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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N 2417 lr
109 8th Skeet Suite 303 Assessor's Parcel No. F it
Glenwood Springs, Colorado 81601
Phone (303) 945-8212
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This does not constitute 0
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. t
PROPERTY $4
Owner's Name Frflnete Black ' ,i Present Address Box 381, Silt, Co Phone_ 876 -5550 k
System Location - , < 0 Highway 13 , Rifle
i ({ Legal Description of Assessor's Parcel No.
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SYSTEM DESIGN ee
/ ' // Septic Tank Capacity (gallon) Other t
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�,- / % Percolation Rate (minutes /inch) Number of Bedrooms (or other)
4 FI) S
i - -/ 1'1 it c'. ', '{ _.1 1,I r'� (-.c - / e i I C`) X - .. I,4
Required Absorption Area - See Attached r . f , r e -, r ,., „, , r , .
Special Setback Requirements: / ."y - v t " } + ! 1... t ` 4 ` " / Mi l` 1
Date_ .%.' Inspector '.,.. ...... e. Li .1 :!I - Ci ✓'
FINAL` SYSTEM INSPECTION AND APPROVAL (as installed)
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Call for Inspection (24 hours notice) Before Covering Installation LL
System Installer_ `1 /A) 17 -et., R
Septic Tank Capacity ) 2 $ v 11 S,
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Co,- - 'LC ( '
Septic Tank Manufacturer or Trade Name
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Septic Tank Access within 8"" of surface L "
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. Absorption Area 4 / C( r r `e, „A 1' / 1 c
¢ - {.,, ,
Absorption Area Type and/or Manufacturer or Trade Name /� `1 C ('��`
Adequate compliance with County and State regulationf /requirements l
Other
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Date 1... -' Inspector ji t-(', R
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
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*CONDITIONS:
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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. { { {{: A
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2. This permit is valid sway for connection to structureswhioh have fully complied with County zoning and building requirements. Con- C Z
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 C'.
variation from the terms or specifications contained in the application of permit commits a Class I, Petty Offense ($500.00 fine — ?t lo
months in jail or both). R t
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Applicant: Green Copy artment: Pink Copy y
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jNI)IVII)i IAT, SEWAGE I)ISPOSAi. S YSTEM APPT,ICATION
i/537
OWNER £4JVCd S 1% ,u1 aecik
ADDRESS e 38 r • G$2- PHONE £X 5$5
CONTRACTOR S3MF
ADDRESS PHONE
PERMIT REQUEST FOR y NEW INSTALLATION ( ) ALTERATION ( ) REPAIR
Attach separate sheets or report showing entire area with respect to surrounding areas, topography of area,
habitable building, location of potable water wells, soil percolation test holes, soil profiles in test holes
(See page 4).
j,OCATION OF PROPOSED AMITY: COUNTY 6
Near what City or Town ■ of
Legal Description S 4 , -•- • �-- �-'- —
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WASTES TYPE: Dwelling (Ofransient Use
( ) Commercial or Industrial ( ) Non - domestic Wastes
( ) Other - Describe
BUILDING OR SERVICE TYPE: Fps
Number of bedrooms: 9 Number of persons
( ) Garbage Grinder (X) Automatic Washer ( ) Dishwasher
,$O1JRCR AND TYPE OF WATER STJPPT.Y. WELL () SPRING ( ) STREAM OR CREEK
Give depth of all wells within 180 feet of system: /C (J
If supplied by communtiy water, give name of supplier:
(ROI INI) CONDITIONS:
Depth to bedrock: AD
Depth to first Ground Water Table: AO
Percent Ground Slope: S'
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: g 41
Was an effort made to connect to community system? A/0
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
i 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:
0 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? 4o
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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. _
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 appliction 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 inusre compliance with
rules and regulations adopted under Article 10, Title 25, C.R.S. 1973, as amended. The undersigned hereby
certifies that all statements make, 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 bre relied on by the local department of health in evluating the same fro 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.
Signed �%7Ie,& .) Dat . - -Z / S
PLEASE DRAW AN ACCT IRATE MAP TO YOI JR PROPERTY
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