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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
109 8th street Suite 303
Glenwood Springs, Colorado 81801
Phone (303) 945·8212
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Permit N~ 3718
AaaeHor's Parcel No.
INDIVIDUAL SEWAQE DISPOSAL PERMIT
PROPERTY
This does not constitute
a building or use permit.
Legal Description of Assessor's Par~l 0No. _______ __.L,_,o,,_t_,_C/.-'-"O)'--¥-V\n-1.!Ju+Lf~.e'-'f'--"S.!__i..Q.L.!_r~c:o.!/,<_~q~tf:'....:'.!c£,__ __ _
SYSTEM DESIGN
• I.DOD
' Septic Tank Capacity (gallon) ______ .Other
-~3=-'-f ___ Percolation Rate (minutes/Inch) Number of Bedroon>s,Jor otrer) 3f 6~tif..fJf2 ~ · 1f:ti ~ #:Jf.iJ1.~.h(3jh) b'-</I~ (L~) ... c.\
1°1'3 Ip ~cf 4:3 ~ (3i. (,) CS'-$'D ~-tr ii;~.,)
Required Absorption Area • See Attached
equlrements:
Date--''2f-<'-4µ.,.'-'2-::::_ ______ lnspector --.+,LJ.,_,,.!1..,A:..H:....:..·..c1'--t\p-''°-'a""."'J""'---------------
FINAL SY.STEM INSPECTION AND APPROVAL (as Installed)
' Call for Inspection (24 hours notice) Before Covering Installation
System Installer /(4 ,S~
Septic Tank Capacity //3ij ~
Septic Tank Manufacturer or Trade Name_{;"'~'""""'"""=·-------------------------
Septic Tank Access within 8" of surface --..!:'Jl!:.~--------------------------
Absorption Area~~"'-""'·"""~"""=--------------~----------------
Absorption Area Type and/or Manufacturer or Trade Name _,..J/z:;;:Z""'i~l'-(L""""'~"'""°'~"":u;"-"':::,"'--.. ---------------
Adequate compliance with County and State regulatlonslrequirements_.;p',,,l<.121J="'---"-c-._ -------------
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Other----------------------7''---:--,,~~---------------
Date '1--') z~ 0 2..
RETAIN WITH RECEIPT RECORDS AT CONS
•CONDITIONS:
1. All installation mu at 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 la valid only for connection to structures which have fully complied with eounty zoning and building requirements. Con·
nection to or use with any dwelling or structures not approved by the Building and Zorllng 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 dlsposal system In a manner which Involves a knowing and material
variation from the terms or specifications contained In the application of permit commits a Cla88 I, Petty Offense ($500.00 fine - 6
months In jail or both).
White. APPL~ANT Yellow. DEPARTMENT
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.. INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER A"-e/ly J dn.-sei--.. ,.,.
ADDRESS 267 hrfrr>4// /.,.,, o:Cf 5i/(.£,:Z. PHONE 9y-(11'( '.lit,'
CONTRACTOR &f)w1.._ C!"""5±ru'-fr.9Jc. , {(i;.y4 n 'f3'...Jk1r111,.)
ADDRESS /~o Ar;k dfl!!s4 !{,£ l<J/,,1./",..1e.f 1 i:,<;1'.91,2 JHONE 970 -2<;"'(-l<jo Z
PERMlTREQUESTFOR ~)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 PRQPOSEp FACD.JTY:
Near what City of Town'---...:."f?.;...;1-0{:'._._(_,.'(:'------,.----------"S,..jz ... e .,._of..,L..,o..,_t _4~35-"-. -~) ..:0:....o-o __ i/J.:___
Legal Description or Address a l#h&f J33 W /-<f)__ ffe:'/fe/5 orchvJ
WASTES TYPE: (,>') DWELLING ( ) TRANSIENT USE ..m_ {,1tf.
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER-DESCRIBE ____ ~~~~--~----
BUILDINO OR SERVICE TYPE: __ S-1/--.r-_""'.])~w_t=l.-...\i_'::J-1--------------
Number of Bedrooms Number of Persons _ _,_ ___ _
(><) Garbage Grinder V..) Automatic Washer
SOURCE AND TXPE OF WATER SUPPLY: fie) WELL
!,><) Dishwasher
( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: _______________ _
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:___.5-..,na....._.1...._/~~s--------
Was ari effort made to connect to the Community System? _ _.;..Al;:..><._,_ __________ _
A site plan is required to be submitted that ipd!cates the following MINIMUM distances;
Leach Field to Well: 100 feet
Septic Tank to Well; 50 feet
Leach Field to Irrlgadon Ditches, Stream or Water Course: 50 feet
Sepdc System to Property Lipes: 10 feet
YOUR INDIVJDUAL SEWAGE DISPQSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT
A SITE PLAN.
GRQUNP CONDITIONS:
Depth to first Ground Water Table. ______________________ _
Percent Ground Slope _________________________ _
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T1J>E OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(-./) 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:
(j) ABSORPTION TRENCH, BED OR PIT ( ) EV APOTRANSPlRATlON
( ) UNDERGROUND DISPERSAL ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
( ) OTHER-DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE?_.lJ..,O"'--· ----
PERCOLAIION TEST RESULTS: (To be completed by Registered Professional Engineer, if the Engineer does the
Percolation Test)
Minutes. ____ ..yer inch in hole No. 1 Minutes _____ p,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 peimit 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 ~.. ~' Date /P ~ ;2 7 -c::J :2.
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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Designate North Arrow
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Your Neighbor's
Name & Address
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Your Plot -Shape to Fit
(No Scale)
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Locate well, all streams, irrigation ditchs, and any water courses. Draw in your house,
septic tank & system, detached garages, and driveway.
If a change oflocation is necessary, you must submit a corrected drawing, before a
Certificate of Occupation will be issued.
County Road (Note the Road Number and Name)
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Your Neighbor's
Name & Address