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108 Eighth Street, Suite 401
Glenwood Springs, Colorado 81601
Phone (970) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPFR T Y �!-L 4
Owner's Name ,5�� I �- c. I� / _ Present Address C/� f Z/¢ Phone P AY -.3 WSJ
System Location
Legal Description of Assessor's Parcel No. , % 7767// dc9 •3
SYSTEM DESIGN
/1
/ — Percolation Rate (minutes/inch) Number of Bedrooms (or other)
Required Absorption Area - See Attached v 5 s C47:- /4 Ii6 V 3 3 d`
Special Setback Requirements: 17 Pe /f v •'4P " 4_ 0 4i_ S..
Date 7— Z 4' - / 7 Inspector _
Permit
Assessor's Parcel No.
This does not constitute
a building or use permit.
Septic Tank Capacity (gallon) Other
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer
Septic Tank Capacity --12, Q 2
Septic Tank Manufacturer or Trade Name
Septic Tank Access within 8" of surface.
Absorption Area l � ,`�� �
Absorption Area Type and/or Manufacturer or Trade Name 73 o
7- 5
Adequate compliance with County and State regulations/requirements
Other
Date / / 7 Inspector
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. Connection 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).
White - APPLICANT Yellow - DEPARTMENT
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