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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit 2'6 i 9
109 8th S(teet Suite 303 Assessor's Parcel No.
_ Glenwood Springs, Colorado 81801 `2
Phone (303) 945 -8212
This does not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit.
PROPERTY `i
Owner's Name Mike Malloy Present Address c/o Bell Country Homes Phone
System Location 0058 Apache Drive, Elk Creek, Lot 6, Block 7, Hew Castle
Legal Description of Assessor's Parcel No.
1 679$ t-aos = 8/5 0
4YSTEM DESIGN
i
' 7$'O Septic Tank Capacity (gallon) E+..& Other
a 7 Percolation Rate (minutes/inch) Number of Bedrooms (or other) 2
qu a9 /rp✓o/n'S 8/S 0 �x 2et7e 4 ,3e0
R
Required Absorption Area - See Attached
Olt
Special Setback Requirements: - 014 /j4// /T5 /NF /L/VA 2 4 Ote Uio -- D /Fc-tl ee -z fe
Date 7 v7't4 Inspector ' Vs4c i°
i
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System installer__.EtP
Septic Tank Capacity /0 00
Septic Tank Manufacturer or Trade Name art ..1 r.dre...
Septic Tank Access within 8" of surface ciE s ` -
Absorption Area 4 9
Absorption Area Type and /or Manufacturer or Trade Name 4- 90 a 4 (o U1v ' jS / 1/47 .7N.t'2 S
Adequate compliance with County and State regulations/requirements -1
Other
Date. 9 ` -S -y4 Inspector /4'- 't
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. 1
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 8
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 jailor both). 1 ' i ; I , . ! 1 , , l i 1 MI
White - APPLICANT Yellow - DEPARTMENT
/
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JNDTVIDIJAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER i% / /O� T '2) '
2/_
ADDRESS lo/ !~rAe pr. PHONE
CONTRACTOR 7�l/ &o -y 'r.4a t '
ADDRESS TO 7,_)x. ,9? c % e, PHONE 9 s/ ?S?»
PERMIT REQUEST FOR )4NEW 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 � FACIT,TTY: COUNTY (Yrt -7)e_ a
Near what City or Town / 1 Ca- s I �e_ Lot ('
Legal Description
WASTES TYPE: Dwelling () Transient Use
( ) Commercial or Industrial ( ) Non- domestic Wastes
( ) Other - Describe
BUILDING OR SERVICE TYPE: a c idr 2-1- a—I
ber of bedrooms: ( g Number of persons
Garbage Grinder Automatic Washer Dishwasher
IRCE AND TYPE, OF WATER SI IPPT,Y: () WELL () SPRING () STREAM OR CREEK
Give depth of all wells within 180 feet of system:
If supplied by communtiy water, give name of supplier: d, ly ef" A / r f 16—
GTROT IND CONDITIONS:
Depth to bedrock:
Depth to first Ground Water Table: '
Percent Ground Slope:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to community system?
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? i✓U
;OIL PERCOLATION 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. _
-lame, 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 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.
Date R/ c Signed r 'yaC u ��
PLEASE DRAW AN ACCT JR ATE MAP TO YOI JR PROPERTY
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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit 2 6 7 9
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.
PROPERTY
Owner's Name Mike Malloy present Address c/o Bell Country Homes Phone
System Location 0058 Apache Drive, Elk Creek, Lot 6, Block 7, New Castle
Legal Description of Assessor's Parcel No.
SYSTEM DESIGN
Septic Tank Capacity (gallon) Other
Percolation Rate (minutes /inch) Number of Bedrooms (or other) 2
Required Absorption Area - See Attached
Special Setback Requirements:
Date Inspector
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation 1 �j/ /�
System Installer_ jL /' � /
Septic Tank Capacity (� —
Septic Tank Manufacturer or Trade Name
Septic Tank Access within 8" of surface
ly7Z
Absorption Area
Absorption Area Type and /or Manufacturer or Trade Name —
Adequate compliance with County and State regulations /requirements_ —
Other
\J
—
Date Inspector —
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 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
. •
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