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'CAAFIELD'COUNTY AND SANITATION DEPARTMENT ` - Permit ' 2550
109 8th Street Suit,,343\' a ,, AssessornprcljNo.
Glenwood Springs, Colorado 81601
Phone ( 303) 945 -8fG1 a t.v 1 :: "'771,,3
►1 .,
-- ,I This ddes not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit.
PROPERTY }'
Owner's Name Patty Clark Present Address \31417 Hwy 6 & 24, Silt Phone 928 - 9248
System Location 3 3J.MT Highway 6 & 24, Silt
Legal Description of Assessor's Parcel No. ' •
394 1' cctc 4 cc.ram• Fs • a- oP 0 9& 'aicoof re'rcdft .17r
SYSTEM DESIGN £/7. .l et 777A T32 • a S w
6
-6v H7aa
- Septic Tank Capacity (gallon) Other
7A1 /6 in Wercolation Rate (minutes /inch) Number of Bedrooms (or other) d Ape. ae•raw//LcaOZ
Required Absorption Area - See Attached
Special Setback Requirements:
Da a ••• 9 - 9G Inspector J j4.td •~ e
^ FINAL SYSTEM INSPECTION ND APPROVAL (as installed) U
Call for Inspection (24 hours otice) Before Covering Installation
System Installer / -.i ... .s • d- Olea iu 11 . easel .
Septic Tank Capacity s
Septic Tank Manufacturer or Trade Name 00,09 O
Septic Tank Access within 8" of surface Ye5
Absorption Area J r X , t9 - oZ J'
Absorption Area Type and /or Manufacturer or Trade Name /`OcK 2- /` /ezi
Adequate compliance with County and State regulationsirequirements ,7.E;
Other , (t T Cnbto.c
r'' r
Date ` / 96 Inspector Otte e.
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 w have fully complied with County zoning and building requirements. Con-
nection to or use with any dwelling or structures not apbroved by the Building and Zoning off ice shall automatically be a violation or a
requirement of the permit and cause for both legal fiction and revocation of the permit.
3. Any person who constructs, alters, or installs an individpal 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 (5500.00 fine — 6
months in jail or both).
White - APPLICANT Yellow - DEPARTMENT
it _A
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER p / - 77 4
ADDRESS 3/•V/7 ( 2/ //yk- /, � �, 4 PHONE 9n— ?are
CONTRACTOR /, &G /4f / Cej (OK
ADDRESS 20. & c 911,E ,We K1 ef PHONE nee' 3. 41/
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 OF PROPOSED FACILITY COUNTY Ggt -r'f Ld
Near what City or Town 6i71 Size of Lot a Y2- /902f
Legal Description or Address 3/407 /{viii it 1
WASTES TYPE: ( Ler DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON - DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPE:
Number of Bedrooms_ 6 Number of Persons_ /
(✓Garbage Grinder (1.4' Automatic Washer (✓) Dishwasher
RCE AND TYPE OF WATER SUPPLY (V) WELL ( ) SPRING ( ) STREAM OR CREEK
Give depth of all wells within 180 feet of system: 70 }'7
If supplied by Community Water, give name of supplier 4/ /A
GROUND CONDITIONS:
Depth to bedrock:
Depth to first Ground Water Table
Percent Ground Slope • '
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: a fl,, /f S - 7 1 '0 3, 71 C ?)
Was an effort made to connect to community system? ( ) YES (vJ NO
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
('4 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:
(VI 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 ?_
2
0>
'e ItOOI_ATION TEST RESULTS: (To be completed by Registered Professional Engineer)
Minutes per inch in hole No. I 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:
Name, 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 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.
Signed s /se Date c346
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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