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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N4 2 3 1 o A
109 8th Street Suite 303 Assessor's Parcel No.
Glenwood Springs, Colorado 81801
Phone (303) 945 -8212
Sr
This does not constitute $
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. I
PROPERTY 0
Owner's Name .1 6A. Parka Present Address - ' . ^ t .r ' • _ 963 -3352 0
k
System Location ?499 Highway 199, Cnrhnnde1s. I
Legal Description of Assessor's Parcel No. 'iN
SYSTEM DESIGN
a
/r'• --a Septic Tank Capacity (gallon) Other li
(
t\) 16, Percolation Rate (minutes /inch) Number of Bedrooms (or other) N/A
Required Absorption Area - See Attached { t
i
Special Setback Requirements:
L
a
Date Inspector. ); I
FINAL SYSTEM INSPECTION AND APPROVAL (as installed) 4
Call for Inspection (24 hours notice) Before Covering Installation t 4
T j
System Installer_. 1' r f 7 :' \f' 5
Septic Tank Capacity . L C i-> q t
Septic Tank Manufacturer or Trade Name iGp' /7,'/1 y 111F
t
Septic Tank Access within 8" of surface yr" 7
i a
Absorption Area t o/ I i }
W, v
Absorption Area Type and /or Manufacturer or Trade Name F I.
u: .w
Adequate compliance with County and State regulations /requirements t r i ! ^ ^ - -5 1'
1
$ 11
Other `
+.
Date '' . y ' . , (Ai /4 ... -i, Inspector ?e_h -i. ').. ., ,.,, %LqS
RETAIN WITH RECEIPT RECORDS AT CONStRUCTION SITE
•CONDITIONS: 4 t
1. All installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chapter t i
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 office 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 i 1'
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). t
I
Applicant: Green Copy Department: Pink Copy
�.i Application
INDIVIDTJAI. SEWAGE DISPOSAT. SYSTEM APPI JCATION Approval By
a County Official
OWNER .6•€ 1Pn n .5.-4
ADDRESS ° - / 3 iLy PHONE9b3- }.qy2_
ONTRACTOR �. 0
' ' ADDRESS S.a ..+v PHONE
:RMIT REQUEST FOR: yQ New Installation ( ) Alteration ( ) Repair
ttach separate sheets or report showing entire area with respect to surrounding areas, topography of area,
tbitable building, location of potable water wells, soil percolation test holes, soil profiles in test holes
;ee page 4). nnll
()CATION OF PROPOSED FACILITY : County L4 - o 0.0
fear what City or Town 0A .k. Q rg✓ eta-12& Lot Size /• C.l.F h n A ,
egal Description
TASTES TYPE : ( ) Dwelling ( ) Transient Use
( ) Commercial or Institutional O) Non - domestic Wastes
(:) Other - Describe A A k A
UILDING OR SERVICE TYPE: C IJt (t1 9 ,k l' xflTct
lumber of bedrooms Number of persons
) Garbage grinder ( ) Automatic Washer ( ) Dishwasher �W )
OI IRCE AND TYPE OF WATER SUPPLY; () well () spring (C)strean or creek
give depth of all wells within 180 feet of system: n� tr�
f supplied by community water, give name of supplier: (.F4li V vrr a_Q z . W M" 4;7:r" -I
1ROI IND CONDITIONS;
)epth to bedrock: \) CY a a-Q
)epth to first Ground Water Table: n
'ercent ground slope: ( �-
)ISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Vas an effort made to connect to community system? -0
CYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(fri Septic Tank ( ) Aeration Plant ( ) Vault
( ) Vault Privy ( ) Composting Toilet ( ) Recycling, potable use
O Pit Privy ( ) Incineration Toilet ( ) Recycling, other use
() Chemical Toilet ( ) Other - Describe:
7 INAL DISPOSAL BY:
(P) Absorption Trench, Bed o ( ) Evapotranspiration
( ) Underground Dispersal ( ) Sand Filter
( ) Above Ground Dispersal ( ) Wastewater Pond
( ) Other - Describe:.
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE?
IL PERCOLATION TEST RRSIJI.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. _
me, address and telephone of RPE who made soil absorption tests;
•
me, 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 - s q ¥ Signed y�
pi .EASE DRAW AN ACCT IRATE MAP TO YOI IR PROPERTY
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