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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
109 8th Street Suite 303
Glenwood Springs, Colorado ~1601
Phone (303) 945·8212
Permit N~ 364'7
Assessor's Parcel No.
This does not constitute
a building or use permit.
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INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
, .. Owner's Name-:5~ r\-h' N Cl nevi
System LocatioQCl '5 j )Ju. S C\. fs l}-S'....-
~ ... ,..... -.. Present Address +-. [.1. L)c, X
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Phone
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Legal Description of Assessor's Parcel No.-----------------------------------
SYSTEM DESIGN
/ooO Septic Tank Capacity (gallon)
--~<[~--Percolation Rate (minutes/inch)
Required Absorption Area· See Attached
Special SetbJ°k Re,.irements:
Date ~fJ.-5/ tyL-7; Inspector
______ .Other
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours. notice) Before Covering Installation
System lnstaller_~~,f-~~O~-----------------------------------
Septic Tank Capaclty_LI ~OLO~=---------~------------------------
Septic Tank Manufacturer or Trade Name -'{_'.o..,__p"'-"R"'J°""IM"'L...· uj,,_· -------------------------
\
Septic Tank Access within 8" ~f surface I~
Absorption Area 'J-.o ~ ( 3 '/.. L\'....-) Vh. Dzd.
Absorption Area Type and/or Manufacturer or Trade Name _,A~~{+"J~· ~t~~«~Tu='-'l."----'t\'--'-_-_,\_·D=-----------
Adequate compliance with County and State regulations/requirements~\-~¥p_,,V""------------------
~· ..
Other • h
Date 11 ~/ Dft-Inspector (:JaNLd IB 0 d;x I I RETAIN 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 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 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
' I
cS'.26-2001 12:~1P FROM:BLDGPLl'NGRRCO 9703843470 EJ:9P%32339
, ' ·'
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
oWNER No.."~ y.A. ~tit\ 1 Po ~><: G.e3 1 CA.Jh""'J~u.. ~1'-2.'.!>
ADDRESS ~ fslX/111€..
1
Cg..da?,..dt~.l . .t. PHONE "f(,~, Z.a.3"'f
CONTRACTOR (_Vl_/js Le;"+z.
ADDRESS 75 ~,w 04:~ LAAt, B~s"'"-lt PHONE '1~'7 -1zsz..
PERMIT REQUEST FOR (A 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 fu±a.rJ:. Me;C-&if~,..Ja._{.e
I '
Lega!DescriptionorAddress koh. lo, II ~ l'Z. 1 Bloc~ 4-1
Size of Lot 11, 1?>1 $1 . .ft.
+t>u.111s~k 4-Cooped""
WASTES TYPE: C)C) DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON·DOMESTIC WASTES
( ) OTIIER-DESCRIBE _______ ~----------
BUILDING OR SERVICE TYPE: $1nglt ~fa~I ~ c:huell1:...5
Number of Bedrooms Number of Persons ------
( ) Garbage Grinder ()(.) Automatic Washer ()() Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: ( ) WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: TMt cf C~o11elglg
DISTANCE TO NEAREST COMMUN1TY SE\VER SYSTEM:--'-'/__.'f:--'-M--'°i,_,,U=---------
Was an effort made to connect to the Community System?-(-ifpS'°---·------------
A site plan Is required to be submitted that indicates the following MINIMUM distances:
Leach Field to WeU: 100 feet
Septic Tank to Well: SO feet
Leach Field to Irrigation Ditches, Stream or 'Vater Course: SO feet
Sepdc System to Property Lines: 10 feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT \VILL NOT BE 1ssm:n \VITHOUT
A SITE PLAN.
GROUND CONPITIONS:
Depth to first Ground Water Table _______________________ _
Percent Ground Slope ___________________________ _
. ' : ·'") -: //) { ,'
2
,.--;..d:2s-2001 12:02P FROM:BLDGPLi=t~GARCO 9-,03843~10 TO: 9F"3632 J:.l9
_ .. ,.. .> """
TYPE OF INDIVIDUAL SEW AGE DISPOSAL SYSTEM PROPOSED
(~) SEPTIC TANK ( ) AERATION PLANT ( ) VAULT
( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POTABLE USE
( ) PIT PRIVY ( ) INCINERA110N TOILET ( ) RECYCLING, OlllER USE
( ) CHEMICAL TOILET ( ) OTHER-DESCRIBE __
FINAL DISPOSAL BY
()() ABSORPTION TRENCH, BED OR PIT ( ) EV APOTRANSPrRATION
( ) UNDERGROUND DISPERSAL ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
( ) OTHER -DESCRIBE ---------------
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATER'> OF llffi STATE? r"I O -------
PERCQLATJON TEST RESULTS; (To be completed by Registered Profes~ional Engineer, if the Engineer does the
Percolation Test)
Minutes ____ _...er inch in hole No. I 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 test!:
Name, address and telephone ofRPE responsible for design oft he systen::
------------------------·----
Applicant acknowledges that the completeness of the application is conditior.al 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 pennit is
subject to such terms and conditions as deemed necessary to inwre compliance with rules and regulations made,
infonnation 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 pennit 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 ~ Da~e '2-• v-O'J..~-
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!