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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N`_' 216
109 8th Street Suite 303 A is Parcel No.
Glenwood Springs, Colorado 81801 !'
Phone (303) 945-8212
This does not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit.
PROPERTY
C harles Johnston 6107 309 Road Rifle Phone_ 625 -1671
Owner's Name Present A ddress
System Location 6107 309 Road, Rifle
Legal Description of Assessor's Parcel No.
SYSTEM DESIGN
7
4 'O Septic Tank Capacity (gallon) Other
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/ " ,./ ` M" Percolation Rate (minutes/inch) Number of Bedrooms (or other) 2 ( f z � / r
II 1
Required Absorption Area -See Attached
5 4 3 C!r f c r �� 4- L �' A O 14 ,J �s e a err / 2 t X 7 X 3
v? # >'fet A.Tdr n'✓' /4' /AIrc f 5
Special Setback Requirements: �S')
Date Q -- "1? Inspector c- >t4tif f tl nrC. a-
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer Olayagraarl n/ancali ' - Doti /Lisa
Septic Tank Capacity no 9 4.4 44 /,2.60
Septic Tank Manufacturer or Trade Name }'pe asrsd-
Septic Tank Access within 8" of surface /
Absorption Area / 7) /7'a41 /(ap i
Absorption Area Type and /or Manufacturer or Trade Name / 4/fl / I C *rig, .e r Slier,
Adequate Compliance with County and State regulations /requirements
Other
Date //1 - /4' - ■3 Inspector 4t '- --t - .
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 i
nection to or use with any dwelling or structures not approved by the Building and Zoning office shall automatically be aviolation or 'hip,:
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
1 variation from the terms or Specifications contained In the application of permit commits a Class I, Petty Offense ($500.00 fine — 6
months in jail or both).
Applicant: Green Copy Department: Pink Copy
Application
• ".l • INDYVIDUA - SEWAGE U OSAL SY TEM APPLICATION Approval by
7 j - -- County Official:
OWNER " e-43 - .�/ - �i ; 7 I
ADDRESS Lf� e' _ PHONE jib 2
CONTRACTOR_
ADDRESS PHONE _
PERMIT REQUEST FOR: ( ) New Installation V'1 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 profile's in test holes. (Se, page 4. /
LOCATION OF PROPOSED FACILITY: County
Near what City of Town / ,r'/C c ) FL.1 Lot Size g ri_e 'r-frk
Legal Description_
WASTES TYPE: ( / ) Dwelling ( ) Transient Use
( ) Commercial or Institutional ( ) Non- domestic Wastes
( ) Other - Describe__,
BUILDING OR SERVICE TYPE:
Number of bedrooms CPC Number of persons
( ) Garbage grinder ( ) Automatic washer ( ) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: (VI well (i.-- ( ) stream or creek
Give depth of all wells within 180 feet of system: AL ,
If supplied by connnunity water, give name or supplier:
GROUND CONDITIONS:
Depth to bedrock: ^T _ •
Depth to first Ground Water Table: g„
Percent ground slope:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to community systern ?_ •
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(r 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? WO —
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S` bML 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:
Nance, 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 porMft.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 416; /ny. -- Signed t lt.. .. ;al's'JJ t
PLEASE DRAW AND ACCURATE MAP TO YOUR PROPERTY
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