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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit 2757
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 Connie Engeler Present Address 1194 Canyon Creek Rd, G. S phone_ 945 - 0474
System Location 1194 Canyon Creek Road (CR 137) Glenwood Springs
Legal Description of Assessor's Parcel No. �1
SYSTEM DESIGN ROCK _ ` EC4' prEL0 -_1 (337 47
fit-ft t ") o& �3Eo . �p�.
( 990 Septic Tank Capacity y (gall n)f F F v 3 64 S Other CNr' k x C c ncl
Percolation Rate (minutes/inch) Number of Bedrooms (or other) ` 9/ Cre5
Required Absorption Area - See Attached
Special Setback
7 Requirements: /i n
Date _ ` Inspector A ` /d Q
FINAL SYSTEM INSPECTION AND APPROVAL (as Installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer Or' ti 6 - 4
Septic Tank Capacity /COO
Septic Tank Manufacturer or Trade Name ten pt-i9>vl
Septic Tank Access within 8" of surface i f
Absorption Area to g
Absorption Area Type and /or Manufacturer or Trade Namess0 d OA I ITS Y NM-7 0-4-7,0 a
Adequate J compliance with County and State regulations /requirements '1 4Es
Other ont GP? � fe, R- Raz r/t'J P eat 6 N
Date 9 - J �'-9 7 inspector ern e
RETAIN WITH RECEIPT RECORDS AT CONSTRUON 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 Ina 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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INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER C Dnni 2 £r) elPr' b n co� $cri Vl�
ADDRESS 11074 Can vJ7 (, ee � PHONE 945 -el 4. t
CONTRACTOR
ADDRESS -e PHONE
PERMIT REQUEST FOR ( ) NEW INSTALLATION ( ) ALTERATION (X) 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 boles (See page 4).
C'
LOCATION OF PROPOSED FACII,ITY: COUNTY a at rrF
Near what City or Town (1Ievt t.4.90C14 Spit-MP Size of Lot r� r crt-c (year_ Se cc,
- Legal Description or Address i Ca vt u t 'irOA,IC Pci o r 1 3 1 c/
A Le ct2oed S pr, S t 81/20/
WASTES TYPE: (Xj DW ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON - DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPE: res Id eM4lct.9.-
Number of Bedrooms '. Number of Persons_
( ) Garbage Grinder (X) Automatic Washer 14) Dishwasher '
SOURCE AND TYPE OF WATER SUPPLY; (X) WELL ( ) SPRING ( ) STREAM OR CREEK
Give depth of' all wells within 180 feet of system: 4
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:
Was an effort made to connect to community system? ( ) YES pO NO
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
( ) SEPTIC TANK ( ) AERATION PLANT ( ) VAULT
( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POTABLE USE
( ) NT PRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
( ) CHEMICAI. TOILET ( ) OTHER - DESCRIBE
FINAL DISPOSAL BY:
(X) 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? NO
2
PERCOLATION TEST RESULTS• (To be completed by Registered Professional Engineer)
Minutes per inch in hole No. I 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 fiirnished by the
applicant or by the local health department lin 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 purynoses 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 i1. ,i - '�.�! Date 4 /3frf}
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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