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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
109 8th Street Suite 303
Glenwood Springs, ColOl'lldo 81801
Phone (303) 945-8212 t -
: i <fNDIVIDUAL SEWAGE DISPOSAL PERMIT
! l PROPERTY
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N ~ Permit -3467
Aneseor's Perce! No.
This does not constitute
a building or use permit
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i t Owner's Name ....1.t-t=DL...!.~.J..1-..L!~ c. ... t._-_____ Present Address ro 72 8 IC ,BRAl.O Ko. S1LI Phone lc2'5 . 5 '5 K.o q
jj SystemlocatlonOJ72 J3.10 Bi<AUOKD) SILT
~ { ·1.ega1 Description of Aaaeaeor"s PadNo. __ · -----:.---:.--;-----;------,-----:--------,--==-~ ) l SYSTEM DESIGN . J..-(J,(Jl;/il, CJ,~~ "f7'.H'Je.k.s ,3 'f ~S·\· !;-· ~c-A· eh~ 1~ ~ ~o r ~ /If') tJO Septic Tank Capacity (gallon)
: , /~r'I/ Ifill{ ! ~ <2'-' Percolation Rate (minutes/inch) . ~
' )' Requ~ Absorption Area • See Attached
-----~Other
Number of Bedrooms (or other) _-...3~~--
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l ~ , Spej_' Setback Requirements: ~ ( ' CH';.;: , I
! • Date JP-11-tJ ::z. ..It~.
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~ ' FINAL SYSTEM INSPECTION AND APPROVAL (as installed) ! ~ Call for Inspection (24 hours notice) Before Covering installation '·
! i °.System lnstaller_~~--02A._-----------------------""'Ac-·. --1 ~ ~ '
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Septic Tank Manufacturer or Trade Name _{!'-""&p""'l,.....~"""""""""=}__~'--· ------------------
Septic Tank Access within 8" of surface ---''"':j1tk'V't1£...::....-----------------------
Ablorptlon Area Lf D,
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Ab..,rptlon Area Type lind/or Manufacturer or ;;ada Name _,,s/h~_,_,~~=-=· :c..::....:.."'~~..:im,_... ___________ ~
Adequate compliance with County and State regulations/requirements __ ~"'!''""'-=----------------
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Other ______________ ~-----------r-----.------------~ Date___i,.~4-='-'-'-.R..=-\'-?..---1-1 ...:...L_Oo_;;-'--1nspector--LM=Uz"'-"'-'""'l'-+J+LruC?<...1.Lc....=L=-------
V RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
OC:ONDITIONS:
1. All installation must comply with all requirements of the Colorado Stele Board of Health Individual Sewage Dlapoeal Systems Chapter
' 25, Article 10 C.R.S. 1973, Revised 1984.
2. This permit Is valid only for connection to otructurea which have fullt oomplled with County zoning and building requirements. Con-
nection to or use with any dwelling or otructurss not approved by Iha Building and Zoning office shall automatically be a vlotmlon 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 lndiYldual-age dlspoael system In a manner which lnvol-a knowing and IMlarlal
variation from the terms or specifications contained In Iha application of permit commlta a Claa I, Patty OlfanM (SIS00.00 line -I
months In jail~
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INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER_,..
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AD DRESS --kt.~~_µa,i.......o~-l<..L.t!::=----Sc£ai'.i:::.P:J.Jlt;.,.:, <!J:>~ PHONE (A,,<£ SS {JO
CONTRACTOR---e-;:I...JZ.e!~-===----------------------
ADDRESS ______ _::::,._ ______ _
PERMITREQUESTFOR (,><'I NEWINSTALLATION ( )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 ofTownL-S......il:.J...i /r...Jr''-------------.!il!Size~ou..fA<Lo!.!lt~Aufj!'.J~!:'..lY-0.i.;y~B=!..Ati~C'..._=
Legal Description or Address ___ ..::.0..::.o--'/..::.d._-'-p_..:...;..:...o _]?~IZ....:.~.=..=Vo:..__l'{._:cl_. ____,,S"--1...Ji /'-''.f-__,Y,'-'fi....:::b:..:5c....)...__ __
WASTES TYPE: ( '>4_ DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER-DESCRIBE. _______________ _
BUILDING OR SERVICE TYPE: ~ M G-{v +1hn)f'{ 4-s
Number of Bedrooms ~ Number of Persons _____ _
("/) Garbage Grinder ~Automatic Washer
SQURCEANPIYPEOFWATERSUPPLY: ( ) WELL
<r<J Dishwasher
( ) SPRING ( ) STREAM OR CREEK
If supplied by Commmrity Water, give name of supplier: ______________ _
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:. ___________ _
Was an effort made to connect to the Commmrity System? _____________ _
A site 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 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 CONDmONS:
Depth to first Ground Water Table NoJf # ff> df r.{ /?nf!U) fvt:;c ,r "
Percent Ground Slope b ±f 2 °?> C) kJ -r>" I
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TYPE OF INDIVIDUAL SEW AGE DISPOSAL SYSTEM PROPOSED:
"<;r>-,_SEP:l;IC TANK ( ) AERATION PLANT ( ) VAULT
( ) VAULTPRIVY ( ) COMPOSTINGTOILET ( ) RECYCLING,POTABLEUSE
( ) 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? Alo
Percolation Test) f }~ ·
PERCOLATION TEST RESULTS: (To be Ml ed by Registered Professional Engineer, if the Engineer does the
Minutes per inch in hol . fr Minutes per inch in hole NO. 3
Minutes per inch in hole o. 2 Minutes. _____ __,per inch in hole NO. _
Name, address and telephone ofRPE who miide soil absorption tests: _____________ _
Name, address and telephone ofRPE responsible for design of the system: ___________ _
Applicant ackn~ledges 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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