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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT N('
Permit -382~
; 109 8th Street Suite 303 Assessor's Parcel No. ;
t • I Glenwood Springs, Colorado 81601
Phone (303) 945-8212
;)f"Jf)-333-ro -3 7._:;
INDIVIDUAL SEWAGE DISPOSAL PERMIT (
This does not constitute
a building or use permit.
' PROPERTY ..
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O_wner's Name.:::k1'1' 'ii>I" 1 ~~ Prasent Addres?.(/9/C /..3l/b 5; ff (,. · ~/l,.5.)__ Phone 309 -J;;J~J
, System Location _ _..O<-t/<_,__,,,,t;'--z-.-____ LA'-'-r-'--(b_u.)-=-~=--=°'=d"--_l/;'-'-ro.=--l,_,_l-'f.'-'--i+_l4!:_11--'-1>_f'--(.'--/ lL--.1..G;:;.J_Cro~~,._____,_,M-'-'-'-es""o...""'----
.• Legal Description of Assessor's Parcel No.--------------------------------
SYSTEM DESIGN
I / )_ S1) Septic Tank Capacity (gallon) Other
\ \ Percolation Rate (minutes/inch) Number of Bedrooms (or othe2 :-ti 1__/ -f W ~ -
Required Absorption Area-See Attached 157 e ~ _ £_~ ~ ~ l.lvvc~ '
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t..-z:i I ,,. k 11\VM.1'\ -/._ ) ~ L v:.. µJ: 32 ~G~c,)G'L 3?w_.,_J,,(;>l<'8.
bDIP /} Special Setback Requirements:
Date_=g_-_?-f)~_-~0_'3~ ____ Inspector j)/JA)-<-jl ') M-#--tJI!-
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
septic Tank capacity--~~~O~ __ V~~------------------------------
Septic Tank Manufacturer or Trade Name ~C~¥~y~=0-_ _.!"-----------------------
Septic Tank Access within 8" of surla~ J
Absorption Area 21~ kb~ ( 14 4 /3 F ,,
/l I~~ If ~to
Absorption Area Type and/or Manufacturer or Trade Name-'~""'-=-!>-''---'------'--------------
Adequate compliance with yunty and State ragulations/raquiraments_.t"'P'W"~~-----------------
Other _________________ ~----f-----~-------------Date~'[,_-~J~~'0~3~ __ lnspector-1<1._._.._.Ad~· _,7J_Le;L~~------
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.RS. 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 disposal system in a manner which involves a knowing and material
variation from the terms or ~p~ficat1ons contained in the appUcation of permit commits a Class I, Petty Offense ($500.00 fine - 6
months in jail or both). r '
White -APPLICANT Yellow -DEPARTMENT
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INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
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ADDRESS,hl '17 (/;11~ r>tl~#
~ONTRACTOR
ADDRESS ilJo
./±(rowlr.€w 7f. PHONE "3 ~9' . 3 35" 7
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• &~r §l{<S<f C ti?.. 3<1<,, siJWoNE 397-3 3.5 '/
PERMITREQUESTFOR ~ NEWINSTALLATION ( )ALTERATION ( )REPAIR
Attach separate sheets or report shov.ing 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).
Near what City of Town'-1-...::.LJ'..-.!.i.....,..=-------1.=-u...:_:..Y.=-~-hllSi~ze2....1ol!.f..J.<L.!.!.lot
Legal Description or Address
WASTES TYPE: /..(> DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL
( ) OTIIER -DESCRIBE
( ) NON-DOMESTIC WASTES
IlUILDING OR SERVICE TYPE: 5/F 1)1>-leill ~
Number of Bedrooms __ t,/...._ __________ N.umber of Persons t/
(v("" Garbage Grinder ( ~tomatic Washer ( ¢i'shwasher
SOURCE AND TYPE OF WATER SUPPLY: (~LL ( ) SPRING ( ) STREAM OR CREEK
lf supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM; It? tit:~~
Was an effort made to connect to the Community System?
A site plan is reouired to be submitted that indicates the following MINIMUM distances:
Leach Field to Well: 100 feet
Septic Tank to Well: !iiO feet
Leach Field to Irrigation Ditches, Stream or Water Course: 50 feet
Septic System (septic tank & disposal field) to Property Lines: 10 feet
YOVRINDIVIDUALSEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT
A SITE PLAN.
GROUND CONDITIONS:
Depth to first Ground \Vater Table
Percent Gro\lnd Slope ~ -•1 't
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
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( ) SEPTIC TANK ( ) AERATION PLANT (~AULT • ' ( j VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POT ADLE USE
( f PIT PRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
( ) CHEMICAL TOILET( ) OTHER-DESCRIBE
FINAL DISPOSAL BY:
( ) ABSORPTION TRENCII, BED OR PIT
Fie.Id
( ) EV APOTRANSPIRA TION
( ~ UNDERGROUND DISPERSAL IJ/J'I; ~ ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
( ) OTHER-DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE
STATE? tJ 0 PERCOLATION TEST RESULTS· (To be completed by
Registered Professional Engineer, if the Engineer does the Percolation Test) Pe'!);:/;;/!~ Cov,.,/. Y
Minutes per inch in hole No. 1 Minutes per inch in hole NO. 3
Minutes ____ per inch in hole No. 2 Minutes _____ ~per 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.
PLEASE DRAW AN ACCURATE
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