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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit 2924
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 Ken Riley Present Address P.O. Box 584, Carbaldale Phone 963 -0794
System Location q 1 4 County Road 107, Carbcndale
Legal Description of Assessor's Parcel No.
CU S OCK Vt'iAC►c— t r t4s
SYSTEM DESIGN L C MA 0 60 t or c•frits --- Siii k
✓
gra EfLec /-fc5 tt r.
1 00 0 optic Tank Capacity (gallon) Other '- y 23 Q
V
het r ✓` .
1 — O Percolation Rate (minutes /inch) Number of Bedrooms (or other) 3
Required Absorption Area - See Attached
Special Setback ' ,r
Date 4' (`I - ` 9Y Inspector A a M
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer Q L4/ t E A.-
Septic Tank Capacity 1 0 0 0
Septic Tank Manufacturer or Trade Name 1
`
Septic Tank Access within 8" of surface 7 G5
c�
f
Absorption Area _ a 7 I1 N 1 1 S 1 k! 3 a 0 Lt, S O F ` P CAC F-1
Absorption Area Type and /or Manufacturer or Trade Name 1 kf r 1 L TA A ro KS
Adequate compliance with County and State regulations/requirements (-or
Other 1
a ? Date O '� 1 �� e Inspector A f 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 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
INDIVIDIJAL SEWAGE DISPOSAL SYSTEM APPLICATION
o.� f ,
OWNER f l y\ -eM J 1 ._
L - / I �n
ADDRESS 1 O- l�rl- I_ Garb __il k 336,2 PHONE q13-079q
CONTRACTOR OG//let 71214(I der
r
ADDRESS PHONE
PERMIT REQUEST FOR )(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)
LOCATION OF PROPOSED FACILITY:
Near what City of Town Co rbomict / / Size of Lot S S °CM S
Legal Description or Address (- eonard SMbd fS10116c
011 6ccinptien 'c-ct/ Ccn,4 R /07
WASTES TYPE: S DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON - DOMESTIC WASTES
( ) OTHER - DESCRIBE /
BUILDING OR SERVICE TYPE: Sn{S4e
Number of Bedrooms 3 Number of Persons I
( ) Garbage Grinder 9<) Automatic Washer 90 Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: (XI WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: / t YLh0
Was an effort made to connect to the Community System?
A site plan is required to be submitted that indicates the following MINIMUM distances:
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 PLAS,
GRO! ND CONDITIONS:
Depth to first Ground Water Table
Percent Ground Slope
2
cl �
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:
9C) 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?
PERCOLATION TEST RESI TI ,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 Date -2 Cl /
PLEASE DRAW AN ACCURA E MAP TO YOUR PROPERTY!!
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