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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
109 8th Street Suite 303
Glenwood Springs, Colorado 81601
Phone (303) 945·8212 1r i f INDIVIDUAL SEWAOE DISPOSAL PERMIT
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Permit N~ 3654
A88e88or's Parcel No.
This does not constitute
a building or use permit.
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J Legal Description of Assessor's Parcel No.--------------------------------!
; SYSTEM DESIGN ' !
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------•Other l· _,!,_,,_..0'-'0"-"(2'--Septic Tank Capacity (gallon)
--~??~--Percolation Rate (minutes/inch)
Required Absorption Area • See Attached
Numbet:o leJ!ro~ms (or oth r) gf 6~.f -~) ·
S-35'. )b~ . '/
Ji./ 7_,,_ If'?<-·
38(, 8# ()/ f1...{3'>tr,,) 9"-;I Yp-<--tS Xii') ~ l: Special Setback Requirements:
Dato 5h ..'.-/~>'t--" j I,.~·'?*'
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inspector _.;..;[J"'r-'-~'-"-J.<-'-'/"--_?lt.-R~~tF'-'g""'-------------
FINAL SYSTEM INSPE. ON.AND APPROVAL (as installed)
Call for Inspection (24 h · rs notice) Before Covering Installation
System lnstaller_~G;~@~~~=--~~~~~9~{~~~·,_t.--___________________ ~1_.1 ___ _
Septic Tank Capaclty_,_)~C~)~O---------------------------------
Septic Tank Manufacturer or Trade Name ---------------------~-------
Septic Tank Access within 8"_ of surface V lAlr'f & & cL d CJ l, &~il
Absorption Area I~~-< lM k0'{t ( ?, vbW"'-> c'>1 <z)
Absorption Area Type and/or Manufacturer or Trade Name --'JJ"'j_..,-'""~-tl-"""-"',Q=f;..-'-'q"fsn._'"-'"-=----------'-'------
Adequate coinpliance with County and State regulations/requirements ___________________ _
Other------------------~----~----------+/ __ _
Inspector ~(J""""11,~A~.h.~·,,_/_· ,_/ ~/LR.~a~Jl~----------Date ?-I').' Or
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
•CONDITIONS:
1. AU lnstall~t(on must comply with all requirements of tho Colorado State Board of Health Individual Sewage Disposal Systems Chapter
2~. Atticlo 10 C.R.$. 1973, Revised 1984. ,....,, L'
-;·., 2.' This permit Is valid only for connection to structures which have fully complied with County zoning and building requirement&. Con~
nectlon 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 ~evocation of the permit
3. Any person who constructs, alters, or Installs an Individual sewage disposal sys .. tem in a manner which Involves a knowi~~-8[1~ material
variation from the terms or specifications contained In the application of permit commits a Class I, Petty OffenseA:$59QJKJ fine - 6
months In jail or both). · .. . .
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White -APPLICANT Yellow -DEPARTMENT
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INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER Jnc1cl _$, Hn5ef rncu1
ADDRESS po 8.oc. $l{ R,.,,-qchcA-te (co
-~ -- - -.. ; -'ff/635
9l/'5 -3 ?YiO (w)
PHONE 970 ·-2125-6237&)
CONTRACTOR~p;:j.ts:az: .. ~M~>ttz~1L~_uO~vJ~~~e~1 ________________ _
ADDRESS _______________ ~
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).
LOCAIION OF PROPOSED FACILITY:
Near what City of Town Po.r91c h0 te Size of Lot 2 . 7 '8 Ac.res
Legal Description or Address Lor C 309 Roi l"i111jhr Exe,.,,pr•oV7
WASTES TYPE: 9<) DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER-DESCRIBE. _______________ _
BUILDING OR SERVICE TYPE: 5nc/s B"'' '" S'"@'" '''""":t H"'.-ne-
Number of Bedrooms--'""'-------------
(>() Garbage Grinder ~ Automatic Washer
Number of Persons --1-----
(X) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: (>() WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: ____ ..:..i::....L.J.. _________ _
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: _ _,_/1(/-"-'-/-/-'---------
Was an effort made to connect to the Community_S_y;.em? __ --'/1/, __ '/l __________ _
A site plan is regulred to be submitted that Indicates the following MINIMUM distances;
Leach Field to Well: 100 feet
Sepdc Tank to Well: 50 feet
Leach Field to Irrlgadon Ditches, Stream or Water Course: 50 feet
Sepdc System to Property Lines: 10 feet
YQUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT
ASIIEPLAN.
GROUND CONDITIONS:
Depth to first Ground Water Table ___ 9_7_-_/C>.~5_f:"'--'--t---'D'"-''eP._B_r?_d_1..,.~'J-+-o-n_re_5_"f _____ _
Percent Ground Slope __ ""5'-%'-"-o---------'----------------
2
- - - - - - - - - - - - - - - - - - - - - - - - - - - - ------
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
-c~ SEPTIC TANK ( ) AERATION PLANT
( ) VAULT PRIVY ( ) COMPOSTING TOILET
( ) PIT PRIVY ( ) INCINERATION TOILET
( ) CHEMICAL TOILET ( ) OTHER· DESCRIBE
---FINAL DISPOSAL BY:
( ~ ABSORPTION TRENCH, BED OR PIT
( ) UNDERGROUND DISPERSAL
( ) ABOVE GROUND DISPERSAL
( ) VAULT
( ) RECYCLING, POTABLE USE
( ) RECYCLING, OTHER USE
( ) EV APOTRANSPIRATION
( ) SANDFILTER
( ) WASTEWATERPOND
( ) OTHER·-DESCRIBE._--_--_-_-_-_---------_---------------_-_--_-_--------------------_-----------------
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE?_-'-/V(---'CJ"'-----
PERCOLATION TEST RESULIS: (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'----~-¥-er inch in hole No. 2-------Minutes. ___ ~--per inch in hole NO._
Name, address and telephone ofRPE who made soil absorption tests: _____________ _
Name, address and telephone ofRPE 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-eompliance 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
talsification 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.
Date __ 3_:::_-_3_/_-0?__,~~---
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPER TYi i
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· SCT R(UAR i_ & CAP
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Approxitnately 2.78 acres
Well production approx. 10 gptn
Telephone & electric at property
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"""APP"OX. CL
H'i GRAYrl DR.
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REBAR '. CAP P.L
Zoning ARRD
No irrigation
Fantastic views
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