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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
109 8th Street Suite 303
Glenwood Springs, Colorado 81601
Phone (303) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
Permit N: 3792
Assessor's Parcel No.
This does not constitute
a building or use permit.
; ~ner's Name/Yl:&Yiz.~1 ~-'L Present Address --f. 0 · & '£ .QI l{ I f S 'i!{ lo~ Phan~ '-6-/ <./ f.. tj
~ ~ystemlocation _____ ~/5~'J.-'--'~~-C_i'<._,____,IS=-l.f_,____-'G'=-fi-=-e1A.::...::~="""'---~--1-'-t"-'-\L/'j5=¥-C,-=,?!L'.....:/l...:..::o_J__/
~ :Legal Description at Assessor's Parcel No. _______ _,d-.'""'-.:...J.l--''(,,_5=-_-_;~=...:N~<!.._-_~0=0~,~0::'..._0~~S;:::z_ ______ _
. -SYSTEM DESIGN 1~
______ Septic Tank Capacity (gallon) ______ ,Other
______ Percolation Rate (minutes/inch) Number of Bedrooms (or other) ____ _
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 Installer 'i1® ~~ ~){
·septic Tank Capacity /51YJ /jh -:(L
<:; J/ vf!"! ? ---z'4 I _L .
Septic Tank Manufacturer or Trade Name ---'<"-{(../_-"'--{ll---/.LJ.,t.,[;..~-J.C:,.,..o.,..--~-k4"""'-14--'~==="'-'=""-------------
Septic Tank Access within 8" of surface ---')4-'t?,'-'~'<'------------------------------
Absorption Area ______________ C::=z..._#_,.~~~-~---· -+------------------
Absorption Area Type and/or Manufacturer or Trade Name--------------------------
Adequate compliance with County and State regulations/requirements. _____________________ _
Other---,------------------~,-------,,------~-------------Date_i_,_-_,,,,_J~-D~3~ __ Inspector -----P<i~lµ<·f/r-"-ld~Jr~lJ'--'-'e'4<1'4w:,tf-=-'=-------
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 autorl)lltically 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 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 /{11Y€ j110.KeJJ21G
ADDRESS ? o lh ~ .214' ,. ?jt<J S <!..() f'/ 6 d 2. PHONE 9 70 9,-J: /f/b t/
CONTRACTOR £ v6ef~66-A/ {J,~AJ.s-r
ADDRESS G;fe,....,,;Cf'f)J..5fti l\.<5 PHONE C\1<.lS-t.. elf~ Jt;~"' S~MA-..... ...
PERMIT REQUEST FOR ( ) NEW INSTALLATION ( )ALTERATION (~PAIR
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 Cl Le A/Woo t; ~P.et.Pf r
Legal Description or Address /513 cie_ ( i; tf
WASTES TYPE: (..(DWELLING
Size of Lot I ~
Qe;.w c-0cl <S"pr • "J s
( ) TR;(NSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER -DESCRIBE
BUILDING OR SERVICE TYPE:
Number of Bedrooms -~..l ____________ N.umber of Persons~-/ __
( ) Garbage Grinder ( ) Automatic Washer,.,.
SOURCE AND TYPE OF WATER SUPPL;i: (-")WELL
If supplied by Community Water, give name of supplier:
( ) Dishwasher
( ) SPRING ( ) STREAM OR CREEK
DISTANCE TO NEAREST (:OMMUNITY SEWER SYSTEM:
Was an effort made to cpnnect to the Community System?,
A site plan is reguired to be submitted that indicates the following MINIMUM distances:
Leach Field to Well: 100 feet
Septic Tank to Well: SO feet
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Leach Field to Irrigation Ditches. Stream or Water Course: SO feet
Septic System (septic tank & disposal field) to Property Lines: 10 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
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
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(:,{ 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:
( ) ABSORPTION TRENCH, BED OR PIT
( ) UNDERGROUND DISPERSAL
( ) ABOVE GROUND DISPERSAL
( ) EVAPOTRANSPIRATION
( ) SAND FILTER
( ) WASTEWATERPOND
( ) OTHER-DESCRIBE. _______________________ _
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE
STATE? /JO PERCOLATION TEST RESULTS: (To be completed by
Registered Professional Engineer, ifthe Engineer does the Percolation Test)
Minutes ____ _,per inch in hole No. I Minutes _____ _,per inch in hole NO. 3
Minutes per 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 of RPE 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 applic 'on and in le · n for perjury as provided by law.
PLEASE ORA WAN ACCURATE MAP TO YOUR PROPERTY!!
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PERCOLATION TESTS FOR DRY WEµ.s (SEEPAGE PITS) ARE PERFORMED AT THE LEVEL OF THE
BOTTOM OF THE PIT (USUALLY 10 FEET>.
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If you call for a percolation test or inspection and for some reason are not ready when the time comes, please call us
before 4:00 p.m. at 945-8212 to cancel the appointment.
THANK YOU FOR YOUR COOPERATION.
(FOR APPLICANT'S INFORMATION)
RECOMMENDED MINIMUM REQUIREMENTS FOR
INDIVIDUAL SEWAGE DISPOSAL SYSTEMS
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