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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N_ 2 3 3 / if
t Assessor's Parcel No.
Glenwood Springs, Colorado 818
109 8th Street Suite 303 (
4
Phone (303) 945 -8212 , 1
This does not constitute 4+
INDIVIDUAL SEWAGE DISPOSAL PERMIT • a building or use permit. i i
PROPERTY t
Owner's Name Wayne Rudd Present Address 01 Park Avenue, Basklt phone 927 -9119 {
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System Location Counts Road 113, Carbondale k
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Legal Description of Assessor's Parcel No. $ t
SYSTEM DESIGN k
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� ' / O Septic Tank Capacity (gallon) - Ether q '
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/, (/ • Percolation Rate (minutes/inch) • Number of Bedrooms (pr other) 2 9
7 , y t
7 / , „ / , o - -/. j r ,-.,, r -,
Required Absorption Area - See A1tarhad 1.j n r;
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Special Setback Requirements: 1! / 17 (�,�� � � ' / r � * . „^ i' I'r °.- t
Date 2c- by _ � �t- , Inspector " ` r 7-7- el,
A t C ( .. s . n e .,, A it
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FINAL SYSTEM INSPECTION AND APPROVAL (as installed) . `'
Call for Inspection (24 hours notice) Before Covering Installation f •
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System Installer IV0/ “ ; %"'
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Septic Tank Capacity / D 0 e')
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Septic Tank Manufacturer or Trade Name eAnt A kr ,e - - L ' -+ 4
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Septic Tank Access within B" of surface '
Absorption Area ik. a
Absorption Area Type and /or Manufacturer or Trade Name ) •�f.� ic.l E' "L�� /z �<%.!e7 C
Adequate compliance with County and State regulations /requirements 4- 7' 4 - 5
1
Other / [ i
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Date y- ,b- 9 Inspector t {i r ,,,i.� w' „:157:x.? • i
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION' ITE
*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.
2. This permit is valid only for connection to structures which have fully complied with County zoning and building requirements. Con- 1
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 C.
variation from the terms or specifications contained in the application of permit commits a Class I, Petty Offense ($500.00 fine — 8 1
months In jail or both).
A
Applicant: Green Copy Department: Pink Copy t '
Application
INDTVIDTJAI. SEWAGE. DTSPOSAT. SYSTEM APPT JCATION Approval By
County Official
OWNER W4VWE QUDO
ADDRESS Q. (4 PARK AuENVE_ PHONE 92141/ "®
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CONTRACTOR L /AYYNE Zi b D
ADDRESS 0 132 PARK 4✓G/WUn BAMt -r Cnwo PHONE9Z - 9ii 9
PERMIT REQUEST FOR: (t New Installation () Alteration () Repair
Attach separate sheets or repo showing entire area with respect to surrounding areas, topography of area,
habitable building, location of potable water wells, soil percolation test holes, soil profiles in test holes
(See page 4).
T.00ATION OF PROPOSED FACILITY : County 56C ArrAreNED SHEET
Near what City or Town 6 LrautuaOT S PR1N G5 Lot Size 40 AcQE
Legal Description THE Nwi /4NWI /4 5Ec Tt on) 11 TDWN Sa1tP 6 5 Our 14 , 2ANG
85 WEST of E 5orr4 PkinWC,PAL Ple RADIAN
WASTES TYPE.: Dwelling () Transient Use
() Commercial or Institutional ( ) Non - domestic Wastes
() Other - Describe
BUILDING OR SERVICE TYPE: eeka idd
Number of bedrooms 2- Number of persons 3
( ) Garbage grinder ( ) Automatic Washer ( ) Dishwasher
SOTJRCE AND TYPE OF WATER ST MP' .Y. well () spring () stream or creek
Give depth of all wells within 180 feet of system: fao rEE C
If supplied by community water, give name of supplier: W: A
GROL JND CONDITIONS;
Depth to bedrock: 14 F Er
Depth to first Ground Water Table: 300 FEt r
Percent ground slope: to 'Zi
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: S MILES
Was an effort made to connect to community system? N0
TYPE INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
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:
7 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
•
'mar PI .AN AND DFSIC'.N FEATURES
Include by measured distance location of wells, springs, potable water supply lines, cisterns, buildings,
property lines, subsoil drains, lake, water course, stream, dry gulch and show location of proposed system by
direction and distance from dwelling or other fixed reference object, and additional submissions in support
of this application such as data, plans, specifications statements and commitments.
G� / ( 2
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SOH. PER COI .ATION TEST REST 11.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. _
Name, 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 Signed 4. - s.ii La • 41
p1 .EASE DR AW AN ACCI IR ATE MAP TO YOI JR PROPERTY
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