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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
109 8th Street Suite 303
Glenwood Springs, Colorado 81601
Phone (303) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
System Location
SYSTEM DESIGN
'/~)~ __ _:_-LL{___!__.::.__ Septic Tank Capacity (gallon) __________ Other
__ ___./_(£! __ Percolation Rate (minutes/inch) Number of Bedrooms (or othe ~ ::2.
Permit 39
Assessor's Parcel No.
This does not constitute
a building or use permit.
Phone, _____________ _
Required Absorption Area-See Attached
Special Setback Requirements:
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Date __ ' 1_·_/=--_,~_o__,_( ____ Inspector _.L,&J....:)...=...:t::.4e::::?t~~:::::.......;~:..:::· ~:..____/~!...:.~=£.=JIC::..'_£===-------------
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspe ctio n (24 hours notice) Before Covering Installation
System Insta ller _____________________________________________________________________________ _
Septic Tank Capacity_.....:::((}=-~~=---------------------------------------------------------------------
Septic Tank Access within 8 " of surface __ 7/kf~ __ .l ______________________________________________________ _
Absorption Area ---='-=!>'-./?2....!:jd'):...:... ____________________________________________________________________ __
Other ____________________________________________ ~----~----------------------------------
7 ~ za-•Y I ~ ~~ /#-= / Date --~---=~-----------------Inspector ------------~---------------------------------------
RETA IN 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 val id only for connection to structures which have fully complied with County zoning and building requirements. Con-
nection to or use with any dwelling or structures not approved by the Building and Zoning office shall automatically be a violation or a
requi rement 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 application of permit commits a Class I, Petty Offense ($500.00 fine-6
months in jail or both).
White-APPLICANT Yellow-DEPARTMENT
GARFIELD COUNTY Page 2 of9
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
owNER ADDREss Pa,""l tf-o..r~ I 3 ~ s-. /fto,l, & I Air m D ~ 1 o f<f
PHONE <I (D-?J8' ~ Jg~ J--I '
CONTRACTOR ADDRESS eo, /k, J3 /J /21/l . {) c?., ~ /65J
PHONE ~t 7tJ-J }}-S5f:J7 1/0 -8?6 -OJ/0
PERMIT REQUEST FOR: ~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, soi l profiles in test holes (See page 4).
Near what City or Town _--L...!!!:....£......!:=-4::~~.__ ____________ _
Size of Lot 11 g c r c..:S
Legal Descriptio~ or Address_~..l!.ii--~~--+-R~t='·Hu.;t/1--------------
WASTES TYPE:
~Dwelli ng ( ) Non -Domestic Wastes
( ) Transient Use ( ) Commercial Or Industrial
()Other: Describe : _____________________ _
BUILDING OR SERVICE TYPE: S ( F D~l(• ":J
Number of Bedrooms ~~----------------
Number of Persons --~~----------------
i4-Garbage Grinder ~Automatic Washer ct4.. Dishwasher
SOURCE AND TYPE OF WATER SUPPLY:
~ELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier:, _______ __:_
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to the Community System? ()Yes DQ. No
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GARFIELD COUNTY Page 3 of9
Asit~_plan is required to be submitted that indicates the following MINIMUM distances;
Leach Field to Well: 100 feet
Septic Tank to Well:
Leach Field to Irrigation Ditches, Stream or Water Course
Septic System to Property Lines:
GROUNO. CONDITIONS:
50 feet
50 feet
10 feet
Depth to first Ground Water: ___________________ _
Table Percent Ground Slope: ___________________ _
TYPE_OFJNPIVIPIJAL SEWAGEPISPOSALSYSTEM PROPOSED:
( ) Aeration Plant () Vault M Septic Tank
( ) Vault Privy
() Pit Privy
() Composting Toilet
( ) Incineration Toilet
( )Recycling/ Potable Use
( ) Recycling/Other Use
( ) Chemical Toilet ()Other-Describe: ____________ _
FINAL DISPOSAL BY:
Pl. Absorption Trench, Bed Or Pit
( ) Underground Dispersal
( ) Above Ground Dispersal
( ) Evapotranspiration
( ) Sand Filter
( ) Wastewater Pond
()Other-Describe: _____________________ _
WILL EFFLUENT BE DISCHARGED DIRECTLYJNTQWATERS OF THEST6IE? u
PERCOLATION TEST RESl.JUs: (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. 4
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GARFIELD COUNTY Page 4 of9
RPE WHO MADE SOIL ABSORPTION TESTS:
Name: ________________________________________________________ __
Address: ______________________________________________________ _
Telephone: ____________________________________________________ _
RPE RESPONSIBLE FOR DESIGN OF THE SYSTEM:
Name: ________________________________________________________ __
Address: ______________________________________________________ _
Telephone: ____________________________________________________ _
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.
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PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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