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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
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3736 I { ,
Permit N~
Aaae11or'1 Parcel No. •
-, 109 8th Street Suite 303
Glenwood Springe, Colorado 81601
Phone (303) 945·8212 -------' f
l This does not constitute
a building or use permtt.
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t INl?.IVIDUAL SEWAGE DISPOSAL PERMIT
I PROPERTY ! Owner's Name -fhtir wi+i. ;~ r b>. (O.. Present Address ~8t).~l{i~o~CJ..~1~1_..5'--'6=-=· .S:::....:..8:...c.11._c._._J _ Phon9 tf S-39 'J.3 l SyatemLocetion 'i/~t/O C.R. flS G'.S. (5/1,..o/
~ Legal Description of Assessor's Parcel No. ------~~~-'~8~'7~--~· ~-~3~-'--"0"o"-----'1_4,_o=-------------
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~/~o~o~o __ Septic Tank Capacity (gallon)
--'-/_l',_ __ Percolation Rate (minutes/Inch)
Required Absorption Area • See Attached
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______ Other
Number of Bedrooms (or other) __ 3'----
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Date_9'----"~"---''"'-J...J2.__ _____ Inspector ~ ~
Special Setback Requirements:
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FINAL SYSTEM INSPECTION ANI) APPROVAL (as installed)
Call for Inspection (24 'hours notice) Before Covering _Installation
System lnstaller.Jet.r l};i)d ''• '· ' ) J { 0. . •' I
Septic Tank Ca:pa:qity_~/'--"(}-'t"-J_,O'---------------------------------
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Septic Tank Manufacturer or Trade Name _;I..£)~"'-'"'"''='--'·~·-------------------------
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Septic Tank Access within 8" ot surface -4-~"---------------------------
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Absorption Area __ •_.1f~l'-"1~:'_~··-''-'-' _.-~---"--"-·',';"'."'·</,_· v_··------------------------
Absorption Area Type and/or Manufacturer or Trade Name~!~~--· _~_v_./_'·_1_··-·~, ·--·~·'~/_"_" ______________ _
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Adequate compliance with County and State regulatlons/requlrements_,,,"+·_.J~;"' .. _' --------------_;_·1.+''":.,: .... i,• 'lf\;•
Other_/_/_/_f/_,.,._-::l ______ -___ -_ -. -7~.-/.-_ .. /~?!'~/~. -------;(i:til~J
Date ~f-'.f'V w:ETAIN WITH1 ::~~~~T-R-E"'~"'~"';-=D~Stc~q.:rad~=~f7.Nfo15,;z;..-::.U;,,C._T_IO-N-S-IT_E ____________ ;:f \'!/~i
•CONDITIONS:
1. All Installation must comply with all requirements ot 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 ccnnectlon to structures which have fully complied with County zoning and building requirements. Con·
nectlon to or use with any dwelling orstr~ctures not approved by the Building and Zoning office shall automatically be a violation or a
requirement of the permit and cause for beth legal aptlon and revocation of the permit
3. Any person who constructs, alters, or installs an Individual sewage disposal system In a manner which Involves a knowing and material
variation from the terms or speclflcatlohs contained In the application of permit commits a Class I, Petty Offense ($500.00 flne-6
months In jail or both).
Whtte • APPLICANT Yellow. DEPARTMENT
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- - - --;:: - - - - - - - - - - - - - - - - - - - - - - - - - ------ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
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OWNER ~O.Sbl\$"C... \\u~wh
ADDRESS <2>'d"\C> \'0 ,,,¥0.d \\$, •1 ~\e-ry..1ood PHONE CJ~~ -<Q<1')2)
CONTRACTOR ~c::i.~'s> \\\)'£LU\\,<
ADDRESS PHONE 9Y~-CQ9')3:>
PERMIT REQUEST FOR ( vJNEW 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 PROPOSERfACILITY:
Near what City ofTown~....:\.O~~~~~.l._~~~~L--.,-----'ml:!.2!,!<Ql~~_o~s~
Legal Description or Address ~~d~"fO~_:~~~~~S!Q,.y,;:,~21-~~~'=!!:!!2.ll<-~;;\:-;t;~\'\:;:;;:ci:~r1~
WASTES TYPE: (i.-rDWELLING (
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( )OTHER-D~E·---------------
BUILDING OR SERVICE TYPE: ~,..._~ ~o.m\..... \\o'<"'t>e.-
Number of Bedrooms J Number of Persons-~~----
( ) Garbage Grinder ( \..}'1\.utomatic Washer
SOURCE AND TypE OF WATER SUPPLY: (1.-}-WELL
( ...YDishwasher
( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: _______________ _
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: \ Q >.-~~-e.=> •
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
Sepdc Tank to Well: SO feet
Leach Field to lrrlgadon Ditches, Stream or Water Course: SO feet
Sepdc 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:
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Depth to first Ground Water Table ___ \~0~<3~------------------
Percent Ground Slope. ___________ '-----------------
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TYPE bF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
( i..r-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:
(vJ' ABSORPTIONTRENCH,BEDORPIT \_-€_~""~€>..~ ( ) EVAPOTRANSPIRATION
( ) UNDERGROUND DISPERSAL ( ) SAND FILTER
( ) ABOVEGROUNDDISPERSAL ( ) WASTEWATERPOND
( ) OTHER-DESCRIBE. _____________________ _
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE?_~'-'-'O""'----
PERCOLATION TEST RESULIS: (To be completed by Registered Professional Engineer, ifthe Engineer does the
Percolation Test)
Minutes. ____ __,.er 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
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.
Date'--_'O=---_<:i._-'D=-.;~:,:__ ___ _
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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Designate North Arrow \...,\.)€..\\
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) ~~<.\v ~un
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Your Neighbor's
Name & Address
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