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Permit N: 36~' !
AsseHor'a Parcel No. ~
GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
109 8th Street Suite 303
Glenwood Springs, Co,orado 81601
Phone (303) 945\8212
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INDIVIDUAL SEWAGE DISPOSAL PERMIT
This does not constitute
a building or use permit.
PROPERTY ·~ Owner'sNamfu~ G.B PresentAddressOolCC.PG;l.{o/Q '$ Phone ______ _
::::.:.'.:::.~.oo~'~'.:]:~ b.
SYSTEM DESIGN ~ \
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_____ Septic Tank Capacity (gallon) ______ ,Qt her
_____ Percolation Rate (minutes/inch) Number of Bedrooms (or other) --~~-
' ' l"rtr Cb l?o cl.. 4-. el. t=:iM ~ulred Absorption Area· See Attached fl!l J lt:I ~ ~ ;;, 7 pcs. T ~ I {;p~" d:> """'....J.~-k,,C 3•1 p<!S ..g.,, 3X{,
Special Setback Requirements: ,~,7"3:d-'j("-'·•A ~~ , '!>Cf P<' ~; (J,. i;;, z ,l("j
Date ____________ Inspector--------------~-----------,·r
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Absorption Area Type and/or Manufacturer or Trade Name------------------------
Adequate compliance with County and State regulations/requirements, __________________ __.;__
Other ~
Date J fJ. • tPo • 0 ;2 Inspector ~Jjfl 7
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
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' " ,•CONDITIONS:
1. All Installation must cOmplywlth all requirements of the Colorado State Board of Health lndividu~ewage Disposal SyStems Chapter· .. t
25, Article 10 C.RS, 1973, Revised 1964, ' ' t' ;
2, This permit Is valid only for connection to structures which have fully complied with CountYloning and building requirements, Con· '
nection to or use with any dwelling or structures not approved by the Building and ZonlnQ o)flce shall auto~m· 19.ll~be a vlolatlon or a ~
requirement of the permit and cause for both legal action and revocation of the pe(ft)lt. ·.... '
3. Any person who constructs, alters, or Installs an Individual sewage disposal syst$rn In * .. rrldn<nl(whlch lnvolv a knowin'1"'tind m. at.rial ',
variation from the terms or specl(icatlons contained In the application of permli <:OmV'lts tr'Class I, Petty fense ($500.0Q.. fine'...;... 6 t
months In jail or b"j~l-\ ~
White. APPLICANT Yellow -DEPARTMENT ' ' :, ,, \
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INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER <:;. D, <:As T£~
ADDRESS tJ b 7 D .i( t (, A'..0 51 L / PHONE 970 ,hf,, O (.ef b
CONTRACTOR /9~1(0,,Y ExG+ctt'tZ?cJ<;---
ADDRESS ~6 C:; , PHONE Y 7o 'f7 I l.S-/J..
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PERMITREQUESTFOR ( ) NEWINSTALLATION (~TERATION ( )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).
LOCAIION OF PROPOSED FACILITY:
Near what City ofTown. ___ 5~t _L~'-----------~S=ize~o=f=Lo~t~-~-·-o_~.4~c~~~"'~_s~
Legal Description or Address Lo T 1 L A~ SA A..1' JZt 6 .
WASTES TYPE: ( '1'i)WELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( )OTHER-DESCRIBE _______________ _
BUILDING OR SERVICE TYPE: _ _,_/(..w..."~-_,_,"'-"'<:!.."-=-----------------
Number of Bedrooms----''-------------Number of Persons _ _,_f ____ _
( ) Garbage Grinder ( '1 Automatic Washer ( .(Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: ( ) WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: ____ N.:~..._ _________ _
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: __ ~+.%~,,,-'----------
Was an effort made to connect to the Community System? __ _:_Yv".:..µ.~---------
A site plan 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 Irrigation Ditches, Stream or Water Course: SO feet
Septic System to Property Lines: (septic tank &leach field)lO feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT
A SITE PLAN.
GRQUND CONDITIONS:
Depth to first Ground Water Table ______________________ _
Percent Ground Slope __________________________ _
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TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
( ) SEPTIC TANK ( ) AERATION PLANT ( ) VAULT
( ) VAULTPRIVY ( ) COMPOSTINGTOILET ( ) RECYCLING, POT ABLE USE
( ) PIT PRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
( ) CHEMICAL TOILET ( ) OTHER -DESCRIBE._,_,t1,""L..LT&t.-=-c,__-"L'--. ~-'-fo--"'(.//"---'-F,'-7€--'t-'-'~~--
FIN~ DISPOSAL BY:
( v{ 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'._._,,l,_1 ___ _
PERCOLATION TEST RESULTS: {To be completed by Registered Professional Engineer, if the Engineer does the
Percolation Test)
Minutes. ____ _,.er inch in hole No. 1 Minutes _____ _,.er inch in hole NO. 3
Minutes er inch in hole No. 2 Minutes er 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
fillsification 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 _~P~._:3_,c__Cc __ .. _~---"'-----Date. __ t-+.fa""'1_P~~-'1_v _______ _
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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