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r E+ GARFIELD COUNTY BUILDI GAND�SANITATION DEPARTMENT Permit t42 3 3 0 0
l :14109 8th Street Suite 303 Assessor's Parcel No.
Glenwood Sp$ngs, Colorado 81601 1 i
t Phone (303) 945-8212
1 This does not constitute ''i .
t % INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. A t
!n PROPERTY p
{ Owner's Name r— L . Present Address _ 0 r� C r. °` f7` / g ' Ph `r' O 5 �. / j
) � System Location �� � ° � � �� / 1 �( ` � `""
t
t Legal Description of Assessor's Parcel No. P'
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n
) 4 SYSTEM DESIGN , ,
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d;
Septic Tank Capacity (gallon) Other
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E1 / Percolation Rate (minutes /inch) rip th'Eror ogais}(orothersC LXM C -t) ) ( p / I
z' —, 30 C tqc u C uR„ar "a�
d Required Absorption Area - See Attached r
A' .n - 1 5 f C 1 rtnib 44) 1C' r.rc H si
t Special Setback Requirements: ^ (�\
1, Date Z ` ) S - 00 - - - I ns p ec t or 114 • J c u Aat r +( '' -
S
g , FINAL SYSTEM INSPECTION AND APPROVAL (as Installed) r
` " Call for Inspection (24 hours notice) Before Covering Installation i i
t • System Installer tt .c- 1Nf4 • °
4
i
t ,, Septic Tank Capacity Thvv __— 2
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Septic Tank Manufacturer or Trade Name
: 4 .
1 , r„),,, , , 611 ,.'d'
J, Septic Tank Access within 8" of surface
• Absorption Area - -- r 2 O n f -t
- irV_#t 2.,t, � I �/O
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Absorption Area Type and /or Manufacturer or Trade Name 2 Rot..» 10 t H C? )7> 4 LVc.4 dw+t y h
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y ! Adequate compliance with County and State regulations/requirements t ;
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s Other (� q ..
. Date 2 l� Inspector 'T. e .chin! • ••"; k_
r RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE )
(.
a r •CONDITIONS: ("
1. All Installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal ystems hapter
" 25, Article 10 C.R.S. 1973, Revised 1984.
(u 2. This permit is valid only for connection to structures which have fully complied with County zoning and building req iremens. Con- r
nection to or use with any dwelling or structures not approved by the Building and Zoning office shall automatically b a viol tion or a
4 requirement of the permit and cause for both legal action and revocation of the permit. -
t 3. Any person who constructs, alters, or installs an individual sewage disposal system In a m anner which Involves a knowng an material ,, ,t. t j t f variation from the terms or specifications contained in the application of permit commits a Class I, Petty Offense ( 00. fine — 8
t months in Jail or both). ( t
i) a. White - APPLICANT Yellow - DEPARTMENT
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER b /l " A/ . CJ9 � 1 p
y / l q
ADDRESS 02 ,L
4 C% ,, z2 ! �i4f2 C08I6�HONE 97o-4211- 3f / 5
CONTRACTOR 5Z.-c-
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 2 Al 12,05 /fir - $M /,c ?0 /4'/f 1 C "Mize of Lot 14C OW
Legal Description or Address 02 0 57 /1 ,0 2 2 7
WASTES TYPE: (x) DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON - DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPE: /1 D/i9t
Number of Bedrooms . Number of Persons ° ,
(/f9 Garbage Grinder d/0 (X Automatic Washer ois Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: ({WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: 7
Was an effort made to connect to the Community System?
A site plan is required to be submitted that indicates the followina 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 PLAN.
GROUND CONDITIONS:
Depth to first Ground Water Table e
Percent Ground Slope
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