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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
1ott Ith Street Suite 30S'
Glenwood Springs, Coloredo '1801 ·
Phone (303) 945-8212 I =LSEWAG<DISPOSAL .....
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This d0.S no\ conatltuta
a building or use permit
!l Owner'SName l(VlhQ,,.)4 i'l t.IMPresentAddress•. 2f') n11x, Pho"" 1~19-~s-
'ii SyatemLocat1on73%3 ---\ Q. ~\JI fuw Q.Qcj/(
. i d. 39Cf -;;>..<{ 3-00 ~ 033 ' ·~ _,.._£-I 1 Legal Description of Assessor's Pare . L ·-~ h SYSTEM DESIGN 17 l.e.4 cA cl~ ~ """1 ti-~ i'H C,)uy ,,i if ~ l..e.ad eA 4'11 ~ ""' "'-k~
1 ! /@ Septic Tank Capacity (gallon)
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______ ,Qt her
Number of Bedrooms (or other) -LJ __ _ ~ i J l1f lof{) At W Percolation Rate (minutes/inch)
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Required Absorption Area -Sea Attached ·-.
Special Setback Req~ments: /Ct~. . A
Date 9 -/~,.,. t!) f-" tns"f"O!J;r,....<-'¥-'-L--""-"="1?/'"'--c:_---------------' . ' 7
f " " FINAL SYSTEM INSPECTION AND APPROVAL {as lnsta(i_ed)
Call for Inspection (24 hours notice) Befora Coverrrlg. l~stallation
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System lnstaller_.,_cc~='--'-'=-==--'--""*~--'----------------------.... / :J ,'
Septic Tank Manufacturer or Trade Name ~,N'-"-.1,Q,_C.._,W"'-"<2.."'"'S.,c_.o...,_ __________________ _
Septic Tank Access within 8" of surface ...Jc4<!!:.dl:'.:: _______________________ _
Absorption Araa 1-'2--L..V.~
Other _______ ~-------~----,.-------------------
Date_\,__,,Oo....·_l_S_-_O_l(,____1nspector_l..,.,,\""-')Mt'-"--'-·~j~]1~1\.Q"--a'-~""---------
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
-CONDITIONS: \
1. All installation must comply with all requirements of the Coloredo State Board of Health Individual Sewaga Dtspoul Syatem1 CMpter
25, Article 1~ C.R.S. 1973, Revised 1984.
2. This permli is valid only for connection to structures which have fully compUed with County zoning and building requirementa. Co•
nectlon to or use with any dwelling or structures not approved by the Building and Zoning office shall automatically be a viot.tlon or a
requirement of the permit and cause for both legal action and revocation of the permit. '
3. Any person who constructs, alters, orinstallsan Individual sewage disposal system In a manner which lnvol-aknowlng and .-lal
variation from the terms or specifications contained in the appHcation of permit commits a Cius I, Petty OffenH ($500.00 fine -8
months In jail or both).
White-APPIJCANT-Y--DEPARTMENT
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RECEIVED JUN 0 1
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER St1arlrA El. .J,,... TP.vwe
Co ADDRESS ~ dO ~ "\" ST /...1 ;=z_£_
CONTRACTOR 6 ' :. -D <.J 11 e/
ADDRESS 42.lP E 4 7~ S/ fl.; FU.; Co
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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 FACILITY:
Near what City of Town.---':5=........./ t.:._-,_l __ __,_16 .... ·-~""'-'-'-='1&;="'-· ______ __,,S,,.iz=e_,.of._.L,,.o,...t _4.L.,_0.__,-1._.3"-A'-'=flR_""""o.:;;S;.__
WASTES TYPE: ~)DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( )OTHER-DESCRIBE. ______________ ~
BUILDING OR SERVICE TYPE: ______________________ _
Number ofBedrooms __ /,__ __________ _ Number of Persons""'~----
( ) Dishwasher ( ) Garbage Grinder ( ) Automatic Washer
SOURCEANDTYPEOFWATERSUPPLY: ( ) WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: ______________ _
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: __ /£..__,d/~1/,,..~e.~s _____ _
Was an effort made to connect to the Community System? ___ -+:....:O'-----------
A site olan is reouired to be submitted that indicates the following 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 _________________________ _
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RECEIVED JUN 0 1 1999 >'
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(><) SEPTIC TANK ( ) AERATION PLANT ( ) VAULT
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( ) VAULT PRIVY ( ) CO:MPOSTING TOILET ( ) RECYCLING, POTABLE USE
( ) PITPRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
( ) CHEMICAL TOILET ( ) OTHER -DESCRIBE
FINAL DISPOSAL BY:
<X> ABSORPTION TRENCH, BED OR PIT ( ) EV APOTRANSPIRATION
( ) UNDERGROUND DISPERSAL ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
( ) OTHER-DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE?---L:fv''-'0'------
PERCQLATION JEST RESULIS· (To be completed by Registered Professional Engineer, if the Engineer does the
Percolation Test)
Minutes. ____ _,.er inch in hole No. 1 Minutes ____ _,per inch in hole NO. 3
Minutes per inch in hole No. 2 Minutes er inch in hole NO.
Name, address and telephone ofRPE who made soil absorption tests: _____________ _
Name, address and telephone ofRPE 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 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
fillsification 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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Sign~~ ~ -Date.___._.;'-./-'-3"'°-· _l_-9.L.....+9----
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RECEIVED JUN 0 1 1999
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Your Neighbor's
Name & Address
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Locate well, all streams, irrigation ditch:, ~: ~y wa~f-/oJrses. Draw in ;o:; house,
septic tank & system, detached garages, and driveway.
If a change oflocation 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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Your Neighbor's
Name & Address
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