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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit IV: 2 4 5 3 }
109 8th Street Suite 303 Assessor's Parcel No. k q
Glenwood Springs, Colorado 81801 F:r # „
Phone (303) 945 -8212
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\:), This does not constitute t
INDIVIDUAL SEWAGE DISPOSAL PERM Vi t`1 0 `., a building or use permit
PROPERTY ti V
4 I 9A°42;150-2.-SinCerit
Tom & Lisa Rogers 355fl1ill Avenue Rifle
Owner's Name Present Addtets , rC Phone_ ts
t. System Location 14 usty oad 210 Alexandaas 14 rates, Rifle •
Legal Description of Assessor's Parcel No. iilll t . in
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SYSTEM DESIGN M ;
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< Other
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J rj f) 7 Septic Tank Capacity (gallogj, . Fit }
'
1 , ,. e •
ii. -, 1 . ' 1 Percolation Rate (minute h ) \ . N14 ber of Bedrooms (or other) 1 1
e,, 3- p'R1 t cficsA FcL. /%l'A 43'l_F --'r p, !'C (
Required Absorption Area - See Attached f 1 1
� f % /l�le7 �H 7 b ,J/ rP a1
Special Setback Requirements: Jyf�Z7, 6' o. t /On ', ♦
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Date /r, - : %7- '/C" Inspector `" fr' +:el av7. ti„. ,
FINAL SYSTEM INSPECTION AND APPROVAL,(as tnstalled) ,,.'
Call for Inspection (24 hours notice) Before Covering Instgllation
System Installer 7 `''' / l e � � �,.,
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Septic Tank Capacity /a So t C ', ' 4 1-, 4 :
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Septic Tank Manufacturer or Trade Name `• •e ?n!`1'E./ t; } ''
Septic Tank Access within 8" of surface j 't r
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Absorption Area 3 73 5 .3 "ea'' 5 (/• ✓ � % ,$„ ! q ,,
Absorption Area Type and /or Manufacturer ar Trade Name -3 - az./ - -4,4//en iX�r7>Q, 27A-• r-)
i i:: Adequate compliance with County and State regulations /requ%pgment1
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r 1 '.,� , t - Other ` -,: M - ,., 4 )
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D ate R , . , /, ,S •y e4or is 4' .T a r.),s5Ix/
RETAIN WITH QI IPT)IECORDS AT CONSTRUCTION SITE p -,
•CONDITIONS: r � ` P t`
1. All installation must comply with all requiakents of She Colorado State Board of Health Individual Sewage Disposal Systems Chapter w , l
25, Article 10 C.R.S. 1973, Revised 1984. +�,I T
2. This permit is valid only for connection to4trllctures which have fully complied with County zoning and building requirements. Con- i '
nection to or use with any dwelling or structures not approved by the Building and Zoning office shall automatically be a violation or a if
requirement of the permit and cause for, legal action and revocation of the permit.
3. Any person who constructs, alters, or installs an individual sewage disposal system in a manner which involves a knowing and material
variation from the terms or specification$ontained in the application of permit commits a Class I, Petty Offense ($500.00 fine — 6
months in )ail or both). ?,
Applicant: Green Copy Department: Pink Copy
ASO/ " i
INDl V I DU ALSEW Ab r. _P_ISPn3AL.-SYSTEM_A
OWNER v i • , er ____,CC :I PHONE NE
•
ADDRESS � � � � '
i •t'
CONTR <, PHONE
ADDRESS ALTERATION () REPAIR
PERMIT REQUEST FOR ( ) NEW INSTALLATION ( )
habitable she location of potable water wells soil + percolation l test holes, area,
soil profiles in test holes
habitable build+ng,
(See page 4 ). COUNTY • r
LOCATION_OF PROPOSED 'AGILITY.: Lot a<
�-
Near what a l Description City or Town e r ,.. Os • i i s t `t
Legal /
Dwelling O `Transient Use
( ) Commercial or Industrial
WASTES "LY_PE: (X) Dwelling Wastes
( —____
( Other - Describe
BUILDING OR SERVICE TYPE: ante '� _ Number of persons
Number of bedrooms: 00 Dishwasher
( ) Garbage Grinder O Automatic Washer SPRING O STREAM OR CREEK
SOLRCI:AN�TY1'_C OF WATEILSLPPLY.: Q<) WELL ( )
Give depth of all wells within IRO feet of system:
If supplied by communiiy water, give name of supplier:
C_ iROUNIICONOITIONS
Depth to bedrock:_
Depth to first Ground Water Table: i
Percent Ground Slope:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to community system?
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
od Septic Tank ( ) Aeration Plant ( ) potable use
Composting Toilet ( ) Recycling, p
( ) Vault Privy ( p Recycling, ( Pit Privy O Incineration "Toile, ( ling, other use y •
( ) Chemical Toilet ( ) Other - Describe:
FINAL DISPOSAL IIY: Evapotranspiration
(X) Absorption Trench, Bed or Pit ( Sand o trtransans
er
( ) Underground Dispersal ) E ( ) San vad Filt Pond
( ) Above Ground Dispersal
( ) Other - Describe:
WILL EFFLUENT BE DISCI IARCiED DIRECTLY INTO WATERS OF THE STATE? At
i9#7 Nva -97,41 t 0ce7'C'
Pic vvivtz r/ T 9 /fir T t
0 r free c sy r,rtr 1 d- /'it c- R's //7/2 C wsprec'
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PLRCQLATl0N TEST_R13SULTS: (o be completed by Registered Professional Engineer)
M inutes per inch in 1 - tole No. 3
Minute,~ per inch in hole No. 1 per inch in Hole No. —
Minutes per inch in hole No. 2 Minutes P
Name, address and telephone of RPE who made soil absorption tests: ,,,
Name, address and telephone of RPE responsible for design of the system:
an t anal tests and reports as m yl + + competeness of
he required t the local conditional upon
nt to such
e made and furnished
a
by the applicant pe by na the local
such ms andtconditions +sas deemed the
el n totim he applcation; and sue c + ompliance with
issuance of Ih permit i
rules eti and rut all statemeitstn ake`inf� mation and reports s it mitte d herewithcand required to be st submitted
certifies tat + nd correct to the best of my
ar e des the i pgnedtot n h are e r elied by the localtdepa+tment +of health in militating the same fro purposes of issuing
are to
the permit applied of th application for or revocation of a ny l pemit grante based or
pon said application result
tion and in legal
the denial of th e
action for perjury as provided by law.
Signed . .! c Mit / 1
Tate
4
PLEAS11 DRAW_AN ACCURATI: YIAT' I'n YnUR_P.R_ .G
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