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° G C OUNTY BUILDING AND SANITATION DEPARTMENT Permit N_ 3 0 r 3 t t
d A is Parcel No. i
109 8th S tree t S uite 303
Glenwood Springs, Colorado 81601 1
t Phone (303) 945.8212 7 }
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' ∎ This does not constitute ■
't INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. t! 7
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' PROPERTY ({ vl (4-. p /� (/
I Owner's Name Pe- ee 1 (r t& Sk6 Pros nt Ad dress 9 VI EdPIWC { X C�rt " Phone °� S 0�' W�
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( System Location 1 i )
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Legal Description of Assessor's Parcel No. i r
i i )Mock- LEACI- F ftsco to to -- T 119SC 1
) SYSTEM DESIGN tt CAA/ -a t$t4 1360 3 d' O pits 7/1 01 # I
k i 1, rr T A O Pc M CS ✓ a
., .t 1 00 n Septic Tank Capacity (gallon) Other ,. ' S 9 8` j
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v 7 3 1 1 0 P Rate (minutes/inch) Number of Bedrooms (or other) r"
t d Required Absorption Area - See Attached I�pt I
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1 Special Setback --9 Requirements: 9 "
` r Date ( _ G q In spector A. a ` f.4 i7 I p
r r FINAL SYSTEM INSPECTION AND APPROVAL, (as installed) $ e
, Call for Inspection (24 hours notice) Before Covering Installation 1` - t
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I 7 System Installer
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Septic Tank Capacity �-- J r (
Septic Tank Manufacturer or Trade Name ` { !— L M 0
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k Septic T Access within 8" of surface ,. ,
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i f Absorption Area .\ T n C /...( C/{' S V F " UN 11 S £ A 5 (� ,
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i t Manufacturer or Trade Name N E11 Vn/ 7 0 2 5
Absorption Area Type an /or anufa 4
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e y c s $ 6
k ' Adequate compliance with County and State regulations /requirements
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Other
f Date 7— _) - S" g'Ci Inspector ,A N
? ; RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE 0
G •CONDITIONS: 1 i
t ^ 1. All installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chapter i t
• 25, Article 10 C.R.S. 1973, Revised 1984. 6 4
t 2. This permit is valid only for connection to structures which have fully complied with County zoning and building requirements. Con- d
nection to or use with any dwelling or structures not approved by the Building and Zoning office shall automatically be a violation or a i A
requirement of the permit and cause for both legal action and revocation of the permit. ,r
!: ; 3. Any person w h o constructs, or installs an individual s ewage disposal s y stem in a m anner which involves a knowing and materiel c
variation from the terms or specifications contained In the application of permit commits a Class 1, Petty Offense ($500.001ine —
+ 6 i
;; i months In Jail or both). i, i
' White - APPLICANT Vellow • DEPARTMENT r e
• • . INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION '
OWNER ke 4- + 611AWNA Pefrc c
ADDRESS 749 /6A 7 ran c Ac's 12 'f/c PHONE 77D Gas- a 6 �C
CONTRACTOR
ADDRESS PHONE
PERMIT REQUEST FOR 04 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 profiles in test holes (See page 4).
LOCATION OF PROPOSED FACILITY;
Near what City of Town R: f7C Size of Lot in Acre.
G2,a -33
Legal Description or Address I% of A- .'Hcrs orctivra NW /fit 5i Seca •i w)5
WASTES TYPE: � DWELLING ( )
TRANSNT USE t L
( ) COMMERCIAL OR INDUSTRIAL ( ) NON - DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPE:
Number of Bedrooms 3 Number of Persons ?
Garbage Grinder ( ) Automatic Washer (kj Dishwasher
SOURCE AND TYPE. OF WATER SUPPLY: 21 WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: NA
Was an effort made to connect to the Community System? NA
Leach Field to Well: 100 feet
Septic Tank to Well: 50 feet
Leach Field to Irrigation Ditches, Stream or Water Course: 50 feet
Septic System to Property Lines: 10 feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED
WITHOUT A SITE PLAN,
GROT TNT) CONDITIONS:
Depth to first Ground Water Table
Percent Ground Slope
2
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(w) 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:
(f) 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?
pFRCOLATION TEST RE..SI TITS: (To be completed by Registered Professional Engineer, if the Engineer does
the Percolation Test)
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
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
pennit granted based upon said application and in legal action for perjury as provided by law.
Signed a Date — P-c — ?4"
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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