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GARFIELD COUNTY BUILDING AND SANITATIONbEPARTMENT 'Karma - 2 6 0 0
-'` 109 8th Street Suite 903 Assessor's Parcel No.
Glenwood prangs, lorado 81601
3 ..a .-i\ ,, Phennb (303)145-8212 , '
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This does not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT •il a building or use permit.
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PROPERTY
Mark & Dianna Fax 309 W. 30th#A, Rifle A ' 625 -3759'
Owner's Name Pratt Address Phone_
' (...• Coutny Roa •P3 Silt:.
System Location ` �"L --A % -,
Legal Description of Assessor's Parcel No. - 4 \ - 8 t•' \ ` ,
SYSTEM DESIGN V,"»'' -\ th \ " \ ,
/0707 Septic Tank Capacity (gallon) Other r ,.
A , 3
/ 7r /1J /1,, PerooYat n Aa(at(lnlrlu(bs/inlbh}t a 1Humberkif4pdrooms (or other) "" I
ry D Qeaid 44- /s044 :3 oL_ CAJ O 6 ARQ41 ?ASf 'J
Required Absorption A }e�! eidlttatbM - �'� \" . % - - » ..1 '
si- /Dr . � -
Special Setback Requirer p-i 2.ft..., V.,4 4.,C14 -5.t.?3 1 ' 1 °' D, i i i 14.
Date iL •- e h Cl 4 Inspector q _ �' 2• I
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours nb(ice) "Before Covering Installation ,
System Installer Q L./1/ N,q.Q p _
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Septic Tank Capacity /D/o!) A
Septic Tank Manufacturer or Trade Name ell pdMA -(,! .
Septic Tank -
Access within 8" of surface 4)1S
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Absorption Area L/S � ~
" a s. •
A Area Type end /pr Manufacturer or Trade Name - - . A I -
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■ Adequate compliatice with County and State � Llations/requirements VE
Other
/"pate 7' / / \ Inspector {sk .��
1 ` N• - ' RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
*CONDITIONS( I
1. All installat oust comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chapter
25, Article 0 CRS. 1973, Revised 1984.
2. This permit is v fiid only for connection to structures which have fully complied with County zoning and building requirements. Con -
nection to or u a with any dwelling or structures not approved by the Building aqd Zoning office shall automatically be a violation or a ,
requirement o 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 — 6
months in )ail or both).
) White - APPLICANT Yellow - DEPARTMENT
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INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER t'l\Ark 4- Ana -Ex4
ADDRESS3Ot% W- 3Q 441. S4 M fl Rt41.,fm21145eP q7 D - (,as-rpsy
CON'T'RACTOR ADDRESS itT PHONE
PERMIT REQUEST FOR (X) 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).
LOCATION OF PROPOSED FA COUNTY Gr, r'- a l4
Near what City or Town 51 1x CA -- — Size of Lot t_O U es_
Legal Description oo F- or o{ lone bti vs 1 The uW 1'y U f'I'y
tit - . .
WASTES TYPE: (X) DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON - DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPE: b ,, ► 11 .. • ■ - 1 �
Number ofBedroonis_ Number of Persons_ 7
( ) Garbage Grinder (X) Automatic Washer 00 Dishwasher
SOURCE AND TYPE OE WATER SUPPLY: ( ) WELL ( ) SPRING ( ) STREAM OR CREEK
Give depth of all wells within 180 feet of system: '\ I a_ a rAgrs.2. C r S7YCy/
If supplied by Community Water, give name of supplier Ix! a �!`
GROUND CONDI'T'IONS:
Depth to bedrock: Itigoic c
Depth to first Ground Water Table P° e5✓Ze4ro tA.4 utP Ta D @P77f or Sbt Pccr
Percent Ground Slope ii/gebi. .. K
DISTANCE 10 NEAREST COMMUNITY SEWER SYSTEM: APPkoK• tc tJ
Was an effort made to connect to community system? ( ) YES 90 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, OTIIER USE
( ) CHEMICAL TOILET ( ) OTHER - DESCRIBE _
FINAL DISPOSAL BY:.
UCl ABSORPTION TRENCH, BED OR PIT Leock. Fuld ( ) EVAPOTRANSPIRATION
( ) UNDERGROUND DISPERSAL ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
( ) OTT TER- DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? 1J p
2
PEItCOLA'I'ION 1'FST 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:
Name, address and telephone of RPE responsible for design of the system:
Applicant acknowledges that the completeness of the application is conditional upon such hither 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 — _��-�!�afi ' Date 3-3—
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!
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