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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT` Permit h _ 2 2 5 2 1
109 8th Street Suite 303 Assessor's Parcel No. ill
Glenwood Springs, Colorado 81601 3
■ Phone (303) 945 -8212
This does not constitute i
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit.
PROPERTY Way Harper 0/0 � \ti
Russell & Rose Rsuman 2162. CR 250, Silt 876-2693
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Owner's Name Present Address Phone \
System Location 2162 County Road 250, Silt 1
Legal Description of Assessor's Parcel No.
SYSTEM DESIGN " '
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i Septic Tank Capacity (gallon) + Other ' ,'' % / I,
/ If fa' 1A b1 rcQlation Rate (minut s/ nch) Nu ` e (o r other .; 3 ' cry' / , f- �r -1. � 1
Required Absorption Area - See Attached � 7 (/ { ;!1 �T ,�. (i f ) .�. Y' «- f,1 - .(n �;", ' °�,,- X nI
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Special Setback Requirements: 1-f / V 7 " 1 C,0 - - .. . 1) hr ` ++< di ./i p' "` .'
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D �%7 r Inspector `� ✓ "1 i ' ,. , �c r (Art el
FINAL. SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours Before Covering Installation
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System Installer
Septic Tank Capacity / 2 6 0 ` 1
Septic Tank Manufacturer or Trade Name ` J • f D 9 I.
Septic Tank Access within 8" of surface /./"-d- 1 7 'i
Absorption Area y7 f 17 ~ a A 4
&-c . p-f 1 2 g k
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Absorption Area Type and /or Manufacturer or Trade Name M1- k..[N� ytan-
Adequate compliance with County and State regulations/requirements C
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Other ¢- i
Date 2-. ` =2 it 9 C Inspector �,,f rill (024 .t - Jaing.
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 ,K
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-
nection to or use with any dwelling or structures not approved by the Building and Zoning off ice 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 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 — 6
months In Jail or both). '* (f.
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Applicant: Green Cbpy Department: ' Copy
Application
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION Approval by
• . County Official:
OWNER . gu SJJ`I (1a s `70 ( j . �'�r W ^^
ADDRESS 2A(07.. Or 7-50 al e_ �JJ PHONE Cl1(9 -7,1 /3
CONTRACTOR Solt
ADDRESS 1) _ PHONE _
PERMIT REQUEST FOR: (✓j 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__________ ojd
Near what City of Town 13 V Lot Size ((AV --
Legal Description
WASTES TYPE: ( ✓) Dwelling ( ) Transient Use
( ) Commercial or Institutional ( ) Non- domestic Wastes
( ) Other - Describe
BUILDING OR SERVICE TYPE: 1<0.�:.C1kw!\k-C.ict
Number of bedrooms 3 Number of persons LI
( 4 Garbage grinder ( '4 Automatic washer (✓l Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: ( ,/) well ( ) spring ( ) stream or creek
Give depth of all wells within 180 feet of system:
If supplied by community water, give name or supplier:
GROUND CONDITIONS:
Depth to bedrock: _
Depth to first Ground Water Table:
Percent ground slope:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: 3,4
Was an effort made to connect to community system? 1110
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
( 4 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? y�h
•
Pnnn 2 __... ..
•SOIL 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.
Name, 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 isdonditional 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 pernitt,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 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 �'/)� Signed I ,i • >' i��
PLEASE DRAW AND ACCURATE MAP TO YOUR PROPERTY
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