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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N_ 2198 1
109 8th Street Suite 303 Assessor's Parcel No.
Glenwood Springs, Colorado 81801
Phone (303) 945-8212
This does not constitute 1 I
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. G
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PROPERTY )
Owner's Name Kevin 6 Tanya Madison present Address 1466 210 Road, Rifle, CO phone 625 -4413 q
System Location 1466 210 Road, Rifle X .
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Legal Description of Assessor's Parcel No. t
SYSTEM DESIGN ' I
/2. S Septic Tank Capacity (gallon) Other 1
/ 4
/ _ Percolation Rate (minutes/inch) Number of Bedrooms (or other) 8
/V �i ec)a/'fi aed. -.r
Required Absorption Area- ee Attached N
fec - /20g0'' Rock 4r Az r fm`f 1) pm'ArGft' S /stc ttSH kit? /¢,,3`It' c c
Special Setback Requirements: 72•5' el" C o 'b' 4c l o t" S vs t- yh I _0 i 4 t!T' i s ..A3 Pfl . 6 s
Date /- /0 7 4 Inspector` 4 6240 4 }
FINAL. SYSTEM INSPECTION AND APPROVAL (as installed) I
a
Call for Inspection (24 hours notice) Before Covering Installation )
System Installer /7 am &It °t. I
Septic Tank Capacity J 2. 5 n
Septic Tank Manufacturer or Trade Name
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Septic Tank Access within � 8" of surface
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Absorption Area J / p th /t I / p t x -- O�-• �f i g l -' - '�� 1 yA/ �7
AbsorptiorfAreaType and /or Manufacturer or Trade Name H 7 . vv -_1?- I
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Adequate compliance with County and State regulations /requirements / i'
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li Other - ` q
p� cy
i Date / —' / J / _ I nspector�rJ't')
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RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE t
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i * CONDITIONS: y 4, y 4
1. All installation must comply with all requirements of the Colorado State Board of Health Indivldual Disposal'Systeras Chapter s
25, Article 10 C.R.S. 1973, Revised 1984. t
2. This permit is valid only for connection to structures which have fully complied with County zoning and building requirements. Con- I
t nection to or use vnth any dwelling or structures not approved by the Building and Zoning office shall automatically be a violation or a I
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 (5500.00 fine — 8 e
months in (ail or both). t
Applicant Green Copy Department: Pink Copy 0
ApplicdLlun
II111IV1UIIAL SEWAGE DISPOSAL SYS1T-I1 APPLI CAI 1011 Approval by
• — —_- — County Official:
OWNER Aim/ 6 J}TNyn- f1!/,ab /SonG — — - --
ADDRESS /r66 ?2/o /C �/ �� � -_ -- IIUIlE62s= y1/43
GMT NACTOIt ' 54
ADDRESS 7 4 _ I'II011E
PERMIT REQUEST FOIL: ( L.4 - 1Uew Ins la11Mimi ( ) AlLe•aiion ( ) nepa1r - - -- AI Each separate sheets or report showing en', ire area wiLb respect to surrounding areas,
topography of area , hall lable building, location of potable walcr wells, soil percolaLion
Lest holes, soil profiles i n Lest holes. (See page 1 I.)
LOCATION OF PROPOSED FACIL1IY: County_ G,� E _ --
Near what CiLy of Town /e /;t — ____ -- Lot Size 27 y? L4cS
Legal Description_ -- - -_ -- -- ------ _! -_ --
WASTES 1YPE: - -- ()4) Dwelling ( ) 1ranslent Use —`
( ) Commnerc1al or Ins 11 to 1!onal ( ) Ilon- domestic Was Les
( ) Other - Describe -- -- ^----- - - -_ --
BUILDING OR SERVICE TYPE: —
[lumber of bedrooms -- __,!lumber of persons_ . 5
( ) Garbage grinder ( 'l Loma 1ic washer ( ,-- r -Uishwasher
SOURCE AIM TYPE' 0[ iJA1Elt SUPI'I_Y: • ( ) wel 1 ()c ) spring ( ) sla•eam or creek
Give depth of all wells within 1B0 feet of sys Lon
:
If supplied by connnuniI.y water, give name or supplier: _ —__ • _—
GROUND CONDITIOIIS:
Depth to bedrock: • — ---- ___.�_- ------ 1.__— ______ ---
Depth to first Ground Water Tall e:��K— —_ - - -�
Percent ground slope: • jL_ — --_ _;-- _------ -- - ---
DIS1AfICE 10 NEAREST COPII11111IY SEWER SYSILEI: w�
Was an effort made to connect. to column ity system?_ A /i4_
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYS1Ell PROPOSED:
(X) Septic Tank ( ) Aural ion Plant ( ) Vault
( ) Vault Privy ( ) Comgros11ng 'Io11e1 ( ) Itecycling, potable use
( ) P Privy ( ) Incineration 101 let: ( ) Recycling, other use
( ) Chemical Toilet ( ) Oilier - Describe: __
FINAL DISPOSAL BY:
()C) Absorption Trench, Bed or l'il ( ) Evapotransp1 rat ion
( ) Underground DIspersa1 ( ) Sand P11Ler
( ) Above Ground 0!sl:'ersaI ( ) Wastewater fond
( ) Other - Describe: — — -----
I11LL EFFLUENT BE DISCHARGED UIRECILY 11110 WAIEItS OF TIIL S1A1E?
Pnoe 2 _. _
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, SOIL PERCOLAT1DN 'LEST RESULTS: (lo be cou by Reg Islcrcd Profess lonal Engineer.)
Minutes _ per inch in hole Ho. 1 Minutes _ per inch in hole Ilo. 3
111 nu Les ' per inch in hole No. 2 Minutes — _ per Inch in hole No.
llama, address and Leleplwne of DPI who made soil absorption Les Ls:
Name, address and telephone of Ill'E responsible for design of the system:
Applicant acknowledges that the completeness of the application is cond11ianal upon such
further mandatory and add itional tests and reports as may be required by the local heal Ili
department to be made and furn by the applicant or by the local heall:h department for
purposes of the evaluation of the appl Ica tion; and the issuance of the perm l't,is'subject to
such terms and cond111uns as deemed necessary to insure compliance with rules and regulations
adopted under Article 10, TiLie 25, C. It. S. 1973, as amended. the undersigned hereby certifies
that all slatemenIs made, in forum Lion and reports submitted herewith and required to be
submitted by the appllcant are or wi11 be represented to be true and correct to the best
of my knowledge and bellef and are designed to be relied on by the 1 oca 1 .depar Went of health
in evaluating the saute for purposes of issuing the permit applied for herein. 1 further under-
stand that any fals1ficaLion or misrepresentation may resu11 in the denial of the application
or revocation of any permit granted based upon said avid Ica lion and in legal action for per -
jury as provided by law.
Date /1—. 7 - 77' - -- - Signed „e.' - A O � -
PLEASE DRAW AND ACCURATE MAP 10 YOUR PROPERTY
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PLOT PLAN AND DESIGN I TAT ODES :
Include by measured dIslance location of wells, spr1ngs, potable water supply
lines, cisterns, buildings, properLy lines, subsoil drains, 1 ake , water course,
stream, di gulch and show IocaLion of proposed system by direction and distance
from dwel11ng or other fixed ref • ce__objec1, and additional submissions in
support of this application :Itch as da La , pl ans , spec" f Ica 1 tons , sla Lenten Ls and
coma] Linen is . NOIZ
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