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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit 2.76 9
109 8th Street Suite 303 Assessor's/ Parcel No.
Glenwood Springs, Colorado 81801
Phone (303) 945-8212
his does not constitute
INDIVIDUAL SEWAGE DIS OSAL PERMIT a building or use permit.
PROPERTY
Owner's Name Rob & Britt Gange Present Address 640 Petterson Ft./Collins one_
System Location 0166 Ra eh Lane. Lazy Diamond A. Lot 11( Glenwood Springs
Legal Description of Assessor's Parcel No.
SYSTEM DESIGN
Septic Tank Capacity (gallon) O the /
Percolation Rate (minutes /inch) mber of Bedro ms (or other) 6
Required Absorption Area - See Attached
Special Setback Requirements:
Date Inspector
FINAL SYSTEM INSPECTION AND APPROVAL (as inst: led)
Call for Inspection (24 hours notice) Before Coverin. nstallation
System Installer_
Septic Tank Capacity
Septic Tank Manufacturer or Trade = me
Septic Tank Access within 8" o - urface
Absorption Area
Absorption Area Type = d /or Manufacturer or Trade Name
Adequate compile ' ce with County and State regulations /requirements
Other
Date 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 D posal 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 I, Petty Offense ($500.00 fine — 6
months in jail or both).
While - APPLICANT Yellow - DEPARTMENT
• INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
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OWNER Rob and Britt Ganger
ADDRESS Petterson, Ft Collins CO PHONE970 493 -8305
CONTRACTOR DM Neuman Construction Co.
ADDRESS PO Box 2317, GS PHONE 945 -7502
PERMIT REQUEST FOR ('/ NEW INSTALLATION ( ) 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 pr files in test holes (See page 4).
LOCATION OF PROPOSED FACILITY: COUNTY
Near what City or Town 4-11, c h a e Trsor( 4410 Size of Lot ,5. 0.2 a S 0
Legal Description or Addres ° S4— l () 0!! ° f;yl U �l lQ YIuvtt .4 - \
WASTES TYPE: (4) DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON - DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPE: cS 11L9 A .
Number of Bedrooms (0 Number of Persons
( .,/j Garbage Grinder (v( Automatic Washer (� Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: ( ) WELL ( ) SPRING ( ) STREAM OR CREEK
Give depth of all wells within 180 feet of system:
If supplied by Community Water, give name of supplier at %I •
.
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GROUND CONDITIONS:
Depth to bedrock:
Depth to first Ground Water Table
Percent Ground Slope
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to community system? ( ) YES ( ) NO
TYPE OFDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(i) 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:
(V) 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 ?, Itfl
2
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f . 9 ,,.A'1'ION TEST RESULTS. (]'o be completed by Registered Professional Engineer)
Minutes per inch in hole No. I 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 finther 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 purposes 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
adopted under Article 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 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. 1 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_tj ��--Q..__ _ Date "4 7. / _ 7
1'A1 _ASI? DRAW ANACCURATE MAP TO YOUR PROPERTY!!
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