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GARFIELD COUNTY BUILDING AND SANITATI6N DEPARTMENT Permit 2573
109 8th treat Suite 303 Assessor's Parcel No.
Glenwood S rings, Colorado 81801. , • e \
Phon (303) 945-8212 .
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This does not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. -
PROP7TY ,
Qwf 's Name James 0. Hyrup Present Address 4269 CR 233. Rifle Phone 625 -1160
-...- / System Location . . Road 233, Rifle
Legal Description of Assessor's Parcel No: •
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SYSTEM DESIGN
/OM /(/ Septic Tank Capacity (gallon) ether // /N M OVA/Percolation lY
percoletion Rate (minutes/inch) Number of Bedrooms ( other) �, -,q{�/
Required Absorption Area'- See Attached S"9 S ,eoe._(�u pi -,
No 6 »fB6/ , ,CO ,I—
3s'q U TtiX l e. et TG.0S q ..ec4.-
Special Setback Requirements: ,3(r4 /3/a. Di tam 19 P R
a / y am / _z „
I Dat= - • — a X 4 6 Inspector 41. V
�' F INAL SY' E M INSPECTION AND APPROVAL (es installed) ` \\
/ Call Tor spection (24 hours notice) Before Covering Installation 1 \
System Installer /1L4)2�1Gf l
1
Septic Tank Capacity / 37) -,r \
Septic Tank Manufacturer or Trade Name COPL<1
Septic Tank Access within 8" of surface W S
Absorption Area 3..SCl 0 i
Absorption Area Type and /or Manufacturer or Trade Nam: 32 T /1 t' ,irtnrotC 19 1Ef1
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Adequate compliance with County and State regulations/r- quirements Yes -`,(
/ Other / -
Date a - J f 91e Inspector s. . !ea t. -. -
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
*CONDITIONS:
1. All Installation must comply with all requirements of the Co orado 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 eve fully complied with County zoning and building requirements. Con-
nection to or use with any dwelling or structures not approv:d by the Building and Zoning office shall automatically be a violation or a
requirement of the permit and cause for both legal actio and revocation of the permit.
3. installs
va I tion from the terms or specificationscontai ed In th app at(on of per a Class I knowing , Petty Offense 4500 1 ne t— 6
months In fall or both).
White - APPLICANT,' Yelpw - DEPART ENT
INDIVIDUAL. SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER , 34711 e C /
ADDRESS <Z67 Car Jd .- Z 3 ? F fIe. PHONE ,€,26 —/J ,
CONTRACTOR
ADDRESS PHONE
PERMIT REQUEST FOR ( ) NEW 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). ( 4
LOCATION OF PI�OP�SG� ��LITY: COUNTY 'slYr t�
Near what City or Town 1 \ P_ Lot
/ al as rno f (, 3 S/0 // cE /y SE /Y .See/ 3 3 %,5S R9,,?o
WASTES TYPE: IX) Dwelling ( ) Transient Use ,
( ) Commercial or Industrial ( ) Non- domestic Wastes
( ) Other - Describe
BUILDING OR SERVICE TYPE:
Number of bedrooms: 3 Number of persons y
( ) Garbage Grinder IX Automatic Washer ( ) Dishwasher
SOURCE AMI TYPE O WATER 5jppj Y: () WELL QQ SPRING () STREAM OR CREEK
Give depth of all wells within 180 feet of system: f onrr
If supplied by communiiy water, give name of supplier:
GRQUN1? CONDIT[0NS:
Depth to bedrock:
Depth to first Ground Water Table:
Percent Ground Slope:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: ny j
Was an effort made to connect to community system? /)/p
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
04 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:
64 Absorption Trench, Bed or Pit ( ) Evapotranspiration
( ) Underground Dispersal ( ) Sand Filler
.( ) Above Ground Dispersal ( ) Wastewater Pond
( ) Other - Describe:
WILL EFFLUENT BE DISCI IARGED DIRECTLY INTO WATERS OF THE STATE? N 0
PERCOLATION TEST REST 1LT5: (To be completed by Registered Professional Engineer) 1
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:
Name, address and telephone of RPE 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 hre 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 f• perjury as provided by la .
al Signed Aditi 1 ` .r/� Date 3 .2 6 - 96,
PLEA: 7 t )RA- At ACCURA_ i TO YOUR PROPERTY
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In OT P1.AN AND DESIGN PRATTIIIES
Include by measured distance location of' wells, springs, potable water supply lines, cisterns, buildings,
property lines, subsoil drains, lake, water course, stream, dry gulch and show location of proposed system by
direction and distance from dwelling or other fixed reference object, and additional submissions in support
of this application such as data, plans, specifications statements and commitments.
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