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t " r � +^ 'arc rote 6 one V pr i n a I + l a . min requires a M{,i a um a "" + ,,tq. it. bf a bsor p tion area P$ bedrgoM. • � tP g„, r 1,
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t' ;Y INAL APPRI')VAL "Or —14)4' EI� i . w d ' „ x i iii u r " + �, h m r"+
t 4 i u system shall be deeme „ Rd be in compiianoe wit the 5 " w a ge ttpbsal L until the as y,ste is approved pr,or t tl t', Illltx ,
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t a Adequ co fiance with "C o u n t y ands fate r1 bu1auonsfrequirem nts.
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° 1. Ali$natallationhrl oomptywlh el lre q u lrement eo ft ,' dr ado tateBoardotHealthlntllvld ¢ewageDlappaalSysteme ^ r g,a4 d@
II Chapter 205 A rt l dl 10 O.R.
t yro , aeted t hp - tl •
2,' Thia t ermlt e, Ve lld onty conn to t + 4i + Moll hive hilly piled tv County zoning end buttdinp
and
r "Coilneotlgq A',o tree with AhY� , W or� not approved t and Zoning oHlo@ Sill II
Ictin S. -Any pers who 4, natr i or InetA e i 1 u w dieposab aysterh 9 m a know " I e '$
mater 11 11.1t s .^
en t Ip'theterms Ir Qlntheappl Petty tNlenae j i
; ." ($500.00.tine n AI mo n ths to 1811 or .both.). c"
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W P f�P,DlioanL. OIN Plnk COPY, ' 'ra�
I
T.--- Application
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION Approval by
County Official:
ADDRESS de _ / /v P` . _ , As o.. -13rIONE 9 = �02 43
CONTRACTOR_ `/' - L/iriA)i_
ADDRESS 1 /4d5 24 ‘21/04,140b $r/y4 PHONE 9 7/13
PERMIT REQUEST FOR: ()e) 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 age 4 4.)
LOCATION OF PROPOSED FACILITY: County Sj9,e A
Near what City of Town ,IODD . Lot Size ei A
Legal Description .I .'MA i. a 4 : 1 -oi ili.S7fl
WASTES TYPE: ()( ) Dwelling ( ) Transient Use
( ) Commercial or Institutional ( ) Non- domestic Wastes
( ) Other - Describe /�
BUILDING OR SERVICE TYPE: SIj34 /, -7 Aa,.;;1
Number of bedrooms : Number of persons 1
( ) Garbage grinder (X) Automatic washer (X) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: ()() well ( ) spring ( ) stream or creek
Give depth of all wells within 180 feet of system:_j_
If supplied by community water, give naive or supplier:J3 /1) P
GROUND CONDITIONS: / e l
Depth to bedrock: 4/'£AE�.e A ) /2)-(9 _
Depth to first Ground Water Table: 1 / I, u c: C
Percent ground slope: 6
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: / 49AX 67,0, i IOGea
Was an effort made to connect to conununity system? ,Q
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(x') 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 ith a 1 ( ) Wastewater Pond / �(
( ) Other - Describe: / /e,975,e aciiT .5 - `fACI /AJ 6 k
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF TIIE STATE? 442,
i
5014 PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer.)
Minutes j� per inch in hole No. 1 Minutes iP per inch in hole No. 3
Minutes 4C per inch in hole No. 2 Minutes per inch in hole No.
Name,.address and telephone of RPE who made soil absorption tests: 5q .. 6 E LO /,),
Name, address and telephone of RPE responsible for design of the system:
Vfafrf 4/9ATZ 7 CO!' e , 20o 46:e2A0 6/E4 w) 2M44 4 5.
9192/
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 periultis 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 4 9:2 Signed
PLEASE DRAW AND ACCURATE MAP TO YOUR PROPERTY
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