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~ t GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N'.: 366'.l
' I 109 8th Street Suite 303 AsaeHor'a Parcel No. I . Glenwood Springs, Colorado 81601
Phone (303) 945·8212 ----------~\
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f ~NDIVIDUAL SEWAGE DISPOSAL PERMIT
This does not constitute
a building or use permit.
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·~cMh.: .. ·•r'sNamablArA"' ~~ ~.:y:ntAddrass fl8 Slr..~.~'1. ~~:::..Rrfff.. Phone
• l~srtam Location IC\'&) ~~ ~w"-'1, 3C}-:5 ~;y(~ Co gr{, SO
I ''" I "'f. LfDa1 Description of Assessor's P~rCel No. -----i'------------.,.,-----------------
-4! ' f ll"STEM DESIGN
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/at2D Septic Tank Capacity (gallon) Other
/'!)" Percolation Rate (mlnutaS,/inch) Number of Bedrooms (or other) :3 f f2ukj-~
Required Absorption Area -Saa Attached l ~~ ~....,.4 -'-/ 3'j, Z .aJ -C '{ P"'> .2.. )(fl
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Special Setback Requirements:
,,/, · JU,/-:> 21,. flfl -2 7 pcs 3/r(,'
?J :3jX'S 2.. '/{ff'
FINAL SYSTEM INSPECTION AND APPROVAL (as Installed)
Call for Inspection (24 hpurs notice) Before Covering Installation
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System Installer ]3 A::""'\.A. \\ ~
Septic Tank Capacity' \Ni) 4& . . . \ ,,-,\ i"
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Septic Tank Manufacturer or Trade Name 1-L..,O:...f'l'-"M=~'-"-g,-.~· ________ !'----------------
Septic Jank Access within 8" of surface _._\ -1-I "'~='-----------,;.·------------------\ . ~
Absorption Area 3o~ {3~ Ob IOeA ·) 2-:, ~~
Absorption Area Type and/or Manufacturer or Trade Name _..I~"-'-' 4~~<",,·,..l_.:b«'-"J-0=,.l------------------
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Adequate compliance with County and State regulations/requirements->+:-&:=-------------------
Othar~---------------------------,--------------
Date_S,_·_f,_·_,0"". -«Y0-------Inspector --l'£"44-i""4""}~1~·d ... ·_-~/~}~lf~· a,~th_-_-_, ----------
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
•CONDITIONS:
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1. All lnst~llat.lol"! 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. ' ' • •
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2. This permit ls valid only for connection to structures which have fully complied with County zoning and building requirements. Con· 1'
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. f
3. Any person who constructs, alters, or installs an Individual sewage disposal system In a manner which Involves a knowing and material r ..
variation from the terms or specifications contained In the application of permit commits-a Class I, Petty Offense ($500.00 fine-6 ..
months In jail or both) .
White -APPLICANT Yellow -DEPARTMENT
T0;9P8762215
• INDIVIDUAL SEWAGE DISPOSAL SYS'JEM APPLlCA'nON
OWNER &n)y /)u ,,.. ..... >".'_ __ _
:=~~~ ~:r.~;S° £t PHONE C:2.f7.JD21
ADDRESS /l'l-75 * ./J-;3:>f.£J//. PHONE f'd-2Zls=' ___ _
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PERMIT REQUEST FOR ( ) :NEW INSTALLATION ( ).ALTERATION ~AIR
Attach 1eparate iheets or repon showing entire area with respect to surrounding areas, topography of area, habitable
building. location of potable water wells, soil percolation test holes, liOil pro&les in test holes (See page 4).
Legal Deacrlption or Addma 11/72 2!C...?C:.. _;J?=S-~----·
WASTES TYPE: ~DWELLING ( ) TRANSIIDIT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WA.>TES
( ) OTHER· DESCRIBE. __________ _
BUJl.DING OR SERVICE TYPB: ~ ~ . ---------
Number of Bedrooms 3 __ Number of PerlOnl --2,._
0'f Oalb1111e Orinder pq_. Automatic Washer V9.._ Dishwasher
SQURCE AND mB OP WATER. SJJPPLY: CM WELL ( ) SPRING ( ) STREAM Cii'. CREEK
H supplied by Comnumity Water, give name of wpplier:. __________ _
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: 2. qr 3 m/f.... £ •
Wu u effort made to connect to the Community System?_@LJJ.<:.__ ________ _
A '''' P''D la nq!drtd to bf gl!m!thd tbet Jndlcatg tile foDmdpg MINIMUM dMtuw;
Leada Flelcl te Well: ::zoo ~ t:./(!J",. 100 feet .
Seft1c Tank to WeD: :;zoo -f= se feet
Leach Field to Irrt&adon Dltchea, Stream or Water Course: 7f!l i 50 feet
Sepde System to Prtperty Llna:<septic tank &leach field)ll feet
XQUR INDIVIDUAL SEWAGE DISPOSAL SYSTE1'1 PERMIT wn .1. NOl' BE ISSJJED \VI1BOUT
ASIDPLAN,
GROUND (',()NDITJONS:
Depth to first Oround Water Table_""'A .... '.._'A'---------------·------
Percent Ground s1ope __ ..,
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f¥1R-2$-2002 11:137A FROM1BLDGPLANG'lRCO 9?~3813478 T0:9P8762215
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
~ SEPTIC TANK ( } AERATION PLANT ( ) VAl.iLT
( ) VAULT PRIVY ( } CO:MPOSTING TOILET ( ) JU!CYCLING, l'OTABLE USE
( ) PIT P1UVY ( ) INCIN£1lATION TOD.ET ( ) RECYCLING, OTHER USE
( ) CHEMICAL TOILET
FINAL DISPOSAL BY:
( ) OTHER-DESCRIBE. _______ . ____ _
JXJ ABSORPTION TRENCH, BED OR PIT
( ) UNDEROROUND DISPERSAL
( ) ABOVE GROUND DISPEllSAL
( )
( )
( )
EV APOTRANSPIRATION
SANDFILTBR
WASTEWATER POND
( ) OTHER· DESCRIBE. _________________ _
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? I/I -----
PERCQLATION IESIMSJJLTS: (To be completed by Registered Professional Engineer, if the Engineer does the
Percolation Tett)
Minutes; ___ --Jl•ft' inch in hole No I Minutes ____ _.per inch in hole NO. 3
Minutes er iach In hole No. 2 Minutes er inch in hole NO.
Name, address lllld telephone of RPE who made 1oil absorption tests: _________ -----
Name. address 111d telephone ofRPE respolllible for dcsian of the 9)'1tem:. ___________ _
Applic&nl B.Cknowlodp that lhe completeness of the application is conditional upon such lbrthel mandatory and
additional testl and repol1ll u may be required by the local health department 10 be made and furnished by the applicant
or by the local health department for pllJ'POsed of the evaluation of the application; IJld the issuance of the permit is
subject to suoh terms 8lld conditions as deenied nocesury to imure compliance with ruteg and regulations made,
infbnnatlon Md repona IUbmltted herewith and required to be submitted by the applicant are or will be represonted to
be true and correct to the best of my knowledge and belief and are dcsisned to be relied on by the local dei1artment of
health in evaluatitJB the wne for purpoBOt of i&Slling the pmnil applied f'or herein. I fllrther underSUlnd that any
fibificetion or misr~tion may rauJt in the denial oftbe application or revocation of any permit grtinled based
upon aaid application 111d in ICSll aetion for perjury as providocl by law.
s· °"1{A__. ~C{W~~Date._· ~'l:~k;;...i.,q,_/io-'---z. __ _ ~ri
PLEASE DRAW AN ACCURATE MAP TO YO PROPER TYi I
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J>esignate North Arrow
Yow Neighbor's
Name&: Adcnss
l1_all\-
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Your Plot-Shape to Ftt
(No Scale)
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-~ . -.--7' it 1/<!f.1-k"'ct.1 .... .., 11~4Ck., -~ f !.µ<-1 e l'e..A I a/'c ~ \ -
.-. --l~-t, . I ;-'-~--""-.l'(j!1c_ Ch. ' 7 7#-'1
Locate well all sllams, ~ aiiSt~ any wa~re::'Q·· ~s:-D~iDYCiiini&."T
septic tank: & system, detadm garages, aad tlM:way.
If a change of location is--wy, you omt submit a coat'Cted drawing, befure a
Ceilifitllle of Oa:upation ..oill be issued.
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Your Neigbllol's
Name & AdclRa
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County Road (Note tiK' Road Number and Name)
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