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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit PS_2 1 9
109 9th Street Suite 303 A is Parcel No.I
Glenwood Springs, Colorado 81601 4
Phone (303) 945 -8212
This does not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit.
PROPERTY t
Owner's Name .zits & Laurie Brunner Present Address P•Q. Box 3877. Evergreen. Rilne 538 -7612
I
System Location County Road 261, Silt.I d
II
Legal Description of Assessor's Parcel No.il
e
SYSTEM DESIGN i
f 0 0 6 Septic Tank Capacity (gallon)Other
Percolation Rate (minutes /inch) Number of Bedrooms (or other)3
Required Absorption Area - See Attached I
Special Setback Requirements:j
Date Inspector fit 1:... /'s ..a.!-.....at -4.6--
FINAL. SYSTEM INSPECTION AND APPROVAL (as installed)`f
1,V Call for Inspection (24 hours notice) Before Cov' ing Installation
System Installer
t
Septic Tank Capacity 1 I
i
Septic Tank Manufacturer or Trade Name S
Septic Tank Access within 8" of surface
4'ZY`r'4 4/ ertAbsorptionArea 1
Absorption Area Type and /or Manufacturer or Trade Name + .F
Adequate compliance with County and State regulations/requirements L i
f
If Other
j
Date 7:. g" Inspector q'YiS
r RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
CONDITIONS:r
1. All Installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chapter i
25, Article 10 C.R.S. 1973, Revised 1984.s
9 2. This permit is valid only for connection to structures which have fully complied with County zoning and building requirements. Con-
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
irequirement of the permit and cause for both legal action and revocation of the permit.
3. Any person who constructs, alters, or installs an Individual sewage disposal system in a manner which involves a knowing and material F
variation from the terms or specifications contained In the application of permit commits a Class I, Petty Offense (8500.00 fine —6
months in jail or both).S.
e Applicant: Green Copy Department: Pink Copy
IPApplicationINDIVIDUALSEWAGEDISPOSALSYSTEMAPI'LICA[IOli Approval by
4 g Mop/ice—
County Official:
OWNER 1 / n
ADDRESS lf, ,89L 3077, gad-re-41 Co 35_ PII0IIE33-5-30-76/7" 5°CONTRACTOR 5 I/C 4.411
ADDRESS Pi2 624414 A,r GLet t t:a5 co S16,41' IONE W5 ° I
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 FACILITY: County grief
Near what City of Town u.Lot Size
Legal Description APturor OPD _ ,urive 5%i of Set-wt 3! rdSSoonii ,QMxeQ / CaoF( o " hM .
WASTES TYPE:Dwelling Transient Use
Commercial or Institutional Non - domestic Wastes
Other - Describe
BUILDING OR SERVICE TYPE: 0oo0 f24in& S1t 4U,aa-t -.
Numbe . of bedrooms r- 3 lumber of persons Z—
Garbage grinder 1 Automatic washer fiDishwasher
SOURCE AND TYPE OF WATER SUPPLY: v spring stream or creek
Give depth of all wells within 180 feet of system:VA____._
If supplied by community water, give name or suppl1er:________
GROUND CONDITIONS:
Depth to bedrock: 71L5 651 /3Y Cii /n*.n TetiAct? 6•S• - /i6
Depth to first Ground Water Table:f
Percent ground slope:
DISTANCE 10 NEAREST COMMUNITY SEWER SYSTEM:__ SmitES me flo,PC
Was an effort made to connect to community system?No
TYPE of IiIUIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
Septic Tank Aeration Plant Vault
Vault Privy Composting Toilet Recycling, potable use
Pit Privy Incineration Toilet Recycling, other use
Chemical Toilet Other - Describe:
FIi1AL DISPOSAL BY:
4 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 1 STATE? NU
Pnne 2
lJ ,_) cm pkw-neboici
SOIL PERCOLATION TEST RESULTS: To be completed by Registered Professional Engineer.)
Minutes .5-7 per inch in hole No. 1 Minutes 5 per inch in hole No. 3
Minutes 5-7 per inch in hole No. 2 Minutes per inch in hole Mo.
Name, address and telephone of RPE who made soil absorption tests: (172. niOni/
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
purposes of the evaluation of the application; and the issuance of the periiiVt,is'subdect to
such terms and conditions as deemed necessary to insure compliance with rules and regulations
adopted under Article 10, Title 25, C.R.S. 1973, as amended. The undersigned hereby certifies
that all statements 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 or issuing the permit applied for herein. I further under-
stand 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 per -
jury as provided by law.
Date z_ 3 A 3 Signed
PLEASE DRAW AND ACCURATE MAP TO YOUR PROPERTY
01 `6aV12E
rat ,,,
R 233
9 Js,crf
Page 3
PLOT PLAN AND DESIGN FLATulws:
Include by measured distance 1oca11on of wells, springs, potable water supply
1 Ines , cisterns, buildings, property lines, subsoil drains, lake, wafer course,
stream, dry gulch and show location of proposed system by direcLion and distance
from dwelling or other fixed reference object, and additional submissions in
support of this appl1cation such as data, plans, specifications, sLalemenls and
connri linen Is.
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