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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N.'' , k 2 31 1
109.8th. Street •, Sulte 303 . .`-•.\ ASS0S 0!;S Parc l
Glenwood Syringe, Colorado 81601 •,,,) )_,_, ■l
Phone (303) 945-8212
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This does not constitute <
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. t
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PROPERTY
Owner's Name Daniel & Kathryn Bin g er present Address P.O. Box 263, Rifle phone_ 625 -3940
System Location 7 /yA tett County Reed 320, Rifle
Legal Description of Assessor s PArcel,
SYSTEM DESIGN
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/� 06 ) Septic Tank Capac"i[g'(gallon) A` Other p
�y 3 (' / f' f ! {si `J, 7 \ ` P e r co l a t ion Rate (mi�utes /inch) }q dumber of Bedrooms (or _) ^ y r �
1 `* p t� r a ft*t" -l'� �,,* .1. -Qa4i �..` d _° /;Z . [» ?( 2 '
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•-,` ,.Required Absorption Area -'See Attache < '
(( ; g 9 'r1 Lo.,M / t Yt c. J -! �n A, cry 3/ if e -t;. •
Special Setback Requirereentts: S• r , � l - .17").4 /r&' ' i ^ N "Y" , 2 yr t; / C (' Ai
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Date (''' ; i - Inspector 1 c „. • 4 ,,tr A, 4,
FINAL SYSTEM INSPECTION AND APPROVAL (as installed) 1 ,
Call 16 r ' Inspection (24 hours notice) Before Covering Installation y
System Installer_ 0LJd,€ r t 5' �/ , c.c.),
Septic Tank 9epacity . '2 - ' p
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Septic Tank Manufacturer or Trade _O—A ftazzario/ t
il... ` v
s ,,r ! Septic T rlk Accra within 8 ekele ` 9 f -5
� A a
Absorption Area lily
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Absorption Area Type and /or Manufacturer or Trade Name £V4 S - !UF /1-7/-07 7 . id 5 - /i e revs
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Adequate compliance with County and State regulations /requirements "S yy
Other(. 6
Date 1/- Q1-'fit- Inspector .i.' . - -
:.-- , 4
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTIO SITE
•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 I, Petty Offense (5500.00 fine —6 4
months in jail or both).
Applicant: Green Copy Department: Pink Copy
Application
INDIVIDI SEWAGE DTSPOSAI. SYSTEM APPLICATION Approval By
Co my Official
OWNER o.,.j c l I. !1644.. -. �
ADDRESS • . r . _ � 3 r i[• PHONE 6-39Y /fO . —
ONTRACTOR
ADDRESS PHONE
ERMIT REQUEST FOR: ( \w 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
iee page 4). I
.00ATION OF PROPOS CTT .ITY : County 0 .4 ; sAA
fear what City or Town is Lot Size App. AX. q•fs we +RS
.egal Description AT . 3 i — To w�v sl.: `S - Rr+Nr c 9' `l - L i-'' ?i1 - TrArl . L
(' A Apple - ,,.1 rt; u ;+sines,
\'ASTES TYPE : ( welling ( ) Transient Use
( ) Commercial or Institutional ( ) Non - domestic Wastes
(:) Other - Describe
tUILDING OR SERVICE TYPE:
lumber of bedrooms S. Number of persons
) Garbage grinder (s)- A Washer (9--
;OiIRCE AND TYPE OF WATER SIJPPI.Y; (4e11 A spring () stream or creek
.'o o
live depth of all wells within 180 feet of system: mow r� .: �I. 4 t
f supplied by community water, give name of supplier: Al A .
;ROI IND CONDITIONS;
)epth to bedrock:
)epth to fast Ground Water Table:
'ercent ground slope:
)ISTANCE TO NEAREST COMMUNITY SEWER SYSTEM; 7 M; Jtt
Vas an effort made to connect to community system? Nn - i . N t /AL ic
[YPE OpISDIVIDUAL 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:
174 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
St -• •
• )IL PERCOT.ATION TEST RESULTS: (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 legal
action for perjury as provided by law.
4
Date 7 —/a — 9y Signed rtr/I))�i►_ - .....4 - -
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