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. ;l'J...,D~ GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N: 3 713 f
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• V ~ 109 8th Street Suite 303 AaseHor's Parcel No. ,
I Glenwood Springs, Colorado 81601
· I Phone (303) 945·8212
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i INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. W
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·: PROPERTY . _8 f Q t
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I System Location~~~~~\ fl.LJ i
I Legal Description of Assessor's Parcel No.--------------------------------
\ SYSTEM DESIGN ..
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_____ Septic Tank Capacity (gallon) ______ Other
-----Percolation Rate (minutes/inch) Number of Bedrooms (or other) ____ _
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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 lnstaller ___ ~O_t.J~fl)_fl-_~~~---------------------------
Septic Tank Capaclty ___ ~/C).~_$~----------------------------
Septic Tank Manufacturer or Trade Name __ eq::...g>A"'f""ck,_,,i:b"'-Ll1'-"ef"-------------------~---
Septic Tank Access with-;;, 8" of surface 4' S'
Absorption Area tf-1."s{/I\ r
Absorption Area Type and/or Manufacturer or Trade Name ------.,..------------------
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 ctlsposal 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 ($500.00 fine -6
months In jail or both).
White· APPLICANT Yellow· DEPARTMENT
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INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER_,...../_---'-<-#~(>'1""-'-"£~S"--_.../?._,_,_.___,~~W"?><=.._~~C.......:.,..,----'-'y~~~"-'-'$=---c;-=-.-~/JiJ_,_,,"---'1'9~n1:..;__.S _______ _
ADDRESS ?08 nJ,<--c..r& J H .v £ C ed6L1>HONE _t.._.t'J_5'_-_1_19'_0 ___ _
CONTRACTOR 6'i. L F -~---------------------------
ADDRESS ____ _....Af,'-'"R=/9-______ _
PERMIT REQUEST FOR ( ) NEW INSTALLATION ( ).ALTERATION (~AIR
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. ___ ~..s~t~:<._7_,· /~~tf~rF.~'=£~------~S=ize~o=f=Lo=t~~ef~o~c~te~E_,,s,___ J Legal Description or Address ________________________ _
WASTES TYPE: ( ,-(DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( )OTHER-DESCRIBE ______________ ~
BUILDING OR SERVICE TYPE: ______________________ _
Number of Persons -----=.,.2. __ _
( '1' Dishwasher
Number of Bedrooms------""'"------------
( ) Garbage Grinder ( r{'Autornatic Washer
SQURCE AND TypE OF WATER SUPPLY: (rl WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: ____ __;_M.,c.gf.;..;.,,,, _________ _
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}
Septic Tank to Well: 50 feet ./
Leach Field to Irrigation Ditches, Stream or Water Course: 50 feet/ /
Septic System to Property Lines: (septic tank &leach field)lO feeV
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 Joi'O k.J/"f', t/1-&
2
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, TYPJil OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
( ) SEPTIC TANK ( ) AERATION PLANT ( ) VAULT
( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POTABLE.USE
( ) PIT PRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTIIER USE
( ) CHEMICAL TOILET ( ) OTIIER -DESCRIBE
FINAL DISPOSAL BY:
( ) 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? ______ _
PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer, if the Engineer does the
Percolation Test)
Minutes. ____ _,,e.r inch in hole No. 1 Minutes _____ ,per 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.
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PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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Designate North Arrow ~~~..41:~ ~I~
Your Neighbor's (
Name & Address
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Your Plot -Shape to Fit
(No Scale)
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Locate well, all streamtfirrigation c!itchs, and any water courses. Draw in your house,
septic & system, detached garages, and driveway.
If a change oflocati n is necessary, you must submit a corrected drawing, before a
ertificate of OCClllla1ion will be issued.
County Road (Note the Road Number and Name) ~ad ~ .P 17
elic~
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Your Neighbor's
Name & Address
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