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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N= 2 0 1 t
109 6th Street Suite 303 A r'e Parcel No.
Glenwood Springs, Colorado 81601 2463 022 00 007
Phone (303) 9454212
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This does not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. t>
PROPERTY 14
Tim Nieslanik 295 Rio Grande Ln,.CarbondaUL 963 -9496
Owner's Name - Present Address Phone q
System Location County Road 100, Carbondale t
.. Legal Description of Assessor's Parcel No. t
SYSTEM DESIGN 1
r �(�`"; >0 Septic Tank Capacity (gallon) Other i
2 7 Percolation Rate (minutes/inch) Number of Bedrooms (or other)
3 i
Required Absorption *r'li - See Attached ,l S'/ 11 / L X l �> i ` 7� x J., / i' Special Setback Requirements: �/ 3d # 1- fkM60.7< # $
�G- /Tc �iJ�4. ,!'C' $� frfai /A c// L
� / f �t ,r..rG �rT % oiV I
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Date r / / /t..r' Inspector 7f i, 4". ! .&- WI"
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer li(illnPr //
Septic Tank Capaolty JQ'N' \r;l 1
Septic Tank Manufacturer or Trade ) Name (1/ F Y? ' ii; r
1 4
Septic Tank Access within 8" of surface f S ; ' i r t ' i ' i ' " ` a
! . /. ! % #I
Absorption Area i 'y"'`50 t , r ,i%f 1 i'- ` k
PP �� �,��,A gLi I.. j'' t 41 1 �., i . ' t k s
Absorption Area Typo an or Trade Name i �i r � ii t� F ( p a
Adequate compliance with County and State regulationsI equirements
Other - ` 1'
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Date i0//9Z / ' s
1 'IRspp4tpr/ ' ' -, J
i ,,, -! Flq -AIIy yVIT)9,fj17:90T JWCO99S Qpl AUCTION SITE
'CONDITIONS: t
1. All instaljatiorishust Comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chapter
25, Arti le 10 C.R.S. 1973, Revised 1 84. „. 2. This permit is v ,tor ectop 44truonifee¢¢ Iy � ISavq;(tt11y"'plied with Count9 zgqbing and building requirements. Con-
nectontooruse�w ith any d sling oratructuresnolf jtovtdby the Building ' aod26ningditi f,
de i'
requirement olthe perm)t pd cau* . for bpth legal antton 56d /evocation of 4iie pa)tfiit.
3. Any person who constructs, alters, or installs an Individual sewage � disposal system in 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 f- 6 i.
months in Jail or both). ) ti. (' ,, , ; / +•. t ,,
A Applicant: Green Copy Department: Pink Copy
Application
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION Approval by
County Official:
OWNER 't? (\1ifSkAs k O °
ADDRESS 7f5 / d 6r $ - *.0/ 4 Lie C PIIONE - g49G• ' S , �
CONTRACTOR .41 y S /Ji
ADDRESS PHONE
PERMIT REQUEST FOR: (J() 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 Cop
Near what City of Town C,'Qi ont »J0 Lot Size Zl e c •
Legal Description 2_¢C3 — 02 - -oe — 0- 0r7
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 (x) Automatic washer (.k) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: ( ) well ( )C) spring ( ) stream or creek
Give depth of all wells within 180 feet of system: // 1r
If supplied by community water, give name or supplier:
GROUND CONDITIONS:
Depth to bedrock: (2‘,1 k vi.c w ,--\ —
Depth to first Ground Water Table: Oh 1-
Percent ground slope:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: One vi.,ite_S'
Was an effort made to connect to community system? /V
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(j) 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:
(X ) 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 TIIE STATE? NO
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P ;; #1
SOIL.,PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer.)
Minutes per inch in Bole 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 pe rmttis 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 sane for purposes of issuing the permit applied for herein. 1 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 9 92 SigneQ `i � _
PLEASE DRAW AND ACCURATE MAP TO YOUR PROPERTY
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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.
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PACIFIC INLAND OPERATIONS — WESTERN SLOPE SALES FFICE
, - 201 Centennial Sveet • SUN tibiG • Glenwood Springs Go 601
3030045-5763 '
.1, DAVID SACK
'ethnical Reptesentative
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JOB NAME: JOB*, Le
LOCATION: SHEET OF 0' 7
SALESMAN: 1 .----- . BY DATE: _
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• ,TRUS JOIST CORPORATION
a divisi of T International
® PA CIFIC INLAND OPERATIQNS WESTERN SLOPE SALES IFt ICE
201 Centennial Street Suite 70TG • • Glenwood Springs, CO 81601
303/9456763
DAVID SACK /tV50,
Technical Representative
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LOCATION: - -- i . - , _ . - S y % - -- OF ------ - - - - --
SALESMAN: _ - 1, BY RIM- DATE: 2 1/4)/AAA
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