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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit « 2 3 1 5 rc R
_ _ 109 8th Street Suite 303 Assessor Parcel No.
Glenwood Springs, Colorado 81601
Phone (303) 945-8212
, This does not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT „4# a building or use permit.
PROPERTY ';
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Owner's Name KrL Present Address 3493 County rd, 331. 8111 Phone 876-2271
System tocati County rd. 331. Silt
Legal Description Of Assessor's Parcel No.
SYSTEM DESIGN If i
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4 0 0 0 Septic Tank Capacity (gallon) Other
/ N �tv`4 3 0 Percolation Rate (minutes /inch) Number of Bedrooms (or other) 3
/� / ,.f / 02. )' /r; ` x - E
Required Absorption Area - See Attached / ' �Pti' /. (� J - f �1 �' t
Special Setback Requirements: p, I
Date 7 A,- 1 // I nspector C �[ � pS1 CI) t c ••_
FINAL SYSTEM INSPECTION AND APPROVAL (as installed) , t l
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Call for Inspection (24 hours notice) Before Covering Installation
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System Installer_ 7'C V f Ai /Zi "l f 1
Septic Tank Capacity ibnO i
Septic rank Manufacturer or Trade Name 6jo1n- + -/F'OL.- (
4
Septic Tank Access within 8" of surface `. V C S t
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Absorption Area "A C � 1
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Absorption Area Type end /or Manufacturer or Trade Name 9 . J - A r (Cali/ L Ofd . • 9 _/ F •«�. , L „ 9
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Adequate compliance with COyn y and State regulations /requirements Yr; t i
Other 4
Date /Q - (^ - 14 Inspector `i$r , / k.. ptt ve_V,.,i d l
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RETAIN WITH RECEIPT RECORDS AT CONSTP UCTION SITE ,i i
*CONDITIONS: 'r
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. i f
2. This permit is valid only for connection to structur which have fully complied with County zoning and building requirements. Con- t
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:
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). jf
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Applicant: Green Copy Department: Pink Copy
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Application
INDIVTDTJAT. SEWAGE. DISPOSAT. SYSTEM APPT JCATION Approval By
County Official
OWNER &Evert a 4Znyt kiR'z
ADDRESS PHONE /SC —
=ONTRACTOR
ADDRESS PHONE
'ERMIT REQUEST FOR: (X) New Installation () Alteration () Repair
Attach separate sheets or report showing entire area with respect to surrounding areas, topography of area,
;rabitable building, location of potable water wells, soil percolation test holes, soil profiles in test holes
(See page 4).
LOCATION OF PROPOSED FACIT.ITY : County C -- e.an
Near what City or Town g i wr Lot Size i4 .4c ec5 ,66,PE oR .CESS
Legal DCSQription • ° rijr �Cf
WASTES TYPE : ()(j Dwelling () Transient Use
( ) Commercial or Institutional ( ) Non - domestic Wastes
() Other - Describe
BUILDING OR SERVICE TYPE:
Number of bedrooms '3 Number of persons a-
() Garbage grinder 0,0 Automatic Washer (V) Dishwasher
SOT TRCE AND TYPE OF WATER ST JPPT 00 well () spring () stream or creek
Give depth of all wells within 180 feet of system:
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If supplied by community water, give' name of supplier:
TROT IND 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? Ala On,vrnunryy 6075 7l'd4, U4Pc.t 00 c0444' ,?C 331.
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
Q() 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:
24 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? No
ipir
.OTT. PBRCOT.ATION TEST RESIN .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. _
dame, address and telephone of RPE who made soil absorption tests;
lame, 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
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.� lV 1 "� Signed d
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pl.EASE DR AW AN ACC! JR ATE MAP TO YOT JR PROPERTY
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