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R / GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N _ 3 0 5 8 .
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109 8th Street Suite 303 Assessor's Parcel No. % P. •
M Glenwood Springs, Colorado 81801 •
1 1 Phone (303) 945 -8212
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S ` This does not constitute d r
c INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. i
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) Legal Description of Assessor's Parcel No.
gout Ie9( Y� 617 0 x ;,
d 5 SYSTEM DESIGN / 1
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to 00 Septic Tank Capacity (gallon) Other C.J) —. & b .72 .
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f / au � Rate (minutes /inch) Number of Bedrooms (or other) 3 „° t,
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Required Absorption Area - See Attached
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g $ Special Setback Requirements: )'
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F Date I l "4j -- 9.1- Inspector �tiL Q/A 1, i
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.` 1 FINAL SYSTEM INSPECTION AND APPROVAL (as installed) is
t t Call for Inspection (24 hours notice) Before Covering Installation 1
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System installer OW '
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r . Septic Tank Capacity , r
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r Septic Tank Manufacturer or Trade Name O f #
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Yo ' Septic Tank Access within 8" of surface 1
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Absorption Area ! •
r ` ` Absorption Area Type and /or Manufacturer or Trade Name /brftt7 . Al w I.
( Adequate compliance with C ounty and State regulations/require ants
Other 0
1 Date /� �� Inspector ��� 14 ��� R
f. RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
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k $ *CONDITIONS: ,. g $,
1. All installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chapter
1 25, Article 10 C.R.S. 1973, Revised 1984.
w ` 2. This permit is valid only for connection to structures which have fully complied with County zoning and building requirements. Con - S "s
nection to or use with any dwelling or structures not approved by the Building and Zoning office shall automatically be a violation or a y), t
requirement of the permit and cause for both legal action and revocation of the permit.
t . 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 —8 ,/ 3
;. 1; months In Jail or both).
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White Yellow ______
• INDIVIDUAL SEWAGE
) DISPOSAL SYSTEM APPLICATION
OWNER IUOR- 1 el-Pr c,C',A f l ff /kxt7i)
ADDRESS f?0..f N I�7 1 97- (.0 \ I. .Q ' /G!- (7 PHONE 97o 98 1- XQ /6
CONTRACTOR
ADDRESS SfrAr e . PHONE STh4A
PERMIT REQUEST FOR Q4 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 t4 le Size of I.ot +0 ac eats
Legal Description or Address t-0+q GjeA65 rase }?A -NCft J f21-16 C &, I n rnrkn
WASTES TYPE: (>9 DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON - DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPE: %) i n/9 I F c4V t 11/4.1 Re.s .
Number of Bedrooms .� Number of Persons
( ) Garbage Grinder x) Automatic Washer (x) Dishwasher
SOI 'RCP. AND TYPF. OF WATER SIJPPI.Y: 0<i WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: IL-+I Pr
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to the Community System? /\.)1
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i • ' . • i • 1 I I • ' I u r ' I I • l I • I ' I i. I ' 1/ \ 1/ 14 1 i ..
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,
GROI JND CONDITIONS:
Depth to first Ground Water Table
Percent Ground Slope
2
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
e4 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:
x3 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? N n
pERCOI,ATION TEST REST 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
permit granted based upon said application and in legal action for perjury as provided by law.
Signed G21'/A10�'/ g Date AO 9 / 8
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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