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OARFIE~OUNTY BUl~DING AND SANITATION DEPARTMENT
109 8th Street Suite 303
Glenwood Springe, Colorado 81601
Phona (303) 945·8212
Permit N~ 367J
A88888or's Parcel No.
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' INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permtt. ~
I l'ROPERTY ~ ~ : j ~~~-~;nnof{b~.J,-: .. .....Jl~U~'ili~~.~~~
I ~ystemLocation?->1So(pt 1\C KDJ)1~C~/;,/ --1:$i£k \ ". ,7 ti. ~tgal Description of Assessor's Parcel No.--------------------------~-----
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Septic Tank Capacity (gallon) ______ .Other
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ID Percolation Rate (minutes/inch) Number of Bedroo~sj?r. o,!_!1er)
797 RI A,._J,~/
Required Absorption Area • See Attached _] "16 ;J -(,._,,, , <-)Z ;; ,;;J ~ ~1
"/7 $'I/ /,.Jui__ :: o? {,.. ~ (~;< (.)
Special Setback Requirements:
Date _ _,b"--'A'--'-/-'-+-fa-=oc.:r ____ Inspector __ /0~'4-th __ . _/_,1._'M.,,_---'.Q __________ _
~i ~ FINAL SYSTEM INSPECTION AND APPROVAL (as Installed)
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Absorption Area Type and/or Manufacturer or Trade Name-~"'/'-, .. ··,,jifoi"·"':;'-·"'b<-: L"ua"'}."'A:>-1"',"'-'---l-''J/."·'-.-'~-· -'-0~---------
Adequate compliance with County and State regulatlonslrequlrements_~~t:-----------------
Other-----------------------::------------------'--
Date_9-'----',__l-_--'-o_'2-"'------1nspector _ _..i)~'--(h=· ""A""-~>"'f._/_7-<--"--7-"[_.e_=_-'-'('i,_.J~-,,___ _________ _
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
•CONDITIONS:
1. All Installation must comply with all requirements of the COiorado State Board of Health'lndlvldual Sewage Disposal Systems Chapter
25, Article 10 C.R.S. 1973, Revised 1984.
2. This perm-ltls-viilld only for connection to structures which have fully complied with County zoning and building requirements. Con·
nectlon 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 Ins. 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 flne-6
months In jail or both).
Whhe ·APPLICANT Yellow· DEPARTMENT
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". ' . . INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER Uo-.v i cQ__ 5+ E.. ,· N k o FF
ADDRESS //~// £ I 1.'.-'e>l""l A ()R. ~NP<"'
CONTRACTOR U • > > cQ S.\--c. i'AJ h o:Pf
S'oe>J.;2.. Co PHONE
ADDRESS $ ,-,..,, W\ (
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 ofTown~R~i .... £-+\-1;, _____________ _.S ... jze ........ o....,fLo""""t_L.j-'-"'O--'A.........._c..._.rc......._s __
LegalDescriptionorAddress03'33 G1eic.t;,s;lv<:B. R;f'lc. co ?flf,SD
WASTES TYPE: (>t,) DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
()OTHER-DESCRIBE'---------------~
BUILDING OR SERVICE TYPE:...,flo:..<..W.m""""e__..L'-'R""'.,"'s"'"iad4-,..,..,""-'-±....,1e-,,.l._\_,__ _____________ _
Number of Bedrooms ___ __. _________ _ Number of Persons --7'-r-----
C>9 Dishwasher ( ) Garbage Grinder (;>q Automatic Washer
SQURCE 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: ___________ _
Was an effort made to connect to the Community System? ______________ _
A site plan is required to be submitted that Indicates the following MINIMUM distances:
Leach Field to Well: 100 feet
Sepdc Tank to Well: 50 feet
Leach Field to Irrlgadon Ditches, Stream or Water Course: 50 feet
Sepdc System to Property Lines: (septic tank &leach field)lO feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT
A SITE PLAN.
GROUND CONDITIQNS:
Depth to first Ground Water Table ______________________ _
Percent Ground Slope __________________________ _
2
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'' TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
. (>4 SEPTIC TANK ( ) AERATION PLANT ( ) VAULT
( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POT ABLE USE
( ) PIT PRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
( ) CHEMICAL TOILET ( ) OTHER· DESCRIBE
FINAL DISPOSAL BY:
(>q 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?_~N'""'O..._ __ _
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 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
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.
·-';J2.aiJ~ n.t' Lf-1?.-o'O-.
PLEASE DRAW AN ACCURATEMAPTOYOURPROPERTYI! :i:-70 ,_;.. -~~r\~=~~'~~~~~~~:--:t-:-1~-;::::===== ~~~ ~tw~
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Designate North Arrow 5e e-/ A!o-JJ 5~ (V'l~/s
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Your Neighbor's
Name & Address
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Your Plot -Shape to Frt
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Locate we~ all Z:Zon 0 W8W co . U ~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.
Your Neighbor's
Name & Address
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County Road (Note the Road Number and Name) 0 333 Q u..«c....k-S ;/v<--v
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