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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit IV _ 22864
109 8th Street Suite 303 Assessor's Parcel No. ;
Glenwood Springs, Colorado 81601 )
Phone (303) 945 -8212
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This does not constitute F '!
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. y
PROPERTY
Nnbty & Tarry Stoneking 0395 Owen Drive, Silt 876 -5917 4
Owner's Name Present Address Phone_ (
System Locator 0395 Owen Drive Silt 1
p I
Legal Description of Assessor's Parcel No. t
SYSTEM DESIGN - 7 r
& R
O( () Septic Tank Capacity (gallon) Other
3 .
-y `, Percolation Rate (minytes /in Number of Bedrooms (or other) ° �. 1 1 ` A ( ) -
6 7o 1 Or N A B 4 • h f ^ C CX ( q V 1, - X 72/ /A F k t h
Required Absorption Area - See Attached f 4 s it it IY , t T - - , t rr n .�, r >r .2.. �r s;;.4 r .. F r ¢
p Requirements: Y 2 1-f r, � (rtc ` / ('-r 3 . 2 . / � , �: . .a 6
Special Setback Re . t
Date /V / Inspector G"" ^ 1 ` A 1 , ° � - r c -
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FINAL SYSTEM INSPECTION AND APPROVAL (as installed) .
Call for Inspection (24 hours notice) Before Covering Installation - /1 {
System Installer ar oT I=1Ln F'a 6 ?rILU,J ,n.J I
g' 42cq.d' /,Qs a n
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Septic Tank Capacity h
Septic Tank Manufacturer or Trade Name Lee .. t
�rp'
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Septic Tank Access within 8" of surface 9P5
Absorption Area S s30
Absorption Area Type and /or Manufacturer or Trade Name 1 ,"F/ L-..T /J //lam 4 a -en i F
Adequate compliance with County and State regulations /requirements 'T es Is + p
7
Other ,
Date _2 4 ,24.7:541-- ,r Inspector /' v ( (J it�f�l/x !. 1
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE j r
*CONDITIONS: 4
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- t
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nection 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. t r
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3. Any person who constructs, alters, or installs an individual sewage disposal system in a manner which involves a knowing and material `y,
variation from the terms or specifications contained in the application of permit commits a Class I, Petty Offense ($500.00 fine — 6 i.
months in )ail or both).
Applicant: Green Copy Department: Pink Copy (I. ti
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„ Application
• TNDIVIT)ITAT, SEWAGE DTSPOSAT. SYSTEM APP TCATION Approval By
County Official
OWNER AJA any E re, gy sip a>E /c /.tiG _
ADDRESS 3 4C 00 {4
e it) ,e/ ice PHONE' ?6 - 307 /, f' 0 • —
NTRACTOR 0
ADDRESS PHONE
KMIT REQUEST FOR: (r) New Installation ( ) Alteration ( ) Repair
ar_.h separate sheets or report showing entire area with respect to surrounding areas, topography of area,
.itable building, location of potable water wells, soil percolation test holes, soil profiles in test holes
page 4).
'CATION QF_PROP SEDFAOILITY : County Cj ARF/ e
ar what City or Town . S /%r Lot Size 3,0 AG-Gs
= T Description iAR c.G / e t. - z " NW s ee no•D 33
".STES TYPE : ( ) Transient Use
( ) Commercial or Institutional ( ) Non - domestic Wastes
( ) Other - Describe
TILDING OR SERVICE TYPE:
amber of bedrooms "4 Number of persons
- Garbage grinder (r Automatic Washer r-Dishwasher
, JRCE AND TYPE OF WATER SUPPLY: (IT well () spring () stream or creek
ve depth of all wells within 180 feet of system:
upplied by community water, give name of supplier:
tOUND CONDTTIONS:
- yth to bedrock:
-pth to first Ground Water Table:
'vent ground slope:
STANCE TO NEAREST COMMUNITY SEWER SYSTEM - /' Ye-
is an effort made to connect to community system? 44.2
'PE , O�F INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(t7 Septic Tank ( ) Aeration Plant ( ) Vault
( ) Vault Privy ( ) Composting Toilet ( ) Recycling, potable use
( ) Pit Privy ( ) Incineration Toilet ( ) Recycling, other use
( ) Chemical Toilet ( ) Other - Describe:
NAL DISPOSAL BY:
(Pr Absorption Trench, Bed or Pit ( ) Evapotranspiration
( ) Underground Dispersal ( ) Sand Filter
( ) Above Ground Dispersal ( ) Wastewater Pond
( ) Other - Describe:
'_L EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? 111-0
L PERCOLATION TEST REST IT .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. _
ie, address and telephone of RPE who made soil absorption tests;
ne, 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/7 / y Signed Ct 4 Q i T /
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PLEASE DRAW AN ACCT JRATF, MAP TO YOI JR PROPERTY
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