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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Perm(4I ft. 2 4 9 '• b ..
' 109 8th Street Sylte 303 Asse /sor's Parcel No. ?
Glenwood Sp Ings o 81601 4!
ph1_41(303) 445 -8212 y;#
�, i.4u This dors not constitute t
INDIVIDUAL SEWAGE DISp ,SAL
{ PER IT a buildin or use permit.
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PROPERTY
Owner's Name
Carolyn West P resent Address 0980 245 Road N.C. Phone 984 -2060 i
System Location County Road 245, Nev Castle
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e
Legal Description of Assessor's Parcel No. . e t t„ e'
h•oc ,<, $ G Civc./a 'ere, ` $4
SYSTEM DESIGN y t, r- /c,,on S R S 6 a /
d. /G. -/: // u $ C. S a
IS Q Septic Tank Capacity (gallon) Other
/ I /q /J M / Percolation Rate (minutes /inch) Number of Bedrooms (or other) 2 ti
HS 4 9✓1 044k "t F NC/ -f Ica' qp
Required Absorption Area - See Attached
a 5 .r LTw" Tar /.s ea B}
a 1 7 ,o- D. Frd6 ee LS- E 4
Special Setback Requirements: if? ' /
thi
{ Date 1 /J !q - 95 Inspector , ` _fle ..�
FINAL SYSTEM INSPECTION AND APPROVAL (as installed) Q
Call for Inspection (24 hours notice) Before Covering Installation
System Installer !Tr vv- Fie? I
Septic Tank Capacity /p/ 9/
Septic Tank Manufacturer or Trade Name r.+ l/D /✓C'
Septic Tank Access within 8" of surface yr^>
Absorption Area .Pee 4s / /-' 2, r Q. /
Absorption Area Type and /or Manufacturer or Trade Name /i z rvA rte." i ?'
i
Adequate compliance with County and State regulations /requirements /.c.-�> I
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1
Date iii it. f' Inspector .7 M.`/
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
I
•CONDITIONS: f
1. All installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chap ter & t
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- i 1
nection to or use with any dwelling or structures not approved by the Building and Zoning office shall automatically be a violation or a I' i.
requirement of the permit and cause for both legal action and revocation of the permit. t
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 specif ications contained in the application of permit commits a Class I, Petty Offense ($500.00 fine— 8
months in jail or both). it
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Applicant: Green Copy Department: Pink Copy ILL
S ASo. ale
(
IN DIV I DUALSEWAG E.1)1SPOSALsySTENLLAPI'_LICATION
OWNER /7,4i-o /y„ T
ADDRESS o?Yo ,,}q S ,Y /l/✓ �( 6, PHONE 24 _
CONTRACTOR Sc /f _
ADDRESS PHONE
PERMIT REQUEST FOR (x) 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).
LQCAI'ION_OI? PROPOSEI)I?AGILITY: COUNTY 6',9,- -hie%!
Near what City or Town New dos /te Pr► Lot
Legal Description S_t.! 7 99 _ a- 9v 9 A R lc/
WASTES :PIPE: (y) Dwelling ( )'Transient Use
( ) Commercial or Industrial ( ) Non - domestic Wastes
( ) Other - Describe
BUILDING Olt SERVICE TYPE: hom
Number of bedrooms: Number of persons
( ) Garbage Grinder (x) Automatic Washer (x) Dishwasher
SOURCE.AND_TY_PE_OI WATEILSUP_P_LY_: () WELL () SPRING () STREAM OR CREEK
Give depth of all wells within 1 HO feet of system: d; l Nz o
If supplied by community water, give name of supplier: /1/rt./ fa sib e.
GROUND) CONDITIONS:
Depth to bedrock:
Depth to first Ground Water Table: — __ --
Percent Grotind Slope: .5 ` --
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: / kin ;
Was an effort made to connect to community system?
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYS'T'EM PROPOSED:
(x) 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:
( ) Absorption 'french, Bed or Pit ( ) Evapotranspiration
(y) Underground Dispersal ( ) Sand Filler
( ) Above Ground Dispersal ( ) Wastewater Pond
( ) Other - Describe:
WILL EFFLUENT BE DISCI IARGED DIRECTLY INTO WATERS OFTI - IE STATE? No
. •
PERCQLA77QN_LEST_RGSUL1'S: (To 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:
Name, address and telephone of RPE responsible for design of the system:
Applicant acknowledges that the completeness of the appliclion is conditional upon such further mandatory
and additional tests and reports as may be required by the local health department to he 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 he 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 _____ea + ��,• (.�,Y Date 8.9-95
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PLEAS_ 12RA W_AN _ACCURATE- MAP_TQYQQI?`PR.QL'P - Y He-5c o - 0( 1(
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