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-ear,<f f ti Ls.iJ <br />f <br />Date Applied: - Septic Permit #: 50 9- oycZ _ <br />Expiration Date: <br />Permit Fee: $ <br />Use Tax: Check <br />Buiildin pa..-+$ tt eorwi-pwe!' --?°` Recpi ` <br />FREMONT COUNTY SEWAGE DISPOSAL PERMIT APPLICATION <br />Owner: Colorado State Land Board Applicant: GCC Rio Grande, Inc. <br />Mailing Address: 1127 Sherman Street Mailing Address: 3372 Lime Roams <br />City, State, Zip Code: Denver, Colorado 80203 City, State, Zip Code: Pueblo, Colorado 8100 <br />Phone Number: 303-_E?Ez.?54 F x r 3 313 Phone Number: _ fj 47 _ .7, 9 Contractor: _Ca n n n B? n t a L Phone: 275-061 5 License : <br />Construction Address: z $ I. D t-k- w 1 N 5- j e Y, r o -.?) -e Cd v r 0. ec.o 912-So <br />Gate/Combination Lock : Directions To Site From Major Thoroughfare: ? prttlude Legible map a oarctions on sack)4 <br />Legal Description: Section 26, TJ. 7S , R68W <br />Type of Structure: Use of Structure: <br />Lot Size: Acres Source, Type of Water: <br />Maximum Potential I of Bedrooms: Basement: Washer: Garbage Disposal: <br />Engineering Fkm: Project Number. <br />Type of System: Absorption Tank Size: Gallons <br />Absorption: Square Feet Perc Rate: MinAnch LIAR: <br />Notes: The GCC Sal Can Project's. CUP 08-003 )wa <br />sanitation closets. The portable structure will only be on site <br />6-8 weeks a vear daring extraction activities. <br />Is Site Within 400 Feet of Sewer Main? ?Yes ONo Or Within a Sewer District? ?Yes o <br />II YES Is A Letter of Refusal To Connect Attached? <br />Is Site In A Designated Flood Plain? ?Yes ©No If YES, Engineer's Requirements Listed? <br />I certify that the sewage disposal system described n, this permit Wit W. installed in compliance with the attached percolation test report and the •remonr County anti <br />State of Colorado Requ'Imions. I understand that I will be responsible for the operation, maintenance, and performance of the individual sewagc disposal system. In <br />addition, I a n aware Thal it is my responsibility to provide the contractor with a copy of Vic attached prrcofarion test report. I am also aware that the issuance, of this <br />pernii does ncit constitute assumption by the local health drpanment or its employem- of liability for failure of any individual sewage disposal sr,.tem. Request for <br />inspection will be required aftEr installation of all pipe and gravel (prior to installation 0 hay, straw or similar pervious malerial) unless otherwise specified by engineer. <br />Tfhn em must be properly protected from off site drainage, vehiurlar traffic, and livestock. Thi sy tt m arhd Rs rtinnkhg arlF r is tlx sok g ?p?nsibiliry d Uhe owner. <br />1 n''Cr !.'+: "?'•rai.• ti c hn.+- ,... i+F•? _??_ .,. , ?i +o.i d.. i SSWned rlti„ ., ds Sy(•iiJrih i., ii i i:. UIlu ..vrF ?+ .?,i: i : '„a. • <br />Approval of a fremura County Indivkkad SEwage Pisl?sal Permit does not quatanree rx assure that the proposed use is permrned within the zone district for the <br />property, nor does it guarantee or assure that any proposed building complies wah applicable land use and requirements for the -.one rfisrriet. such as setbacks. height <br />restricdan, or other sknilar issues. You have the respons and obligation to verify and confirm that all proposed uses are allowed in the zone district and conform to <br />the recpifrements of the zone dis>:ict for the. property. <br />Owner or Applicant's Signature: L Date Applied: <br />DEPARTMENT USE ONLY <br />Permit Has Been: Approved f X Disapproved ? Date: ! s '. rnt `?'" <br />r. + ! ,` t. <br />Notes: II irtf T i,?: !.Y - !J?X1< Lr? !^?!?{ Y? ?_. ?.Qr4?:^r!? ?1 ' {i2 t <br />e r7!'t } •c i .? .'1.' ;:'+'7 Sy ?' l ??' . Y i +l V ?? / i r7 ?S <br />Approved By. _ Date Appromd': [2,009 <br />Prepared 8y: ` Date Prepared: -?f <br />. 12CVi5fd pry09/7.pefi F/' <br />!; WI-I!TE t:QPY . Omer t Copy • YE 1.1 OW COPY • Instat!rt's Copy • GfI V EN COPY - Office Copy