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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
108 Eighth Street, Suite 201
Glenwood Springs, Coloradof 81601
Phone (970) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
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Permit '1 l
Assessor's Parcel No.
a393-//y-00-oo/
This does not constitute
a building or use permit.
PROPERTY
In YZicLl afcl O633Cac As[;'laf3 ( `14)e_ 862-3 It
Owner's Name / Present Address Phone -�
System Location 00 5� C.ac-h Flims f'c(. (et(e0AcQa le Co 5003
Legal Description of Assessor's Parcel No
SYSTEM DESIGN 11 P77JIV
Septic Tank Capacity (gallon) Other
Ltsf / !.f f (.0 like C ree k 5ubcf
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
Septic Tank Capacity
Septic Tank Manufacturer or Trade Name
Septic Tank Access within 8" of surface
Absorption Area
Absorption Area Type and/or Manufacturer or Trade Name
Adequate compliance with County and State regulations/requirements
Other
Date .�' L <' -- v .37. Inspector
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
*CONDITIONS:
1. All installation must comply with alt 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 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 specifications contained in the application of permit commits a Class 1, Petty Offense ($500.00 fine — 6
months in jail or both).
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INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER jfrc4aro fnOp trore
ADDRESS(X/33 (aG fu S F/a lir &'I
CONTRACTOR 8 (LOS /N/,,7 -rife
ADDRESS 3 3 f."
PERMIT REQUEST FOR ( ) NEW INSTALLATION
PHONE 963 -36//
PHONE %C9 -3`f/
/lee/aee talloJy
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 FACIILITY:
Near what City of Town Ca r b e /V a it
Legal Description or Address Lof /, u P Ca t fle
WASTES TYPE:
Size of Lot [, / acre..?
Gree fr t6033 QCK.sRah
Rel .
( DWELLING ( ) TRANSIENT USE c' ddi
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER—DESCRIBE
BUILDING OR SERVICE TYPE: S 'd/6 � r a t( y
Number of Bedrooms ( Numberuof Persons
O Garbage Grinder (y5 Automatic Washer QO Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: ( ) WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: uP Ca f f /e Cr ee k- Ha A
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: `% IYl ,' s
Was an effort made to connect to the Community System? /1/61
A site plan is required to be submitted that indicates the following MINIMUM distances:
Leach Field to Well:
Septic Tank to Well:
Leach Field to Irrigation Ditches, Stream or Water Course:
Septic System (septic tank & disposal field) to Property Lines:
100 feet
50 feet
50 feet
10 feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT
A SITE PLAN.
GROUND CONDITIONS:
Depth to first Ground Water Table /10 /
Percent Ground Slope 3 70
2
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(() 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:
00
( )
()
( )
ABSORPTION TRENCH, BED OR PIT ( ) EVAPOTRANSPIRATION
UNDERGROUND DISPERSAL ( ) SAND FILTER
ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
OTHER -DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE?).6
PERCOLATION TEST RESULTS:�J(To be completed by Registered Professional Engineer, if the Engineer does the
Percolation Test) a%/i`r
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 of RPE 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 pennit 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.
Signed
Date / /O—s
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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County Road (Note the Road Number and Name)
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