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} ~. l' ~ ;;;p-J """'"° "'""" .......... ANO .... ,.,,.. .............. ..~. NC . 3 6t 8 i (} , ? 109 8th Street Suite 303 AsseHor'a Parcel No. 1 -·: /p Glenwood Springe, Colorado 81801 ----------4
Phone (303) 945·8212 4
This does not constitute I
a building or use permit. J
l INDIVIDUAL SEWAQE DISPOSAL PERMIT 4Cf(o
PROPERTY 7.o~~.~~
Owner's NamefPe~";Irojlf' KUn Present Address c.£..a47 ~. 6-s\\.\L Phono98+-0 ~18' i ~
' System Location (.~<,0£:; (947 ~,.) Co ~p,
i Legal Description of Assessor's Parcel No.
' SYSTEM DESIGN
1 ~l~~~~O~-Septic Tank Capacity (gallon) ______ Other
~ , -----Percolation Rate (minutes/Inch) Number of Bedrooms (or other) 3 f <-itttS"6tir /), "f:tlt.4/
1 z 'lzlil Rtdi £ ~ r..<.h I Required Absorption Area· See Attached r,2 I l:b /.7 -...J. Qt,~ ~ .:J.!L
','., Special Setback Requlre~!~ts: ,· ' "1;Z'!f ::::1: ~~ ~:J-~ rff\1~ ,,
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Date /4-'2 s-;..o'? · , . Inspector-~-""· ~"""~"""'r<:>"""o..:;"""------------------
1, FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
6 Call for Inspection (24 hours notice). Pelore Covering Installation .,
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System lnstaller_(!h""°"~"J?r""",/,"''4"-"---------------------------------
Septic Tank Capaclty_11.2!2~.:l, ---------------------------------
Septic Tank Manufactl,frar or 'Trade Name
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• Septic Tank Access within 6" of surface_~ ~ .. :· , ,
'AbsorptlonArea ~4 h,...d. (!~<J_J Uf )<,
·,Absorption Area Type and/or Manufacturer o'..Jr~de~,.· ~=L!~=='-"'""""'----------------
Adequate compliance with County and State regulations/requlrements_,~ff'{""/,"''d""'-----------------
Other------------------,,.----,~~-.,--_..,.,,_,,,,._ ______________ _
Date 7-a/2-()L Inspector ...,-:1::.-$, w
RETAIN WITH RECEIPT RECORDS AT CO~ION SITE
I •CONDITIONS:
~ 1. All Installation must comply with all requirements oflhe Colorado State Board of Health Individual Sewage Disposal Systems Chapter
25, Article 10 C.R.S. 1973, Revised 1984. I 2, This permit Is valid only for oonnectlon to structures which have fully complied with County zoning and building requirements. Con·
• nectlon to or use wllh any dwelling or structures not approved by the Bull ding and Zoning office shall automatically be a violation or a
' ~ requirement of tho permit and cause for both legal action and rovocetlon of the permit.
j f 3. Any person who constructs, titers, or Installs an lndlvldual sewage disposal system In a manner which lnvolvesa knowing and material
I i variation from the terms or l"poclflcations contained In the application of permit commits a Class I, Petty Offense ($500.00 fine - 6
...-·, months In jail or both).
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I \ White. APPLICANT Yellow-DEPARTMENT
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INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
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OWNER I (f!t r f>lrtt= feese.;
ADDREss f o 6a 1-JS,Le /J£J12 Ca.>Jl.e ['oX-tiD<l1 PHONE q10 ·9Y'-/·6'?7:1
CONTRACTOR Trey L }; /so/I
ADDRESS e(), 84 /.37/ ,/(:f/.e, c, R/L5P PHONE 9~-'il76-t?/~
PERMIT REQUEST FOR M_ 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:
NearwhatCityofTown--"J"A..,.z.,_)_,C""'""'ar:; .... t'"-"L=----------'S""jze""-"ofuLo......_t -'=~<..:.._,.,_85~7=~---
Legal Description or Address ___ ~Cv~~&J~ .... &-..~~1 _______________ _
WASTES TYPE: (XQ_ DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( )OTHER-DESCRIBE ______________ ~
BUILDINGORSERVICETYPE:J'R~D~s~iJ ........ 1n~k~&~l_lf,,UM.!.m,.e<-=----------------
Number ofBedrooms _ _,_...._ _________ _ Number of Persons -1+------
(KJ Dishwasher ()0 Garbage Grinder (/>() Automatic Washer
SQURCE AND TypE OF WATER SQPPLY: ( ) WELL b(') SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: _____ ~J_;~/i~-------
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: ___ /.,,...)..,./_,_(/,__ _____ _
Was an effort made to connect to the Community System? ____ _,_A.,.)-1/ ..... '4:'-'---------
A site oJan Is required to be submitted that Indicates the following MINIMUM distances;
Leach Field to Well; 100 feet
Septic Tank to Well; SO feet
Leach Field to Irrlgadon Ditches, Stream or Water Course; SO feet
Sepdc System to Property Lines; (septic tank & leach field )10 feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHQUT
A SITE PLAN,
GROUND CONDITIONS:
Depth to first Ground Water Table _____________________ _
Percent Ground Slope. _________________________ _
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WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? ______ _
PERCOLATION TEST RESULIS: (To be completed by Registered Professional Engineer, if the Engineer does the
Percolation Test)
Minutes. ____ _iper 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.
Signed -zym ~ Date t.. -2-(, ·• 2-<"0 2-
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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