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Home My WebLink About02651 .. ' .. f •,� ..?�. af. • r' 1 GARFIELD COUNTY1U1DING AND SANITATION DEPARTMENT Permit 2 U 51 109 8th Street Suite 303 Assessor's Parcel No. Ienv(opd SprI1gp,;Cpiorad¢,4j801 - Phone (303) 945 -8212 This does not constitute l INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. PROPERTY p r c p e 'e. /. Owner's Name Bret Cloes Present Address 1111 Arnold Ct, Rifle Phone "t5"5t _ System Locetionil Mesa Road, Grass Mesa Ranch, Lot 58, Rifle Legal Description of Assessor's Parcel No. SYSTEM DESIGN r4 Septic Tank capacity (gallon)_ 1 Oftt / a l 1 I Y / ,ion t Percolation Rate (minutes /inch) Number of Bedrooms -/ ( _ or other) ! (� l� X Required Absorption Area / (l See Attached 0 X1. 1 �i err }'r -4 _Ito ci11 1{ Er+t' / J(;I/e 1X3.L )»( ( A.IS'S(4« . � / ,4 Special Setback Requirements: A Date 1 1 2 - 3 - 7 4 Inspector `..� ell e 02 _ --- N , FINAL SYSTEM INSPECTION AND /APPROVAL (as installed) Call for Inspection (24 hours notice) Before Covering Installation System installer_ P' � 1C � - "� -- -- Septic Tank Capacity 0 0 0 Septic Tank Manufacturer or Trade Name l.¢ Septic Tank Access within 8" of surface surface ( / --- - - - - -- - - Absorption Area a r / Pvt� / A¢ 7 Absorption Area Type and /or Manufacturer or Trade Name J NL'Jt 4 •��'T'� -'o'� Adequate compliance with County and State regulations /requirements GG�/ ` Other.... .. .... 7 (� Cy Date 7 ' " ) / r / 7 Inspector �'7' T,�dl% -- 4 44 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 I, Petty Offense ($500.00 fine 6 months in jail or both). White - APPLICANT Yellow - DEPARTMENT INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICA'T'ION OWNER Skt T GLOSS ADDRESS , S.SME,S#PI IONI3 379 - GO X 76 CONTRAC'T'OR SELF ADDRESS 111( oLO U ; 2 PHONE 625 344 O PERMIT REQUEST FOR (3/61EW INSTALLATION ( ) ALTERA'T'ION ( ) 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 Zest holes, soil profiles in test holes (See page 4). LOCATION OF PROPOSED FACILITY: COUNTY 644 £L 0 • Near what City or Town P.1 Far Size of Lot 4.0 A-Cttt S Legal Description or Address I t - l.0 /' v s /°5S ttO y f6AO 'AI WASTES TYPE: (( )\Vt TANG ( ) TRANSIENT USE ( ) COMMERCIAL OR INDUS'T'RIAL ( ) NON-DOMESTIC WAS'T'ES ( ) OTI IElt - DESCRIBE BUILDING Olt SERVICE TYPE: Number of Bedrooms 1 Number of Persons 4- ( ) Garbage Grinder ( ) Automatic Washer ( ) Dishwasher SOURCE AND TYPE OF WATER SUPPLY: ( ) WELL ( ) SPRING ( ) S'T'REAM OR CREEK Give depth of all wells within 180 feet of system: NONE If supplied by Community Water, give name of supplier GROUND CONDI'T'IONS: Depth to bedrock:, Depth to first Ground Water T )le Percent Ground Slope 1) DISTANCE TO NEAREST COMMUNITY SEWER SYS'T'EM: Was an effort made to connect to community system? ( ) YES (%4 NO TYPE OF INDIVIDUAL. SEWAGE DISPOSAL. SYS'T'EM PROPOSED: (N/ SEPTIC TANK ( ) AERA'T'ION PLANT ( ) VAULT ( ) VAULT PRIVY ( ) COMPOSTIN(i'I'OILE'I' ( ) RECYCLING, POTABLE USE ( ) PIT PRIVY ( ) INCINERATION '1'OII.1i ' ( ) RECYCLING, O'I'LIER USE ( ) CIIEMICAI. TOILET ( ) O'T'11EIt - DESCRIBE FINAL DISPOSAL. 13Y: ( ) ABSORPTION TRENCI1, BED Olt PIT ( ) EVAPOTRANSPIRATION (1411NDERGROUND DISPEItSAI, ( ) SAND FILTER ( ) ABOVE GROUND DISPERSAL, ( ) WASTEWATER POND ( ) OTHER - DESCRIBE WILL EFFLUENT BE DISCHARGED DIItEC1'LY INTO WATERS OF 'HIE STATE? N 2 d'ERCOLATION 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: 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. 'fhe 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 (J2Jt-(, Date to 7 i4 - ` 6 _ :ASE DRA A AN A RA'Z'E MAP T YOUR PROPERTY!! I Ft 2T 70 CaCA% /oA/ fL/tN njc f Mr s og re a Sf 9: 5Ia Q 7 4 � icy 4 / L l 3 Onwfrt