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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit 1`r. 2 4 4
109 8th Street Suite 303 r c Assessor's Parcel No. fit,
Glenwood Springs, Colorado 81601 ' • ., `
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
ifttties & Kalin Coed Present Address 363 Prefontaine Rifle Phone_ 62S -3452 k
System Location
N�a� O County Road 320, Red Apple Subdivision, Lot 43,Rifle 1 ,
Legal Description of Assessor's Parcel No. li
SYSTEM DESIGN
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0 0 0 Septic Tank Capacity (gallon) Other f
a {} h 3 q
� • r t . A'1 Percolation Rate (minutes /inch) Numbgy,91 Bedroomg(or other) y 2 F{ip` 0. 2
/�62 ':- /9 rkr •9 A e.tat t 32i`_.%y, 'I }� /,R$(2, rli tck
Required Absorption Area - See Attached r _ ,� `'t
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Special Setback Requirements: . 2 f � t
C� c r - i 4rtr -40 .7t cry 33 r.tio...c.a.. 1
PC i i k
Date (" -, 4, O 7 , c - Inspector x - iu '' , n 'Q..
FINAL SYSTEM INSPECTION AND APPROVAL (as installed) It k I&
Ca for Inspection (24 hours notice) Before Covering Installation r j t ).. R i
System Installer .Set F /SF?L'r, Goein
Septic Tank Capacity /4 Ca. \ n p
Septic Tank Manufacturer of Trade Name [ nPL 4AJJ _._ t. f
1
Septic Tank Access within 8" of surface L 5 , k
Absorption Area to .4 1
Y
Absorption Area Type and/or Manufacturer or Trade Name G a 1 p ` An y ' 7-Per r
Adequate compliance with Courity and State regulations /requirements PIES Y.
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Other
Date 7" 13 9 Inspector j4s t. c tYK/�artA_,..• yy
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE i, r
CONDITIONS: ' i
1. All installation must comply with all requirements of tht, Colorado State Board of Health Individual Sewage Disposal Systems Chapter j 4
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 off ice shall automatically be a violation or a 1
requirement of .t he' 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 N
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 Si
INQLYdI?IIAL.SEWAGE DISPOSAL SYSTEM APPLICATION
7
OWNER Ude1JMe_ L Kt}I tN G ood
ADDRESS 3173 Pre-in' &4ntNe Ave C o PHONE haS- -I
CONTRACTOR Se
ADDRESS et3 RD. 320 rifle PHONE
PERMIT REQUEST FOR ( 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 a).
LOCATIOMSICPROPOSED EACILIT_Y: COUNTY (7 FW Fie /c
Near what City or Town F,1 fe_ Lot "0 fted C.dh
I.egal Description R — %i/t-L- 7'(-, gee 3ki epin iL r 43•
WASTESTYP_E: 00 Dwelling ( ) Transient Use
( ) Commercial or Industrial ( ) Non - domestic Wastes
( ) Other - Describe
BUILDING OR SERVICE TYPE: Se PTCG + k(AcL l /a.
Number of bedrooms: 3 Number of persons 2
, tiler (i)_ Automatic Washer OC),Dishwasher
S IIRCEAND TYPE hL WATEILSUPP_LY: ftd WELL () SPRING () STREAM OR CREEK
Give depth of all wells within 1RO feet of system: I4NKaatit w ell /}p/ PcNor../1
If supplied by communtiy water, give name of supplier: N/A
GROUND COND_LTIONS:
Depth to bedrock:
Depth to first Ground Water Table: T
Percent Ground Slope:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: LAN Kowa • 1,t. n) /A6
Was an effort made to connect to community system? 'N 0 , IAN Ruts( /r+fb /e
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:
(4) Absorption Trench, Bed or Pit ( ) Evapotranspiration
(4J Underground Dispersal ( ) Sand Filter
( ) Above Ground Dispersal ( ) Wastewater Pond
( ) Other - Describe:
WILL EFFLUENT BE DISCI IARGED DIRECTLY INTO WATERS OF THE STATE? N7
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P_ERCOLATIOILLTESLRESULTS: (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:
Nance, 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 LO x"" Date it —
PLEASE DR3AVLAN_AC CIJRAT_R.MAP TO YDLl13_POPM'RTY
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