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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
109 8th Street Suite 303
Glenwood Springs, Colorado 81601
Phone (303) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT . :Ne- 1846 This does not constitute
e building or use permit.
Owner ThoolaQ:e E. & Winifeni R. sJoiner
System Location C1'y8.u:a River Rd. 14cN", 1
Licensed Installer _.T Ji__QCS7g{-rugetr.{tm ///
Conditional Construction approval is hereby granted for a gallon '?/7, ! f S
--t1r t � // .
- -. Septic Tank or Aerated treatment unit. l v. I s (V F - 1-E : n ,
Absorption area (or dispersal area) computed as follows: - - -� /_ _ =7 f Y C
1 N41 +'I,
Perc rate of one inch iQ /. � _ minutes requires a minimum of
sq. ft. of absorption area per bedroom.
Therefore the no. of bedrooms x sq. ft. minimum requirement = a total of
T - (9 ,(� 2 r r sq. ft. of absorption area.
May we suggest:
Ly /����� (� n � r� F R l-' �/ S r �J Y� F
Date__ f / �l ' / Inspector ✓✓ ,�,aR.- ,f! / jy/
FINAL APPROVAL OF SYSTEM:
t ^
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.
C 1, =.- Septic Tank access for inspection and cleaning within 12" of ground surface or aerated access ports above ground
surface.
' V, Proper materials and assembly. y
0 V. Trade name of septic tank or aerated treatment unit.
r) ( Adequate absorption (or dispersal) area.
Adequate compliance with permit requirements.
CJ Adequate / compliance with C / 9 unt y nd St/ate rregulations /requirements.
V Other / (k 4 JA (-4 e c . De 5 [c) n ` 9I .
Date 1 / 8/8y
_ Inspector — — - _ J I al _ -14-4
// / �" _
RETAIN WITH RECEIPT RECORDS to 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 commits a Class I, Petty Offense
($500.00 fine — 6 months in Jall or both.).
Applicant: Green Copy Department: Pink Copy
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION Appropprovaval by
by
OWNER < I County Official:
ca • a N'
CzO9 (
CONTRACTOR 'T s ( uthcP.4 L 0 4 a 1 PHONE `j 6 3-
ESCTOR
ADDRESS fig ua _pnlnntirt&Go (bo PHONE °I (�, A 3 0.5
t. PERMIT REQUEST FOR: (✓S 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 l-, etn .C, e (ck
Near what City of Town 0 n , i o r1 d Lot Size _
1 6 QE .C n "
Legal Description S 3 — _ Q jr
c) / /,, (d /F� / 4) ;ve 1.
WASTES TYPE: ( 'Dwelling
( ) Transient Use
( ) Commercial or Institutional ( ) Non- domestic Wastes
( ) Other - Describe
BUILDING OR SERVICE TYPE,
Number of bedrooms Number of persons
( vrGarbage grinder ( t4 Hutomatic 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:
GROUND CONDITIONS:
Depth to bedrock:
Depth to first Ground Water Table:
Percent ground slope:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to community system?
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
( ) Septic Tank ( ) Aeration Plant ( ) Vault
( ) Vault Privy ( ) Composting Toilet
i ( ) 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:
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? - -••
Page 2
; ton' 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 i 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 7- / & - Signed
PLEASE DRAW AND ACCURATE MAP TO YOUR PROPERTY
•
Page 3
PLOT PLAN AND DESIGN FEATURES:
Include by measured distance location of wells, springs, potable water supply
lines, cisterns, buildings, property lines, subsoil drains, lake, water course,
stream, dry gulch and show location of proposed system by direction and distance
from dwelling or other fixed reference object, and additional submissions in
support of this application such as data, plans, specifications, statements and
commitments.
Page 4
OMB 3067 -0077
FEDERAL NATIONAL E FLOOD INSURANCE PROGRAM
Espirito: /M41911
ELEVATION CERTIFICATE
This loom is to be used for. 1) New /Emergency Program construction in Special Flood Hatard Areas: 2) Pre •FIRM construction alter
September 30. 1982. T) Post -FIRM construction', and. e) Other bu rated as Post-FIRM rubs
• Wii7 -e4 ' Ted J /trio I o 9 ! Pfinq° den Rd No(Wibrock �� Good
• BUILDING OWNERS / ADDRESS `l
NAME
L. DT l d I�'oc,� Cie Pk ✓0 A diV /Sliln bard / /d �o un 7 Y
PROPERTY LOC • TI ON Lot and 91• k numbers a d address If aval bl • 1
r
• 4. / l i de /i /, I f. .4 iia /4
I certify That 1; - information on 1 is cardiic Iep m
resenls my • t effort AN Interpret the dal. vallable. I tinders!, - • that any false
statement ma (be punishable by fine or emir ., onment under • U.S. coo Section 1001. w /
SECTION I ELIGIBILITY CERTIFICATE (Completed by ocal Community Permit Olfici. •r a Registered Professional Engineer.
Architect. Or Surveyor)
2OMMUNITY NO PANEL NO SUFFIX DATE Or FIRM FIRM ZONE OATS OF CONSTR (•5E FLOOD EIEV BUILDING IS
On •0 Zone . use Swat
2t�s I�S 1'3 A3 11 k4 81 (9 132— Po `!NM ea
d �U
TO NO 11 Is intended that the Building described above will 0e constructed in compliance with the community's flood plain
❑ ordina The certifier may rely on community records. The lowest floor (including basement) will be at an elevation
of 11. NGVD. Failure to construct the building at this elevation may place the building in violation of
the comma ity's flood plain management ordinance.
YES NO The building described above has been construct.° in compliance with the community's flood plain management
❑ 0 ordinance based on elevation data and visual inspection or olneFr easonable means.
If NO is checked. attach copy of variance issued by the community.
YES NO The mobile home located at the address described above has been lied down (anchored) in compliance with the
❑ ❑ community's flood plain management ordinance. or In compliance with the NFIP Specifications.
MOBILE HOME MAKE MODEL YR. OF MANUFACTURE SERIAL NO. DIMENSIONS .
x
(Community Permit Official Or Registered Professional Engineer. Architect. or Surveyor)
NAME S et A vL ey L.; (1 ( p ADDRESS P-o. 13 6 X I Z I
TITLE 1^ �L .SU CITY ` a irt cs'L Sc i( STATE CO I 714 C " /c V3
/ SIGNATURE _mYc A / /lra tC 't' -' DATE / 7- &"TfPHONE 3a3 -9, 3 - JOSZ
SECTION 11 E VAT( CERTIFICATION (Certified by a Local Community Permit Official or a Registered Professional Engineer.
Architect. or Surveyor.)
FIRM ZONE Al -A30: 1 Candy that the by di 1 property location described above has Me lowest floor (including basement)
at an elevation of feel. NGVD (mean sea level) and the average grade al the building site is at
an elevation of eel, NGVD.
FIRM ZONES V, Vl -V30 1 certify that the budding at the propery location described above has the bottom 01 the lowest floor beam
at an elevation of feet, NGVD (mean sea level). and the average grade at the building site
is at an elevation of feet. NGVD.
FIRM ZONES A. A99. AO. AH. and EMERGENCY PROGRAM: I certify that the building at the properly location described above
has the lowest floor elevation of feel. NGVD. The elevation of the highest adjacent grade next
10 the building ie feet. NGVD.
SECTION 111 FLOODPROOFING CERTIFICATION (Certification by a Registered Professional Engineer or Arehilecll
1 certify 10 the best of my knowledge, information. and belief. that Inc building is designed so that the building is watertight. with
walls substantially impermeable to Inc passage of water and structural components having the capability of resisting hydrostatic
and hydrodynamic loads and effects of buoyancy that would be caused by the flood depths, pressures velocities. impact and uplift
forces associated with the base flood.
YES ❑ NO ❑ In the event of 1loo0ing, will this degree of floo0prooling be achieved with human intervention?
(Human intervention means that water will enter the building when floods up to the base flood level Do..
cur unless measures are taken prior to Inc flood to prevent entry of water (e.g . bolting metal shields over '\
doors and windows).
YES ❑ NO 0 Will the building be occupied as a residence?
11 the answer 10 both questions is YES. the fl00dprOOling cannot be credited for lalmg purposes and mtaclual lowest floor must De
Completed and certified instead. Complete both the elevation and Iloodprooling certificates
lr
FIRM ZONES A. Al•A30. V1-V30. AO and AH: Certified Floodorooled Elevation is feet. INGVDI
THIS CERTIFICATION IS FOR 0 SECTION 11 ❑ BOTH SECTIONS II AND III (Check One)
CERTIFIER'S NAME COMPANY NAME LICENSE NO. (or Allis Seal)
TITLE ADDRESS ZIP
SIGNATURE GATE CITY STATE PHONE
The Insurance agent should attach the original copy o1 1M completed form to the flood Insurance policy ...Bastion.
the second copy should be supplied 10 the policyholder and the Third copy retained by the agent
INSURANCE AGENTS MAY ORDER THIS FORM 593.117 r�
FEMA Form 11 APR 82 REPLACES FEMA FORMS •1-01T1 AND 111.101T). FEB BO, WHICH ARE OBSOLETE. 53 /1