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G ARFIELD C UNTY BUILDING AND SANITATION DEPARTMENT Permit N2 — 1 d S F t
P . 109 8th Street Suite 303 Assessor's Parcel No.
i 9lenwood Springs, lorado 81801 S
0? Phone 903 75.8212 i r
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i J This does not constitute
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P INDIVIDUAL SEWAGE DISPOSAL ERIAIT a building or use permit. t
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Owner's Name / � l ., I , . ��. /.tAL! Present Addre ,__I Phone •
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I S System Location I r e .
'' " Legal Description of Assessor's Parcel No 7 1
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i,,,, S YSTEM DE S G /N- r 1 C c H IA M dttt se 0 2. 2 P I EC ES t !
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a /L Septic Capacity (gal a I • f er N ' It (
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� � ! /3 'I Percolation Rate (minutes/inch) � � � be? Bedrooms (or o ) f Q 0 NI [Hy( 0E4
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t F, Required Absorption Area - See Attached -1 +,
, ; Special Setback Requirements:
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1 p Dat / / —/ o _/ 9 Inspector 40.1 y
/ FINAL SYSTEM INSPECTION AND APPROVAL (as installed) 1
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°' Call for Inspection (24 hours notice)
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tic cee) Covering Installation j
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5 $$ee pticrTank Capacity �O j - 0 k- Yb 1 `
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" ptic Tank Manufacturer or Trade Name W I'!
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`! Septic Tank Access w 8 of suril}ce
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• t Ab so r p t i on Area
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Absorption Area Type and /or Manufacturer or Trad�.Name t 1
i 1 Adequate compliance with County and State reglations/requirements r
4' oar — o k rb ' t �L L C Cot A C <i - p ie C t O o r. s
�' D to Z - rC( ` O 4 Inspectd� �' � (] �f I.
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, RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE e s
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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.
4 t ,/ . This permit is valid only for connection to structures which have fully complied with Count zoning and building requirements. Con- / 't
• a el nection to' Qui s_witherfy dwelling Or structures not approved by the Building and Zoning officeshall automatically be a violation or a ti;
•r requirem nt of the permit and cause for both legal action and revocation of the permit. .
r 1 3. Any person viho constructs, tars, or installs an individual sewage disposal system In a manner which involves a knowing and material ij
variation from - he terms or specifications contained in the application of permit commits a Class I, Petty Offense ($500.00 fine — 8 ), r
months In )ell or both). ite- APPLICANT - Yellow DEPARTMENT - ( te r . ' I (��
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER ROC k M 1 G 1 hun
ADDRESS I-O 1 L9ty rgrt SvLcJ v slot PHONE
CONTRACTOR Owner-
ADDRESS PHONE 12S -8S?7
Ow Rep.
rt4rg 844Cg
PERMIT REQUEST FOR ) 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).
LOCATION OF PROPOSED CILITY:
Near what City of Town i-c le pp 1 Size of Lot 3,3 ao .
Legal Description or Address t -ot 1 I- g" i9 r Su6d, v 7 5 io A
WASTES TYPE: ( ) DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL 1 ( ) NON - DOMESTIC WASTES
(K OTHER - DESCRIBE 6 - 1 v rc h
BUILDING OR SERVICE TYPE:
Number of Bedrooms Number of Persons
04-Garbage Grinder ( ) Automatic Washer AC) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: ( WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: 1 M ; I e f I vs
Was an effort made to connect to the Community System? Ye
A site elan 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 BE ISSUED WITHOUT
A SITE PLAN.
GROUND CONDITIONS:
Depth to first Ground Water Table
Percent Ground Slope
2
A.
•
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
pm() 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? No
pERCOI.ATION TEST REST IL.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 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 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 , /��i Date 3/3/
12SS-559964) 625 -2-la )
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
PIGns s ohm; +lei ; 1J A )9 5)4 ?lent
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