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•· ·, ~ -.;•: . .-• GARFIELD COUNTY BUILDING ANDaANITATION DEPARTMENT
1 ! r 109 Ith Street Suite 303 t J Glenwood Spring•, Colorado 81eo'I
1 ! a Phone (303) 945-8212
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~ ! . lftllVIDUAL SEWAGE DISPOSAL PERMIT -It .
Permit N~-. 3,4 Z 6
AHeHor'a P8rcel 'flio.
This does not con.~ltute
a building or uie P.mlt.
f~ .RTY .
-1 f ~r's Name f(l, Hvn,. m~ Present Address I (!o (.e;2.S'1 R.i-f(-e Co Phone
: q:..s~mlocalion uro Gnyrrfy /{"'o.J &S't R1:.ffe C..&~/5o
-! ' '-911al Oeacription of Assessor's Parcel No.------------------------------
! ~ SYSTEM DESIGN , /J,·7 ?u.c Tor 'f 1 ,..;,,,.
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' ' _,J,,_?-~.$1l...._ __ Septic Tank Capacity (gallon)
1-"#£
Required Absorption Aree -See Atteched
Numberoll!edro:Oms(orother) f R1J!/ ;.~ 1}t, 1 • ,, < 4 • f-1 e s ( B"'L V' ~ !
edi e J r6 f-<-,, ' _sr, , " , w()l/J""" ~, ~r;.11ur~
Percolation Rate (mlnulel/inch)
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Special Setback Req~-;?1".0}
Date h·l1o?, Inspector __,_j)"-'UAk=-'-'·J~/'7-u.&_:;:_::_£-=------------
i t FINAL SYSTEM INSPECTION AND APPROVAL (.; installed) \~ . '
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Call for Inspection (24 hours notice) Before Covering Installation
System lnstaller__f.;'L.i.'<,,/,,lo:I.~'--------------------------------
Septic Tan~Capaclty ;!. CJ OD 'f} 1 f-
Septlc Tank Manufacturer or Trade Name ,fl.Ac_lil~~/:ill!~--------------------------'=6}->~
Septic Tank Access within 8" of surface~..-~-------------------------
Absorption Area ~al
Absorption Area Type and/or Manufacturer or Trade Name 4~-;zoV'~d"""""'~'-'=u:z::...~-------------
Adequate compliance with County and State regulatlonslrequirements_ffe2i<F"'""'------------------
Othe•---------------::;:::;;oo~""'----;~#"---C?,,..-:""~-----------
Date '7~/o 3 Inspector:;;;~
RETAIN WITH RECEIPT RECORDS AT CON~E
i ·~ •CONDITIONS: •• 1 ;
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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, Revleed 1984.
2. Thia permit is valid only for connection to structures which have fully complied with County zoning and building requirements. Con-
nection to or usa with any dwelling or structures not approved by the Building and Zoning office shall eutomatlcally be a violation or a
requirement of the parmit and causa for both legal action and revocation of the permit.
3. Any person who constructs. alters, or Installs an Individual sawage disposal system in a manner which involves a knowing and material
variation from the terms or specWlcatlons contained In the application ol permit commits a Clase I, Petty Offensa ($500.00 fine -8
months in jail or both). ·
· While· APl1UCANT Yellow. DEPARTMENT
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INDIVIDUAL SEW AGE DISPOSAL SYSTEM APPLICATION
PERMIT REQUEST FOR ( w{' NEW INSTALLATION ( )ALTERATION ( )REPAIR
Attach separate sheets or report showing entire area with respect to surrounding areas, topography of area, habitable
building, location of potable water wells, soil percolation test holes, soil profiles in test holes (See page 4).
LOCATION OF PROPOSED F?ILI~ /)
Near what City of Town K/.El!3_ . Ll>. Size of Lot ?tiJ'mq.
Legal Description or Address _..._IJ._.16""""'"-4&,_...~ .... 'l> ..... ,...,tf/i.,..,._ _____________ _
WASTES TYPE: ( 11" DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER-DESCRIBE_..,.......-,-------------
BUILDINGORSERVICE TYPE: 5/£ ~
Number of Bedrooms 1 1
Number of Persons~$ ____ _
( ) Garbage Grinder (vf Automatic Washer (~shwasher
SOURCE AND TYPE OF WATER SUPPLY: ( ""WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: ______________ _
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:_M___,/i=,__ _______ _
Was an effort made to connect to the Community System? _____________ _
A she plan is required to be submitted that indicates the following MINIMUM distances:
Leach Field to Well: 100 feet
Septic Tank to Well: 50 feet
Leach Field to lrrigadon Ditches, Stream or Water Course: 50 feet
Sepdc 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 ____________________ _
Pen:entGroundSlope. _______________________ _
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TYPE OF INDIVIDUAL SEW AGE DISPOSAL SYSTEM PROPOSED:
(X) .s.EPTIC TANK ( ) AERATION PLANT ( ) VAULT
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( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POTABLE USE
( ) PIT PRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
( ) CHEMICAL TOILET ( ) OTHER -DESCRIBE
FINAL DISPOSAL BY:
<)() 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? Alh
PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer, if the Engineer does the
Percolation Test)
Minutes ____ -rer 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 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
fiilsification 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.
Sign Date.--""-'¢__.__i'-J-==?~/) _
ACCURATE MAP TO YOUR PROPERTY!!
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Designate North Arrow
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Your Neighbor's
Name & Address
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Your Pio¥ -Shape to Fit
(No ~9ale)
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Locate well, all s Jams, irrigation ditchs, and any water courses. Draw in your 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) 11~/J 11 !?A t.~9 f2d::l6
'enc e:\wpwiA6G\Vipducil c I loo
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Your Neighbor's
Name & Address
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