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4 ,, - w GARFIELD COUNTY BUILDING AND SANITA DEPARTMENT Permit N ' _ 3 1 6 n s ; }
{ 109 8th Street, Suite 303 Assessor's Parcel No. i
i Glenwood Springs, Colorado 81801 k
Y Phone (303) 945-8212 ..
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( This does not constitute
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t. r INDIVIDUAL SEWAGE DISPOSAL PERMIT e building or use permit
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y PROPERTY
) Ir Owner's Name n104 h N< Isen tbiaoPesentAddrese 6 7 / I -"" i6 ?1 Phone 9 47- 9 r
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ystem Location t k
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)• �' Legal Description of Assessor's Parcel No. g' /6 ', r
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T SYSTEM DESIGN L e ACM C H A ■-ii 3 en (3 C -L-L 7 SI 1 2 v k r T1 j 1
t 1- A e kV CH (g9 la ( ,i . r
4 7 J Septic Tank Capacity (gallon) Other e
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1 1, 1 g Percolation Rate (minutes /inch) Number of Bedrooms (or other) s
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Required Absorption Area - See Attached
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b Special Setback Requirements: : ..'
Y Date 6 - 3— 1 9 Inspector A hl c) '
sf e, FINAL SYSTEM INSPECTION AND APPROVAL (as installed) �'� i
- Call for Inspection (24 hours notice) Before Covering Installation o
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System Installer
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1 • Septic Tank Capacity 1 '2.. r 0 —
7 ,) Septic Tank Manufacturer or Trade Name J- l ' ` & A (Z' et ',
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t r Septic Teak Access within 8" of surface v d '
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1) Absorption Area
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Absorption Area Type and /or Manufacturer or Trade Name t � "� F / L `� n A �' `� U l�l I Tf
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Adequate compliance with County and State regulations/requirements ', )
K other A L 4 .- — Ov r Nov 9£ r T ScPr re t4- NK i
) i Da 7 a r t ` / 9 Inspector r'- " /V
1 l• RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE • ,
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*CONDITIONS: • I /
', k• 1. All installation must comply with all requirements of the Colorado S tate Board of Health Individual Sewage Disposal Systems Chapter a '
25, Article 10 C.R.S. 1973, Revised 1984. I
r ; 2. This permit is valid only for connection to structures which have fully complied with County zoning and building requirements. Con- 4 S
i I nection to or use with any dwelling or structures not approved by the Building and Zoning office shall automatically be a violation or a C
requirement of the permit and cause for both legal action and revocation of the permit.
t 3. Any person who constructs, alters, or installs an individual sewage disposal system Ina manner which lnvolvesa knowing and material t-
variation from the terms or specifications contained in the application of permit commits a Class I, Petty Offense ($500.00 fine — 8 ' 1
i ; months in Jall or both). i
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t ti VVlalte APPLICANT Yellow - DEPARTMENT i
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INDIVIDUAL SEW` EbfSP(, SAr
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INTER Al 6 so 4 v ; .YU V- - a s T-
ADDRESS g 0 X 147 134 -s4A r C- R fist/ " ` oN .
CONTRACTOR iza _
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ADDRESS PHONE— _T_
PERMIT REQUEST FOR (44 EW INSTALLATION
( ) ALTERATION_.�'��_: =--
Attach separate sheets or report showing entire area with respect to surrounding areas, topo _..
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habitable building, location of potable water wells, soil percolation test holes, soil profiles in test,h`
LOCATION OF PROPOSED FACILITY } 3
Near what City of Town 0 6 . &� C `° •
g P t~ 1 (- civS F � s µ _
Legal Description or Address � c
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WASTES TYPE: (c�DWELLING ( ) TRANSIENT USE x
( ) COMMERCIAL OR INDUSTRIAL ( ) NON - DOMESTIC WASTES_
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( ) OTHER - DESCRIBE . .,__^ -
BUILDING OR SERVICE TYPE: itq, -"
Number of Bedrooms 2. Number of Persons 2 J*S
( ) Garbage Grinder ( Automatic Washer ( ) Dishwasher
SOi JRCE AND TYPE OF WATER SI JPPLY ( LL ( ) SPRING ( ) STREAM OR CRE8Ie
4 N�,e.
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If supplied by Community Water, give name of supplier: l• o s•--s et S ev R � +ms= _-
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: ` #1 '¢
:.67. ,1
Was an effort made to connect to the Community System? 6 3 ,ilw{r' 7 •
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:'S _ UP \ ULJU ,' t 1 .,..'
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Leach Field to Well 100 feet
Septic Tank to Well 50 feet
Leach Field to Irrigation Ditches, Stream or Water Course: 50 feet +ty ,
Septic System to Property Lines: 10 feet , ,•'' t
1 R INDI / I A W• E DI P • AL Y TEM PET.►LI I 1 o I
WITHOUT A SITE PLAN, I
GROI JND CONDITIONS: v.: if �s • ' Y
Dept to first Ground Water Table `r 4 ,
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Percent Ground Slope w
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Y . �' < x RxY 34
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ryp 'Lt F + � r 7ffi
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OF INDIVIDUAL SEWAGE DISPOgaj
SEPTIC TANK
( ) VAULT PRIVY ( ) COMPOSTIN(},yL
( ) PIT PRIVY ( ) INCINERATIO °=
( ) CHEMICAL TOILET ( ) OTHER - DESCRIBt`
FIN DISPOSAL BY:
( kic ABSORPTION TRENCH, BED OR PIT ( )„
( ) UNDERGROUND DISPERSAL ( ) ::`>`SA1412a_
( ) ABOVE GROUND DISPERSAL • ( ) WA�.'S]vY-
( ) OTHER - DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? - _ .. - _
pERCOLATION TEST RPSI IT,TS: (To be completed by Registered Professional Engineer, if
the Percolation Test) . - -_
'-
Minutes per inch in hole No. 1 Minutes per inch in hole (1=
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 thefrA
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 r �c � Date ! l 3 /9 7
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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