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A GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N- 2 4 5 9
109 8th Street Suite 303 Assessor's Parcel No. q
Glenwood Springs, Colorado 81601 t
Phone (303) 945 -8212 ! t
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This does not constitute k t
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. 7
PROPERTY k`
Owner's Name Chrie M. Christensen Present Address 0680 CR 294, Rifle phone_ 625- 1758'
System Location 0680 County Road 294, Rifle
Legal Description of Assessor's Parcel No. k
ii
SYSTEM DESIGN
1 ! 1 Septic Tank Capacity (gallon) Other / L y J
Cl / 1 0 .4 f ft/reek"- !l "— ip, fro, .f.. / r.• /` S
r - i. Percolation Rate (minutes /inch) - Number of Bedrooms (or other) - 77 - 7 / Ar
/ / 1 1 Ci r R i',,-4. - d. -c-el c- t 1, efli (Tv 9 - r
Required Absorption Area - See Attached . / `,- �! x le n 4 - P y
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i-7 .1. .-, -` n et 1 s v r • � ( 1 r 0,9- a r, t 1
Spec Setback Requirements: ? ,` , r .e , `'0 ; . . -- l ; - t.k'e-p
Date 7— / - t <° I actor _, _ C
FINAL SYSTEM INSPECTIQ,N AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
%Syystem Installer_ / . ..E.at C_ 4Y
0 f
Septic Tank Capacity / 0 0 0 CC t
.-1.G4 4 5 ■
Septic Tank Manufacturer or Trade N �!' �,
Septic Tank Access within 8" of surface L'''
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Absorption Area eU.�('(I[' ''" � yrj--°h� / /rO U ru- t! k j
Absorption Area a Type 4pd /or Manufacturer or Trade Name - �r M. , a -4 ,
. ` caTe3 -L- I •
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Adequate compliance with County end State regulations /requirements
/ Other
Date '7_ / h/ .— 1 / - Inspector _/ - -r ^ r<.,,,-- 2i C 11,,1
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE 6
*CONDITIONS:
1. All installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal stems Chapter r,
P Y 8 i i' 9 P Y P Vi
25, Article 10 C.R.S. 1973, Revised 1984. 44
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 pprstructuregnot approved by. the Building and Zoning off ice shall automatically be a violation or a
requirement of the permit and cauke for both legal action and revocation of the permit. a r:'
3. Any person who constructs, alters, or installs an individual sewage disposal system in a manner which involves a knowing and material i ;
variation from the terms or specifications contained in the application of permit commits a Class 1, Petty Offense ($500.00 fine — 6 `.
months In jail or both).
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Applicant: Green Copy Department: Pink Copy
•
INDIVIDUALSEWAGE D__ISPDSA1_SYSTEM_AP_PLICATION
OWNER 44i4 !RAT NSEN
ADDRESS 4. fl C► C PHONE i cS — I7�Si
CONTRACTOR
ADDRESS PI IONS
PERMIT REQUEST FOR ( NI:W INSTALLATION ( ) ALTERATION ( ) REPAIR
Attach separate sheets or report 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).
LQCATION_lIL PROPOSI31? IACILITY: COUNTY _ 6i -RFIEJ 0
Near what City or Town R IFLt_ Lot
Legal Description +SNCLOS €D
WASTES_T_YL'L'': ( ( ) Transient Use
( ) Commercial or Industrial ( ) Non - domestic Wastes
( ) Other - Describe
BUILDING OR SERVICE TYPE: Swen. Rsmo.s{ JJrvnt.
Nimilly of bedrooms: Number of persons Z
(11-Garbage Grinder ( PrXiiionut tic Washer ( Dishwasher
SQURCEANI? TYPE_OILWATER_SUPPLY: () WELL () SPRING () STREAM OR CREEK
Give depth of all wells within I HO feet of system: N//{- pp r7
If supplied bycommunliy water, give name of supplier:_�1N b# IK It=t1�
GROUNNSONDITIONS:
Depth to bedrock:
Depth to first Ground Water "Table:
Percent Ground Slope: / -ro Z
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: S(Y) PLUS
Was an effort made to connect to community system? YES
TYPE OF Ity1)IVIDUAI. SEWAGE DISPOSAI. 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 DI SAL BY:
edi Absorption french, Red or Pit ( ) Evapotranspiration
O Underground Dispersal ( ) Sand Filter
( ) Above Ground Dispersal ( ) Wastewater Pond
( ) Other - Describe:
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OIL THE STATE? M 0
L'ERCOLAT ON_T :ST_RESULTS: (To be completed by Registered Professional Engineer)
Minutes per inch in hole No. I Minutes
Minutes per inch in 1 No. 3
inutes
per inch in hole No. 2 Minutes per inch in Hole No.
Name, address and telephone of R PE who made soil absorption tests:
Name, address and telephone of It PE responsible for design of (he system:
Applicant acknowledges that the completeness of the appliction 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 inusre compliance with
rules and regulations adopted under Article 10, Title 25, C.R.S. 1973, as amended. The undersigned hereby
certifies that all statements make, 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 bre relied on by the local department of health in evluating the same fro 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..
Signed /L 41 4 - ice_ Date 7 -7 -C '/C
P_ LEASE, DRAYY_ ANACC URA7ILMAP_T4_YQUILPROPEICIY (pz /
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