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GARFIELD COUNTY BUILDING AN SANITATION DEPARTMENT Permit N _ 2 4 7 7 M
109 8th Street Suite 303 Assessor's Parcel No. W
Glenwood Springs, Colorado 81601
Phone (3031 945-8212
This does not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. I t ,
PROPERTY in
. l `l °' ..,49—`74asrq i4.
Brian Bark P.O. Box &3 4 Glenwood 945-5648 y
Owner's Name Present Address Phone_
System Location ! Z �8 County Road 313 Silt
is
Legal Description of Assessor's Parcel No.
Nd ( �ef5 p �° rre
SYSTEM DESIGN �� � /Gil O
T J¢ t 40 r- - % > c ti
la
s-n Septic Tank �� ' ail J n eFe- JD A St a ;P • •c. t
t
n /AI n b Percolation Rate (minutes /inch) Number of Bedrooms (or other) (3) 4
Required Absorption Area - See Attached
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Special Setback Requirements , .._ . ; \, t ^� m •• ` a `
Date $ 49 y inspector
A NAL SYSTEM INSPECTION D APPROVAL (as installed) , V;
Call for Inspection (24 hours nO icl) B�fofe- Covering Installation - "" •
'r ., •- y,
System Installer_ s :' ti
Septic Tank Capa /az5 9r.- '� P
Septic Tank Manufacturer or Trade Name /o' O(Y(.) i i
U1 y i{
Septic Tank Access within 8" bf �9ur1ace I,.>4 r' t 8
Absorption Area e re i> t F-4,, . ✓;.h., -'-- / 41 • � l
') / l : : ,. r. r ( ) . ^! fy •
Absorption Area Type and /or Manufacturer or Trade Name f% .-> /)v -` /: ',` ")
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Adequate compliance with County and State regulations /requirements y r 5 t, j
Other 7C C /d / &YC' / P 1
i
Date 7/ /i/7 Inspector v A; 'r- t p
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE it
*CONDITIONS: 01
1. All installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chapter 1l ' }
25, Article 10 O.R.S. 1973, Revised 1984.
2. This permit is valid only fortonnection 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. C
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 — 9
months in jail or both).
it
Applicant: Green Copy Department: Pink Copy 8
INDIVIDLIALSEWAGE_DISPQSAL SYSTP.M_APP_LICATION
OWNER "kit Intl `tRl9"0....1-<
ADDRESS 't?6 ? ox I9 z 7 e, P12. PHONE (720i 3 299289
CONTRACTOR 'hun9 - N U&flp �,(
ADDRESS PHONE
PERMIT REQUEST FOR (x) NEW 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).
LOCA110I4.0LPRQPQSED..1'ACILITY: COUNTY Cr et tg-F I L��
Near what City or Town rviv1 Gr`1srLC Lot
Legal Description
WAST ESTYPE: (X) Dwelling ( ) Transient Use
( ) Commercial or Industrial ( ) Non - domestic Wastes
( ) Other - Describe
BUILDING OR SERVICE TYPE:
Number of bedrooms: 4 Number of persons 9
( ) Garbage Grinder ( ) Automatic Washer ( ) Dishwasher
SOLRCE_A DTY1'_LOI ATEKSUITLY_: (x) WELL () SPRING () STREAM OR CREEK
Give depth of all wells within 180 feel of system:
If supplied by communiiy water, give name of supplier:
GROUND CQNDI110NS:
Depth to bedrock: _
Depth to first Ground Water Table:
Percent Guilin(' Slope:
DIS'FANCETO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to community system?
TYPE OF INDIVIDUAL. SEWAGE DISPOSAL SYSTEM PROPOSED:
k) 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:
(.4) Absorption 'french, Bed or Pit ( ) Evapotranspiration
( ) Underground Dispersal ( ) Sand Filter
( ) Above Ground Dispersal ( ) Wastewater Pond
( ) Other - Describe: _
WII.1. EFFLUENT BE DISCIIARGIiD DIRT C'I'LY INTO WATERS OF THE STATE? 4/0
•
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P_TiRCQLATION 17 :ST1?,ESLLT.S: ("I'o he completed by Registered Professional Engineer)
Minutes per inch in hole No. 1 Minutes
Minutes per inch in Hole No. 3
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 RPT's responsible for design of the system:
Applicant acknowledges that the completeness of the a ppliction isconditional 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. 1 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 Taw.
Signed A /Sj.
Date 8 AAS
PLFASF _1)RAW_AN_ACCLRA'1'IiMAP_'ffl YOLICP_ROPFRTY
to 27a T
074-7/ Gi9$i ci 0/`/ co � �1. 313
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