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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N _ 2 4 4 2 i;
109 8th Street Suite 303 Assessor's Parcel No.
Glenwood Springs, Colorado 81601
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Phone (303) 945 -8212
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This does not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit.
PROPERTY
Owner's Name Barb Julius Present Address P.O• Box _30/ Silt Phone 876 - 2701
System Location 0123 Mohawk. Mineota Estates. Lot 9, NilinS 1, Silt 9
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Legal Description of Assessor's Parcel No. _ i'
SYSTEM DESIGN h (
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000 ty,d, , J .,- F f.c..- .cr.r / / — 2..(i 7 / ti
il-retAcc' -La Septic Tank Capacity (gallon) Other _-/ 7 : - --
V " _ A,,, (' Percolation Rate (minutes /inch) Number of Bedrooms (or other) 3 {
/.- -y _.x
1 " / 7 Tam ii_cre,..i� 4- S ,,,,,A; &cc f
Required Absorption Area - See Attached -}- r .; /� , -
/ '4 � n � 1, 1 T om,-) / - ..'n err �'i/�I ` ' . ...( ; C ' .�I; g
Special Setback Requirements: 7 h , 1 /�^"c r' -- 44, ,C j" --4' (-- , . , 6 ' y O ii. 4 c ml.? li
Date d -, C- i c Inspector C . 'tt . . t .• n n i {� "`.r.r,,t.., t- f ?
FINAL SYSTEM INSPECTION AND AOROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering'1 stallation t t
'J System Installer_ ? -!' " i r �'•;�
Septic Tank Capacity / f 3 P
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Septic Tank Manufacturer or Trade Name r., of )'� '(C qtr( '
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Septic Tank Access within 8" of surface
Absorption Area ! {/ 0 it i,
Absorption Area Type and /or Manufacturer or Trade Name 2111 1+J4' *ci - 4.17w y -- u "l, / (l
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Adequate compliance with County and State regulations /requirements /` Y
Other J i i
Date ",3 /0 Inspector - °0- 71 �i 4,, ry 4 /
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE b
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*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-
nect ion 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. S
3. Any person who constructs, alters, or installs an individual sewage disposal system in a manner which involves a knowing and material z
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). M
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Applicant: Green Copy Department: Pink Copy ¥ ,
INDIYI DUALS filAQE_DISPnSAL SYSTTIYiAPPJICATION
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OWNER 3'ZtlAziwL. j 2/
ADDRESS 7q6 • mix 3c2 c �1 PHONES r771�J
CONTRACTOR Z C
ADDRESS z4, V ,C fl-1 j ( y/. 4 PHONE e2„--
PERMIT REQUEST FOR (00 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).
LOCATfON_OF_PRUPOSEf? EACILIT_Y: COUNTY
Near what City or Town . 5/ /7` Lot
Legal Description 4'7- 7 o%z3 14-4,,✓e 4 -- Whir,,)
WASTESTYP_E: Pt) Dwelling ( ) Transient Use
( ) Commercial or Industrial ( ) Non - domestic Wastes
( ) Other - Describe
BUILDING OR SERVICE TYPE:
Number of bedrooms: 5' Number of persons
(pc) Garbage Grinder (kj Automatic Washer (p) Dishwasher
SOURCEAND TYPJLQE ? MTE&SUPP_LY_: () WELL () SPRING () STREAM OR CREEK
Give depth of all wells within HO feel of system:
If supplied by community water, give name of supplier: 777/ 41,47 /97-eleetio-
GROUND CONDITIONS:
Depth to bedrock:
Depth to first Ground Water Table: T
Percent Ground Slope: e %
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: , 5 —
Was an effort made to connect to community system? 1 zv
TYPE OF INDIVIDUAL. SEWAGE DISPOSAL SYSTEM PROPOSED:
00 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:
(00 Absorption 'Trench, Bed or Pit ( ) Evapotranspiration
( ) Underground Dispersal ( ) Sand Filter
( ) Above Ground Dispersal ( ) Wastewater Pond
( ) Other - Describe:
WILL EFFLUENT BE DISCI 'ARCED DIRECTLY INTO WATERS OF THE STATE? 720
P_ERCQLATIQN_TEST_ tESULTS: (1'o be completed by Registered Professional Engineer) �.
Minutes per inch in hole No. I 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:
Nance, address and telephone of 121 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 hre relied on by the local department of health in evluating the same fro purposes of issuing •
the permit applied for herein. 1 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.•
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Signed t_ � Date <S " O ��
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PLEASE DRA 'WAN_ACCI IRATE_MAP_T.2Y LI13_PROPERT1'_
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L'IS TflAN.AN1 DES1Gt MATLIRCS
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, pecifications statements and commitments.
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