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1 GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
109 8th Street Suite 303
Glenwood Springs, Colorado 81801
Phone (303) 945 -8212
A 9 n This does not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT ' 'v A a building or use permit.
Owner Mn', , and r nna Ilrentjee
System Location Wstbank, Piling 3, Lot 28, Glenwood Slob. OD
Licensed Installer __Gary Helsel
Conditional Construction approval is hereby granted for a /0 0t 1 gallon
4-� Septic Tank or Aerated treatment unit.
Absorption area (or dispersal area) computed as follows:
Perc rate of one inch in /0 minutes requires a minimum of 276 sq. ft. of absorption area per bedroom.
Therefore the no of bedrooms l x sq. ft. minimum requirement = a total of Co ' / Sq ft. of absorption area.
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May we suggest r /7:> c.“/ �� cif /411 Pi - < ;
e
Date t , Inspector
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.
(2' 1 - Septic Tank access for inspection and cleaning within 12" of ground surface or aerated access ports above ground
surface:
Proper materials and assembly.
�� �t��t7q� �.�7 C OQ -�e
�K Trade name of septic tank or ae t ed treatment .,cl //
O h Adequate absorption (or dispersal) area. / 2 / .c7-t-/
c=
62l \ / Adequate compliance with permit requirements.
Adequate compliance with County and State regulations /requirements.
_ Other / /o
Date 573[/ n 9 —_ Inspector iv4 / _
RETAIN WITH RECEIPT RECORDS / CONSTRUCTION SIT
"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 commits a Class I, Petty Offense
($500.00 fine — 6 months in Jail or both.).
Applicant: Green Copy Deportment: Pink Copy
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION Approval by
OWNE& 13o8 �- DON Nq I4c' County Official:
ADDRESS PHONE
CONTRACTOR GA a Y II
ADDRESS 1 010 ( FR t 4 /C4) Oc PHONE 99S 6 s L(
PERMIT REQUEST FOR: (✓rNew 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 an F iv e
Near what City of Town & 2 5. nu vs Lot Size ( •tR c-IE'
Legal Description Lo r 2 8 tr It- ' N 6 et 3 1.0 C Srts4 NM_
WASTES TYPE: ( Dwelling ( ) Transient Use
( ) Commercial or Institutional ( ) Non - domestic Wastes
( ) Other - Describe
BUILDING OR SERVICE TYPE: '&5 /Oc c
Number of bedrooms 3 Number of persons 4
( ) Garbage grinder ( 44- Automatic washer (-- 'Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: ( of well ( ) spring ( ) stream or creek
Give depth of all wells within 180 feet of system: 4)0/06
If supplied by community water, give name or supplier: We C return RA
GROUND CONDITIONS:
Depth to bedrock:
Depth to first Ground Water Table: UnKNooLe
Percent ground slope: 3% 1oo .eox.
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: G t c,v urcvv CPe fA) s S M ic- e
Was an effort made to connect to community system? /1.10
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
( L4 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:
( t) 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? Al 0
Page 2
SOIL PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer.)
^ ''Miribtes 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._
Nance, 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 permitiS 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. ,, // / o
Date Mo9 Z2 MS/ Signed See -7 y�
PLEASE DRAW AND ACCURATE MAP TO YOUR PROPERTY
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