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INDIVIDUAL SEWAGE ÞISPOSAL PERMIT
PROPERTY
Owngr's
Sy6tðrfi Locati
Legal Descfiption of Assessor's Parcel No.
$YSTEM DESIGN
Permit 4ê01Êu
Aoosssor'c Parcel No
Thfs does nol constilute
a buildlng or uss psrmlt.
Ê4:525 vAddrese38tÇ
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. _*_. .other
GARFIELD COUNTY BUILDING AND SANITAÏION DEPARTMENT
108 Eighth Strcet, Sulte 201
Glenwood Sprlngs, Goloradof 8160f
Phone {970} S45-82{2
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I âc rb,/
tSæ sÊptic rank Çapaclty {sallon)
O túa,¡/ S,i,J.
s{.f.,{¡r,L--v-aV ø,ü1 ¿J
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Required Absorption Area - See Attached
Specfal Sêtbaok Requírements:
sdl
1'^-o r.l'he^of"(2r^^"/T 'f
ií - /ç>
l{.Peroolatíon Rate (mínutedinch)ol B€drooms (or Öth€r)
[nt
Number
ÛÐB ú
h ó5 l//\
Date r-.- lt - Þfr lnspsclor
FINAL SVSTEM INSpÊCTION AND APPROVAL (as installed)
Call for lnspection (24 hours notlce) Before Govoring lnstâllatlon
Ir q
System
€)4$êptic Tank
Septlc Tank Manulacturer or Trade Name
SÉptic Tank Access wlthin 8" oT surlace t'øs
Absorption Area
Absorplion Area Typo andlor Manufâcturer or Tradê Name # 4 t{'l*,
Adequate compl¡åncè with County and Statê
{KOthør
Date lnspeclor
RETAIN WITH RËCEIPT AT CONSTRUCTION SITE
*GONDITIONS:
1. At¡ ínstallationmustcomplywíthall roquirementsoftheColoradoStateBoardofHealthlndividual SewageDisposal$ystemsChapter
25, Article 10 c.R.s. 1973, Revised 1984.
2. This permlt is valid only for connectlon to structures whlch have fully complied wlth County zoning and building requirements. ton-
nectlon tu or use witlr any dwelling orotruoturo$ not approv€d by the BuildÌng anct Zoning olficc thtll åutomüiôâlly bc a v¡o]åtion ors
requirement of the pêrmit and cause for both legal action and revocation of the permit.
3. Anypersonwhoconstructs,alters,or¡nstallsanindividuälsewag€dieposalsysÌEminamannerwhlchinvolvesaknowlngandmaterial
vaiiation from the terms or specificatione contained in the appllcation of permit commits a Class l, Petty Olfens€ {$500.m f ins - 6
manth$ in i8¡l or both).
While - APPLICANT Yellow - DEPARTMËNT
SYSTEM APPLiCATION
ADDRESS æ5tfls*|lß %PHoNE*ÎÊã:gÞfl
CONTRACTOn or*llrtFia*
ADDRESS PHONE
PERMIT REQUEST FOR þ NTW INSTALLATION O ALTËRATION () 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).
LqcATrohr oF PRop o ËFÐ".FACr L_n:{i
Near what City of Town . ÊtLî ' - .,. Size of fot ,l,Õ:41-{klÉ.€*
Legal Dcscription or Address rlJa( ,ßrt ll L¡.t l.¡r I ?a¡¡çr Vrrlf$-y ¿'€rc{ilûd0}
WASTES TYPE:( ) TRANSTENT USE
( ) NON-DOMESTTC WASTES
( ) OTHER -DESCRTBH
BUILDING OR SERVICE TYPE: €¡t¡JGnu¿ ÉOat t¡'l
Si nwnll"lNc
() COMMERCIAL OR INDUSTRIAL
Number of Bedrooms
( ) Garbage Grinder
umber of Persons 4
ÇQ auto*atic V/asher dnishwasher
) wËLL SPRING () STREAM OR CREEK)
(
(
If supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST COMMT.INITY SETyËR SYSTEM: ã n4*Tgq
Was an effort made to connect to the Community Systern?¡..1 ¡..
A ufe plan is-rp-quirpd.fq he-su,þ,mitted thalindicatpsj!-rc"fqllort¡pl[MlNlMUl.vl distanc"çsj.
Leach Field to Well: 100 feet
SeptÍc Tank to tilell: 50 feet
Leach Fietd to lrrigation Ditches, Stream or Water Course: 50 feet
Septic System (septic tank & disposal field) to Property Lines: l0 feet
YO"UR INDIVIDUATSEW-Aç.E DI$PPSAI{SYSTPM"PERUIII WLI{N.QT BE_I$$UED VI¡ITHOUT
A SITE PLA}I.
GROUNÐ C_Or-'lprTLÇNSj
Depth to first Ground Water Tublt
PerccntGroundSlop* .-.,. -- , , .,... . - .__ ,,,, .,--
ÕL
TYPE OF iNDIVIDUAL SEV/AGE DISPOSAL SYSTEM PROPOSËD:
O AERATION PLANT
( ) coMPosTrNc T0ILET
( ) TNCINERATTON rOILBr
CHËMICALTOILETil OTTTER-DESCRIBÊ
FINAL DISPOSAL BY:
}{
()
()
()
()
()
()
SEPTIC TANK
VAULT PRIVY
PIT PRIVY
ABSORPTION TRENCH, BED OR PIT
TINDERGROT.IND DISPERSAL
ABOVE GROI-IND DISPERSAL
()
()
()
VAULT
RECYCLING, POTABLE USE
RECYCLTNG, OTHER USE
EVAPOTRANSPIRATION
SAND FILTER
V|iASTEWATER POND
K ()
()
()
OTHER-DESCRIB
WILL ËFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? Nl, O
BFRCOLATI9NJEST RSSUI,T$; {To be completed by Registered Professional Engineer, if the Engineer does the
Percolation Test)
Minutes-per inch in hole No. 1 Minutes -. -.. . per inch in hole No. 3
Minutes*---per inch in hole No. 2 Minutes inch in hole No.
Name, address and telephone of RPE who made soil absorption tests:
Name, address and telephone of RPE resporisible for design of the system:
Applicant acknowledges that the completeness of the application is conditional upon such fi.¡rther mandatory and
additional tests and repotts aq may be required by the local health department to be made and fumished by the applicant
or by the local health department for purposed of the evaluation of the application; and the issuance of the permit is
subject to such terms and conditions as deemed necessary to insure compliance with ruIes and regulations made,
information and reports submitted herewith and required to be submitted by the appiicant are or will be represented to
be true and correct to the best of my knowledge and belief and are designed to be relied on by the local department of
health in evaluating the same for purposes of issuing the permit applied for herein. I fi.lrther understand that any
falsification or misreprebentation may result in the denial of the application or revocation of arry permit granted based
upon said application and in legal action for perjury as provided by law.
Dare ol * ob * aE
DRATY AN ACCURATE MAP TO YOUR PROPERTY!!
Signed
3
Desþnate North ArrowCounty Road Qtfote the Road Number and Name)-- <_ounlr-r GÐ Z.AlYour Neighbo/sNarne & AddressJueu¡åShape to FitYour(Nort{d-/iqJþ¡,rl\F$.tS*¡t3all streams, inigarion ditchs, and any v/ater courses. Draw in your house,septic tank & systenl detached garages, and driveway.of location is necessary, you must submit a corrected drawing, before aCertificate of Occupation will be issued.tszYour Neighbor'sN¿n¡e & AddressãÈ cþpFù60\spdo8Þlo'tJóèL3 n)
ffi'æur|
please sc"oú
Billing Address
Jenny Roberts
1 1 48 County Road 237
silt co 816s2 usA
Job Address
Jenny Roberts
1 148 County Road 237
silt co 81652 usA
Roto Rooter Plumbing
P.O. Box 1800
Glenwood Springs, CO 81602 United
States
(970) 945-5519
Description of Work
lnvoice 11971229
lnvoice Date 1 0 /20 /2020
Terms COD
Com pleted D ate 1 0 /20 /2020
Customer PO
Pumped, cleaned and inspected 1500 gaflon septic tank and disposed of waste at state approved facility.
Task #
SËP-HAND
DIG
SEP.NC/DEB
SERVICEGWS
Description
Hand dig lids per foot...$140
Quantity Your Price Your Total
1.00 $140.00 $140.00
Pump septic tank 1000 gallon minimum 1500.00 $0¿0 $600.00
SERVICE FEÊ FOR A FULLY QUALIFIED TECHNICIAN AND FULLY EQUIPPED TRUCK 1.OO $29.00 $29.00
ON SITE
Paid On
10/2O/2020
Type
Check
Memo Amount
$769.00
5ub-Total
Tax
Total Due
Payment
$769.00
$0.00
$?6900
$769.00
Balance Due $0O0
Thank you br choosing Warren lndustries lncorporated
This invoice is agreed and acknowledged. Payment is due upon receipt. A service fee will be charged for any returned checks, and a
financing charge of 2.5Yo per month shall be applied for overdue amounts.
10t2012020
lfind and agree that âllwork performed by Roto Rooter Plumbing has been completed in a satisfactory and workmanlíke manner. I
have been given the opportunity to address concerns and/or discrepancies in the work provided, and I either have no such concerns or
have found no discrepancies or they have been addressed to my satisfaction. My signature here signifies my full and final acceptance of
all work performed by the contractor.
10/20n020