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Cs GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N2 3 4D 6
T;i 109 8th Street Suite 303 Assessor's Parcel No. ; y
4 Glenwood Springs, Colorado 81601
Phone (303) 945.8212
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1 16 ! This does not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. ( '
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PROPERTY ?r
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I: f. Owner's Name 41 1 C LL ^ ( Oi Present Address 9, d• e ' P «y'( GIo'1W ! J� Phv:At c, Pc/- 0c t 77 1
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3 System Location .esq r `; • a I. Al ' e C s-/�e C kf (/
11 t Legal Description of Assessor's Parcel No. r '
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SYSTEM DESIGN �
4. FOOD QA' Septic Tank Capacity (gallon) Other
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i Percolation Rate (minutes/inch) Number of Bedrooms (or other) �+ 3.e
`' (027 ' % Fr .Si>t rvnt9 1bAy Iixt,L, M
Required Absorption Area - See Attached
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Y Special Setback Requirements: ti 1
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t Date 10 / (3-0 _ Inspector �• ii ;:
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FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
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r ' Call for Inspection (24 hours notice) Before Covering Installation
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i ! System Installer (Jr a bi+lvv■ t' t
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Septic Tank Capacity /2t ? f
8 f , Septic Tank Manufacturer or Trade Name <.JPxCI. r j
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;) Septic Tank Access within 8" of surface r * '
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9 1 1, - 4A- - t I d,,, -o& i Qf tt.) if Absorption Area FT IF
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t Absorption Area Type and /or Manufacturer or Trade Name +, � yr� �w ( r
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Adequate compliance with County and State regulations/requirements r `
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Other f' ,
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$1 Date Ai- M 0/ Inspector •4. )
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,. ti RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE , ti "
f I •CONDITIONS: d
I r 1. All installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chapter 1 •
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- 1 •
nection to or use with any dwelling or structures not approved by the Building and Zoning office shall automatically be a violation or a (f
` • requirement of the permit and cause for both legal action and revocation of the permit. r
3. Any person who constructs alters, or installs an individual sewage disposal system in a manner which involves a knowing and material `F t
variation from the terms or specifications contained in the application of permit commits a Class I, Petty Offense (5500.00 fine — 8 !. i
x ;m onths in jail or both). r 1
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I - . White - APPLICANT Yellow - DEPARTMENT
•TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(7Q 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: -•
(14 ABSORPTION TRENCH, BED OR PIT ( ) EVAPOTRANSPIRATION
( ) UNDERGROUND DISPERSAL ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
(1) OTHER - DESCRIBE 'fl- \U e
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? A,Io
PERCOLATION TEST RESULTS: (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 � /r %.% WIS Lr Date 6 . / L • 2 eV e
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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