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GARFl~D COUNTY BUILDING AND SANITATION DEPARTMENT
109 8th Stre91 Suite 303
Glenwood springs, Colorado 81601
Phone (303) 945·8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
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N ~ Permit •
AsseHor's Parcel No. ·
This does not constitute
a building or use permit.
Legal Description of Assessor's Parcel No. -----------------------_!~~~-=::::.iU!~~
SYSTEM DESIGN
/2 S<)
_,,, __ ..........
Septic Tank Capacity (gallon) ______ ,Other
_ _:_/_,_/ ___ Percolation Rate (minutes/inch) Number of Bedrooms (or other) <./ -f C-uf/?,
/,,o 3 ..c::~ //Q · t I-.~.,,./. ,.~,-,;;;-,,,_
Required Absorption Area· See Attached ;:;-0 / ,oe,. 1,.. / ,., , ~-"'" 2,. P .:~ 7-.r._ /4rvv-p-".#"? -v ;:)C'$
f,., / ::!:" t -......,.( ·"'/,~."'· '? 3z P~s J.3,...o '·
(001µ-( ~/ ..... • Special Setback Requlrem!nts: ___ ___:?:' G\\...-_...?. ,.._,P.1'9 IF'~ J f f>c-S JJ "("' Q tl
Date I/ I f'-CJ Z-Inspector ~...b"""~"'<.L...'-'C1"'"'-'"°""'""~='/;;;.;z..· -.-------------i
FINAL SYSTEM INSPECTION AND APPROVAL (as Installed) j ' l
' Call for Inspection (24 hour$ notice) Before Covering Installation
'<IJ.'Ll!&.L.._, _______ +------·· _____ l ! System Installer__.... ~
Septic Tank Capaclty• _ __,/_,:Z:::....)7.:::_0 ______ -.,,------------'"---~------
septlc Tank Manufacturer or Trade Name -'('-""~'7,-.(!."""'2"'-'""'<'=="===·~----------·'_· -----------
Absorption Area Type a~d/or Manu_facturer or Trade Name ..,.,J61!..a'.4'..a.;£,~U)_~e!_:_ ____________ _
Adeq~ate compliance with County and State regulations/requlrements_fl~-"tJ::J"--"-----------------
Date---'-/-'}-'I'-. 2....c--.,(;;...J'-_~_,O""'-'L= ___ .1nspector --:I~ .:;<(/?£?~ Other ~~
RETAIN WITH RECEIPT RECORDS AT CONSTRU;r; ~
•CONDITIONS:
1. Ali'hlll.illatlon 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 dwellin6 or struct,µres not approved by the Building and Zoning office shall automatically be a vlolatlon or a
requirement of the parmlt and cause for both legal action 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 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 James Gornick & Maria Sanchez
ADDRESS P.O. Box 1296 Glenwood Sp&s. CO 81602 PHONE 970-379-1763
CONTRACTOR___.:O~w~n~e~r~/~Bu~1~·1~d,_,e~r~----ll;.~1-------------------
ADDRESS _____ c._.'£"l>-=· ~, Bb..2f.....11=,+=---PHONE _____ _
PERMITREQUESTFOR (x) NEWINSTALLATION ( )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:
Near what City ofTown._~N.,.,e""'w,__,C,,,,a""s..kt-"-le,._ __________ _..S,..ize"'-"o"-'fLo..,...t'---'7'-'.-"0'-'3-"4-A""'cwrue::..os.___
Legal Description or Address NE 1/4, Section S, T6S, R91W, of the 6th P.M.
WASTES TYPE: (x) DWELLING C.~;;ll'f ~. C. ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER-DESCRIBE. ______________ _
BUILDING OR SERVICE TYPE:--'P,_,r,_,i,_,,m""a~r_,_y---'!.Re"'s""'i..,d,_,e'""n""c""e ______________ _:_ __
Number of Persons_,.,___ ___ _
(X) Dishwasher
Number of Bedrooms __,,4'---------------
( X) Garbage Grinder ( X) Automatic Washer
SQURCE AND TYPE OF WATER SUPPLY: ( x) WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier:. ________________ _
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:. _ ___.2;.__wmc.i..i....,l e,..s.__ ______ _
Was an effort made to connect to the Community System? __ ...:;Nc:;o ____________ _
A site plan ls 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 feet
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. ___________________________ _
2
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., Ty};E OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(x) 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:
(X ) 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=o ____ _
PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer, if the Engineer does the
Percolation Test)
Minutes, ____ ,per 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 aP. lication and in legal action for perjury as provided by law.
Date ~bdo 2 •
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Designate North Arrow
Your Neighbor's
Name & Address
Proposed
Driveway
Cnty
Proposed
Residenc-e------+\--tL.
-w-
Your Plot -Shape to Fit
(No Scale)
Valley Rd
1 D~Proposed Out Building
I '~V?V'.-?C '~
I I Proposed Septic -E-
~ I Existing Water Well
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-s-Ware & Hinds Ditch
Locate well, all streams, irrigation ditchs, and any water courses. Draw in your house,
septic tank & system, detached garages, and driveway.
If a change of location 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