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GAP"'IEUM! ll!i 11'.r'f IUILDING AND-.1IANITATION NIWl'IMeNT 2192 ,~ ~ .
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; .'G111waad 8priftg9, ColoNdD &IIOf
' Phone (303) M$-1212
81WAGE DISPOSAL PUIIIT . '
Thia doN not conllllutl
a butldlng or Ule permit.
¥tlret ... """ tnfrs@ Pr81entAddreaa 6101 ca 331, au,, co Phon~_8_7_6-_5_205 __
6107 CoUDtJ' ._. 331, fllt
Ltgal O.Crtptlon of Auauor's Parcel No. _____ __.J"-'---Y-'-.::b:...L-{-_ _,_l...;O::c....,~:::·:_ __ o_o_-_f/_S---_. _' · ____ _
SYSTEM DESIGN
~lnetaller· _______________ _
Septic Tank Capaclty_.......;'----'-----------
SePtlc T1111k Manufacturer or Trade NalN --1---\--------i
I Septic Tank AcCMS within 8" of~ _,... __ ____.: ____ ---,1
Abeorptlon Area ________ \_......ccc-______ .....,
Ablorptlc:,n Area Type and/or Mari~ or Trade Name ___ _
Adequate compli,nce with County and 8!ate regulaliona/requiraments_
Other __________________ _
"-'--..::....------~~Dlar _____ _
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·. o;mER :rJgXoL +: No.ncA, 4de.t\\9n
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MDREss S;\\, Co 8-llo.S")_ P11ot1E 82'='-
PERMIT REQUE~T FOR: ( "'l New Install a lion ( /\Iteration ( ) Hepa Ir
/\pp I ica ti 011
/lpprova 1 by
County Official:
Attach separate sheets or report showing entire area with respect to surrounding areas,
topography of area, habitable liuilding, location or potable water wells, soil percolation
test holes, soil profiles in test holes. (Sec page 4.)
LOCATION OF PROPOSED r/lCILITY: County Cor£~\6
Near what City of To~rnc__?,~:_\>.:\L-____________ ---'Lot Size '/ QC re:.
Legal Description ____________________________ _
WASTES TYPE: ( vf Dwell i11g
( ) Con111ercial or lnstilutioi1al
(
(
) Transient Use
) Mon-domestic Wastes
( ) Other -Describe ___________________ _
BUILDING OR SERVICE TYPE: _______________________ _
!lumber of bedrooms l\ thnnber of persons __ '-l_,_ ____ _
( /) Garbage gri11der ( ,f Automatic washer (~Dishwasher
SOURCE ANO TYPE OF WATER SUPPLY: ( /J well ( ) spri 119 { ) s Lream or creek
Give depth of all wells within 180 feet of system:_?,__;----,~-----------
If suppl led by co111mu111ty water, give name or suppl ier:_.,_N'.'4-t~'/r1--_________ _
GROUND CONDIT IONS : /
Depth to bedrock =----------------------L---------
Depth to first Ground Water Table: _____________________ _
Percent ground slope: __________________________ _
DISTANCE TO HE/I.REST CO~U·IUNITY SEHER Si'SlEM: _ _.i___:,;M~' ___________ _
Was an effort made to connect to conwnunity system?_ul!.Ll..-------------
TYPE OF INDµ'iUU/\L SEU/IGE OISPOS/IL SYSTEM PROPOSED:
(0 Septic Tank ( ) /\eration Plant
( ) Vault Privy ( ) Composting Toilet
( ) Pit Privy ( ) Incineration Toilet
(
(
(
) Vault
) Recycling, potable use
) Recycling, other use
( ) Chemical Toilet ( ) Other -Describe: ____________ _
FINAL DISPOS llY:
(
{
(
J\bs_orption Trench, !led or Pit
) Underground Dispersal
) Above Ground Dispersal
( ) Other -Describe:
(
(
(
) Evapotranspiration
) Sand Filter
) Has tewa ter Pond
WILL EFFLUENT BE DISCII/\RGED DlllECTLY INTO ~l/\TERS OF TIIE ST/\TE? -----------
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.SOIL .PERCOLI\TIOH TEST R£SUL1S: (To be completed by Rcgislered Professional Engineer.)
Minutes ____ per inch in hole No. 1 Mi nu Les ___ per inch in hole Ho. 3
Minutes per inch in hole No. 2 Minutes per inch in hole t\o.
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 compleleness or the application is conditional upon such
further mandatory and additional tests and reports as may 1.,e required by the local health
department to be made and furnished by the appl leant or by the local heal 1:h department for
purposes of the evaluation or the a;ipl ication; and the issuance of 1:he peni1i'.t. i-s subject to
such terms and conditions as deemed necessary to insure compliance wl th rules and regulations
adopted under l\rticle 10, Title 25, C.R.S. 1973, as amended. The undersigned hereby certifies
that all statements made, information and reports submitted herewith and required to be
submitted by the applicant are or will be represented lo be true and correct to the best
of my knowledge and belief and are designed to be relied on by the local deparlment of health
in evaluating the same for purposes of issuing the pennit applied for herein. I further under-
stand 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 per-
jury as provided by law.
PLEASE DllAH /\ND I\CCURI\TE MI\P TO YOUR PROPERTY
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PLOT PLAN ANO OESIGN FEATURES:
Include by measured distance location of wells, springs, potable water supply
lines, cisterns, buildings, property lines, subsoil drains, lake, water course,
stream, dry gulch and show location or proposed system by direction and distance
from dwelling or other fixed reference object, and additional submissions in
support of this application such as data, plans, specirications, statements and
con111i tmen ts.
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