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GARFIELD COUNTY B UILDING AND SANITATION DEPARTMENT Permit
108 Eighth Street, Suite 201 Assessor's Parcel No.
Glenwood Springs, Coloradof 81601
Phone (970) 945-8212
Th is does not constitute
a bu il ding or use permit.
SYSTEM DESIGN
--'---' _(,___ Septi c Tank Capacity (gallon) ______ Other
_--J-1 ...... ·@.,;.--=. __ Percol ation Rate (minutes/inch) Number of Bedrooms (or other) _"__.!__/ __ .;_ f
1/u.r.f . 11, t ,1)
Required Absorption Area-See Attached '1 dl ( ,, ll tA)
,'_j ~~ :~J, '( !p ) L ' ~ P ? Special Setback Requ i rements:
1\ .~
'/ / ~ ( /
(
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Date I fl /7 I! I~ (.
I I
I nspector ___ _:/ __ ·,_,_._._:_• _(_)_l_:(__,_(----=...--:--=-""---'~-----------
FINAL SYSTEM INSPECTION AND APPROVAL (as install ed)
Ca ll for Inspection (24 hours notice) Before Covering Installation
Se ptic Tank Capacity _ _:I_')..:..__L..::.-;-?:.~----------------------------------
Vv• ( \r\ \'(.) Absorption Area--·~~------------------'-'::..:.....::.__ ________________ _
Absorption Area Type and/or Manufacturer or Trade Name _.;:_____!~'-"l '--'t--=fl-'-'~::..:..:=-'---~-l-\::..:"-:..:.'...::{_~.::...__1..._:( ----------
Adequate compliance with County and State regulat i ons/requirem ents._---'--'1 I~'·...!:..__ ________________ _
[
Other ______________________________ ~----------------
1
{..-( {I 'I A /1 . ) d f'(. I{ Date __ +-''7-----------ln s pector _~~.;_.;__.:_ _____________________ ___
r{('(ob RETAIN WITH RECE IPT RECORDS AT CONSTRUCTION SITE
*CONDITIONS:
1. All install ati on must comply with all requirements of the Colorado State Board o f Health Indi vidual Sewage Disposal Systems Chapter
25 , Article 10 C.R.S. 1973, Revised 1984.
2. This permit is va l id only for con nection to structures which have fully complied with County zoning and bui lding requirements. Con-
n ection to or use with any dwelli ng or structures not approved by the Buildi n g and Zoning o ffice shall automatically be a vi olation or a
requirement of the permit and cause for both legal action and revocation of t he permit.
3 . Any person who constr ucts, alters, or i nstal ls an individual sewage disposal system in a manner which Involves a knowing and material
variation from the terms or specifications contained in the appl ication of permit commi ts a Class I , Petty Offense ($500.00 fine-6
months in jail or both).
White-APPLICANT Yellow-DEPARTMENT
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
ADDRESS ______________________________ __
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 profiles in test holes (See page 4).
LOCATION OF PROPOSED FACILITY: Lor 'f ,fJfe_t €)<t'.~V<fl~t.,.
NearwhatCityofTown StL'T, eo SizeofLot /0 !idi..t'J
Legal Description or Address \51=: Jl.i,, N t: K;1 Ntcl K!. !SIC C .5L Tiu3/' 5' 5, i&IAJC.t 7t tt! t!r f., PJ11.
I •
WASTES TYPE: ()() DWELLING ( ) TRANSIENT USE Ry.W\ L-V\
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER-DESCRIBE ________________________________ _
BUILDING OR SERVICE TYPE: StN iltL£. fA1'4lL( /(t5>rbtJJCL
Number of Bedrooms -----""3"'--_________________ Number ofPersons. ___ .• -""3~-----
(~ Garbage Grinder ( /9 Automatic Washer
SOURCE AND TYPE OF WATER SUPPLY: ()(}WELL
If supplied by Community Water, give name of supplier:
()<!) Dishwasher
( ) SPRING ( ) STREAM OR CREEK
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: __ ---'-"J_,c:::_.:>--'-M""tL.=i:-=-0 ____________ _
Was an effort made to connect to the Community System? ___,AI="----------------------------
A site plan is required to be submitted that indicates the following MINIMUM distances:
Leach Field to Well:
Septic Tank to Well:
100 feet
50 feet
Leach Field to Irrigation Ditches, Stream or Water Course: 50 feet
Septic System (septic tank & disposal field) to Property Lines: 10 feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT
A SITE PLAN.
GROUND CONDITIONS:
Depth to first Ground Water Table ________________________________________________ __
Percent Ground Slope ________________________________________________________ __
2
TYPE OF INDIVIDUAL SEW AGE DISPOSAL SYSTEM PROPOSED:
(~) SEPTIC TANK ( ) AERATION PLANT ( ) VAULT
( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POT ABLE USE
( ) PIT PRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
( ) CHEMICAL TOILET( ) OTHER-DESCRIBE
FINAL DISPOSAL BY:
( ) ABSORPTION TRENCH, BED OR PIT ( ) EVAPOTRANSPIRATION
CX) UNDERGROUND DISPERSAL ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
( ) OTHER-DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? ;Jo
PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer, if the Engineer does the
Percolation Test)
Minutes. __ q-'---__ per inch in hole No. I
Minutes ~ per inch in hole No. 2
Minutes _ ___L/_1.---___ per inittJCe No.3
Minutes / 0 per inch in !role No. _
Name, address and telephone ofRPE who made soil absorption tests:------~-------
Name, address and telephone ofRPE 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.
Date r(J G-{S t)(,,
RATE MAP TO YOUR PROPERTY!!
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~ ffi~ ~ocate well, all streams, irrigation ditchs, and any water courses. Draw in your house,
septic tank & system, detached garages, and driveway.
If a change of location is necessary, you must submit a corrected drawing, before a
Certificate of Occupation will be issued.
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