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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N. 2 0 9 0 t
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109 Bth Street Suite 303 Assessor's Parcel No.
Glenwood Springs, Colorado 81801 ' 4
Phone (303) 945 -8212
_ This does not constitute 4
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit.
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PROPERTY 1
Owner's Name Jamabld )togbadats Present Address 0596 CR 113 Carbondale Phone 945 -9228
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System Location 0596 County Road 113, Carbondale
Legal Description of Assessor's Parcel No. t
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SYSTEM DESIGN u j
Septic Tank Capacity (gallon) Other ; t
Percolation Rate (minutes/inch) Number of Bedrooms (or other) 3
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Required Absorption Area - See Attached
Special Setback Requirements: 1
Date Inspector # ,i
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
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System Installer eit " '�✓�' • tr r -
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Septic Tank Capacity 11 I ' y -' - J d9)tY2'br1.
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Septic Tank Manufacturer or Trade Name
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Septic Tank Access within 8" of surface`' i
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Absorption Area pp
i .. Absorption Area Type and /or Manufacturer or Trade Name . /�' -` +i' - ; r = ~___
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Adequate compliance with County and State regulations /requirements — ' "I
Lr Other 1(
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� Date � . Inspector -
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
i.. 25, Article 10 C.R.S. 1973, Revised 1984.
4.., c 2. This permit is valid only for connection to structures which have fully complied with County zoning and building requirements. Con-
nection tooruse With any dwelling or structures not approved by the Building and Zoning office shall automatically be a violation or a
- requirement of the permit and cause for both legal option and revocation of the permit.
r 3. Any person who constructs, alters, or Installs an Individual sewage disposal system in a mannerwhloh involves a knowing and material
it variation from the t or specifications contained In the application of permit commits a Class 1, Petty Offense ($500.00 fine — 8
months In )all or both).
h Department: Pink Co
Applicant: Green Copy Deperlm Copy
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Application
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION Approval by
County Official:
OWNER .� - �
ADDRESS X 59 , a gd irk N. ✓/,� 0 PHONE qv - 9zza /
CONTRACTOR_ .A/3t M
ADDRESS PHONE
PERMIT REQUEST FOR: ( ) 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 C 47
Near what City of Town (1 ACe Lot Size
Legal Description , -/, r r
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WASTES TYPE: ( `-f Dwelling ( ) Transient Use
( ) Commercial or Institutional ( ) Non- domestic Wastes
( ) Other - Describe _
BUILDING OR SERVICE TYPE: _
Number of bedrooms Number of persons 9
( ) Garbage grinder ( ) Automatic washer ( ) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: ( %-1 well ( ) spring ( ) stream or creek
Give depth of all wells within 180 feet of system: ,
If supplied by community water, give naive or supplier:
GROUND CONDITIONS:
Depth to bedrock: _
Depth to first Ground Water Table:
Percent ground slope:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: A
Was an effort made to connect to conmiunity system?
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 THE STATE? / 1 - 7.0
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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.
Nance, address and telephone of RPE who made soil absorption tests: ///
Name, address and telephone / of RPE responsible for design of the system: a_
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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 . is 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 /777 Si gned I
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PLEASE DRAW AND ACCURATE MAP TO YOUR PROPERTY
Page 3
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440
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