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ti d GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N2 3 0 2 2 ,
• u 109 8th Street Suite 303 Assessor's Parcel No.
r Glenwood Springs, Colorado 81801 :
I _t Phone (303) 945-8212
. • r This does not constitute
1 1 a building or use permit. � ,,
INDIVIDUAL SEWAGE DISPOSAL PERMIT
•
PROPERTY i
f. r Gt4 P ReL t92 /110 13 RI- [ "le Co (o 5
�, O wner's Name I R J � • Present Address 10 � Y Phone 3 . (
• � ^ • S ystem Location I Adi 1{w y 13 & J It Co 8 I ,050 ..
4
t L • egal Description ofASa ,'B LOCK -- LEACH- r % /o ( - 782 az i t
i SYSTEM DESIGN Z� L AC H— C H, A r n {3 a: R QED _ s 7 u N I T S --r 1 0 G9 , i
' 3) tt tt T2 cf.( c nC5 = 4 8 V N(tS —_i1•, b '9 l isc ? i
{ ( 1 2-S - Septic Tank Capacity (gallon) Other
, � 3� 1"
Percolation Rate (minutes /inch) Number of Bedrooms (or other) + y
i'
Required Absorption Area - See Attached
F E' 4
{ ( Special Setback Requirements: `,
% t I Date ' — Inspector ; E
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FINAL SYSTEM INSPECTION A APPROVAL (as installed)
• • } Call for Inspection (24 hours notice) Before Covering Installation f • t •
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I system Installer__' 4 /[, S V Iv 0 hw I.( C 0 A C I f'
I.
of
• 4 Septic Tank Capacity ( • . S V
t Septic Tank Manufacturer or Trade Name D 0 036 , y (C. • `i • Pi i v) ii
,t— 3 3
Septic Tank Access within 8 " s o surface \/ t � T
Absorption Area i U N 1 1 C [ ! a C ti ' Cf
S Absorption Area Type and/or Manufacturer or Trade Name
I 1 Pt TRQ rotes
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• M n 4i- Adequate compliance with County and State regulations/requirements Purl 1 / (,1 .1 ( +
C n 1 C5 ? )
1` t f I ✓1 i `
1 > , Other 5U 6 3 E ck T o a A rc/ I y ftot' A L 4. !
I Date 9.- / v-4 I Inspector An no (
Ir } e
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE ' 4
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.
i , ` 2. This permit is valid only for connection to structures which have fully complied with County zoning and building requirements. Con- r
• 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
} ` requirement of the permit and cause for both legal action and revocation of the permit.
j t, f
3. Any person who constructs, alters, or installs an individual s ewage disposal system in a manner which involves a knowing and material I '
variation from the terms or specifications contained in the application of permit commits a Class I, Petty Offense (5500.00 fine — 6 t
months In jail or both). y '
White - APPLICANT Yellow - DEPARTMENT 1 4
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
~ OWNER C✓l.0 (z / 1 ) -v
) ( - Peet
ADDRESS IC) a-e2 j 13 PHONE
CONTRACTOR r R �./✓�Aw^ r r1�n
ADDRESS f Oat 4. 14 ?-) ! PHONE fo,S —
PERMIT REQUEST FOR V) 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).
J.00ATION OF PROPOSF,D FACTLITY
Near what City of Town J $ l Sze of Lot 3 IV ( 2
Legal Description or Address 1 O5--$ 1', 1 c 6 RI(occe
WASTES TYPE: (jQ DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON - DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPE:
Number of Bedrooms -144 ' Number of Persons Co
(X) Garbage Grinder (A) Automatic Washer (X) Dishwasher
SOT MCP, AND TYPE OF WATER STJPPLY: (X) WELL (X) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: 1 O nn
Was an effort made to connect to the Community System? ' �a
A site plan is required to be submitted that indicates the following MINIMUM distances;
Leach Field to Well: 100 feet
Septic Tank to Well: 50 feet
Leach Field to Irrigation Ditches, Stream or Water Course: 50 feet
Septic System to Property Lines: 10 feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL, NOT RE ISSUED
WITHOUT A SITE PLAN,
GRO! ND CONDITIONS;
Depth to first Ground Water Table (')OtR 1106
Percent Ground Slope 1 `!.,
2
•
.:TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
()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:
) 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? P10
pFRCO1.ATION TEST REST II ,TS: (To be completed by Registered Professional Engineer, if the Engineer does
the Percolation Test)
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 teleplpne of RPE who made soil absorption tcst / ,
t ( 1 t __. -1 4;'
Name, address and telepho a of RPE responsible or esign o 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 purposed 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
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 c .,J A - Pd (-TJ /YY Date i /,�2,�1ff
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!! ///
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