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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit 2695
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 Tamers & Edward Duplicr t Address P.O. Box 516, New Castle Phone_ 945 -8242
46089 Highway 6 & 24, Glenwood Springs, CO
System Location ........����
Legal Description of Assessor's Parcel No. R pC Lc - LEACH F (E L b I tQ e a t Ott,
SYSTEM DESIGN GO PIECES IN Fs LT-ntro& S — tl3 0 (3 ED
on (Slo- dppos q i ll AS Tarots(
Iles o Septic Tank Capacity (gallon) Other
1 I
7Mbr ercolation Rate (minutes/inch) Numberpf Bedroords (or other) 5
• Requir Absorption Area - See Attached
Special Setback [ Requirements:
Date • — f —q I nspector A nt�_ 1;
FINAL SYSTEM INSPECTION AND APPROVAL (as installed) • -
Call for Inspection (24 hours notice) Before Covering Installation
System Installer v•-&
Septic Tank Capacity J / 0 a
/ 4 Septic Tank Manufacturer or Trade Name r gi . 4
Septic Tank Access within 8•• of surface (/ --- 1 , ry
Absorption Area / 1.3 IP Absorption Area Type and /or Manufacturer or Trade Name, {./11 f/ 7 1 - 4 A r Row R 1, n es w S 4 / t
Adequate compliance with County and State regulations/requirements
Other
a - 3
Date 1 — 71 Inspector e0 ' F'
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 per / pllt.
3. Any person who constructs, alters, or installs an individual sewage disposal syytem in ...Manner which involves a knowing and material
variation from the terms or specifications contained in the application of oarmit commits a Class I, Petty Offense ($500.00 fine — 6
months in Jail or both). .
White - APPLICANT Yellow - DEPARTMENT
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER rvm c , W4 •I C
ADDRESS °d'_. no eu1Cu e • t . o 'E - - • • 917S - gatia
CONTRACTOR
ADDRESS PHONE
PERMIT REQUEST FOR )(NEW INSTALLATION ( ) ALTERATION REPAIR
Attach separate sheets or report showing entire area with respect to surrounding areas, topography o area,
habitable building, location of potable water wells, soil percolation test holes, soil profiles in test holes (See page 4).
LOCATION OF PROPOSED FACILITY; COUNTY .rc-; w
Near what City or Town q �o .-Ob SRI - in •c 0X Size of Lot
Legal Description or Address- e • • -f- •o I : (C D
WASTES TYPE: DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON - DOMESTIC WASTES
( ) OTI IER - DESCRIBE
BI11LD OR SERVICE TYPE: 7 i \� remi Dwe ` • . W
Number of Bedrooms_ _ • . - r1 •. Numbe of Persons_ i
( ) Garbage Grinder ( Automatic Washer ( Dishwasher
SOUIkCE AND TYPE OF WATER , APPLY •
,� 1_ WELL ( ) S &LNG ( ) STREAM OR CREEK
Give depth of all wells within 180 feet of system: 1 p
► f supplied by Community Water, give name of supplier (c \J-e rC ei v�
GROUND CONI)I'I'►ONS:
• Depth to bedrock:
Depth to first Ground Water Table
Percent Ground Slope
DISTANCE 1'O NEAREST COMMUNITY SEWER SYSTEM: L. n ou )�
Was an effort made to connect to community system? - ( ) YES NO
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
per SEPTIC TANK ( ) AERATION PLANT ( ) VAULT
( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POTABLE USE
( ) PET PRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
( ) CHEMICAL TOILET ( ) OTHER - DESCRIBE
FINAL DISPOSAL BY:
bj ABSORPTION TRENCI I, ►3ED 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
• r 4
PERCQI,A"1'ION TEST RESULTS: (To be completed by Registered Professional Engineer)
•
Minutes per inch in hole No. I Minutes per inch in bole 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 purposes of the evaluation of the application; and the issuance of the
permit is subject to such terns 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 oflhealth in evaluating the same for ;imposes 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 Date ID G r c
s dt
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