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GARFIELD COUNTY BUILDING AND. SANITATION DEPARTMENT Permit N . 2254
109 8th Street Sulte 303 A is Parcel No.
Glenwood Springs, Colorado 81601
Phone (303) 945.8212
This does not constitute a
INDIVIDUAL SEWAGE DISPOSAL PERMIT , a building or use permit. k
) PROPERTY ..
Owner's Name
Michael Hammes Present Ad dr e ss ' 5363 100 Road. Carboudeleone_ 963 -9298
System Location 5363 County Road 100, Carbondale
• Legal Description of Assessor's Parcel No.
SYSTEM DESIGN ("
There is * 1230 gallon septic tank on the property, an additional 143 square foot of
Septic Tank Capacity (gallon) Other . infiltrator . bsd has bean added.
Percolation Rate (minutes/inch) Number of Bedrooms (or other)
Required Absorption Area • See Attached
Special Setback Requlremas:
Date ilnspector 1
-- FINAL SYSTEM INSPECTION AND APP YALt(as installed)
Call for Inspection (24 hours notice) B re Covering Installation �y/�
System Installer .'S•j .Am' '✓I "'k AI ' ' - ,;y"
Septic Tank Capacity f k
Septic Tank Manufacturer or Trade Name • -
�e ertH/S. -4 , �
111 ' ¢
F; 3,1
Septic Tank Agoess within 8" of surface %'y ( `t ��
t fs
Absorption Area /�/ } in', cc Lied. Absorption Area Type and /or Manufacturer or Trade Name -¢- ,
to compliance with Count and State Adequate County regulations/requirements
9 q
A
Other • �'^�^����,,, }
Date '- .9 - -/ / Inspector fr" 7 (OW ' F
, RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE i
•CONDITIONS: i t
1. All Installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chapter i
25, ArticiejQ,C R S. 18p,,Revlsed 1984, r:
2. This permit is valid only fol. connection to stfu attires whiohttave fully com lied with County zoning and building requirements. Con- 1
nection to or use with any dwelling or structures not approved by the Builr ng and Zoning office shall automatically bea violation or a
requirement of the pefinit and cause for both legal setieaend , revooatteaotdhe.permil< .:: , :: -
3. Any person wllo conatruole, re, o
al�e�rislah`s an fn`ilrJid�i1'�s6wG6e dl6pbsel'sy$lbin fnemennerwhicfiinvolveseknowing and material
variation froth the terms&or specifications contained in the application of hermit commits a Class I, Petty Offense (5500.00 fine — 6
months in )all or both) if
Applicant Green Copy Oepartmenti; ift a ry{
Application
JNDIVIDTJAI. SEWAGE DISPOSAI. SYSTEM APPJ.ICATION Approval By
M1 County Official
OWNER M1GIACI_ N An.M < 0 j
ADDRESS ` . �� 3 ( 3 I tr 24 , PHONEWAi yz � .
CONTRACTOR C tt`'LM 1 C N.q tq C- I2DA-)SS L) 'C, .
ADDRESS `P t::.• $ a>C 44c ak i' -Od'LC PHONE `k03.144
PERMIT REQUEST FOR: () New Installation 0 Alteration () 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).
J.00ATION OF PROPOSED FACIJ.ITY : County 1
Near what City or Town C' - R- (?flJDM - Lot Size 91.9Sl f `/93 9 7
Legal Description
WASTES TYPE : k4 Dwelling () Transient Use
( ) Commercial or Institutional ( ) Non - domestic Wastes
( ) Other - Describe
BUILDING OR SERVICE TYPE: -NC /6 fez -w
Number of bedrooms N} of persons
( ) Garbage grinder ( ) Automatic Washer ( ) Dishwasher
,SOI IRCR AND TYPE OF WATER S1 JPPJ.Y; well () spring () stream or creek
Give depth of all wells within 180 feet of system:
If supplied by community water, give name of supplier:
(iROTJND 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:
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:
Pic), 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? /0
PIA
TOIL 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. _
Name, 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 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 legal
action for perjury as provided by law.
Date ?.f 9 y Signed ;at
pT,EASE DRAW AN ACCT JR ATE MAP TO YOT JR PRO','
in 40T PI AN ANT) T)FSICON FF,ATI TR 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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SHIP TO . 42, , "/ . °, �
COPELAND SN i IP T -
ED CONCRETE INCORPORATED - 1 .r -? - . - - ea - :- 7..
.,
Manufacturers of Precast Concrete Products ', G, a
Also Distributor of Related Items ��,� .-) a
28803 U.S. Hwy. 6 Rifle, Colorado 81650 E
625 -1112 0 a r ? ? e • _ , - w ' .
�.ar sue ,i.2 lLy -l ,a . � j7.1� . /•,--c. '• f�4t /IYtJ� � •
' SOLD TO . . _.i .. . -sr
--- ��.dira4 - -. ' J P.O.NUMBER
® RESALE ISM
DATE
JOB NAME
D `
CUS MEP NO. SALESMAN /
"A ___.
EXTENSION
WEIGHT Snippe0 ,
Q I G in
- 0 e min ... 1
/ Li Al Via/. :ea_ L
' ,I • 2
j ,. 4 � I _ - q • � 9 0 20 3
I r man It
r
TO T AS ANT ON O E MATERIAL (INCLUDING NEW MACHINE PARTS SUPPL IS LIMITED -�
. - S TO THAT AS PROVIDVID BY THE BV THE E MANUFACTURER, COPIES ILS O WHICH ARE AVAILABLE UPON REQUEST. 6, �'' r
DRIVER'S GNAT RE /r Salie Ma
NOTICE - : 4/
LESS (0 6. IF PAID BY a- 4-a- - 9l
NO DISCOUNT AFTER THIS DATE.. THIS IS A CASH -.
DISCOUNT AND MUST BE PAID ON TIME TO TAKE
to S'
DISCOUNT. TOTAL -.
THANK YOU
- Please pay on invoice. Statement will be sent on request only.
•
A i FINANCE Do TO CHARGE OF 1 � % P ER MONTHE H ISs N ANN PERCENTAGE RATE OF 1:
N? 1110 r C tut C DG i crc__nr.ner