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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
108 Eighth Street, Suite 201
Glenwood Springs, Coloradof 81601
Phone (970) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
Permit 4 3 S 3
Assessor's Parcel No.
This does not constitute
a building or use permit.
PROPERTY n /
Owner's Name �C) mel 'c m t � k Present Address 146 S �� f''� \f - ( �Q&� Phane%� ~ r 0 T 09 ti
System Location /40 SKIPiler' �• 4 t (-e g+(0
Legal Description of Assessor's Parcel No Lo r 1(mi tel- • `ice ` * 4s
SYSTEM DESIGN
Septic Tank Capacity (gallon) Other
Percolation Rate (minutes/inch) Number of Bedrooms (or other)
Required Absorption Area - See Attached
Special Setback Requirements:
Date Inspector
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer
Septic Tank Capacity
Septic Tank Manufacturer or Trade Name
Septic Tank Access within 8" of surface
Absorption Area
Absorption Area Type and/or Manufacturer or Trade Name
Adequate compliance with County and State regulations/requirements
Other
Date Inspector
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
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER v'etv60.1". Lei
ADDRESS 4101 Ski/fa NA
CONTRACTOR ii nee
ADDRESS .Sa++4 as ctLuec.
PHONE 9yg-$87$
PHONE 30,..r aj .44
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 L..ar4ono1aIc Size of Lot J. `s- Ac"`t
Legal Description or Address td Val £„* L t a1:0.. i 1{O
WASTES TYPE: (X) DWELLING J ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER — DESCRIBE
BUILDING OR SERVICE TYPE:
1 Ian ki,1 i.1) 4 tT ab () 4r/,k.
Number of Bedrooms 044 Number of Persons
( ) Garbage Grinder ( ) Automatic Washer ( ) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: (>0 WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: /f0.
Was an effort made to connect to the Community System? NA
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 (septic tank & disposal field) 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
2
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
SEPTIC TANK
( ) VAULT PRIVY
( ) PIT PRIVY
( ) CHEMICAL TOILET( ) OTHER -DESCRIBE
( ) AERATION PLANT ( ) VAULT
( ) COMPOSTING TOILET . ( ) RECYCLING, POTABLE USE
( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
FINAL DISPOSAL BY:
ABSORPTION TRENCH, BED OR PIT
UNDERGROUND DISPERSAL
ABOVE GROUND DISPERSAL
OTHER -DESCRIBE
( ) EVAPOTRANSPIRATION
( ) SAND FILTER
( ) WASTEWATER POND
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? No
PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer, if the Engineer does the
Percolation Test)
Minutes per 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 of RPE who made soil absorption tests:
Name, address and telephone of RPE 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
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 Date I0 -2S Roo'7
PLEAS RAW AN AC ' TE MAP TO YOUR PROPERTY!!
3
Designate North Arrow
Your Neighbor's
Name & Address
Your Piot - Shape to Fit Lit
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Your Neighbor's
Name & Address
Locate well, all streams, irrigation ditchs, and any water courses. Draw in your ouse,
septic tank & system, detached garages, and driveway.
If a change of location 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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