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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit 2 5 2 5
109 8th Street Suite 303
Glenwood Springs, Colorado 81601
Phone (303) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
Assessor's Parcel No.
This does not constitute
a building or use permit.
PROPERTY
Owner's Name Bill Mahoney Present Address Box 206, Glenwood Phone 945-0999
System Location 1180 Quicksilver Way, Grass Mesa Ranch, Lot 1, Rifle
Legal Description of Assessor's Parcel No
SYSTEM DESIGN
%O Septic Tank Capacity (gallon) Other
3
/ A /N bel 44/Percolation Rate (minutes/inch) Number of Bedrooms (or other) •
5 'd -. 40K LFs7¢K t •+-d C NC preb,0r eg-.�K ix-ei ,e,
Required Absorption Area - See Attached ,,72/ .T/uFi47/gi472/ 1 AEA -
I A/ 2i'/r7x0. /1' ,C -.k
Special Setback Re Tgrenis:
Date fie? S`
Ily"� a
FINAL S+STEM INSPECTION AND APPROVAL (as installed}
Call for Inspection (24 hours notice) Before Covering Installation
{r Inspectors.-� t
System Installer
Septic Tank Capacity /a>c
Septic Tank Manufacturer or Trade Name aiyG.4.1.4a-
Septic Tank Access within B" of surface 5' 5
Absorption Area 3e?
if7
p
Absorption Area Type and/or Manufacturer or Trade Name go/ i _ 'F/Lt 7d 9 /7
Adequate compliance with County and State regulations/requirements r' /5
Other
Date /03 95 -
Inspector
RETAIN WITH RECEIPT RECORS AT CONSTfiUCTION SITE
*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-
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 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
variation from the terms or specifications contained in the application of permit commits a Class 1, Petty Offense ($500.00 fine — 6
months in jail or both).
White - APPLICANT Yellow - DEPARTMENT
•
•
INDIVIDUAL, SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER LrYli(i t, 0 , -,Q_
ADDRESS13v X �--Q 6 � `�7 d
dz
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CONTRACTOR -S / ^1^4
ADDRESS 4f*lJ
( yc� 1 L4 Pt,rA u "e
PHONE 7' r 4 ? 7 1
PERMIT REQUEST FOR (V) NEW INSTALLATION
PHONE )-?5-75-r7
( ) 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 lilies (See page 4).
LOCATION OF PROPOSED FACILITY: COUNTY e)e L �I
Near what City or ]'own f 1 -() Size of T,ot 7 %9 - Y e -S
Legal Description or Address �dpp'u4A-o intU2A-c•1/4. L- /
WAS'T'ES TYPE: (\ DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPE:
Number of Bedrooms_ 3 Number of Persons
( ) Garbage Grinder ) Automa 'c Washer 'j) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY; J) WELL ( ) SPRING ( ) STREAM OR CREEK
(iivc depth of all wells within 180 feet of system: i z c" -Ft
If supplied by Community Water, give name of supplier
GROUND CONDITIONS:
Depth 10 bedrock:
Depth to first Ground Water Table
Percent Ground Slope
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: .3 ' -
Was an an effort made to connect to community system? ( ) YES (V) NO
TYPEV INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(V) SEPTIC TANK ( ) AERATION PLANT ( ) VAULT
( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POTABLE USE
( ) PIT PRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
( ) CHEMICAL `T'OILE'T ( ) OTHER - DESCRIBE
FINAk DISPOSAL BY:
ABSORPTION 'TRENCII, BED OR PIT .27"10 W0f ( ) EVAPOTRANSPIRATION
( ) UNDERGROUND DISPERSAL ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND)
( ) OTHER -DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF l'IIE STATE?
2
L)
' ' 111:1C()I,A"liON TEST RESU1,7'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 oldie application is conditional upon such fiirther 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 oldie application; and the issuance of the
permit is subject 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 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 be relied on by the
local department of health in evaluating the same for 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 Q Date r 1— 61— 7
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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