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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit 2613
109 8th Street Suite 303 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. 1
PROPERTY
James A. Gornick 593 Ginseng Road, N.C. 984 -0454
Owner's Name Present Address Phone
oa85' Co Road 261, Silt
System Location ,
Legal Description of Assessor's Parcel No.
SYSTEM DESIGN
..5 Septic Tank Capacity (gallon) G4e5' ae. Other
9 5✓
Percolation Rate (minutes /inch) Number of Bedrooms (or other)
/fl / N 9 49 /rrile5 I0 f •1 f O ' LEACirArt
Required Absorption Area - See Attached
2 30 L'N'/s /Nfi//JP/9/U2 ow ,Evo AF /O$ri4 /N TP ____
Special) Setback Requirements: - `S63
Date g; l eq ° Inspector a;
FINAL SYSTEM INSPECTION AND APPROVAL (as Installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer 4 r w / 5 ' /Ge-
Septic Tank Capacity /50 0 0
f / t
Septic Tank Manufacturer or Trade Name 5 '� G / C � , L; L. �-I t
Septic Tank Access within 8" of surface Y 1 - / `
� J � / /
Absorption Area ( 3 i
r r
Absorption Area Type and /or Manufacturer or Trade Name L A 1- 1 / ...t. I r 1). 1 612 S
Adequate compliance with County and State regulations/requirements ‘
i 5
f Other G� / �/7, �(` -(/7
•
Date — / G ` / ( ` A Inspector /-`^. / �``. C-g c .
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE r , •
*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 ($500.00 fine — 6
months in Jail or both).
White - APPLICANT Yellow - DEPARTMENT
r • INDIVIDUAL, SEWAGE DISPOSAL, SYSTEM APPLICATION
OWNER ,J �li .✓ L/r
ADDRESS - i,,. . - i e "O
.j/ PHONE —' >e — -5
CONTRACTOR 1• : , �. - i> .
ADDRESS PHONE "7.0 9s Z46y
PERMIT REQUEST FOR (>1 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 I ofiles in test holes (See page 4).
LOCATION OF PROPOSED FACILITY: COUNTY I,b
Near what City or Town Size of Lot t &e r> S
Legal Description or Address G 7b z4) �
WASTES TYPE: (]I0 DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON - DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPE:_________ cur>=
Number of Bedrooms rel t •- [ - p r, t Number of Persons i
((.) Garbage Grinder (3)0 Automatic Washer (>4 Dishwasher
SOURCE AND TYPE OE WATER SUPPLY: (4 WELL ( ) SPRING ( ) STREAM OR CREEK
Give depth of all wells within 180 feet of system:
If supplied by Community Water, give name of supplier
GROUND CONDITIONS•
Depth to bedrock:
Depth to first Ground Water Table
Percent Ground Slope
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: 2rri /F
Was an effort made to connect to community system? ( ) YES ( ) NO
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
( ) 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:
( ) 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
. f'f {W TEST RESULTS (To he 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 absoiption 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 proposes 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 proposes 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 for perjury as provided by law.
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