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GARFIELD COUNTY BU I LDING AND SANITATION DEPARTMENT
108 Eighth Street, Suite 201
G le nwood Springs, Coloradof 81601
Phone (970) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
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Owner 's Name r _)( ) (\ J (•' 1 I Present Address )n It I. 0 7
PROPERTY
Permit
Assessor's Parcel No.
This does not constitute
a building or use permit.
Phone _______ _
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System Location ___ =>-.L-~:;;:=;;---->---'-"'t_=---'='' Jc.;.'-'---~\~""--=-----------------------
10[0 --) l ~ 1 -:;:2N 1 _ ,1\7\ --:-1 1 .J Leg~ Description of Assessor~ Pare~ No·--------~~~--~~~-~~~~) __ ~~-~~~----------~
SYSTEM DESIGN
-~~~==~'-"-/)-"--=0'---Septic Tank Capacity (gallon) Other
_ __,_/_7'----Percolation Rate (minutes/inch) Number, of Bedrooms (or ot~er) 5-/" {,11' j JJ~.y ·
/S...J::1 .$ Pr·~' 0< /£{ .
Required Absorption Area-See Attached _.... rl! · ~ / .--/1 ~t 1/~ &'t"-( ./ ( 1 '1? tp t , ' ~~ -1' L 1-t..G-.,'\ -"' · 7 . -J '
j 3.5' I1J I ,, /J....._ ~ .::. / (.) 2. t.v?-vtA-Special Setback Requirements :
3 {) /iif.,.._,·r/-7-1~ £ Date ___ _.:_/_:{.;:::.1---'" ::::..__-__ b ___ Inspector __ A_-..,./ ________________________ _
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
I '
System Installer ;// ( ( ,1f 1ft
Septic Tank Capacity __ /_,_,~~;>~y_; _________________________________ _
/1 ( ~ Septic Tank Manufactu rer or Trade Name ___:1__:_~"':___:L~P~.:..'___:_~_:__ _____________________ _
Septi c Tank Access within 8" of surface _{7'/L.!:....;;~:__--------------------------
Absorption Area , )t t·vnv·i; J t. 'I l I v 11 1 ~
Adequate compliance with County and State regu l ations/requirements. __ l-=t?:__1 _________________ _
Other __________________________________________ _
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
*CONDITIONS:
1. All installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chapter
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 requ irements . Con-
n ection 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 revocation of the permit.
3. Any person who constructs, alters, or installs an individual seWage disposal system in a manner which involves a knowing and material
variation from the terms or specifications contained in the appli cation of permit commits a Class I, Petty Offense ($500.00 fine~ 6
months in jail or both).
White-APPLICANT Yellow-DEPARTMENT
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER _______ G~~~~~~~~f~L=o~~~~~~~g~oo~M~£~---------------------
ADDRESS ___ &~3~5~~~~C~-~~~-~3~1/+1_S~t~_TL'~c~o~8~t~L~,~~z=·---PHONE f3 Th -2818
CONTRACTOR \itJ' o ODS/VI tTl-/ CorJ'S T.
ADDRESS 353 lfAr<..vE:y (AP td., SiLT, Co. 8/&~·z_ PHONE 87&·Z8z.z..
i I
PERMIT REQUEST FOR (X) 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: 80 A."-·
' NearwhatCityofTown SILT SizeofLot 72Bo X 3qoo' -------=:.:_:::.:____________________ :'jt;...C-TtON 30~ SE Y<j
Legal Description or Address TowtJSrl!P " 5oc•m, RAN~ IS "'I IA!E.!ll oF (,}"P.M. 5E<-Tt otJ 31 : IV£ ?-"4
WASTES TYPE: ( XJ DWELLING C:, 3:5/o C !'<. 511 ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
()OTHER-DESCRIBE ________________________________ _
BUILDING OR SERVICE TYPE: ____ 'S_r_,_'-_"'-__ .:..~"'..:.R.:.:A.:.._M_E. ___ R..:.t:..· _s_, t>_£=· ;V __ T_t_il_L_. ______________________ _
NurnberofBedrooms 3 F!l\lt'oH£D 2 FUTtJR.c Number of Persons 3 __ ___::__ ____ _
( 0 Garbage Grinder (v) Automatic Washer ( ")Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: ( 0 WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: N·A.
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: ___ (p __ }:""z-'-M'-,L-'E.=-~=-------------
Was an effort made to connect to the Community System? __ __,N..::._D __________________________ _
A site plan is required to be submitted that indicates the followin~: MINIMUM distances:
Leach Field to Well:
Septic Tank to Well:
100 feet
50 feet
Leach Field to Irrigation Ditches, Stream or Water Course: 50 feet
Septic System (septic tank & disposal field) 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 ______________________________________________ _
Percent Ground Slope ______________________________ _
2
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
( )'-) SEPTIC TANK ( ) AERATION PLANT
( ) VAULT PRIVY ( ) COMPOSTING TOILET
( ) PIT PRIVY ( ) INCINERATION TOILET
( ) CHEMICAL TOILET( ) OTHER-DESCRIBE
FINAL DISPOSAL BY:
(--;) ABSORPTION TRENCH, BED OR PIT
( ) UNDERGROUND DISPERSAL
( ) ABOVE GROUND DISPERSAL
( ) VAULT
( ) RECYCLING, POTABLE USE
( ) RECYCLING, OTHER USE
( ) EVAPOTRANSPIRATION
( ) SAND FILTER
( ) WASTEWATERPOND
( ) OTHER-DESCRIBE·--------~----~~~~~-~~~---
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? NO
PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer, if the Engineer does the
Percolation Test)
Minutes 11
Minutes /7
per inch in hole No. 1
per inch in hole No. 2
Minutes / _s-
Minutes /7
I
per inch in hole No. 3
,lfr/G--
:f3Bl mel! in lmle No.
Name, address and telephone ofRPE who made soil absorption tests:--------------
Name, address and telephone ofRPE responsible for design of the system:...,-----------
!5 ~ e; f'u.J•'~-1Bttv'4 1 B3t t:A IL&oA.D, e1n.fi%: 0 z5-s 3 7o
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 11~ /(, ~ Date 1-/1j!Jb
PLEASE DRAAN ACCURATE MAP TO YOUR PROPERTY!! '
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Locate well, all streams, irrigation ditchs, and any water courses_ Draw in your house,
septic tank & system, detached garages, and driveway.
If a change of location is necessary, you must submit a corrected drawing, before a
Certificate of Occupation will be issued.
County Road (Note the Road Number and Name)
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