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lie' R.PlELD C bUNTY BUIL G AND SANIYATiON"DEPARTMENT "'
p d k t0 2014 Blake,Avenue
tip! f °r t, w' Glenwood Springs, Colorado 81601
r r, I, i ' v'• , ' Phone,1303) 945-8241
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C PEE ' i t w I REQtILREI � .
. This does t constitute
" i DJ " VI DUAL'SEWAGE DISPOSAL PERMIT jt, 13 a building or use permit.
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i1 Owner gaol. T` r�?M
System LQCatitin 7fl' e0 ,44.1 Si Sr?.— • I, Cr /e /1, 0 S 4G '. Vie) S C
a 1 Licensed Installer
• Conditional Construction approval is hereby - granted for a �� gallon /.z r' 'tx n'..t :3b?vpOO.< Y 20 X /•S
ahk or AeSetad treatment e.5c' nrwt r4 soA r r ry
'ft e
JX S ptic T tment unit.
- r Absorption area (or dispersal area) computed as follows;
Perc rate of one Idgh in • t. minutes requires a minirnuin of Via- sq. ft. of absorption area per bedroom.
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x•1' Therefore the no.^ •,f b edr o oms . „ett4s- x N04- sq. ft. minimum requirement = a total of V 4 " sq. ft. of absorption area.
. " May we suggest /' * i 1-1.-- .. — 3.l�7 c - VS iiC J/�f �� >aesC).1raEi5t
as 472' Y4. -Geer- e 4--(3' frM}�
u ,y .P— /7 -.-3 /r /ems /
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APPROVAL (5F
S TEM:
- I " � NAL AP SYSTEM:
,
r t , No system shall be deemed to be in compliance with the Sewage Disposal Laws until the assembled system is approved prior to cover.
"µ •` • ' ing any part.
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II � ----'r Septic Tank access for inspection and cleaning within 12" o ground surface Ofllpra'ted access ports above ground
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Proper materials and assembly• oW
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, a0e name of septic tank or aerated treatment unit. ;/ p w
- •i .._. Adequate absorption (or dispersal) area -
-_!'t '
� .-- Adequate compliance with permit requirements.
ale i _ ' dequate compliance with County and State regulations /requirements" 'l
Other
� �
I I J. Date /Q — e �.7 , `1 � InS{�eCtOf ".,, '<4
v.±, � °9 l' " 1 RETAIN WITH RECEIPTREOORDS AT CONSTRUCTION SIT
t ON
sr l °• , a i A l l p y with all requirements of t Gp nt �In Savage DllppsatEt4ho a'tions, adopted pursuant to au-
*w "' a uthority granted in 6 85 1963, amended 68 $1' r 00100i: "r •- •:, " tp ,,, q,a a 1
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1' ,This permit is valid only for C onnection to strueturas'' sv
i ' itht e .0011y Cori lied 'with Count l zoning end building requirements.
s 1 r, (1 " ,' =Connection to or use with any dwelling or, structures op •approved by the Buildingend Zoning ,office shall automatically be a viola.
,: 1, '' Lion of a requirement of the permit and cause for both legal action and revocation of the permit.
3. Section III, 3.24 requires any person who constructs, alters, or installs an individual sewage disposal system in a manner which in-
volves a knowing and material variation from the terms or specifications contained in the application of permit commits a Class 1,
Petty Offense ($500.00 fine — 6 months in jail or both).
Applicant: Green Copy Department: Pink Copy
" INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION Approval by
= 1 Application
t r Countf Official
R 4 �
OWNER r
ADDRESS 7840 her 7'j PHONE Jjrs $97S' te-`
CONTRACTOR S� n-, " "`���
ADDRESS PHONE
/ ".:4in/427.7,”rnvy
PERMIT REQUEST FOR:
(.C) 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 17 n
Near what City of Town g4 /4 non" Lot Size.,' $f` /7`Crf s
Legal Description
WASTES TYPE: ( ) Dwelling ( ) Transient Use
( >c) Commercial or Institutional ( ) Non- domestic Wastes
( ) Other - Describe _
BUILDING OR SERVICE TYPE: • c5 - •1 tr i[o vsz
Number of bedrooms N /A- Number of persons /0- /Z
( ) Garbage grinder ( ) Automatic washer ( ) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: ( ) well ()‹ ) spring ( ) stream or creek
Give depth of all wells within 180 feet of system: —
If supplied by community water, give name or supplier: Caff /& Crrlk a.4f1 Q3sc
GROUND CONDITIONS:
Depth to bedrock: ro,'- - t 7 ?' _
Depth to first Ground Water Table: /` e` " e -
Percent ground slope: e r> - ra-
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was 'an effort made to connect to community system?
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(jam) Septic Tank ( ) Aeration Plant ( ) Vault
( ) Vault Privy ( ) Composting Toilet ( ) Recycling, potable use
( ) Pit Privy ( ) Incineration Toilet ( ) Recycling, other use
( ) Chemical Toilet ( ) Other - Describe:
FINAL DISPOSAL BY:
(CI_ 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 THE STATE? 41o'
Page 2
P EJ€OLATION TEST RESULTS: (To be completed by Registered Professional Engineer.)
Minutes per inch in hole No. 1 Minutes per inch in hole No. 3
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
purposes 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 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 of 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 applicatio. ... in legal action for per-
jury as provided by law.
Date mZ7 /97 /779 Signs. l<
PLEASE DRAW AND ACCURATE MAP TO YOUR PROPERTY
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