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i GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N: - 2098
109 8th Street Suite 303 Assessor's Parcel No.
,p Glenwood Springs, Colorado 81601
Phone (303) 945.8212 E
This does not constitute L t
p _ INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. 9
PROPERTY I
Owner's Name Ron Mittleid.T Present Address Box 821 a Silt Phone 945 -1004 I
System Location
0957 County Road 25 Silt t
Legal Description of Assessor's Parcel No. 4
SYSTEM DESIGN I
1 0 0 0 Septic Tank Capacity (gallon) Other L
P 3 1
.< ^+i .c 0 Percolation Rate (minutes /inch) Number of Bedrooms (or other) n
Required Absorption Area - See Attached 7 L" fj 47 ( e- c -4-- ,2q e e2 I�[ r,_ i
fix , W , 3 / X3 'Ac t , � .. 3 ' / P�c Slam, )+7
Special Setback Requirements r
s7F
Date / 2 K —73 3 Inspector . T`J n i \ -44!{'J✓.i . .U.nt.,/ "gyp Se„.Y2- .i.C, ✓r' . i
I FINAL SYSTEM INSPECTION AND APPROVAL (as Installed) e1 (
I Call for Inspection (24 hours notice) Before Covering Installation
System Installer CJ' . l i oa
Septic Tank Capacity n / t
1 Septic Tank Manufacturer or Trade Name fez-met
,+w 1
F . Septic Tank Access within 8" of surface %., 4"
"1 Absorption Area / r , A ) — t /t ... ,
Absorption Area Type and /or Manufacturer or Trade Name (/ [ et A '-° 02)24 Ea?
Adequate compliance with County and State regulations/requirements pp
i
Other 7 �/ r! y
Date / — 2 yi _ / J Inspector �,,1_i ) I t J 4cr' ^ � . + $ l
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
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. Con-
nection
to or use 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 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 p
variation from the terms or specifications contained In the application of permit commits a Class 1, Petty Offense (5500.10 fine - 6 1'
N months In )ail or both). t
a
Applicant: Green Copy Department: Pink Copy I
Application
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION Approval by
— — — County Official:
OWDER antitieR -- r I"') 1 ' 4,‘ PIIOME 9i /X 0 ' / t'1�1 0
11)DRESS rime 8it�� _ —_ `?
:ONiRACTOR - . _ _ -- $eL- - --_ —_ -- - - - -- )M
'IUURESS�__._ -- - -- -- PHONE
'ERMIT REQUEST FOR: 'C) New Installation ( ) Alteration ( ) Repair
kttach separate sheets or report showing entire area with respect to surrounding ar s,
topography of area, habitable building, location of potable water wells, soil percolation
Lest holes, soil profiles in test holes. / (See page 4.)
'.O CATION OF PROPOSED FACILITY: County 6/ eP/6 .-D
Tear what City of Town _ ,Sn_r _ Lot Size
'egal Description 1 "Ant Of &hvO /N 1,o7 frt ,Scc IS'S /r'9 /G4.)
WASTES TYPE: (x) Dwelling ( ) Transient Use
( ) Commercial or Institutional ( ) Won- domestic Wastes
( ) Other - Describe _-
RUILUING OR SERVICE TYPE:__ >°s q/e/2CC_
(lumber of bedrooms 3 _ Number of persons
( ) Garbage grinder ( ) Automatic washer (X) Dishwasher
WURCE AND TYPE OF WATER SUPPLY: (X) well ( ) spring ( ) stream or creek
Give depth of all wells within 180 feet of system: Ori friJUGt1P)
If supplied by community water, give name or supplier: /VA--
GROUND CONDITIONS:
Depth to bedrock:
Depth to first Ground Water Table: (J/j,ki?o'v
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Percent ground
L/
DISTANCE 10 NEAREST COMMUNITY SEWER SYSTEM:_ w __ --
Was an effort made to connect to community system? PO -�
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:
(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 THE STATE? iV c7
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4111 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 Ho.
L address and telephone of RPE who made soil absorption tests: „ /flne..rJOe`C
, r
lame, address and telephone of RPE responsible for design of the system: •
1pplicant 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
lepartment to be made and furnished by the applicant or by the local health department for
"urposes of the evaluation of the application; and the issuance of the pormft,i3'subject to
such terms and conditions as deemed necessary to insure compliance with rules and regulations
'dopted under Article 10, Title 25, C.R.S. 1973, as amended. The undersigned hereby certifies
'fiat 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
If 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
•r revocation of any permit granted based upon said application and in legal action for per-
jury as provided by law.
/ 3 4/13 3 4/13 Irate _ 3 /lj Signed MaKA
PLEASE DRAW AND ACCURATE MAP TO YOUR PROPERTY
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Page 3
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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, (+ater 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
couwitments.
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Page 4
JOB —_ � T - Go D 2c / 1 C. r$I/x7*7Ce -
SCHMUESER GORDON MEYER, INC. SHEET NO OF_
1001 Grand Ave. Suite 2.E P.O. Box 2155
Glenwood Springs, C0 81601 pen, CO
(303) 9451004 As (303) 925 -6727 81612 CALCULATED BY DATE
FAX (303) 945-5948 FAX (303) 925-4157 CHECKED BY DATE
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