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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit Ne 3 d 2 3 •
r 3 109 8th Street Suite 303 Assessor's Parcel No.
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_ Glenwood Springs, Colorado 81801
f Phone (303) 945 -8212
I ! This does not constitute s
, A INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. $
14 . PROPERTY t'
F r �,, yid' r I r n 1 � J
f ..Owner's Name n� ) ; u IX G m Present Address (0 44 �I n� ( &e iC O� � 3 Pho 4 � - 1 ' I I
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Ifn eK CReeK M • Ca&bondale CS/ R h o s.;
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f System Location
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f . Legal Description of Assessor's Parcel No.
A , SYSTEM DESIGN ■
- r / (PO a ()SD . i
r,•,I� i t 1 Septic Tank Capacity (gallon) Other
C
)' J Percolation Rate (minutes /inch) Number of Bedrooms (or other) 3 13Q ., .
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+ } Re Absorption Area - See Attached ✓ �� t L r � O . I ,� ' n T I I }
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bit DE.
i Special Setback Requirements: �.S Ca '
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+ Date I -2C Inspector . , .4 — — 1.„. ' F
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t FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation t r
t 1 ' System Installer 1� CL• t': )t 47---44 dwl keen V S. '
ft 4
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Septic Tank Capacity dr CO •i' O • ._ •. r
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Septic Tank Manufacturer or Trade Name
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i t Septic Tank Access within 8" of surface / - O v
7 Absorption Area ,
t p e
Absorption Area Type and /or Manufacturer or Trade Name • r
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• Adequate compliance with County and State regulations/requirements / t� 1 '
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Other $
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) Date N / • 00 Inspector 4 \ 1,
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RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE z w
4 *CONDITIONS: ' '
1. All installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chapter • •
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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-
nectiontoorusewithanydwellingorstructuresnotapprovedbytheBuildingandZoningofficeshallautomaticallybeaviolationora �, .f
requirement of the permit and cause for both legal action and revocation of the permit. z y
i? 3. Any person who constructs, alters, or installs an individual sewage disposal system in a manner which involves a knowing and material t '!!
variation from the terms or specifications contained in the application of permit commits a Class I, Petty Offense ($500.00 fine — 8 +.
months In Jail or both). `
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White - APPLICANT Yellow - DEPARTMENT
01/07/1994 04:41 9709634472 WELCH EXCAVATING PAGE 02
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TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
xi 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:
ASSORPYION TRENCH, H® OR PIT ( ) EVAPOTRANSPIRATION
( ) UNDRREMOWS DISPERSAL ( ) SAND FILTER
( ) MOVE OROINt DISPERSAL ( ) WASTEWATER POND
( ) OTHER - ORKSI t
WILL EFFLUENT 111B DISCHARGED DIRECTLY INTO WATERS OF THE STATE? NO
Mak (To be completed by Registered Professional Engineer. Wilts Engineer does the
Pwoolation Teal)
hfiaMO pee ink in hole No. I Minutes per inch in hok NO. 3 ,
hStnsea pr bsoh in Mole No. 2 Minutes per inch in hole NO.
Nat», ddrees Mel MM/MMy of RPE who made Boa absorption tests:
New, address and edambone of RPE responsible fot design of the system:
AppSaat aelmendedipn de the campNteeas of the application is conditional upon such further mandatory and
additional tells me rep M as ay be required by the food health department to be made and furnished by the applicant
or by the fond h e delnel Mllt kr pwpoeed of the evaluation of the application; and the issuance of the pemtit is
subject to snob tansy aid maim a deemed necessary to insure compliance with rules and regulations node.
inkometian ad opus aindded Said, ad required to be submitted by the applicant are or will be represented to
be sus ad ant se die best of my knowledge and belief and are designed to be relied on by the local department of
health It evalanhen the se (br purposes of issuing the permit applied for heroin. 1 further underhand that any
AIBNonion or nsimenesentien try result in the denial of the application or revocation of any permit granted based
upon said *Sian and 1 led satin. for perjury as provided by law.
Sigurd _ ? 4 X D p'Z �� , �� Date — 2 2- 0p
PLEASE DRAW KN A VUR ATB MAP TO YOUR PRDP€RTYu
3
01/07/1994 04:41 9709634472 WELCH EXCAVATING PAGE 03
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