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GARFIELD COUNTY UILDING AND SANITATION DEPARTMENT Permit 2821
1 „ ^9th Street Suite 303 Assessor's Parcel No.
GIenWeed Springs, Colorado 81601
'Pho'ne 945-8212
,,, \`
This does not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit.
PROPERTY
Roy Savage ! '" 5953 320 Road, Rifle 625 -5278
Owner's Name 1 Pres Phone
450 County ?toad 320, Re ' ple'Orcbard, Lot 19, Rifle
System Location i' 1 (.
Legal Descriptior) of Assessor's Parcel No.
d (2 LC'AC 13 r0 - - 7 Li S N
SYSTEM DESIGN 2 eI i1 C M n rn ✓lC2 (SC (� 9 y-i N
1 e ,, r, r i - ( n E 6'C /4 C 5 ,
(it/ A
,.
7S-0 1 Sgptic nk Capacity (gallon) Other
in
1, _ Fn ot(
1 - 3 � Percolation Rate (minutes /inch) Number of Bedrooms (or other) 2
Required Absorption Area - See Attached :,
Special Setback Requirements: `
Date (0 - -2 - 4 -, Inspector h R 'N C-
i
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installati
System Installer 12601) Pl
r • . k
Septic Tank Capacity / Coo I.
Septic Tank Manufacturer or Trade Name tripe-mist 3
Septic Tank Access within 8" of surface ye S
Absorption Area • orel-
Absorption Area Type and /or Manufacturer or Trade Name $4 4P . /P Q Ntrnh6 •2 5 lu Tl
Adequate compliance with County and State regulationahequirements V6 5
Other
Date /O s' /8 -97 Inspector /i1 i ll Prifir !� - LQ�
RETAIN WITH RECEIPT RECORDS A T 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 1, Petty Offense ($500.00 fine —6
months In )ail or both).
White - APPLICANT Yellow - DEPARTMENT
-
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION 50
OWNER � c__. /J
ADDRESS Si SS ' r 3 ' 01,0( / I. fr-it e PHONE 6 2- 3 3/4
CONTRACTOR /l B y Sc _
ADDRESS Si S S - 3 2-0 /l A gI : 4 (c_ PHONE PJ tr ' ( 6 7s-
PERMIT REQUEST FOR (K) 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 profiles in test holes (See page 4)
J,OCATION OF PROPOSED FACILITY: //
Near what City of Town /� <' t lc_
// // / Size of Lot S`k (-ICS
Legal Description or Address La f ('t AEA 4,ae(c Str,L ° t.'U1�S
WASTES TYPE: Q) DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON - DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPE: S t n8.1c Pa nt' I y � �rb ( ew I
Number of Bedrooms Number of Persons _ 3
9) Garbage Grinder (X) Automatic Washer (QC) Dishwasher
SOIJRCE AND TYPE OF WATER SUPPLY: (1C) WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: 7M i / CS
Was an effort made to connect to the Community System? �d
• s ;n• •IA ! 1 .si i •s • h. fl u.in I u ti li •
Leach Field to Well: 100 feet
Septic Tank to Well: 50 feet
Leach Field to Irrigation Ditches, Stream or Water Course: 50 feet
Septic System to Property Lines: 10 feet
YOUR INDIVIDUAL. SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED
WITHOUT A SITE PLAN.
GROIIND CONDITIONS:
Depth to first Ground Water Table / $ 0
Percent Ground Slope
2
— - irrans
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(n) 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? PO
?P,RCOI ,ATION TEST RESI T1,TS: (To be completed by Registered Professional Engineer, if the Engineer does
the Percolation Test)
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 purposed 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
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 197,,,,'4K S QWki. Date 7/(17 7
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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