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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N.. 2 4 9 6
. 109 8th Street Suite 303 Assessor's Parcel No.
Glenwood Springs, Colorado 81601 S
Phone (303)945.8212
rt
This does not constitute t
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. r'
PROPERTY
Terry & Linda Bendetti. 0233 CR 265, Rifle 625 -4344 , .
Owner's Name Present Address Phone_ �l.
d
System Location 0233 County Road 265, Rifle, CO a )
Legal Description of Assessor's Parcel No.
7
C
SYSTEM DESIGN ( t
f`
1 S A! Septic Tank Capacity (gallon) Other r I
N 4 - -
i • / A ' /t' Percolation Rate (minutes /inch) Number of Bedrooms (or other)
icJaG.( t L-fo1Ct/ 1o4Y AOscfreMAn jtnt4 -
Required Absorption Area - See Attached Joie* � El J .4.-r a%ayjbj.5 al `4
ld ,,,,} r.7 g. o IP /SAS.'snx a .39 r A .. I
Special Setback Requirements: s ` ��
I.
Date 9- .9j.,. " CY S' inspector +2 Air ejoL -f,.. `
FINAL SYSTEM INSPECTION AND APPROVAL (as installed) , .
Call for Inspection (24 hours notice)kefore Covering Installation
Via /i a
S Installer a (2 ., ; .P , 4,
Septic Tank Capacity _27)iO
Septic Tank Manufacturer or Trade Name L'!`'P/ /yi(L'.�'- t
1 .
Septic TaA Access Within 8" of Surface 4 C
Absorption Area ✓ &+ % ( - -' /' ' - - • ; (:
1 1
Absorption Area Type and /or Manufacturer or Trade Name 49 cc) - i . is i ',,,, j teL + `, ,
Adequate compliance with County and State regulations /requirements Ye.: ii
1 p
t
Other
p
Date 14- St- iJ r�r-.- Inspector . __go.., 4 ,7,, , ,,,, 4- {
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE 4
*CONDITIONS:
1. All installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chapter m ;
, 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. r
nection to or use with any dwelling or structures not approved by the Building and Zoning office shall automatically be a violation or a t
requirement of the permit and cause for both legal action and revocation of the permit. i +
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 — 8 f
months in jail or both). }
Applicant: Green Copy Department: Pink Copy -
e:
Application
TNDTVIDI JAI. SEWAGE DTSPOSAT. SYSTEM APPT JCATION•' Approval By
County Official
OWNER %P rr. .c 2;,d R e rnd rtJ, 4 I D�
ADDRESS �/ . 01 / n.wr.4', lQnn 2 6 5 PHONE 62S -4344- / b
:ONTRACTOR Owner
ADDRESS PHONE
'ERMIT REQUEST FOR: (v Installation () Alteration () Repair
tttach separate sheets or report showing entire area with respect to surrounding areas, topography of area,
abitable building, location of potable water wells, soil percolation test holes, soil profiles in test holes
See page 4).
,OCATION OF PROPOSE) EACH TTY : County C n.r C. Id.
dear what City or Town P: le Lot Size t - 7 a A r r es
£gal Description
WASTES TYPE • (Dwelling () Transient Use
( ) Commercial or Institutional ( ) Non - domestic Wastes
( ) Other - Describe
3UILDING OR SERVICE TYPE:
lumber of bedrooms 4- Number of persons 3
v' Garbage grinder (-7 Automatic Washer (r)Dishwasher
101IRCE AND TYPE OF WATER ST IPPT.Y: () well () spring ( ) stream or creek
live depth of all wells within 180 feet of system: N. writ c
f supplied by community water, give name of supplier: 12. C le
.ROT IND CONDITIONS:
depth to bedrock: Peeper f" ka. ■ I
depth to first Ground Water Table: De r p r r -}-►sw T Q
'ercent ground slope: X 3 in
)ISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: _E-‘ H.: l r
Alas an effort made to connect to community system? ■l 0
[TYPE OF 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:
'zINAL DISPOSAL BY:
(4 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? n! 0
OTT, PRRCOT.ATION TEST R EST IT.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. _
lame, address and telephone of RPE who made soil absorption tests;
dame, 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 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 9 /2.0 / 9 S Signed r t,. /3 h - 7
In .EASE DRAW AN ACCT IRATE MAP TO YOUR PROPERTY
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- • • MINCE '' � _ � 447
PI DT PT .AN AND DF.SIC11N FF.ATIJRES
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.
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