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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
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Owner's Nam Q'S lel1 Sk ti 4 °Presennt Address
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System Location
Permit NE 34 4 9
Assessor's Parcel No.
This does not constitute
a building or use permit.
D6a4 ! f le Cf. ate P1cZ Phone r 475-1$0 `j
0%5 sit N. Ai -C 1e Coe I6s o
Legal Description of Assessor's Parcel No
SYSTEM DESIGN
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Co -f$13 v(ef(c CKeeK ES s
Septic Tank Capacity (gallon) Other
Percolation Rate (minutes/inch) Number of Bedrooms (or other) 3
IYo.2 a' ITb e4t4JEt. a4CM ttb OPS
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70I a' t CII c (� TREE CtflS 37
Inspector �G
Required Absorption Area - See Attached
Special Setback Requirements:
1—xS-8
Date
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before CoveringInstallation
System Installer V wx)t'li!
Septic Tank Capacity
(7.50
Septic Tank Manufacturer or Trade Name Garb A,
Septic Tank Access within 8" of surface
Absorption Area
*
37 ix< LEA eft nottiget9 iJ nF ktt- s LY)
Absorption Area Type and/or Manufacturer or Trade Name
Adequate compliance with County and State regulations/requirements
Other
Date 7- - t - b I Inspector n yl ,4 1 244/# �'.,‘
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
yrs
*CONDITIONS:
1. All installation must complywith 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 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
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 materiel
variation from the terms or specifications contained In the application of permit commits a Class 1, Petty Offense ($500.00 fine — 6
months In Jail or both).
White - APPLICANT Yellow - DEPARTMENT
•
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER Levu cu a/kb 7 d. A,,ei to y is pacLP y _ ,/
ADDRE _ .. 4 PHONE --Clin 5 ' 32-7--
CONTRACTOR
ADDRESS PHONE
N e 'CLI. c7"'t ;
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, soil profiles in test holes (See page 4).
LOCATION OF PROPOSED FFACILITY:
Near what City of Town 'el c �Q ,�1�
Legal Description or Address 09 45- / / /es -a
Size of Lot 4. 37 GK.
WASTES TYPE: (>0 DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPE: St N7
Number of Bedrooms 3 Number of Persons c_q
(y) Garbage Grinder Automatic Washer (>4 Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: ( ) WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: Ri-iie C PIPP EcsM4e> Cts r" w
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to the Community System?
A site plan is required to be submitted that indicates the followine MINIMUM distances:
Leach Field to Well: 100 feet
Septic Tank to Well: 50 feet
Leach Field to Irrigation Ditches, Stream or Water Course: 50 feet
Septic System 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:
(1) 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:
(X) 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? �0
PERCOLATION TEST RESULTS: (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. _
Name, address and telephone of RPE who made soil absorption tests:
Name, address and telephone of RPE responsible for design of the system:
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 tare 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 L
Date l6 - -C L
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY??
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