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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N: 22 37 I
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109 8th Street Suite 309 A is Parcel No. 1
Glenwood Springs, Colorado 81601 1
Phone (903) 945-8212
This does not constitute -
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit.
PROPERTY „t -
Kirk Swallow 2169 CR 321, Rifle 625 -1180
Owner's Name Prgsen5ft ress Phone
System Location 10 County Road 121, Rifle
Legal Description of Assessor's Parcel No.
SYSTEM DESIGN
y i .
1 6 0 Septic Tank Capacity (gallon) Other / r 6. - �/ / / � '
c .ti`s Percolation Rate (minutes /inch) Number of,pedrooms (or other) y , 1 /-- / .. i r
I 1 / CI • /. - ri... -�-- A - t{ _ ,r- ( (cc�{ / • X [:7 -' - q '��:
Required Absorpti Area - See ANeelwd / 9 , V /7 ' re)? , L r- „ f , rte • O ` r 3 7 f A ( t 4
Special Setback Requirements:
[I r �'"''��� 1
Date y ° z. 2- 7 Inspector' P r9n1 � ...14,-u
FINAL SYSTEM INSPECTION AND APPROVAL (as Installed) \\
Call for Inspection (24 hours notice) Before Covering Installation
System Installer Xi O K p)Ldq
Septic Tank Capacity J.? S'
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Septic Tank Manufacturer or Trade Name 0 I/j
i • Septic Tank Access within 8" of surface pfe
4
Absorption a /11) �. ,..,
I • AbsoSp11o1%Area Type and /or Manufacturer or Trade Name Jwr<c- 117i#TZ'I / /es .
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Adequate compliance with County and State regulations/requlrements 9
..
Other
'r /) Date �- 43 - 9V Inspector /�++ c9/. p_Gc,�u- sa...0 ,
�• RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
' ,4 ? •-'CONDITIONS: !;�(
1. All ir, lailRion must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chapter
2,3; 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-
, 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 aknowing and material
I 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
JNDIVIDI JAT, SEWAGF. DISPOSAT. SYSTEM APPI ,ICATION Approval By
/� /> Official
OWNER l\ ►Eta e-‘111-04/ County O
ADDRESS 49/0 L D 3G-/ Rif ( r&. PHONE 150 —
ONTRACTOR /Pt g✓ieliZom/
ADDRESS a /4 Co id 3?-1 Pifl to 7 / 6 ) PHONE / (
ERMIT REQUEST FOR: New Installation () Alteration () Repair
ttach separate sheets or report showing entire area with respect to surrounding areas, topography of area,
abitable building, location of potable water wells, soil percolation test holes, soil profiles in test holes
See page 4).
.(CATION OF PROPOSEDI CILITY : County 6-:42-69-20
fear what City or Town 16-Li Lot Size 7 2 Al'
egal Description 474-7179C-al) VASTFS TYPE : QQ Dwelling () Transient Use
(( ) Commercial or Institutional ( ) Non - domestic Wastes
( ) Other - Describe
tUILDING OR SERVICE TYPE:
dumber of bedrooms a Aar' Number of persons fcu
/) Garbage grinder (1) Automatic Washer (I) Dishwasher
;011R CE AND TYPF, OF WATER SIJPPI.Y; () well () spring () stream or creek
live depth of all wells within 180 feet of system:
f supplied by community water, give name of supplier: C// en/ frog - i;n7fMet
1R01JNT) CONDITIONS;
)epth to bedrock:
)epth to first Ground Water Table: MO -SOO Ft
'ercent ground slope: /SOS
)ISTANCE TO NEAREST COMMUNITY SEWER SYSTEM 2m
Vas an effort made to connect to community system? Aro
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:
7 INAL DISPOSAL BY:
Absorption Trench, Bed or Pit ( ) Evapotranspiration
( ) Underground Dispersal ( ) Sand Filter
( ) Above Ground Dispersal ( ) Wastewater Pond
( ) Other - Describe: 4 �
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? /
�-u' ?jib t,. ,t
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')IT. PERCOI.ATION TEST RESULTS: .TS: 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. _
ame, address and telephone of RPE who made soil absorption tests;
tame, 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 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 understand 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 perjury as rovided by law. Date � e e Signed
in .F ASF. DRAW AN ACCI IRATE MAP TO YOT JR PROPERTY � e A1?9c) HO
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pi.0T PLAN AND DF, IGN FRATTJRFS
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Include by measured distan location of wells, springs, potable water supply lines, cisterns, buildings,
property lines, subsoil drains, lake, water 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 commitments.
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