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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N: 2 2 2 I
109 8th Street Suite 303 A is Parcel No. ,
Glenwood Springs, Colorado 81601
Phone (309) 945-8212
This does not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. '°
PROPERTY
Owner's Name Donald 3 Stephanie Swan Present Address P.O. Box 1791, Glenwood Phone 927 -9758 •
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System Location 0644 County Road 170, Henke Exemption, Tract 2, Carbondale
Legal Description of Assessor's Parcel No. ,
„.. /
\,SYSTEM DESIGN 73 r ■ 1
'77 c , ISeptIc Tank Capacity (gallon) Other / � ' 1
_ 2 , tv ��..�( 2 D o� T .ft r . i l rs ` r. f' f P ' ,. (___ �' , � '�, f
/1 1 ' f,," r Percolation Rate (minutes/inch) Number of Bedroo 1 ros other) 2 ` r / I nc
2 1:r . r$(—GAi -4— c r A : . f -�. ' 7l X. ��� '
CC
Required Absorption Area - See Attached J f X �.. 1 -7- ,� !, y rr 7 r ' ' c A -,. „ r
- y� rl C . f
Special Setback / Requirements: 1 °/ - r,- t-,1 J fDA - C �' T l ' ` C••• n .,, .? c / `, 4 '
Date i � ( /. L� 9 �'� Inspector 6 .--T e , 1 J 1 .. W f;. '„C
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
P
System Installer Q[.d Nse
Septic Tank Capacity ficO
Septic Tank Manufacturer or Trade Name Cppe.10oc1....
Septic Tank Access within 8" of surface of 5
Absorption Area 5 17s
Absorption Area Type and /or Manufacturer or Trade Name — - L 1 A l a i O 0, '
Adequate compliance with County and State regulations/requirements y e•
Other
Date 1- 'fns Inspector ,v a-j -yt_y
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RETAIN WITH RECEIPT RECORDS T - 1 ON RUCTION SITE
*CONDITIONS:
4 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 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
variation from the terms or specifications contained In the application of permit commits a Class I, Petty Offense ($500.00 fine — 8
months In Jail or both).
I .
Applicant: Green Copy Department: Pink Copy'
Application
# -. INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION Approval by
. — County Official:
OWNER 1 ) o rpc,�c( 6 x- S7 ipAcii, . Su/tti
ADDRESSJQ a < /73/ (3 /oo!( se, I602 PHONE '/27 ggSy
CONTRACTOR_ 57 _
ADDRESS So- e. PHONE Se-rn e
PERMIT REQUEST FOR: ()C) 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 Ci r Pjelc{
Near what City of Town l ,per{ borl,r(al a Lot Size
Legal Description `jee_ 4+/zi.c_hcd
WASTES TYPE: ( X) Dwelling ( ) 'Transient Use
( ) Commercial or Institutional ( ) Non - domestic Wastes
( ) Other - Describe
BUtj.DING OR SERVICE TYPE: Resi depica
Number of bedrooms Q Number of persons
(X) Garbage grinder (>c) 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: N0/1/E
If supplied by community water, give name or supplier: /v'
GROUND CONDITIONS:
Depth to bedrock: _
Depth to first Ground Water Table:
Percent ground slope:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to community 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:
(,O) Absorption Trench, Bed or Pit ( ) Evapotranspiration
( ) Underground Dispersal ( ) Sand Filter
( ) Above Ground Dispersal ( ) Wastewater Pond
l
( ) Other - Describe:
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF TIIE STATE? /1/OM
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•OIL 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 No.
lance, address and telephone of RPE who made soil absorption tests:
lame, address and telephone of RPE responsible for design of the system:
%pplicant acknowledges that the completeness of the application is conditional upon such
urther 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 permit is subject to
uch 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 niy 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 3Ja493 Signed if/
PLEASE DRAW AND ACCURATE MAP TO YOUR PROPERTY
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Paae 3
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EXHIBIT "A"
A tract of land situated in the NW 1/4 of Section 17, Township 7 South, Range 87
West of the 6th Principal Meridian, Garfield County, Colorado, more particularly
described as follows:
Beginning at the West Quarter Corner of said Section 17; thence N 00 °49'39" E.
1006.25 feet along the Westerly line of said Section 17, to the True Point of
Beginning; thence continuing along the westerly line of said Section 17 N 00 °49'39"
E. 503.15 feet;
thence S 88 °43'37" E. 443.26 feet;
thence S 00 °49'39" W. 503.15 feet;
thence N 88 °43'37" W. 443.26 feet to the True Point of Beginning.
Together with and subject to a private non - exclusive easement for access and
underground utilities thereto as dedicated in the instrument recorded in Book
at Page of the records of Garfield County, Colorado.
4.416.44'35° 5.043 L e•OB ° 52'41" rG =10 ° 35 . 20 ' r
R• 335.50'
R. 729.24' R•SIB.B1 R•518.61' I F
C(l0•ALIb °54b5'•E ARCZIO1.00' ARC•BO.39 ARC .95.90 I A
4 C1-15.14.80 B
4 E. CHD•N.0 C140= 5.89 °57.35'E 0
01.70'
ARC. 95 05' -\ •06.90' - BO 50 _ _ _ - ._ - 95.11 -
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�0 „ f-0raN"" 5. 64.59'61 "E
w ,,,.„.0.44,:c � 3,.0 " / Y `t I 209.5 I
63.95 /A i 1 I
A 50 ROAD 1 /1 /I aA I I
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D15TANC0 44. A 1 14 //‘ \
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W. 95.55 V. 111.71' r -
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E 12 56' '�- TRACT 1 / d
F 234.04 -\ 5.12 AC?
E. 107 26 - \ I .R _ L , \ r..0 RO EASEMENT q5 III TRACT 5
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15 INNING TRACT 3
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