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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit
109 8th Street Suite 903 Assessor's Parcel No.
Glenwood Springs, Colorado 81801
Phone (303) 945 -8212
This does not constitute
ftNDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit.
PROPERTY
David Guinnee I.O. Box 458, Carbondale 963 -9421
Owners Name • Presbnt Address Phone
System Location 0078 Pine, Satank, Carbondale
Legal Description of Assessor's Parcel No. �pP
SYSTEM DESIGN I06 .iirLP
/ A.WX> Septic Tank Capacity (gallon) Other
rr
/A1 34 M rnpercolation Rate (minutea/i ch) Number of edrooms (or other) � " •
/ /Oar 6 .1 t6,odS 13 set (tMG QA�►yt tDioPbs'
Required Absorption Area - See Attached T Nn drg44 S'3 A 2 £ a A
Special Setback Requirements: /{ 0r0 Frai Stie � A4
Date /d' /g 9-S- Inspector /4 psi
FINAL SYSTEM INSPECTION AND APPROVAL (as installed) 1
Call for Inspection (24 hours notice) Before Covering Installation
System Installer 649 'sae_
Septic Tank Capacity /Coo
I .
Septic Tank Manufacturer or Trade Name 0 etz -RNn
Septic Tank Access within 8" of surface Y e S
Absorption Area
Absorption Area Type and /or Manufacturer or Trade Name
Adequate compliance with County and State regulations/requirements
i 1-7�1
Other rigs% tor' /.z of r .� 0
Date 1/ - 9- yS Inspector f( et
„ /
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
*CONDITIONS:
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.
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.
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 — 6
months in )ail or both).
White - APPLICANT Y - EPARTMENT
r
INDIVIDUAL SEWAGE DISPOSAI. SYSTEM APPLICATION
OWNER b A-v 6-uI N NLt: ",�
ADDRESS 00 7 8 P// P.0, 1301- /16 CA il30vb4-g4IONE ?CS 1 1 c) 3-#70 /
CONTRACTOR ru4 "EA Oes. or ti; tt Inn i c
ADDRESS PHONE
PERMIT REQUEST FOR (KNEW 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).
LOCATION O F' PROPOSED FACII IT'Y: COUNTY
Near what City or Town C'/YA30i1/DA -Lic Size of Lot / 57< t K $S
Legal Description or Address /1/4ry6 r2. G Lori 3 Aft/ 04- /cts 3 i v *A � Nucec 9
/H-v*. c. h) / JO - chip-ern" Z r.'tn s; t
WASTES TYPE: (.) DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON - DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPE: % -c
Number of Bedrooms (3 t\ 4-tt iti � Number of Persons 2- 0 � t�c�
( ) Garbage Grinder ( --) Automatic Washer (- Dishwasher
SOURCE AND TYPE OF WATER SUPPLY. ( ) WELL ( ) SPRING ( ) STREAM OR CREEK
Clive depth of all wells within 180 feet of system:
If supplied by Community Water, give name of supplier C}3R130n/I1).q -U�
GROUND CONDITIONS;
Depth to bedrock:
Depth to first Ground Water Table
Percent Ground Slope
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: 1 - 2 '
7
Was an effort made to connect to community system? ( ) YES (-3 NO
TYPE OF INDIVIDUAL SEWAGE DISPOSAI, SYSTEM PROPOSED:
(- 5 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 AI3SORPTION TRENCII, BED OR PIT ( ) EVAPOTRANSPIRATION
(4' UNDERGROUND DISPERSAL ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
( ) OTHER - DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? Nd
2
PERCOLATION TEST RESULTS: (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.
Name, address and telephone of RPE who made soil absorption tests:
Nance, 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 may be required by the local health department to be made and furnished by the
applicant or by the local health department for proposes 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. 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 law.
Signed 0 ortr _ Date /u/ (y/ 9 S
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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