HomeMy WebLinkAboutApplication- Permit:;;. ,. ,,' ////Certificate Of Occupancy No. 2815 , No ~hange in tile character of occupancy of a b,ullding shall be made without a Certificate of Occupancy -(UllC Sec, 502) Building
Department Garfield County, Colorado This certificate is issued pursuant to the requirements of Section 307 of the Uniform Building Code celtifying that at the time of issuance, thi.s
structure was in compliance with the various codes adopted by the County regulating building construction or use for the following: Use Classification Single Family Dwelling w/Double
Garage Building Penni! No. _--=-54.:.:5:..:6 ____ _ Group R-3, M-l Type of Construction ___ V:..:-.:N~_~ __ _ Zone District ____ _ Owner of Building __J: ..:i=m:..::ze~g'C:a::r-=s.:::ki~
_______ Address 522 N. Traver Trail, Glenwood Springs Building Address 0234 Springridge Drive, Glenwood Springs, co Locality Springridge Place, Lot 20 Contractor Owner Address __sa_
rn_e_ __________~ __ __ By Cb4tji ~.1!--V"..cL Chief uilUli Official Date June 25, 1996 Issuance of a Certificate of Occul'ancy shall not be construed as an approval of the provision
of this code or of other ordinances of the jurisdiction. Certificated presuming to give authority to violate or cancel the provisions of this code or of other ordinances of the jurisdiction
shall not be valid. (UBC Sec. 307(0».
GARFIELD COUNTY BlllLDING.SAN1TA'UONBDdPLANNINGDBPARTMHNT 109 Ith Street Suite 303 Gleb.W~ Spriola.. Colorado 81601 (303) 945-8212 No. 5456 Job AddRO'_ _______0_2_3_4_ _S_p_rin_grid_g_e_
_D_r_i_v_e_,_ _L_o_t_ _2_0_,_ _G__le_n_w_ood_ S_p_r_i_n_g_s_ _____________ _ Nature ()rWork ___ --"B"'u:.::i::l~d:.::i:.:n:ig"_.:P:.;e:::.rm::.::l.::· .:;.t __________________________________________
___ _ U .. orDuildiD,Kg ___ -=S:.:i::n:!g,,1::.:e:...:F:.:a::m::1::·1::y'-::Dw.::..::e::l::1.:ic::n~gc...::W~/.:D::o:.:u:.:b:.:l::e::....:G::a::r::a=g~e~ _____________________ Ow~~ _______
~J~1~·m~Z~e~g~a~r~s~k.:i~ ________________________________________________ __ CODlntctor _______ c:.Dwn=:.:e:.:r~ ________________________________________ __ Amoun' or Pmuil $_~2'_..
J 6;u8l,;9'"•'. . ;4!!4L--,-___' --_ Permit; 1,628.73 Da",_~Ma=r..,c",h"",""3"0,... ....1.", ,,9",,,9,,-5 ____________________ Plan : 1,057.22 Paid $1,057 .22 2-22-95 S. Archuleta
GARFIELD COUNTY, COLORADO PERMIT NO. S cf 'S"h PARCEUSCHED NO. 1 LEGAL T LOT NO. 20 BLOCK OEseR 2 3 CONTRACTOR r) /" I.J >C R ADDRESS 4 ADDRESS A, PEel.) ('fli r> , 5 ENGINEER HI&H CouiJTlCy
EMG-. ADDRESS 6 S.F Of BUILDING 7 USE OF BUILDING ,rur;:: . 8 'NEW oADDlTION 1:IAlTERAlIQN nREPAIR nMOVE nRF.MOVE 9 DESCRIB!! WOR,,· 10 GARAGE SINGLE COoUB0~> 2/~RP~T SiNGLE DOUBLE DRIVEWAY
PERMIT ONSlTESEWAGEDlsrOSALPERMIT ~ SITF.PINI 11 V~r.uA'1ON OF WORK: ~ ,~-'~ 1~'IUSTEDVN. S PH 9'fo-C'fhJ WK PH. '1t;.S. 9':< 'ft/PI I UCENSE NO PH r ,-s--/C S" 7 LICENSE NO. PH liCENSE
NO. HEIGm NO OFFLQORS 7 SCHOOL IMPACT fEE. • L NO. or: BUILOINGS 2N ~~E OF BUILDINGS NOW ON ..J::1H-PARCEL n PARCEL SPECIAL CONDITIONS; NOlleE SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL,
pLUMBING. HEAliNG. SrECfo\tAPPIlQVAIS RfQUIR'fO RecfNEo t~orR~QUIRF.D VENTILATING OR AIR CONDITIONING. I--"""~""'~"--+_--"'"",!~_-+ _ -",!~"'-_-I'--"'''-''''''''''''''-II THIS PERMIT
BECOMES NUll AND VOID IF WORK OR CONSTRUCTION AUTHORIZED IS ZOMNG ~ NOT CQMMf:NcEDWITHIN lao DAYS, OR IF CONSTRUCTION OR WOOK IS SUSPENDF.D 1-.:::..;;;.=----+--..<:..---4--------1-----'-11
OR ABANDONED FOR A PERIOD OF 180 OAYS AT NU TIME AFTER WORK IS COMMENCEh I_::":::EAI.:.::..:'::":::DE:::P.:T::. --1------+-------+------11 I HEREBY CERTtfY THAT I HAVE READ AND EXAMINED
THIS APpLICATION AND KNOW HIE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS AND QRDlNfl.NCES I-~':::'R::E::D:::EP.:T::. ---1-------1-------+------1 GOVERNING HilS TYPE OF WORK
WILL BE COMPLIED WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT DOES NOT PRESUME TO GIVE II...:s::OI::L::RE:::P.:O::.R::.T _ + ______ f ______ -If.-_____ "1 AUTHORITY
TO VI;Z3OLAOTRE ~C ANCEliT~HPRE; OVISK>NS a: IWY OTHER SrATE OR ~~~. LAW REGU TING CONSTR I N OR THE PERFORMANCE OF SETBACKS f'"~'..RUOTION/, . "'0"') ;7 _ 2:1 _ 9 r a-.:=="--'-I-----+------I------J
rl/iutalure.::~(\~I.s.0(\ 1I~'m~'h ;i r;;-~ 1.": 1t0uI...~l,d l!l~.IOod (\OliC~b!JYB. FLOOD HAZARD V -2"1'·'«/7/.-,//\f iI. ' ,..-1'1·.~ I..:M=A::.:"u~r:..:..":;:OM::.:E'__lr----_\_-----+---_l1
Building Deparlm~OVaJrt;p Ptanning Depailmenl Approval/dale ... OTtiER AGREEMENT PERMISSION IS HEREBY GRANTED TO THE APPLICANT AS OWNER, CONTRACTOR AND/OR THE AGENT OF THE CONTRACTOR
OR OWNER TO CONSTRUCT THE STRUCTURE AS DETAILED ON PlANS AND SPECIFICATIONS SUBMITTED TO AND REVIEWED BY THE BUILDING DEPARTMENT IN CONSIDERATION OF THE ISSUANCE OF THIS PERMIT THE SIGNER
HEREBY AGREES TO COMPLY WITH ALL BUILDING CODES AND lAND USE REGUlATIONS ADOPTED BY GARFIELD COUNTY PURSUANT TO AUTHORITY GIVEN IN 30.26.201 eRS AS AMENDED. THE SIGNER FURTHER AGREES
THAT IF THE ABOVE SAID ORDINANCES ARE NOT FULLY COMPLIED WITH IN THE LOCATION, ERECTION, CONSTRUCTION AND USE OF THE ABOVE DESCRIBED STRUCTURE, THE PERMIT MAY THEN BE REVQKED BY NOTICE
FROM THE COUNTY AND TKAT THEN AND THERE IT SHALL BECOME NULL AND VOID. ." THE ISSUANCE OF A PERMIT BASED UPON PlANS, SPECIFICATIONS AND OTHER DATA SHALL NOT PREVENT THE BUILDING OFFICIAL
FROM THEREAFTER REQUIRING THE CORRECTION OF ERRORS IN SAID PLANS, SPECIFICATIONS AND OTHER DATA OR FROM PREVENTING BUILDING OPERATION BEING CARRIED ON THEREUNDER WHEN IN VIOlATION OF
THIS CODE OR ANY OTHER ORDINANCE OR REGUlATION OF THIS JURISDICTION. THE REVIEW OF THE SUBMITTED PlANS AND SPECIFICATIONS AND INSPECTIONS CONDUCTEO THEREAFTER DOES NOT CONSTITUTE AN
ACCEPTANCE OF ANY RESPONSIBILITIES' OR LIABILITIES BY GARFIELD COUNTY FOR ERRORS, OMISSIONS OR DISCREPANCIES. THE RESPONSIBILITY FOR THESE ITEMS AND IMPLEMENTATION DURING CONSTRUCTION
RESTS SPECIFICALLY WITH THE ARCHITECT. DESIGNER, BUILDER AND OWNER. COMMENTS ARE INTENDED TO BE CONSERVATIVE AND IN SUPPORT OF THE OWNERS INTEREST. Garform.OO3 I HEREBY ACKNOWLEDGE THAT
I HAVE READ AND UNDERSTAND THE AGREEMENT ABOVE IINITltfl;J , ;< • .22.IJJ:.
• GARFIELD COUNTY BUILDING AND PLANNING MINIMUM APPLICATION REQUIREMENTS for SINGLE FAMILY DWELLING CONSTRUCTION including NEW CONSTRUCTION ADDITIONS ALTERATIONS and MOVED BUILDINGS
In order to understand the scope of the work intended under a permit application and expedite the issuance of a permit it is important that complete information be provided. Adequate
and complete information will prevent delays in the plan review process. Reviewing a plan and the discovery that required information has not been provided by the applicant may resul
t in the delay of the permit issuance and in proceeding with building construction. The owner or contractor may be required to provide this information before the" plan review may proceed.
This causes delays because other plans that are in line for review inay be given attention before the new information may be reviewed after it has been provided to the BUilding Department.
. Please review this document to determine if.you have enough infonuation to design your project and provide adequate information to facilitate a plan review. If you do not, it may be
helpful to obtain a boolt titled 'Dwelling construction under the Uniform Building Code. This book is available to you through this department at our cost. Also, please consider using
a design professional for assistance in your design and a construction professional for construction of your project. To provide for a more understandable plan in order to determine
compliance with the building, plumbing and mechanical codes, applicants are requested to review the following check list prior to and during deSign. Applicants are required to indicate
appropriately and to submit completed check list at time of application for a permit: I
• 1. Is a site plan included that indicates the distance of the proposed building or addition to property lines, other buildings, set back easements and utility easements? Yes _~'-No
_____ (1) Not necessary for this project _____ (2) 2. Does the site plan include the location of the I.S.D.S. (Individual Sewage Disposal System) and the distances to property lines,
wells (on subject property and adjacent properties) , streams or water courses? Yes _____ No L (I) Not necessary for this project _____ (2) 3. Does the site plan indicate the location
and direction of the County or private road accessing the property? Yes .1L__ No _____ (1) Not necessary for this project _____ (;!) 4. Do the plans include a foundation plan indicating
the size, location and spacing of all reinforcing steel in accordance with the uniform building code or per stamped engineered design? Yes L__ No _____ (1) Not necessary for this project
_____ (2) 5. Do the plans indicate the location and size of ventilation openings for under floor crawl spaces and the clearances required between wood and earth? Yes L__ No _____ (1)
Not necessary for this project _____ (2) 6. Do the plans indicate th~ size an location of ventilation openings for the atti):, roof joist spaces and soffits? Yes .1/__ No __ ,-__ (L)
Not necessary for this project _____ (2) 7. Do the plans include design loads as required under the Uniform Building code for roof snow loads, ( a minimum of 40 pounds per square foot
in Garfield County) floor loads and wind loads? Yes X__ No _____ (L) Not necessary for this project -----(2) 8. Does the plan include a building section drawing indicating foundaj.ion,
wall, floor and roof construction? Yes _1::...__ No _____ () Not necessary for this project -----(2) 9. Does the building section drawing include size and spacing of floor joists, wall
studs, ceiling joists, roof rafters or joists or trusses? Yes L__ No _____ (11 Not necessary for this project _____ (2) 10. Does the building section drawing or other detail include
the method of positive connection of all columns and beams? 'IES 2
" Yes __V__ _ No ____ (1) Not necessary for this project ____ ") 11. Does the plan indicate the height of the building or proposed addition from the highest point of the building or
addition measured at mid span between the ridge and the eave down to existing grade contours? Yes .L__ No _____ (1) Not necessary for this project ____ Il) 12. Does the plan include
any stove or zero clearance fireplace planned for installation including make and model and Colorado Phase II certifications or phase II EPA certification? Yes _____ No _;L_(1) Not necessary
for this project _____ Il) 13. Does the plan include a masonry fireplace including a fireplace section indicating design to comply with the Uniform Building Code Chapter 377 Yes _~___
No L_(1) Not necessary for this project _____ (2) 14. Does the plan include a' window schedule 'or other verification that egress/rescue windows from sleeping rooms and/or basements
comply with the requirements of the Uniform Building Code? Yes _~__ No ____ (I) Not necessary for this project _____ (2) 15. Does the plan include a window schedule or other verification
that wind0l;Ys provide natural light and ventilation for all habitable rooms? Yes L__ No _____ (1) Not necessary for this project _____ ") 16. Do the plans indicate the location of glazing
subject to human impact such as glass doors, glazing immediately adjacent to such doors; glazing adjacent to any surface normally used as a walking surface; sliding glass doors; fixed
glass panels; shower doors and tub encl0pres and specify safety glazing for these areas? Yes _____ No _____ (1) Not necessary for this project _____ (2) 17. Is the location of all natural
and llquid petroleum gas furnaces, boilers and water he¥ers indicated on the plan? Yes _____ No _£:':' __ (1) Not necessary for this project _____ (2) lB. Have two (2) complete sets
of constructions drawings been submitted with ,e application? Yes _____ No _____ {() Not necessary for this project _____ (2) 19. Have you designed or had this plan designed while considering
buildin~ and other construction code requirements? Yes jc'::__ No _____ {3} 3
20. Does the plan accurately indicate what you intend to construct and what will receive a final inspection by the Garfield Building Department? Yes _~_ No _____ '" 21. Do you understand
that approval for design and/or construction chan~ are required prior to the application of these changes? Yes _____ No -----(3) 22. Do you understand that the Building Department will
collect a "Plan Review" fee from you at the time of application and that you will be required to pay the "Permit Fee" as well as any "School impact" or "Septic system" fees required,
at the time you pick up your building perm~t:y Yes _IL__ No _____ ," 23. Are you aware that you are required to call for all inspections required under the Uniform Building Code including
approval on a final inspectionJll'ior to receiving a Certificate of Occupancy and occU~cy of the building? Yes ____ No _____ (31 24. Are you aware that the person signing the Permit
Application whether the "Owner", "Agent of the Owner", "General Contractor", "Contractor" or otherwise, signing the application is the party responsible for the proje~~complying with
the Uniform Codes". Yes _1::....__ No _____ '" I hereby acknowledge that I have read, understand and answered these questions accurately to the best of my ability. date Phone: '1'1,<;:-t:<fOld
(days); 7'7'',)";-9';': 0')1 (evenings) 2 E"~AA:S"fiU 7(,£fS"/LJ~ULJ: Project Name: loT. dO 5}t:IA/tf hOG':=-84('£ Project Address: 4
Notes; (1) If you have answered RNo" 011 any of these questions you may be required to provide this InformatJon at the request of lhe Building Official prior to beginning the plan review
process. Delays In Issuing the permit are to be expected. Work may not proceed without the Issuance of Ihe permtt. (2) If you have answered "Not necessary for this project" on any of
the C'!uesHohS Bnd It Is determined by Ihe Building Oltlclal Ihat the InFormation Is necfasary to review the applJeation and plans to delermlne minimum (ompllance wllh the adopted coues,
please expect lhe following: A. The appllcalloll may be placed behind mc.re recent allpHcaUons (or building permits In the revIew process: and nol reviewed until required inrormatlon
has ueen provided and the application rotales again (0 first posllion for review. B. Delay tn Issuance of the permit. C. Delay In proceeding wllh construction. (3) If you answered ~No"
10 rhls questlun the circumstances descrIbed In the question could result In a ~Stop Work Otder" being Issued or a ·Cer!Hicate or Occupancy" not t.,elng Issued. PerApp01.94 Effective
May I, 1994 5
March 7, 1995 Jim and Brenda Zegarski 522 North Traver Trail Glenwood Springs, CO 8160 1 Re: Foundation Design for Residence @Lot 20, Spring Ridge Place Garfield County, CO HCE File
Number 93003.11 Dear Mr. and Mrs. Zegarski: High Country Engineering, Inc. (lICE) has reviewed the architectural and structural plans provided by you, as well as the soils report prepared
by Hepworth-Pawlak Geotechnical, Job Number 194-556, dated 1/19/95. The structural drawings are sheets Sol through S-6. Sheets S-l through S-3 were drawn by International Specialties
Group, and dated 4/19/93. Sheets S-4 through S-6 were drawn by HCE, with Project Number 93003.11, and dated 4/19/93. As you know, this house was originally intended for a lot in Aspen.
HCE worked with the International Specialities Group architect on that project to provide structural engineering. The original project was designed with a Snow Load of 75 pounds per
square foot, and an allowable foundation soil bearing pressure of 2000 pounds per square foot. At the currently proposed location, the snow load is 50 pounds per square foot, and the
allowable soil bearing pressure is 4000 pounds per square foot (if the upper loose soils are removed and the footings are placed on the natural bedrock, in accordance with the soils
report). We understand that no changes are proposed in the foundation or framing design. Therefore, the structure, as designed for its original location, is adequate for its currently
proposed location. 923 Cooper Avenue· Glenwood Springs, CO 81601 Telephone: 303-945·8676 • FAX: 303·945·2555
.' " Zegarski March 7. 1995 Page 2 If you have any questions or need additional information. please contact us. Sincerely. TPB/soe
.......... -~4 , , GARFIElD.COUNTY BUILDING AND SANITATION DEPARTMENT Permll ... . -. '": :' .•. ., 241SHI . 109 81h Sireel ' Sulle 303 Glenwood SprIngs. Colorado 81GOl Phone (303) 945-8212
A •• e •• or', Parcel No. i t INDIVIDUAL SEWAGE DISPOSAL PERMIT PROPERTY This does not consti1vte a building or use permit. Owner's Namo_-'J-=im--'-Z"'e-'=fl-a-'n-=k-i_ ____ Present
Address _ 5_22_ _N._ T_ra_v_er_ T_r_ai-l',-_ G_.S_. Phono _9/_,5_-6_/,2_0_ _ 0234 Sprin!!r1dge Drive, Lot 20, Spr111gride Place, Glonwood Springs System Location, _ ______ ="---'-_-'''-_::..
___ ...: ___ -=--' _ ''--_____ -'--_ _ ____ ---.:-'-_-'--_ Legal Description ot Assessor's Parcel No. ______________________________ _ ____ _ SYSTEM DESIGN ,~: :---...... -______ Septic
Tank Capacity (gallon) ______ ,Othe-r---"'------.___.... ______ Percolation Rate (minutes/inch) Number of Bedrooms (or other) __-~' -_---_--. Required Absorption Area· See Auached Speoial
Setback ReCluirements : Date _ ___ __________ 'nspector ______________________________________________________ _ FINAL SYSTEM INSPECTION AND APPROVAL (as inslalled) Call lor Inspection
(24 hours notice) Before Covering Installation System Installer f[7h ~ Septic Tank capaCItYfL-I-.;',[.Y).-J·.~~-~-1r.-lZ=:...----------------------------Septic Tank Manufacturer or Trade
Name -f!.e:"f"~""<:""tt". .. t .~.rc ;....--------------------------Sepllc Tank Access within 8" of surface -lY'''''''t-=.S·. ~-----------------------------Absorption Area _ '1'1-"te';.u1;2LQ_
_______ ____ _________________. _ _______ Absorption Ares Type andior Manufacturer or Trade Name ~-l-I,,{"'h"F'---,':.I.''-'·'"f'-:·Li'L.Jl lJ.¢:o."t<~(,'"-_________________ Adequate
compliance with County and State regulatlonslreqUirements_Y',' ,.<:(--C'>:>-_________________ _ Other ______________________________________________________________________________________
_ Date ,;.--1 '1;;= -CONDITIONS: Inspector 1,('", .y:th. «; /(&4'1""' ' RETAIN WITH RECEIP; RECORDS AT CONS-T~~6TION ~ TE 1. All installation must comply with all requirements of th6
Colorado State Board of Health Individual Sewage Disposal Systems Chapter 25, Article 10 C.RS. 1973, Revised 1984, 2. This permit Is valid only for connection to structures which have
fully complied with County zoning and building requirements. Connection 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 (evocation of the permit. 3, Any person who construcls, alters, orinslalls an individual sewage disposal
system in a manner which in\lolves a knowing and material variation from the terms or speCifications contained in the application of permit commits a Class J, Petty Offense ($500,00
fine -6 months in jailor both). Applicant: Green Copy Department: Pink Copy P ~ : ! f II.' . H L' I n t. l ~j • L 1,< I l ; H f i. h ! , . ! I H I i f I r I ! Ii f H I i •~ ff n Ii d
·H, J I H t ,. ---------------~-1 i
" ... i .. INDIYIDl !AL SEWAGE DISPOSAL SYSTEM APPUCATION OWNER :T,AMES 12 ZERAlbSK( ADDRESS ;522 d f 8,AIIC'R. (RAIL CONTRACTOR ____ ~S~AruM~E _________________________________ __ ADDRESS
PHONE _____ _ PERMITREQUESTFOR (0NEWINSTALLATION ()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 FACIUTY: COUNTY -->..G,.l.l:IA. .c.... r:EC.lI,4;F;.JI-cDu·'
--__________ Near what City or Town G t.El) 1'100 Q :?ee II !I; S' Lot _2"-"Q<--________ _ Legal Description Se& lUG 'RIDGE S'" G a III! .rlO AI WASTES TYPE: (t{Dwelling ( ) Transient
Use ( ) Commercial or Industrial ( ) Non-domestic Wastes ( ) Other -Describe ___ ....,,-________________ _ BUILDING OR SERVICE TYPE: ---"S...l..lJIIJ~Gul"".E:c_..cEiJ:!.A.I!:I"I.l.JIL.l.l..ly~
____ ..,..,..--------Numberofbedroorns: y., Og, S Numberofpersons_-<Lf-'--_______ _ (0Garbage Grinder (Yj Automatic Washer (v)'Dishwasher SOURCE AND TYPE OF WATER SUPPlY: (to WELL ()
SPRING ( ) STREAM OR CREEK Give depth of all wells within 180 feet of system: __ --;:::::-__ """""',..-_---,=:::-______ _ If supplied by communtiy water, give name of supplier: Sea tlJG.
rf(IOG E" SPa h 1£11.) tQ},} GROl!ND CONDITIONS: Depth to bedrock: _____~ S.LE~F....J.4::>,...LT..1T..t;.Au.;C..tI=i:!.!E~Ou-....S..u. .l.wlB ~.~SXJ"-UlL _ _S :l..LJTUI..LIJ.<O'-..)Y~
____ Depth to fITSt Ground Water Table: _______________________ _ Percent Ground Slope: ____________________ ---' _________ _ DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: _____________
_ Was an effort made to connect to community system? _---'N..>L.lo!p ____________ _ TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED: (J{ Septic Tank ( ) Aeration Plant () Vault (
) Vault Privy ( ) Composting Toilet () Recycling, potable use ( ) Pit Privy ( ) Incineration Toilet () Recycling, other use () Chemical Toilet () Other-Describe: nUPHIG-By bllGf.( CWIJ7I'ZX
fi)B. FINAL D!§)POSAL BY: (v[ 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?.....!.:.")~Q'___ _ T '0" I ,
'. <I' ••• .. • PERCOLATION TEST RESt !I.TS: (fo be completed by Registered Professional Engineer) Minutes per inch in hole No. I Minutes per inch in Hole No.3 Minutes per inch in hole
No.2 Minutes per inch in Hole No. _ , S \::T InrAc..l-u~D Name, address and telephone ofRPE who made soil absorption tests: ___________ _ Name, address and telephone of RPE responsible
for design of the system: _________ _ Applicant acknowledges that the completeness ofthe appliction 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 purposes of the evaluation of the application; and the issuance
of the permit is subject to such terms and conditions as deemed necessary to inusre compliance with rules and regulations adopted under Article 10, Title 25, C.R.S. 1973, as amended.
The undersigned hereby certifies that all statements make, 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 bre relied on by the local department of health in evluating the same fro purposes of issuing the pennit applied
for herein. I further understand that any falsification or misrepresentation may result in the denial of the application or revocation of any pennit granted based upon said application
and in legal action for perjury as provided by law. '" 'r