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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
109 8th Street Suite 303
;:/ Glenwood Springs, Colorado 81601
Phone (303) 945-8212
This does not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT rn 15 4 9 • abuilding or use permit.
Owner Rif –K_""4 itfr_ / (nVl el i e 1 Don l f CA 1 i C k`(,r' F cd
System Location al S J 1 1 3 R (' 0,1-)c) n G a ( e' er ( 0
Licensed Installer I_ OA _ AL' L- P. r
Conditional Construction approval is hereby granted for a 1 000 gallon
7 Septic Tank or Aerated treatment unit.
Absorption area (or dispersal area) computed as follows: 4,1 ? ( p
Perc rate of one inch in 3J minutes requires a minimum of -.' sq. ft. of absorption area per bedroom.
Therefore the no. of bedrooms 3 x
jar 6 sq. ft. minimum requirement = a total of t sq. ft. of absorption area.
May we suggest: 'r-
Ttt /o ? 3
Date !' ltd /Y �, .Inspector ^,. (1 5 ALP r rioQ n
FINAL APPROVAL OF SYSTEM:
No system shall be deemed to be in compliance with the Sewage Disposal Laws until the assembled system is approved prior to cover•
ing any part. '
✓/ .. Septic Tank access for inspection and cleaning within 12" of ground surface or aerated access ports above ground
surface.
// Proper materials and assembly.
y Trade name of septic tank or aerated treatment unit. CO Fe la nOf
✓/ Adequate absorption (or disper sal) area.
/
✓/— Adequate compliance with permit requirements.
t/ Adequate compliance with County and State regulations /requirements.
Other ((////���
Date `�' 17/Oth . Inspector _ I L/!Y ✓ .___ __ -_
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
`CONDITIONS:
1. All installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems
Chapter 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. Connection to or use with any dwelling or structures not approved by the Building and Zoning office shall
automatically be a violation of a requirement 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 variation from the terms or specifications contained in the application of permit comm its a Class I, Petty Offense
($500.00 fine — 6 months in )ail or both.).
Applicant: Groan Copy Department: Pink Copy
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION Approval by
"OWN R �. Op4' /E - pon4 � 1�4 5 • r - �� County Official:
A ESS # R.4-3 R A„ 1/3 J l�+ PHONE 90
CONTRACTOR nil/ Wi
ADDRESS
PHONE
PERMIT REQUEST FOR: ( ) New Installation (x) 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 C4 ' ,C /`q ,(,0
Near what City of Town ernPje (24V____ Lot Size__ ____l______
Legal Description 1.411 ` T
• y
lT# Rp
WASTES TYPE: (x) Dwelling
( ) Transient Use
( ) Commercial or Institutional ( ) Non - domestic Wastes
( ) Other - Describe
BUILDING OR SERVICE TYPE:
Number of bedrooms 3 Number of persons .2
( ) Garbage grinder ( ) Automatic washer ( ) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: (X) well ( ) spring ( ) stream or creek
Give depth of all wells within 180 feet of system:
If supplied by community water, give name or supplier:
GROUND CONDITIONS:
Depth to bedrock:
Depth to first Ground Water Table:
Percent ground slope:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: At M /115
Was an effort made to connect to community system? /VW
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(>0 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:
( ) Absorption Trench, Bed or Pit ( ) Evapotranspiration
( ) Underground Dispersal ( ) Sand Filter
( ) Above Ground Dispersal ( ) Wastewater Pond
( ) Other - Describe: ,4:82571r:44/ Cl2F4
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? /f/Q
Page 2
_ PERCOLATION 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 application and in legal action for per-
jury as provided by law.
Date my 987 Si gned ii � i �.,.. . I , t i
PLEASE DRAW AND ACCURATE MAP TO YOUR PROPERTY
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Page 3
GARFIELD COUNTY
tp,Sanitation N 3628
1 , • * ❑ Building
❑ Planning
109 St. Suite 303
Glenwood Springs, Colorado 91601 k DATE:
' Telephone 303: 9454212 / 625 -5571 , F' L/ Eli /'
( RECEIVED FROM: Inn /1116 C t;" lifia
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