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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit 11 Z 4 El 7
109 8th Street Suite 303 Assessor's Parcel No. $ tl
' Glenwood Springs, Colorado 81601;
Phone (303) 945 -8212 i
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This does not constitute q S
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. ' 6 I.
PROPERTY " )S'
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Owner's Name Alysnn R. .Tungjnhsnn Present Address P.O. Ent 251, Silt Phone_ R7fr•2446 tt
System Location 00) q Wn*nnn_ny Uay , Slarrn Viatw Rwnnh, l.ot 15, Silt ' i -
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Legal Description of Assessor's Parcel No.
e
SYSTEM DESIGN
/ i S eptic Tank Capacity (gallon) Other p: f
/ - '1'ercolation Rate (minutes /inch) Number of Bedrooms (or other) 3 '''
fy 0 ,e' 71 ' /fir, 1, _f _ f.. r.' rx r : 1 I ( is
Required Absorption Area - See Attached 0 x. r n T
Special Setback Requirements: ,-- J. `/ )l 1' r - I : ' ' / 4 ' ' r / I b {
.
Date 1 Inspector l -.. r,;/ ( ' 'c,t'.',nO y
._._ x � >
FINAL SYSTEM INSPECTION AND APPROVAL (as installed) ''?
Call for Inspection (24 hours notice) Before Covering Installation ti
System Installer_ ` &HJ/ S /EX' `"iA TiN4 y 4'
Septic Tank Capacity /000 f i
t Septic Tank Manufacturer or Trade Name Covire'r9/1/2i7 r
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Septic Tank Access within 8" of surface to i. A
Absorption Area Cr :'2' A ,/ Fes. 4, i 9 -, +.' .2.- :..., � e F
Absorption Area Type and /or Manufacturer or Trade Name . - e i.e.?'
Adequate compliance with County and State regulations /requirements e
6
Other
Date S't /eVYS Inspector 7in,. r' .7.vo So.,
5'
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE ,
*CONDITIONS: } 4
1. All installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chapter x,
25, Article 10 C.R.S. 1973, Revised 1984. ry'
2. This permit is valid only for connection to structures which have fully complied with County zoning and building requirements. Con-
nectiontoorusewithanydwellingorstructuresnotapprovedbytheBuildingandZoningofficeshallautomaticallybeaviolationora p
requirement of the permit and cause for both legal action and revocation of the permit. r
3. Any person who constructs, alters, or installs an individual sewage disposal system in a manner which involves a knowing and material ,t
variation from the terms or specifications contained in the application of permit commits a Class 1, Petty Offense ($500.00 fine — 6 � t
months in jail or both).
Applicant: Green Copy Department: Pink Copy t i
Application
INDIVIDUAL SLWRUE DISPOSAL SYSILi1 AI'I'I_ICAI1011 Approval by
• County Official:
OWNER • V, � ` � Ark . � ( � � 1 Y � . - / / a ' --
ADDRESS onu j O _ 5 ni0IL
CONTRACTOR
ADDRESS _ -- -------- _- _-- _----- _ -__ -- PHONE PERMIT REgULST FOIL: Hew 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
Lest holes, soil profiles In Lest holes. (See page '1.)
LOCATION or I'ItOPOSLU FACIL1 IY: County_ __
Near what City of Town 9kk y-i_$$ __ -_ -- ---- __ - _ -- -- Lot Size S
Legal Description ✓QF. _e - - -- - -- - -- - -
WASTES TYPE: '('Q_ Dwelling ( ) 1lransicnt Use ----- - - - - --
( ) Commercial or Institutional ( ) Non- domestic bastes
( ) Other - Describe
BUILDING OR SERVILE IYPC: LoYYte , ------_-_____._ __.___,_�-- _.._- ._.______ -. -._-
(lumber of bedrooms ;Humber of persons _
Automatic washer b<) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: • ( - 7,43 well ( ) spring ( ) stream or creek
Give depth of all wells within 180 feet of system: '
I y 12.5 - - -
If supplied by community water, give name or supplier:- -- _lgLk___._ ___— _.- _-- -- __ -- -_
GROUND COIIUITIOHS:
Depth to bedrock:
Depth to first Ground Water Table:_____
Percent ground slope: '
DISTANCE 10 NEAREST COMMUNITY SEWER SYSlLfi: __. __________-- ___ - _____
Was an effort made to connect to community syslem7"
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSILM PROPOSED:
1>C) 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 IIY:
( ) Absor Trench, Bed or Pit ( ) Evapotranspiration
( ) Underground Dispersal ( ) Saud Filter
( ) Above Ground Dispersal ( ) Wastewater fond
( ) Other - Describe: — - -- - - -- — — — .._ -- - --
HILL EFFLUENT BE DISCHARGED DIRECTLY 11110 WAIERS OF 1 1 1 E S1ATE7_ NO
• • •
Pour
,1. ..
1
.S011..I'EIICULAfIUR ZEST RESULTS: (lo be completed by Registered Professional Engineer.)
Minutes per inch in hole Nu. 1 Minutes __ per inch In Role Ilu. 3
Minutes ' per inch in hole Ito. 2 Minutes __ per Inch In hole No._
Nance, address and telephone of RI'E who made soil absorption tests:_
Name, 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 he 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 perlili't,Ts sub,iect 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 lo 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 Apartment of health
in evaluating the same for purposes of issuing the permit applied for herein. 1 further under-
stand 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 per-
jury as provided by law. • Date \rM4 �7 `1! -� Si g ned • _ ♦ .ASt aS4,, ,.
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PLEASE DRAW AIIU ACCURATE MAI' 10 YOUR PROPERTY
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• I'LOT PLAN AHD 9131611 1U\1l1RLS:
include by measured disLance 1ocaiIon of well springs, potable wafer supply
1 Ines , cisterns, buildings, property 1 Ines , subsoil drains, 1 ake, waLer course,
stream, dry gulch and show 1oca1ion of proposed sysLeni by dIrecLion and disLance
from dwelling or other fixed reference objec 1, and add 111 anal submissions in
support of this application such as data, plans, specifications, statements and
connii talents.
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