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i : 1 GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit K 2 4 9
- r 109 8th Street Suite 303 Assessor's Parcel No.
Glenwood Springs, Colorado 81601 1„
Phone (303) 945 -8212 3
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' This does not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT ` - a building or use permit. 1 a
PROPERTY •
Owner's Name Clifford Cerise ' Present Address 0086 :'CR 104 Carbondale Phone_ 963-3669
System Location 0086 County, Road 104. Carbondale
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Legal Description of Assessor's Parcel No.
NF∎15 '' Rte i< E LF E+t✓ -4 a t44: di4. , 444 bn a ore- -xelea -- c yGl or w
SYSTEM DESIGN 7c x ow r,e F'n i Ne •?- pew'
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rise's 9 � Pt iicT a ik G p d? (g allon- seal.. •jttte?S`Othen . I
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1" _ „./. $ na ercolation Rate (minutes/inch) Nurn er of Bedrooms (or other) 2 t
Required Absorption Area - See Attached $p
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Special Setback Requirements:
Date f(Y •1 — �S Inspector /1 44. ✓ r' 25/...pY UA -.m1.
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FINAL SYSTEM INSPECTION AND APPROVAL (as installed) )
Call for Inspection (24 hours notice) Before Covering Installation
System Installer el(p $ F f
Septic Tank Capacity / 006 I(, •
Septic Tank Manufacturer or Trade Name p it l Lt‘ 9tar ,- 4
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Septic Tank Access within 8" of surface T 11 f'S
Absorption Area q6"4:1 1T 34 Qt S 7 1, r2t vi, hi) P,
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9 Absorption Area Type and /or Manufacturer or Trade Name 4- 0 1 A t Y ' /L 1 f'4'Tr',z 3 ' 1 rJ i
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Adequate compliance with County and State regulations /requirements LJ(c
Other / '1.! gg // c �` Inspector S . ;j - . '-s - — fl,.
Date ��' ,�71v" J P r
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RETAIN WITH RECEIPT RECORDS AT CO STRUCTION SITE PI
*CONDITIONS: s
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- 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 ' ?
requirement of the permit and cause for both legal eotion -and revocation of the permit. k
3. Any person who cohstruCts, alters, or installs an individual sewage. dispose) 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 (ail or both). y
Applicant: Green Copy Department: Pink Copy y
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1NDI V1 DUA LSEWAGIMP _ISPnSAL_SYSTEM_AP_PT,[CATION
OWNER C1,' • �� ��-
ADDRESS 00 : ' 't1 #l�/IL'71 �i sna 943 flt!!%
CONTRACTOR 5 ,,
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ADDRESS PHONE
PERMIT 12EQUEST FOR IX 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 lest holes, soil profiles in test holes
(See page 4). �,/ ���
LOCA ION_QLPROPOSI:) A LIT_Y :: COUNTY ..4[ '.p
Near what City or wn LR ® 1-it Lot /
I.egal Description 4 �j�{ /2 —
0 7 — F 0024 0,e i� , %1!a./
WASTLSTYP_h: 44 Dwelling ( )'transient Use
( ) Commercial or Industrial ( ) Non - domestic Wastes
( ) Other - Describe
1111I1.DING OR SERVICE TYPE:
Number of bedrooms: Number of persons 0
po Garba Grinder Automatic Washer Dishwasher
SOURCL ANT? T_YPE.OF WIITLILSUPP_LY_: ( ) WELL (X SPRING ( ) STREAM OR CREEK
Give depth of all wells within 180 feet of system: .'Z-c WC_/A &
If supplied by community water, give name of supplier:
GROI!NDSOND_[TIONS:
Depth to bedrock: r Depth to first Ground Water fable:
Percent Ground Slope: 51 L f
DISTANCETO NEAREST CL)MMIJNI'I'Y SEWER SYSTEM:
Was an effort made to connect to community system?
TYPE OF INDIVIDIIAI. SEWAGE DISPOSAL SYS'T'EM PROPOSED:
1}Q 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:
t4 Absorption Trench, Bed or Pit ( ) Evapotranspiration
() Underground Dispersal ( ) Sand Filler
( ) Above Ground Dispersal ( ) Wastewater Pond
( ) Other - Describe:
WI1.I. EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? v7ye2
P _ Ii RC 4 LATION_'EST_RESLIITS: (To be completed by Registered Professional Engineer)
Minutes per inch in hole No. I Minutes
Minutes per inch in Hole No. 3
per inch in hole No. 2 Minutes per inch in Hole No. _
Na ne, address and telephone of RPI: who made soil absorption tests:
Name, address and telephone of RPE responsible for design of the system:
Applicant acknowledges Ihat 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 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. 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.
/ /
Signed _ ,�i 7' �o� `_
/ mate
PLEASE]) iA1Y_1N_ACCLRATE.MAP_TO YOUlt_P13nPERTY_
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JOB NAME: _C...E. IDO-1/ r. - maw_ JOB #
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LOCATION: SHEET _ OF
SALESMAN: BY DATE: (Q
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