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GARFIELD COUNTY BUILDING/AND, SANITATION DEPARTMENT Permit 1♦r 2 4 H 0
109 8th Street Suite -303 Assessor's Parcel No.
Glenwood Savings, Colorado 816Q) , , ..
Phone (303) 945 -8212 pp
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t This does not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. Y
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PROPERTY ;
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Owner's Name Jamee 1, Atidria Rolland -SeflJ t Address P.O. Box 3363, Glenwood Phone_ 945 -0453 Sl
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System Location \ County Road 115, Glenwood Springs„
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Legal Description of Assessor's Parcel No.'
4{'GU4( O L lily // - ss& i
SYSTEM DESIGN J '+i :Ptl,r f S- .414 a N �'Qs ` t *
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/1 6 Septic Tank Capacity (gallon) Other
` f.) -3A mfA Rate (minutes /inch) Number of Bedrooms (or other) 2 tI
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Required Absorption Area - See Attached
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Special Setback Requirements: ,
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Date ; L - -- Inspector /1/.Q'r L._, .i) G7.r 'r 4t e 1L `, 0
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FINAL SYSTEM INSPECTION AND APPROVAL (as installed) ' , t 5
Call for Inspection (24 hours notice) Before Covering Installation { I
System Installer_ / /ti /?,AA3/ dejec4 tfT X iii
Septic Tank Capacity tea* cafe
Septic Tank Manufacturer or Trade Name -Ci n.G4N0
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Septic Tank Access within 8" of surface y
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Absorption Area 42 //✓f /[ /7494Ti.2.4„S /9/ ,02.,,-9 _ „� !hi'
Absorption Area Type and /or Manufacturer or Trade Name .444/C �✓�'£J✓
Adequate compliance with County and State regulations/requirements
7 C,
Other 6 A= . II It
Date it' -,-'I - IC Inspector •
7 i Y
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE t
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•CONDITIONS: k
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. R
2. This permit is valid only for connection 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. Ei
3. Any person who constructs, alters, or installs an individual sewage disposal system in a manner which involves a knowing and material L
variation from the terms or specifications contained in the application of permit commits a Class I, Petty Offense ($500.00 fine — i
months in Jail or both). 66 K t
Applicant: Green Copy Department: Pink Copy i
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INI)IYIIMAI. SEWAGE 1)ISI'OSALSYSTEN1\PPLICA1MN
OWNI:It JG wn¢n
A I) DR I?SS - - - - ?p 33 03 -Sc.0
( 'ON • I'ItACI'OR � } � — PHONE z5�5 -ovsi w
----- -. K- r�uwn> 5 wK
ADDRESS
Pliltt`-II'I' RISQI IISS'I' I OIL INSTALLATION - - PI10NE
(w NEW ( ) ALTERATION ( ) REPAIR
Attach separate sheers or report showing entire area with respect lo surrounding areas, topography of area,
habitable buildin location of potable water wells, soil percolation lest holes, soil profiles in test holes
(See page '1).
LOCATION OF PR OI'OSIiD I''Apll.l COUNTY "as. -m
Near what City or Town k:cf-t,yvd Slot - —
- -''!m Lol NA
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Legol I h tic riplton �- �- P't�.c,i _ --
1 c ., p�+1�, � ,mo 'Iv sE '/� 5��� r�
c'e'y` , K ev-�'y dMA -i 2 O , W fi — *-- - -- L ,
-�vu o 1
Kw-P/4.4 501 /4 e7 ., " ` °- 1 L� (� I t S n,o no,4, , a K.t Itr-c e l . a�(o..� - �.c1�i«1
WASTES I I:S I _l • I E: ( I )wellin
O Transient u isicnl Use
( ) ('onnercial or Industrial ( ) Non - domestic: Wasles
( ) Other - Describe
1111 . VICE TYPE: ra?r� �-� ^
ll 1 _4? L,
Number 01 bedrooms: - - —
( ) Garbage (;cinder Nuncber of persons __�- -- — --
( ) Automatic Washer
SOI RC E_AND "LYPE ()V WATER SUPPLY: WEIL ( )Dishwasher
(live depth of ‘ill wells within 1811 lire( of system ( SPR1NG ( STREAM OR CREEK'
If supplied byconuounliywater, give — —
Lilt C
I ) O (, ve Hanle of supplier: -- _ ---
_ LNI_ CONDITIONS:
Depth to bedrock: Lin lzvNow40
Depth to first (around W ilcr Table:
Percent (;round Slope:
DISTANCE 'I NEAR EST (1)MtvlIlNI'I'1'SEWER SYSTEM: N
Was an effort made to connect to community system7. q __ 1?.lu 1?BL.><
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
() Septic Tank ( ) Aeration Plant
( Vault
( ) Vault Privy ( ) Composting I o Ict ( ) Recycling, potable use
( ) Pit Privy ( ) Incineration foilcl
( ) Checnical'I'oilel ( ) Other - Describe: .. ( Recycling, other use
I_ DISPOSAL 111':
(JO Absorption Trench, Iced or Pit
( ) Underground D ( ) ispersal ( ) ai'u I'i l ter piralion
( ) Above Ground Dispersal ( Wastewater Pond
Sand Diller
( Olhcr - Describe:
111.1. EI:I I.IJEN•I' Ill: DISCI IAR(IND Dllt IiCfI.Y INTO WATERS OIL •1'I Ifs S'I'ATii'?
•
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L11.A'I'I(_)N " It1:S1!1:1'S: (To be completed b
tvtinntcs ___ Y Re gisierecf Professional Engineer)
her Inch in hole Nn. 1
Minutes ___ Minutes per inch in Hole No. 3
_.__ per inch in hole No. 2 Minutes
per inch in Hole No.
Name, ;lddress and telephone of 121'1 who made soil absorption lusts:
----
Name, address and telephone of It PE responsible for design of the system:
Applic;lnl acknowledges that I he completeness oflheappiiction 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 Ihe.;ipplicnnl or by the local health depnrlolcot for purposes of the evaluation of the application; and the
issuance of the permit is subject lo such terms and condi t ions as deemed necessary lo inusre compliance with
rules and regulations adopted under Article 10, Title 25, C.It.S. 1971, as amencle.d. The undersigned hereby
eertilics that all NIalements ma le, informal ion and reports submit led herewith and required to be submitted
by I he applicant are or will It represented to he true and correct to the hest of my knowledge and belief and
arc designed lo pre relied on by the local deportment of health in evinaling the same fro purposes of issuing
the permit applied for herein. I further understand Ihal any falsification or misrepresentation may result in
Ilse denial of the application or revocation of any permit granted based upon said application and in legal
action Ihr perjury as provided by law.
Signed ._ 'IOW / tit/
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op )a le __ �J
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