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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N. 2 2 3 9 1 t
109 6th Street Suite 303 A re Parcel No.
Glenwood Springs, Colorado 61601
Phone (303) 945.8212 1 i
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ii . `! .--, N 1 1 T ' I This does not constitute
1 INDIVIDUAL SEWAGE DISPOSAL PE 'M !T (ti
a buildin 9 or use permit.
PROPERTY 1
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Cheryl HiecLer Present 511 CR s Rifle Phone 623 -9531
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Owner's Nam
System Location • 0511 County Broad 216, Rifle
ii Legal Description of Assessor's Parcel No.
p SYSTEM DESION 1 , - >,- , er
f 7 0 Septic Tank Capacity (gallon) Other 4
EP
22 f .' P_
it I m � / Percolation Rate (minutes/inch) Number Bedrooms (or other) , / . / • ) C..
y / f< P / 4 A 4" t 4 %3 e . ti-, .X-97 ' - IA ■
Required Absorption Area - See ANacneo / r
r .1 r � _._�t ' r on' / 5 -' J 2.{ C. 4..y i
Special Setback Requirements: �, 1.. ""f �' " C' � f'
Date _ 2 - 9 Inspector C Prr i rl (Q.4 ' t
1
FINAL SYSTEM INSPECTION AND APPROVAL (as installed) &
Call for Inspection (24 hours notice) Before Covering Installation
System Installer l J '7 f t
N Septic Tank Capacity n id / s r' / ( 7 � /
I I' Septic Tank Manufacturer or Trade Name twit a t / j 7
a Septic Tank Access whin 8" of surface L'
1 I - / ' I o e + j Q {�
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Absorption Area - ./ X , X ' 1 `r 1 ittl ,1 .al.t -�J C,, rz
Absorption Area Type and/or Manufacturer or Trade Name /9Mt - / -).Q t"
......... : r 1 1St S �,,,___ -'
Adequate compliance with County and State regulatjpp 7nt quire ; n i'
1." ` 4 /
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Other 1 J /t /
Date ' . i " / a `- 7 / , ! (r 6 » ' inspector , j ? ( k 4 244.:4
11 RE AIN VyIJ) IECE REC A COj SITE
Y' r /W EI}
CONDITIONS: lt,hl it y fi y � 1G/
1. All Installation must comply w th all too irements f tWa Cdlo State Board of Health Individual Sewage Disposal Systems Chapter
25, Article 10 C.R.S. 1913, F7tyised 1984. ' j'/ a
2. This permit is valid only for connection t6 'ructures whl h have fully complied with County zoning and building requirements. Con- f Al,
nection to or use with any dwsOlInddr structures not app$ved bytheBuilding and Zoning off ice shall automatically be a violation or a j
requirement of the permit and for both leg I ttio d revocation of the permit. i
I, 3. Any person who constructs, alters, or installs an Ind sewage disposal system In a manner which involves a knowing and material "•
variation from the terms or specif ications contained In the application of permit commits a Class I, Petty Offense ($500.00 fine' 6 5
months in )ail or both).
Applicant: Green Copy Department: Pink Copy
Application
JTTDIVIDIJAT. SF.WAGR DISPOSAT. SYSTEM APPI.ICATION Approval By
County Official
OWNER eher L l/� S c/2e /—
ADDRESS 511 c/9 /-) ; 9./ !o PHONE/a�5'`/.S
CONTRACTOR fa • 01, n jar
ADDRESS 5 n-vvi P PHONE
PERMIT REQUEST FOR: () New Installation () Alteration 04 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).
J.00ATION OF PROPOSED FACIT JTY : County Sl / C RrD
Near what City or Town S% L f Lot Size /V/. .S Act
Legal Description
WASTES TYPE : (k) Dwelling ( ) Transient Use
( ) Commercial or Institutional ( ) Non - domestic Wastes
( ) Other - Describe
BUILDING OR SERVICE TYPE: /4 Fu S 2_
Number of bedrooms Number of persons
( ) Garbage grinder (kr Automatic Washer ( ) Dishwasher
,SOT JRCF, AND TYPE OF WATER SIMPLY (0 well () spring () stream or creek
Give depth of all wells within 180 feet of system:
If supplied by community water, give name of supplier:
C:ROT JND CONDITIONS:
Depth to bedrock:
Depth to first Ground Water Table: - - G' -
Percent ground slope: 3CVO
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM iV -
Was an effort made to connect to community system? rti 0
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
00 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
04 Underground Dispersal ( ) Sand Filter
( ) Above Ground Dispersal ( ) Wastewater Pond
() Other - Describe: , I
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? Iv
,SOIT. PERCOLATION TEST REM JLTS: (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. _
.Name, address and telephone of RPE who made soil absorption tests;
Name, 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 provided by law. �D n / ,
Date y- 20 -9/ Signed ELI / CLIG `/ ,
P ,EASE F SE DRAW AN ACCI JRATF. MAP TO YO1 JR PROPERTY
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