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v GARFIELDCOUNTY BUILDING AND SANITATION DEPARTMENT Permit N_ 2 1 0 3 !
109 8th S rsst agile 303 Assessor's Parcel No
Glenwood 130010e, Colorado 81601 $
' Phoflf (303) 94541212
e1/4,, This does not constltye
r a building or use permit. ^ '"°
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY . ;
Jerel Ferguson l 0124 Fairway Lane 0.8. 945 -6190
Owner's Name ,..�.y Present Address Phone
System Location Lot 26 .- Woetbank Rattans, — Filing 2
Legal Description of Assessor's Parcel No
' SYSTEM DESIGN BB
■
Sept ic Tank Capacl (g Ilon) #r, the
m tit,' J 3 r' H n f. Pt 4, 0 4 -�
. 2 Percatie nute/i h) N br of Beme (or other) 1 fit ') Required Absor n Area - (?'? / 14 ' 3 ' ^( 7_ 8 t a _tyv eve 3 4 rtA—e1L® y
4 7f r"; f C e eK t Al n 1. .e -C r. R
Special Setback Requir t9Y'" �.LkT". {y G7 i
+. Date �+" / T - / 3 Inspector — ' 4 71 ` ' {
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours` notice) Before Covering Installation +
System Installer ss , G ' Crenr � e n / /C-19.511-4421.- i 1
Septic Tank Capacity OUP (((fff / a C 0
) .I
Septic Tank Manufacturer or Trade Name t- 41 °) +�i�f
Septic Tank Access within 8" of surface 40-- # ^t
Absorption Area 4 . . - 1 a 3 RenAri 415 / 2 .
Absorption Area Type and /or Manufacturer or Trade Name rile 1 ter -
A dequate compliance with County and State regulations/requirements Z.—•
Other
Date 7 3 9' 19 - Inspector ,�r� -Q�.✓�
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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
c 25, Article 10 C.R.S. 1979, Revised 1984.
2. This permit is valid only for connection to structures which have fully complied with County zoning and building requirements .`Con-
nection to or use with any dwelling or structures not approved by the Building and Zoning off ice shall automatioally be a violation or a
requirement of the permit and cause for both legal action and revocation of the permit.
ti 8 ^ Any person who cogatrusts, alters, or installs an individual seW&ge disposal system Inc manner which Involves a knowing and material
variation from the terms or specifications contained in the application of permit commits a Cletus I, Petty Offense (8500.00 fine --8
months In fail or both). r
Applicant: Green Copy Department: Pink Copy
Application
''. INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION Approval by
County Official:
OWNER 1 .-) Fe-vs i Jsb n ADDRESS o1a4 Cale - (E1 S PHONE(pfgb 1106
CONTRACTOR_ I 5er ?<C ' (sQy1g -}_, � ✓KJ.r ia.C-
ADDRESS . , 150c12(30- t��GS�i1�� (f PSIGZ( PRONE qai -343 1
PERMIT REQUEST FOR: ( ) New Installation ( ) Alteration (x) 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 Gar Ptf)r{
Near what City of Town n , o Lot Size 1.129 an'es
Legal Description_ (.-C+ Zfn ([)es {'-pink FairI S A
WASTES TYPE: (X) Dwelling ( ) Transient Use
( ) Commercial or Institutional ( ) Non - domestic Wastes
( ) Other - Describe
BUILDING OR SERVICE TYPE: _
Number of bedrooms 4 Number of persons
040 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:
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: Umk.nruan
Was an effort made to connect to community system? n ig
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
( ) 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:
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF TIIE STATE? A/O _
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SOIL 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 Mo.
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 pervuttis 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. 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 (o- (Co- R3 Signed tkAiti7m4.4
o
PLEASE DRAW AND ACCURATE MAP TO YOUR PROPERTY - �•
U d
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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
conini tments.
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