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N'..1 / GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit 1'�. 2 2 5 6
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109 8th Street Suite 303 Assessor's Parcel No. r
Glenwood Springs, Colorado 81801
Phone (303) 945 -8212 r
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This does not constitute It j
INDIVIDUAL SEWAGE DISPOSAL. PERMIT a building or use permit. f
PROPERTY f
Owner's Name Richard 6 Karen Haff Present Address 46535 Highway 6, Glenwood Phone_ 945-.5704 f`'
System Location 46535 Highway 6, Glenwood Springs X
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Legal Description of Assessor's Parcel No. . „
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SYSTEM DESIGN
LEACH FIELD REPLACEMENT ONLY,
Septic Tank Capacity (gallon) Other
, 2 Required Absorption Area - See Attacka4 ^ � r ' 7 � ' ' C , (or other , ^ , • , • ` ' ( ( - �. ` r .�' /, a k� i'j e .�?
,H U rolation Rate minutes /inch Number of Bedrooms Pec
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Special Setback Requirements: a .. er. ' •�'
Date __ t1 Inspector C -` " I (Q,4,- CA44, i t
FINAL SYSTEM INSPECTION AND APPROVAL (as installed) tl Ij
Call for Inspection (24 hours notice) Before Covering Installation j 1
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System Installer_ l rp 1 /: ", d c' 1?
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Septic Tank Capacity ��// • F • A 4,-., ../ ) ` e
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Septic Tank Manufacturer or Trade Name � =� ' �' �'�'' �''
Septic Tank Access within 8" of surface 1 .
Absorption Area `�/ !) ' .1 a _
Absorption Area Type and /or Manufacturer or Trade Name t 1 7: i r - - / 4. , , i n i ( • c
Adequate compliance with County and State regulations /requirements
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Other IiI
Date / / -- / - l f 1I Inspector L._ ). -- — l f i .,,, e . _ c 4
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RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE 0 S
•CONDITIONS:
1. All installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chap ter ;;,
25, Article 10 C.R.S. 1973, Revised 1984. F
2. This permit Is valid only for connection to structures which have fully complied with County zoning and building requirements. Con- p:
nection to or use with any dwelling or structures not approved by the Building and Zoning office shall automatically be a violation or a t4
requirement of the permit and cause for both legal action and revocation of the permit. 1
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 —
months in jail or both).
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Applicant: Green Copy Department: Pink Copy
Application
INDIVIDTJAT, SEWAGE DISPOSAT, SYSTEM APPLICATION Approval By
County Official
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OWNER dr ./ ( a AJ - , /
ADDRESS - 3 - r / E_ • PHONEQYt- - 7rr
'ONTRACTOR d . - -St-EP Or WI Q, - 4 - 1.n .
ADDRESS PHONE
'ERMIT REQUEST FOR: ( ) New Installation (y Alteration &a.44 / C
Attach 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 holeswk -i j±
;See page 4). O
LOCATION F_PROPOSEDFACTT,TY : County 1 �J - <�/r�, n� o -/ ,� ��
Near what City or Town e., -,,, J.�-f 4Ps .� a - U Lot Size
Legal Description
WASTESTYPE : welling ( ) Transient Use
( ) Commercial or Institutional ( ) Non - domestic Wastes
() Other - Describe
BUILDING OR SERVICE T P
Number of bedrooms Number of persons 3
( ) Garbage grinder (0 Automatic Washer ) Dishwasher
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SOUR E AND TYPE OF WATERSUPPI,Y: (well () spring () stream or creek
Give depth of all wells within 180 feet of system:
If supplied by community water, give name of supplier:
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:
(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 pISPOSAL BY:
0 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 THE STATE? gaet
JOIT. PERCOT.ATION TEST REST II .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. _
game, 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.
Date Sr y Signed % A .ate,^ i a-
21. EASP' DRAW AN ACCT JRATE MAP TO YOi IR PROPERTY
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