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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit 2 6 6 2
109 8th Street Suite 303 Assessor's Parcel No.
Glenwood Springs, Colorado 81601
Phone (303) 945 -8212
This does not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit.
\ PROPERTY
Owner's Name Jay Duplesye Present Address 3204 CR 214 Silt Phone 876 -1960
System Location 37S4 County Road 237, Silt
Legal Description of Assessor's Parcel No.
SYSTEM DESIGN
AAV Other Al /"421 1 444#'
A:00 Septic Tank Capacity (gallon) . 41° (,%�
/0 Percolation Rate (minutes /inch) ‘51.4".. Number of Bedrooms (or other) 3
Required Absorption Area - See Attached 4# Qc�ic LPG Bei
=a /u.v"t /•v.r', r•9naa °Az B/' d /`2-7.sE 4
Special Setback Requirements:
'T' ireements: —37,3*
8 Date O Oda" - /.p Inspector Lj
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer TOM " - AAA?"
Septic Tank Capacity /Aa"l'lr
•
Septic Tank Manufacturer or Trade Name i�
4 1, F/�
(oArieuo
Septic Tank Access within 8" of surface y.
Absorption Area - '0 -- j3 2/ 4 ) n ii75 - to-c45
Absorption Area Type and /or Manufacturer or Trade Name 7,'a'A7 (?C'
Adequate compliance with County and State regulations /requirements yts
Other r9 7v Car–
Date /O 8 - it; Inspector T" `e•
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION 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 I, Petty Offense ($500.00 fine —6
months in jail or both).
White • APPLICANT Yellow - DEPARTMENT
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
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OWNER �■ ( • e
, , ' L t�.- L S
ADDRESS - PHONE X76 X94
CONTRACTOR ' i%L" ev0,. 1
ADDRESS 4 s, i /....A// PH E
PERMIT REQUEST FOR r\ NEW INSTALLATION ( ) AL'T'ERATION ( ) 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 pri .-s in •st holes (See page 4).
LOOCA_I'ION_OF PROPOSED FACILE" COUNTY ails 1 - + __
Near what City or Town __-- - - _ -- - Sine of L �r 4Ares --
Legal Description or Address �p 2 e W 71-ca 3� )
WAS'T'ES TYPE: DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON - DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE . TYPE:
Number of I3edrooms 3 Number of Persons_
( ) Garbage Grinder 4 Automatic Washer ( Dishwasher h � 1
SOURCE? AND TYPE OF WATER SUPPLY,: ( ) WELL ( ) SPRING ( ) STREAM OR CREEK
Give depth of all wells within 180 feet of system: Of de- o
If supplied by Community Water, give name of supplier it -rl O•I SI /
?-t
GROUND CONDITIONS:
Depth ur bedrock:
Depth to first Ground Water Table
Percent Ground Slope
DISTANCE 'f0 NEAREST COMMUNITY SEWER SYSTEM: ' 0 i .vim
Was an effort made to connect to community system? ( ) YES NO
TYPE I: INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(t4 SEPTIC TANK ( ) AERATION PLANT ( ) VAULT
( ) VAULT PRIVY ( ) COMPOSTING TOILET (, ) RECYCLING, POTABLE USE
( ) PIT PRIVY ( ) INCINERATION TOILET ( ) RECY LNG, OTHER USE
( ) CHEMICAL TOILET ( ) OTHER - DESCRIBE _ -. - / .1
FINAL DISPOSAL BY:
64 ABSORPTION TRENCH, BED OR PIT ( ) EVAPOTRANSPIRATION
( ) UNDERGROUND DISPERSAL, ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
( ) OTHER- DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? t
2
• PERCOLATION TEST RESULTS (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 ofRPL' 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 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 insure compliance with rules and regulations
adopted under Article 10, Title 25, C.1t.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. 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.
X — ‘—a `�/
Signed__ I— .y� Date 1!v
PLEASE DRAW AN ACCURATE MAP To YOUR PROPERTY!!
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