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` GARFIELD COUNTY BUIL I G AND SA TA 10N DEPARTMENT Permit Nn 3 S 6 3
/ ? !. . 1 109 St FYStl�ei U% i it SANITATION 'kg Assessor's Parcel No.
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a ,, This does. not constitute. '
'14 I INDIVIDUAL SEWAGE DISPOSAL PERMIT a building Or, use permit. f I
• k PROPERTY .
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Owner Name '!n J
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System Location �
8163
} Legal Description of Assessor's Parcel No €/
j ti SYSTEM DESIGN 2 4 ( F ( P R 7 & A -On. S 1 3 T RE 1. C t CS OF 8.'
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` • i t( Septic Tank Capacity (gallon) Other
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S Percolation Rate (minutes/inch) Number of Bedrooms (or other) - 1
' Required Absorption Area - See Attached ,
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Special Setback Requirements: c
Date _ Inspector
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1 f FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
k Call for Inspection (24 hours notice) Before Covering Installation
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e ; System Installer —_
S 11
Septic Tank Capacity 4
1 Septic Tank Manufacturer or Trade Name __ —.
2
' I. Septic Tank Access within 8" of surface _._...__
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Absorption Area Zh '
Absorption Area Type and /or Manufacturer f or Trade Name /� �i+ - '�'r + +�'� t
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Adequate compliance with County and State regulations/requirements .
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f Other __.. _ ........ .4! -- - r -
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f D a te Inspector 1 I A I p / 1 Fayros, f
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE t f
1 ' *CONDITIONS: 4
1. All installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chapter t `.
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- s
nection to or use with any dwelling or structures not approved by the Building and Zoning off ice shall automatically be a violation or a I
' ` requirement of the permit and cause for both legal action and revocation of the permit.
4 + 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 . f .
(t months in )ail or both). {
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White - APPLICANT Yellow - DEPARTMENT
SOIL PERCOLATION TEST'RESULTS: (To be completed by Registered Professional Engineer.)
Minutes per inch in hole No. 1 Minutes <6
per inch in hole No. 3
• Minutes /Q per inch in hole No. 2 Minutes per inch in hole No.
^ address and telephone of RPE who made soil absorption tests: a3& _y-ai L, 4
PO&',c /¢St', enttptwoo 0 -5-"vi 1/245 O 84 el 9'7e 29S - zss
'lame, address and telephone of RPE responsible for design of the system: clgn
rplicant acknowledges that the completeness of the application is conditional upon such
irther mandatory and additional tests and reports as may be required by the local health
iepartment to be made and furnished by the applicant or by the local health department for
)urposes of the evaluation of the application; and the issuance of the pernii't is subject to
ich terns and conditions as deemed necessary to insure compliance with rules and regulations
.dopted under Article 10, Title 25, C.R.S. 1973, as amended. The undersigned hereby certifies
:hat all statements made, information and reports submitted herewith and required to be
Jbmitted by the applicant are or will be represented to be true and correct to the best
f 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 under -
'tand that any falsification or misrepresentation may result in the denial of the application
r revocation of any permit granted based upon said application and in legal action for per-
jury as provided by law.
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ate � /6 /917 Signed �.�!'.rI?J /�.. L ! `�
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LEASE DRAW AND ACCURATE MAP TO YOUR PROPERTY
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