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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N : 2 3 0 6 1
109 8th Street Suite 303 Assessor's Parcel No.
Glenwood Springs, Colorado 81801
Phone (303) 945 -8212.
` - This does not constitute 0
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit.
PROPERTY It
X
Nathan B. King 720 Grand, Glenwood Sprinns 945 -8933 i
Owner's Name Present Address � one
f ,b - Y , a ¢n�c e_..cr _.44 (r
System Location New Cant
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Legal Description of Assessor's Parcel No.
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SYSTEM DESIGN
00 0 Septic Tank Capacity (gallon) Other I
" ' =' `JO S. .ctt: L0 _ u4-0.A „2.0 n/6 1 .. •,• } ..,
' "- "'M Percolation Rate (minutes /inch) Number of Bedrooms (or other) 3 3 / 0 '
pp y � !�
1 O 1 n r R rat -, Q,.i,4 )c t,- VI l„ �. CT. / na rX 4 n x,3 BCRa/o k
Required Absorption Area - See Attached I , • ". •
• Special Setback Requirements: el; r i h (B tr. �r /:; : i rn - '3f rt9Q {•i. - {
Date K- 9 - 7 At Inspector J-3 evi LtTe/i`-z, j;
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer. 0-14'7 X1,0 -•.)
Septic Tank Capacity 0
Septic Tank Manufacturer or Trade Name 1! c azi_ e .aL4 2
f
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Septic Tank Access within 8" of surface /i"' t
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Absorption Area G -r c Q ' 5 R q- U6 7
Absorption `'�-, :- (Y fi t
• sorption Area Type and /or Manufacturer or Trade Name �'
Adequate compliance with County and State regulations /requirements
Other i
i i Date 7 / 3 - e n) Inspector
; 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
25, Article 10 C.R.S. 1973, Revised 1984. F {F.
f 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 office shall automatically be a violation or a
f 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
8 variation from the terms or specifications contained in the application of permit commits a Class I, Petty Offense ($500.00 fine —6 88
months in jail or both). 1'
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Applicant: Green Copy Department: Pink Copy M
Application
INDIVIDI JAI . SEWAGE 17ISPOSAT. SYSTEM APPT.ICATION Approval By
---14 /" County Official
OWNER / _ / / /
ADDRESS S :Wrt/ ' PHONE 1°a s
;ONTRACTOR iZEiir fllrrff� AO.-
ADDRESS AO • _I i r. PHO /� '
'ERMIT REQUEST FOR: () New Installation () Alteration () Repair
Utach separate sheets or report showing entire area with respect to surrounding areas, topography of area,
iabitable building, location of potable water wells, soil percolation test holes, soil profiles in test holes
See page 4).
• : l • ': •'• '. . : , 1ty <.
gear what City or Town , ,rte Lot Size 3 • /� r'
_egal Description _ n ( `
WASTES TYPE • Dwelling () Transient Use
) Commercial or Institutional ( ) Non - domestic Wastes
()Other - D n
3UI DING OR SERVICE TYPE: J
g ber of bedrooms Nytthber of persons
Garbage grinder (Automatic Washer (Dishwasher
>OT JRCF. AND TYPE OF WATER Si JPPLY: () well () spring ( . re.. .r c . /
Dive depth of all wells within 180 feet of system: alai, i / -`� -
`f supplied by community water, give name of supplier:
1R01IND CONDITIONS:
Depth to bedrock:
Depth to first Ground Water Table:
'ercent ground slope:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:_ '
Was an effort made to connect to conununity system?
CYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
54' Septic Tank ( ) Aeration Plant IA- 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 THE STATE?
. • ,........ _h „ ,
t '
OILPERCOI.ATION TEST REST IT (To be completed by Registered Professional Engineer)
Minutes per inch in hole No. 1 Minutes per inch in Hole No. 3
Minutes 1 per inch in hole No. 2 Minutes ____ per inch in Hole No. _
Tame, address and telephone of RPE who made soil absorption tests: i �J
Tame, address and telephone of RPE respon'ble for design�f the system; " / ,Sir,
7) b 2rA_Awinoto a
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 applic. lion and in legal
action for perjury as provided
J / v by law. g
Date v — 0C Signed
4 1111.
PLEASE DRAW AN ACCI JR ATE MAP TO YOT JR PROPERTY
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