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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N - 2 26 6
109 8th Street Suite 303 Assessor's Parcel No.
Glenwood Springs, Colorado 81801
Phone (303) 945 -8212 p
This does not constitute A •
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. F
PROPERTY rq
Charles Donelen 7293 233 Rd, Silt 945 -8601 11
Owner's Name Present Address Phone_
System Location 7293 233 Rd., Silt i
if
Legal Description of Assessor's Parcel No. #
SYSTEM DESIGN
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6 oa Septic Tank Capacity (gallon) Other
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.. // .r.,.: (t 3
,< Percolation Rate (minutes /inch) Number of Bedrooms (or o
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77 9 L � `) o r 4 ' ? --1-- a l., c- rct l (Ls - - f z X /( r' S[ 3 '-s e-
Required Absorption Area - See Attached --
N1/' // G s? _6 7-7, 44417,- • 1n- , l +Y ,Z J - r4 .,c <,
Special Setback Requirements: ,y / -/ 4, u P C43 I-0 1;f) F'✓ e 1t e .2 ^y (: < i -! -.o ', •
Date — 3 / ii Inspector v- �r,,,. (c ` .tnr c /v14 r
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation i {{
System Installer_ fl ht , 1 C 7` 8 y
Septic Tank Capacity /, n 0 (2 !r t
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Septic Tank Manufacturer or Trade Name Ci, Qnn w))
Septic Tank Access within 8" of surface /- ------- f !
Absorption Area .2 A MAr t y / '- 1 i•, `#'- / - 1 3 / pr —'-
Absorption Area Type and /or Manufacturer or Trade Name .4t. jj-ti7.M"ea- - 9..kr `v'r' I
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Adequate compliance with County and State regulations /requirements d "�
Other 5. .
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Date (j ' - S+� Inspector " "'��✓J r` 4 I
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
*CONDITIONS: a
1. All installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chapter I 3
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 ora p 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 materiel i ;
variation from the terms or specifications contained in the application of permit commits a Class 1, Petty Offense ($500.00 fine — 6 .
months in jail or both). ¢y
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it
Applicant: Green Copy Department: Pink Copy r
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Application
INJ)IVIJ)T TAT. SEWAGE T)ISPOSAI. SYSTEM APPI.ICATION Approval By
I � County Official
OWNER c,4$14GS JJONEtSJ
ADDRESS 1243 Q.0-#133 Sur, Co PHONE gQr $60/
CONTRACTOR G1 ?2U& /—C—WP's
ADDRESS 3/o if RD if 331 8/ � co PHONE a`7(o
PERMIT REQUEST FOR: New Installation -10W6 Alteration ( ) Repair
Attach separate sheets or report showing entire area wi� ith 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 FACT! ,ITY : County , rn LLD
Near what City or Town 5? !r' Lot Size q, 9 4c e
Legal Description 9 ft(' ,V //i SW s6
3t -+S"92
WASTES TYPE ; Dwelling () Transient Use
) Commercial or Institutional ( ) Non - domestic Wastes
() Other - Describe
BUILDING OR SERVICE TYPE: Thifti,te arwa ' Pavecieg
Number of bedrooms ✓ Number of persons 3
( ) Garbage grinder ( ) Automatic Washer ( ) Dishwasher
SOT JRCE AND TYPE OF WATER ST JPPT.Y: 0, well () spring () stream or creek
Give depth of all wells within 180 feet of system:
If supplied by community water, give name of supplier:
MOT TNT) 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:
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? AM
;OIL PERCOT.ATION TEST REST .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. _
dame, address and telephone of RPE who made soil absorption tests;
dame, 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 //0 Z3 7 Myf Signed &WA
PLEASE DRAW AN ACC! JRATE MAP TO YOIJR PROPERTY
Jl
?LOT PL AN AND DF.SION FEAT! JR RS
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.
S ATT
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I hereby certify that the improvements on that certain described parcel
of land situated in the S1/2SO4 of Section 36, Township 5 South, Range
92 West of the Sixth Principal Meridian, County of Garfield, State of
Colorado, excepting utility connections are entirely within the boundaries
of the parcel, except as shown, that there are no encroachments on the
described premises by improvements on any adjoining premises, except as
indicated, and that there are no apparent easements affecting the parcel
in evidence or known to me, except as noted. It is further certified
that this improvement location certificate was prepared for the sole use
of Duane Maywood, that it is neither intended as nor represented to be
a land survey plat or improvement survey plat, and that it is not to be
relied upon for the establishment of fence, building, or ocher future
improvement lines. .
SCARRO'W D WAL :ER, IN .
By: • tMIT7WAPF:<i .:rt /. >-
Robert A. t•lamsley
Registration No. 7 J 7Z
Date February 24, 1977
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