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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit 2553
109 8th Street Suite $03 Assessor's Parcel No.
Glenwood Springs, Colorado 81601 -�
Phone (303) 945-8212
This does not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit.
PROPERTY
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Owner's Name — Rcbart Murr Pr, Areas 601 T1. sit Apr. 20 G. S. Phone 4454 934
System Location 0074 Antlers Lane, Rifle, CO
Legal Description of Assessor's Parcel No.
ea O antic" $L F.ra4 $so (,uo gmeait t )..5 )
SYSTEM DESIGN ; 84.ta ...V6/LT.Qi9 1 RrC4.
Car 6 - 1>rraoiettia f4
= Septic Tank Capacity (gallon) Other /�
/ I / At 442 pints n Percolation Rate (minutes/inch) Number of Bedrooms (or other) L )
Required Absorption Area - See Attached
Special Setback Requirements:
41- me
Date
'O - f4 r Inspector
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) B B � efore Covering Installation
System Installer BOB 230 ! %v1v
Septic Tank Capacity /COO emot
Septic Tank Manufacturer or Trade Name . -le A/0
Septic Tank Access within 8" of surface �*� - /z/SERS
Absorption Area //7,YFnffrae
Absorption Area Type and /or Manufacturer or Trade Name J/we &L 772/72
Adequate compliance with County and State regulations /requirements keS
Other it 7-See CU
M< 3 — Al - r6 Inspector CUM<
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 1, Petty Offense (8500.00 fine — 6
months in Jail or both).
While - APPLICANT Yellow - DEPARTMENT
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• i •
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
S eitn
OWNER Koster ier, /7 1 1`4 g
ADDRESS 6c/ 2i -T Ar,ao A, 61'1-iONE 9/5
CONTRACTOR S6G f
ADDRESS sA r!: PHONE Si nE
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).
! OCAf1ON OF PROPOSED FACILITY: ' p COUNTY RAP ti fi D
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Near what City or Town7w �t Si t 14- /`;FL E Size of Lot 90 4L ref S
Legal Description or Address 0079 AtiTL2 ' LN• et'FLE GO g
WASTES TYPE: Q(') DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON - DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPE: MUSE ) 19
Number of Bedrooms 2- Number of Persons_
( ) Garbage Grinder ( ) Automatic Washer ( ) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY; ( ) WELL • 0/(SPRING ( ) STREAM OR CREEK
Give depth of all wells within 180 feet of system: N o rt 3i of Re co A 0
If supplied by Community Water, give name of supplier ''/A
GROLJND CQ DITIONS•
Depth to bedrock: (7,)
Depth to first Ground Water Table t
Percent Ground Slope
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to community system? ( ) YES ( VIVO
TYPE OF 1 1VIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
( OF
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:
(t4 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 O
2
r. PERCOLATIOIIiEST RBSULTS• (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.
Nance, 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 limber 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 teens 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 'nay 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_ //!% \ Date / VJ 76
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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