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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit 251 r-
109 8th Street Suite 303 Assessor's Parcel No.
Glenwood Springs, Colorado 81801
Phone (303) 945-8212
This does not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit.
PROPERTY 1072 Budapest Hungary
Marc Holtzman Kakzi Ut 42 717 -829 -3185
Owner's Name Present Address Phone
County Road 100, Carbondale
System Location
Legal Description of Assessor's Parcel No.
SYSTEM DESIGN
r
/ 51-00 ✓nercSSeptic Tank Capacity (gallon) Other
/ " I a I144- 'Polation Rata (minutes/inch) Number of Bedrooms (or other) 2) -
G74 jrr red a'I -rti l bP or4 °ib Rgse/>ps .1(4L't -'
Required Absorption Area =See Attached ails Raab( ¢ 4E ?ctr 5 sr D •
Special Setback Requirements: . {64, ' /d r 1) I r.COLS Or* 3-4 BA-
Date j) -�o Inspector "{irk. 6 grin o2
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer �ns ZAr+Io.est
Septic Tank Capacity AC r,..41
Septic Tank Manufacturer or Trade Name r nPt°cmA /O
Septic Tank Access within 8" of surface )/.0 S- 2/".•;77.V fX'TP/✓/7P�
�/
Absorption Areq " // .1o7 4.(914/ / 0 _' 7 /
Absorption 9re4 Type and/or Manufacturer or Trade Name / /✓F // JYTA i?2C ..
Adequate compllance with County and State regulations/requirements Ile. .
Other OK 777 4/vPR /
Date //- ?O -q r Inspector _Ce2.4te,
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 Cully 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 — 8
months in Jail or both). L on ^t'i /0 C4lIP4At
anctr Rentomsnl- awn"-
White - APPLICANT Yellow - DEPARTMENT P -e. 64r fl
-- Gc 8/42/
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INI?LV_IDUALSEWAGILI21SILOSAI, SYSTJ;M.ARELICATION
OWNER (Y1RCC Hot" re, (AO
ADDRESS PHONE
CONTRACI'OR2gmn c,rq ri%nt f
ADDRESS P o 7� 4 CAbont t ke, PHONE gc Ingqi
PERMIT REQUEST FOR ( ) NEW INSTALLATION ( ) ALTERATION ( ) REPAIR
Attach separate sheets or report showing entire area with respect to surrounding areas, topography ofarea,
habitable building, location of potable water wells, soil percolation test holes, soil profiles in test holes
(See page 4).
LOCA IO.N_C)IL PROPOSI:12J ACILJ"L'Y: COUNTY
Near what City or Towne>#'1�ldfl e, Lot 2io
Legal De cription—Cc- ,►)n%1n; r pxt; UA o
C) O
RAN- 6 (C,3
WASTE S TYPE: ;(4 Dwelling ( ) Transient Use
( ) Commercial or Industrial ( ) Non - domestic Wastes
( ) Other - Describe
13U1I.1)1NO OR SERVICE TYPE:
Number of bedrooms: SIX Number of persons
60 Garbage Grinder (X) Automatic Washer Dishwasher
SOUItCILANIY YPE Q1? WATER_SUPPLY IC WILL ( ) SPRING ( ) STREAM OR CREEK
Give depth of all wells within 180 feet of system: 'ZOO
If supplied by communtiy water, give name of supplier:
GROUND CONDITIONS:
Depth to bedrock: c r�,��
Depth to first Ground water "fable:
Percent Grotind Slope:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to community system?
TYPE OF INDIVIDUAL. SEWAGE DISPOSAL SYS'T'EM 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 DISPOSAL BY:
4 Absorption Trench, Bed or Pit ( ) Evapotranspiration
( ) Underground Dispersal ( ) Sand Filter
( ) Above Ground Dispersal ( ) Wastewater Pond
( ) Other - Describe:
WILL EFFLUENT BE DISCI IARGED UIItI CfLY INTO WATERS OFTHE STATE? 00
PtSRf'QLA]]Q NrfST ESULTS:(I'o he 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 It PE responsible for design of the 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. 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.
Nk . • i
Signed I f
`r`, , IC7LQ) 19E)
Date
PLIiASI.12RAW N_ACCURA E..MAP_"f4 YQI_tI_LROPI RTY.
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