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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit . . 1 2 3 0 1 i
109 8th Street Suite 303 A is Parcel No. 4
Glenwood Springs, Colorado 81801
Phone (303) 945•8212
This does not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit.
PROPERTY
Owner's Name q�
William K. Graham Prese Address 1978 Hwy 133, Carbondale Phone_ 963 -0584
System Location 0054 Ute Way, Minsota Estates, Lot 16, Silt
Legal Description of Assessor's Parcel No.
SYSTEM DESIGN i (
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Septic Tank Capacity (gallon) �ther A . r ' , ; ,
+` R60 en - ,.� • t 1 22/ t1 ; i- r 4 f / A <
/ t ,, / � 1t :+ 11 1, •. Percolation Rate (minute's/inch) mbar glBedrnbms (o / r / other) �.- {. ` ,t " U (1 ) yy
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Required Absorption Area -'See Mashed '7 t - r P' ...1 1.vrr 1^ •. - 3' / h c -' ,
r 1 -.t ic (.,(.41!".4 n r r - .r (1 .�' - J , F
Special Setback Requirements\ /
'
Date t✓y •' r'. i �� - 'f'l/ Inspector C .. 4 ' ".ay'\i > <W LN.S-
t
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer I-1 •- t ry / ti OI ;•' /r6 r3 r 1 floc e 7" T . 6e'rt.isT . 6a ,
o )
Septic Tank Capacity • /Oen j
Y
Septic Tank Manufacturer or Trade Name / 4 .q ti
7 1
Septic Tank Access within 8" of surface Cr F S I i
Absorption Area �1•sl
Absorption Area Type and /or Manufacturer or Trade Name C - '/ 4 - . r -1 . <. % .i ii: L T l/.,7 - ,'r 5,
Adequate compliance with County and State regulations /requirements Yer- s
Other 4
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Date 42 - • Sf ' >.< Inspector I�j• as .j 7k- mia c
RETAIN WITH RECEIPT RECORDS AT CONSTFUCTION SITE
1 *CONDITIONS:
1. Al! installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chapter
k 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-
nectiontoor use with any dwelling or structures not approved by the Building and Zoning office shall automatically be aviolationor F
Y requirement of the permit and cause for both legal action and revocation of the permit. d
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 jail or both).
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Applicant: Green Copy Department: Pink Copy _ –
Application
INDIVIDI JAI . SEWAGE DTSPOSAT. SYSTEM APPT ,ICATION Approval By
I County Official
OWNER Nkilm g• fa hair(
ADDRESS 1 9xr //wr 133 CarbohdaIe 6. 2.1423 PHONE "' Ara —
'ONTRACTOR Basal l onstrvG ron
ADDRESS 17138' Navy 133 RP tone 6. 7/623 PHONEWS
ERMIT REQUEST FOR: (X) New Installation () Alteration () Repair
tttach 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
'ice page 4).
,OCATION OF PROPOSED FACIT.ITY : County l arfiel€l Covti]y
Tear what City or Town ‘i/1( Lot Size l • (15 Acres
.egal Description Lot I/o Faith, i{ .. Mt sta Estate R&• — 00S The ale layp Su
VASTES TYPE : 00 Dwelling () Transient Use o
( ) Commercial or Institutional ( ) Non - domestic Wastes
( ) Other - Describe
TUILDING OR SERVI,C TYPE: Fov r
dumber of bedrooms (( Four Number of persons 0)
Garbage grinder (Xj Automatic Washer A Dishwasher
;OI /RCP.. AND TYPE OF WATER SI IPPT.Y; OQ well () spring () stream or creek
Jive depth of all wells within 180 feet of system: _
f supplied by community water, give name of supplier: d Vcl I ey Far S Es 4 N
TROI TNT) CONDITIONS
)epth to bedrock: U/1 ki7owet
)epth to rust Ground Water Table: I00
'ercent ground slope: /0'%
)ISTANCE TO NEAREST COMMUNITY SEWER SYSTEM 4 tthJes
Nas an effort made to connect to community system? dO
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(Xj 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:
( 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?
a
fHT, PERCOT.ATIDN TEST REST IT.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. —
lame, address and telephone of RPE who made soil absorption tests;
lame, 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.
Dat A j / 991/ Signed Oars x - .tu- --
pT,R SR DRAW AN ACCT IR ATE MAP TO YOI IR PROPRRTY
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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 dr other fixed reference object, and additional submissions in support
of this application such as data, plans, specifications statements and commitments.
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