500.00 fine — 6
months in )all or both). -
Applicant: Green Copy Department: Pink Copy
Application
jhWDIVIDIJAI. SEWAGE DISPOSAT. SYSTEM APPLICATION Approval By
Cut, County Official
OWNER (.0C)-40 Cu t�, _
ADDRESS - •-• .• s • :. 4a . _ t2.50 PHONE coaS -�,a,) 5Q
ONTRACTOR �� L1 ...� [7 1 f�
ADDRESS Anc t'(o- (e 2_4 o PHONE (r0 :
ERMIT REQUEST FOR: (S) New Installation () Alteration () Repair
ttach separate sheets or report showing entire area with respect to surrounding areas, topography of area,
abitable building, location of potable water wells, soil percolation test holes, soil profiles in test holes
See page 4).
.00ATION OF PROPOSED FACILITY : County
tear what City or Town Lot Size 1®,Q9 ,Arms
.egal Description Lo - F 1z, 1 t' nom ��•�r` jy, ��b�o l t` ^,�
PASTES TYPE : ( ) Dwelling ( ) Transient Use
( ) Commercial or Institutional ( ) Non- domestic Wastes
( ) Other - Describe
IUILDING OR SERVICE TYPE: 3' R-im -c j, ^l\nma
Dumber of bedrooms 3 Number of persons 7
4, Garbage grinder ($ Automatic Washer (4 Dishwasher
.O1 JRCE ANT) TYPE OF WATER SIMPLY: (y,) well () spring () stream or creek
3ive depth of all wells within 180 feet of system: C6 OW �, (,J.44 rt . ,_ t h,( 1� J- ,.>n
f supplied by community water, give name of supplier:
3RO1 JNJ) CONDITIONS:
)epth to bedrock:
)epth to first Ground Water Table:
'ercent ground slope:
)ISTANCE TO NEAREST COMMUNITY SEWER SYSTEM. u n-' t Lis
Vas an effort made to connect to community system? N' 6-
I'YPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
00 Septic Tank ( ) Aeration Plant ( ) Vault
( ) Vault Privy ( ) Composting Toilet ( ) Recycling, potable use
( ) Pit Privy ( ) Incineration Toilet ( ) Recycling, other use
( ) Chemical Toilet ( ) Other - Describe:
•INAL DISPOSAL BY:
(,q 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? NO
)11. PERCOT.ATION TEST REST JI.TS: (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. —
ame, address and telephone of RPE who made soil absorption tests;
!ame, 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 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 understand 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 le
action for perjury as provided by law.
Date 3- 7- ! id `I Signed azin.ue-
®` 1/4
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p1.EASE. DRAW AN ACCT JRATE MAP TO YOI JR PROPERTY
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PLOT PLAN AND DESIGN FRATI1R ES
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 commitments.
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