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M GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit 2565
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
Ron Mittle present Address 0957 CR 250 Silt Phone 876 -2867
Owner's Name.
System Location
0957 County Road 250, Silt
Legal Description of Assessor's Parcel No. 2
SYSTEM DESIGN
pat Receipt aFinar 6W0
jaSO Septic Tank Capacity (gallon) Other
Percolation Rate (minutes /inch) Number of Bedrooms (or other)
1 (ALSO PERMIT #2098)
Required Absorption Area - See Attached 1 a) O-(/ rp.E,ysnvo S G'At
Special Setback Requirements:
Date Inspector
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer etweAe
Septic Tank Capacity PS/7
Septic Tank Manufacturer or Trade Name isgoCZA.uo
Septic Tank Access within 8" of surface y
Absorption Area I YSO / OOte) 04' — 1 /9/At /30aC0 Fe-YG A.Art.J7, 3490 tif
Absorption Area Type and /or Manufacturer or Trade Name Eerie /owrn' $p
Adequate compliance with County and State regulations /requirements_/
Other OK w lre9Pae
Date y`o - S Inspector TA /�°
1
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 off ice 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 dispstem In a m a a n r Class which lnvolvsiakne knowing and fine material
variation from the terms or specifications contained in the application of permit
months In jail or both).
White - APPLICANT Yellow - DEPARTMENT
INDIVIDUAL SEWAGE DISPOSAI, SYSTEM APPLICATION
OWNER .0241 /72.7 - r e/At
ADDRESS C,P d30 S /L PHONE no" 029 7
CONTRACTOR S ioG
ADDRESS PHONE
PERMIT REQUEST FOR ( ) NEW INSTALLATION ig) ALTERATION ( ) ItEPAtlt
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).
LOCATIDN OF PROPOSED FACILITY, COUNTY &,M',' eez)
Near what City or Town Size e of Lot 3 /Vcttr5
Legal Description or Address_
WASTES TYPE: ();14 DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON - DOMESTIC WASTES
( ) OTHER - DESCRIBE —
BUILDING OR SERVICE TYPE:_ _
Number of Bedrooms 13 ctX /37. / i°fra ) Number of Persons_ is
( ) Garbage Grinder ( ) Automatic Washer ( ) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY QO WELL ( ) SPRING ( ) STREAM OR CREEK
(five depth of all wells within 180 feet of system: /DO
If supplied by Community Water, give name of supplier
GROUND CONDI'T'IONS;
Depth to bedrock:__ ?
Depth to first Ground Water Table Moue
Percent Ground Slope on
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: c>? nvc 63
Was an effort made to connect to community system? ( ) YES (X) NO
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(X) SEPTIC TANK ( ) AERATION PLANT ( ) VAULT
( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POTABLE USE
( ) PIT PRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
( ) Cl IEMICAL TOILET ( ) OTHER - DESCRIBE
FINAL DISPOSAL. BY:
ABSORP'T'ION TRENCH, BED OR PIT ( ) EVAPOTRANSPIRATION
( ) UNDERGROUND DISPERSAL. ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
( ) OTHER - DESCRIBE
W11.i. EFF BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? No
• 2
• R PKCA?A , 1'ION 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 fu 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 terns 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_- - `�L /! erne/D Date �!
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
c 977,rie
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