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AHeHor's Parcel No.
GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N'.:.
109 8th Street Suite 303
Glenwood Springe, Colorado 81601
Phone (303) 945·8212
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INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
This does not constitute
a building or use permit.
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t Owner's Name R.;ff'i
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~ -+&d~ Present Address PO .&rgq '{;J.C. '6/bCf/ Phone G/g · l/r'<,?
l System Location c~ ';ic/C ~L.wCasf(~ w 'i'/6 Y7
t Legal Description of Assessor's Parcel No. () t J~O 'fi:J Pl( € )GQ!\l\f1i<> ,;'\
t SVSTEMDESIGN :;J.f"-'?J•33f-00-/'S
' / ()Q() Septic Tank Capacity (gallon)
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__ 4~Cf~-Percolation Rate (minutes/inch)
______ Other
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t( 0 pc..(i. \(~ t
Required Absorption Area • See Attached
Special Setback ·Requirements: :
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I Date _ _,_,! O""+l lul-Jl-1.C:>.JJ....""'-----Inspector _ __,_()a,_,"""c-t"'h~· J...._~flt_,,, ... U--L ..... ==='--------.-----
j FINAL SYSTEM INSPECTION AND APPROVAL (as installed) ,/
~ . Call for Inspection (24 hours notice) Before Covering Installation ~ ~-.. I \ '
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/\' \ System lnstaller-'-·_".:...£.1 .:L"W:.'CJ·:' ____________________ c.__-+J.1<----------
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Septic Tank Capaclty_l_:t'-:-''c;:..)u,.,'::_ _____ ~""l'""' ------------------------
Septic Tank Manufacturer or Trade Name ~c.·~: ~(;-./"--:~~,.,/~o::--"'--------------------------
~ptic Tank Access within 8" of surface ~W.'-"''--------------------__:_----,-----
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sorptlon Area _J_-"7=·=---------------------------"--------
A1~orptlon Area Type and/or Manufacturer or Trade Name ~e>-"'"-;b..,I'"" l,1-'-/"-;-"i,-"'.,."-.--'/o-'-,-'."'P=-------"--.,,-..-------' #""
Ade ate compliance with County and State regulatlons/requlrements.~'¥-<..,· ·'c:?.:· '--------d.,..."'--------. '
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Other----------------+---------------.,....,,---------...~
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Date //_ /?f-loot... Inspector --z;;~7;. ~ · '~· --,./
/ /_,, /'l "'OhETAIN WITH RECEIPT RECORDSATCO~ION s~fE ;-· . ·
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•CONDITIONS: .. J .
1. All lnstallatlon must comply with all requirements of the Colorado State Board of Health ln~.ivldual Sewage Disposal Systems Chapter
25, Article 10 C.R.S. 1973, Revised 1984. · · · ·
2. This permit ls valid only for connection to structures Which have fully compliea with County zoning and building requirements. Con-
nection to or use with any dwelling or structures not aP:·proved by the Bullding'a}ld Zoning ()ffi.ce st)all automatically be a violation or a
requirement of the permit and cause for both legal •ctlon and revocatlori_o( the perm I\··
3. Any person who constructs, alters, or Installs an Individual sewage dlsposa,f •.~: tem In a m'inper which Involves a knowing and mate.rial
variation from the terms or specifications contained In the appllcatlO"'h of~ermlt commit• a Class I, Petty Offense ($500.00 fine\-6
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months In )all or both). '·~···: ...... · · ·
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I White· APPLICANT Yellow· DEPARTMENT
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' INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER (\-h~ JS ffj
ADDRESS Co :KJ. V-/o PHONE $'';&z6'95
CONTRACTOR • Ho.c\.,"I" -"i<'ieti'j
ADDRESS 1€11 c'fD Rd i G-1.,.,,,v.JoocJ '5f'JS. (!Q%/t,o( PHONE 98</-21Sl(
PERMIT REQUEST FOR iy1 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 11/e. .. d C2.stl-e SizeofLot 8.70 Ac..
Legal Description or Address TR.Ac. I Z 1 tlar l+J K•'ff'f &.cgvq/,°tJ.J
WASTES TYPE: ")><> DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( )OTHER-DESCRIBE. _______________ _
BUILDING OR SERVICE TYPE: __ J<,~1'~5~''~p/~-t>-.J_t~,·o..._,__( -----------------
Number of Bedrooms Number of Persons----''-----
( ) Garbage Grinder ~ Automatic Washer J><O_ Dishwasher
SOURCE AND TypE OF WATER SUPPLY: ~ WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: ____ M~0~A~----------
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: ______ z~. s~· ~rn~1~lc:~!>~---
Was an effort made to connect to the Community System? ___ _.M"-"""""------------
A site plan is required to be submitted that Indicates the following MINIMUM distances:
Leach Field to Well: 100 feet
Sepdc 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.
GROUND CONDITIONS:
Depth to first Ground Water Table ____ __;;2_7'1_i'.>_F_ec:_f-______________ _
Percent Ground Slope ____ ~J~'.7,---------------------
2
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TYPE GF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
~ SEPTIC TANK ( ) AERATION PLANT ( ) VAULT
( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POTABLE USE
( ) PIT PRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
( ) CHEMICAL TOILET ( ) OTHER· DESCRIBE
FINAL DISPOSAL BY:
9<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? _ _,.t</~C)"----
PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer, ifthe 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
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_--==C5~r-T ~-~,..---~ Date. __ _..&._-_1_7_·--=0'-'2-=-------
PLEASE DRAW AN ACCURATEMAPTOYOURPROPERTYI!
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