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r ~~ ::rf~ GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
108 Eighth Street, Suite 201
Glenwood Springs, Coloradof 81601
Phone (970) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
Permit
Assessor's Parcel No.
This does not constitute
a building or use permit.
PROPERTY \.l n
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Owner's Name } ( \ I ) ,-. D a ~e _0 Present Addri\s [ n ('(>(""tQc t ~ "rl It-) Phone(( ) ~-55' {o 7
System Location D lf5{ R~\ '""' l n )l
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11='c::-' . ..., =<:J---.-'J\.r,_;ry-1 I ~ p,·rnPI' ~~"~ Legal Description of Assessor 's Par cel No. "' ~ ,]· I.-.J UU '.1_~ N:=) . t 't f. r ~*' . f _ •
SYSTEM DESIGN
.L./."'-(:""«'-=--'J'-----Septic Tank Capacity (gallon) _A/,'-=-.:...L/;q ___ Other
__ 1_.t~) __ Percolation Rate (minutes/inc h) Number of Bedrooms (or other) 3-1 ~~e £1.
Required Absorption Area-See Attached ( r'tj j -1 ~0 5-'o -I u I r ~ ~ /f "':',,1.1 1
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Special Setback Requirements : 6 () $( :1 ....,..
4
/<.<" ..( ..e--8-<,/ _ 67 ~~~ (J(...,~ ~ -' I
Date __ -~L'---=0::.._:_/ ______ Inspector S'?k~Ar'r-:h7'{' {_ffpp /JAA7 ~~ n )
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
,
Septi c Tan k Capac ity __ _:_ __________________________________ _
Adequate compliance with County and State regulations/requirements_....:'.;-'.:..c1'-=-------------------
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Other __________________________________________ _
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
*CONDITIONS :
1. All installation must comply with all requirements of the Colorado State Board of Health Indivi dual Sewag e Disposal Systems Chapter
25, Article 10 C.R.S. 1973, Revised 1984 .
2. This permit is valid only for connection to struc tures whic h have fully complied with County zoning and building requirements. Con-
ne ction to or use with any dwelling or structures n ot 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
va riation 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 SEW AGE DISPOSAL SYS TEM APPLICATION
OWNER Go\..."' J-Oe;'b ~,.J,C ,j d.-,
ADDRESS '75'1 &a"" c.\--f.~<;;.\(. I (v. xlbso , PHONE f, 2.~-q 7 Js-
CONTRACTOR ~' ck k'4e~\~ ...
ADDRESS blf SJ > Yh ·Het (),..
PERMIT REQUEST FOR ~ NEW INSTALLATION ( ) ALTERATION ( ) REPAIR
Attach separate sh eets or report showing entire area with respect to surrounding areas , topography of area, habitable
building, location of potable water wells, soil percolation test hole s, soil profiles in test holes (See page 4).
LOCATION OF PROPOSED FACILITY:
Near what City ofTown __ L..S ..L;_,_I -'-~-----------Size of Lot /0 .1 1 A<
Legal D escripti on or Address <D8a.a. ~Ct (YJ . (_ tl s· :II l o I ~~ ts'L
WASTES TYPE: (?<) DWELLING ( ) TRANSIENT US E
( ) COMMERCIAL OR INDUSTRIAL ( ) N ON-DOMES TIC WASTES
()OTHER -DESCRIBE ______________________________ __
5Jr ~-"e t \~ BU~DINGORSERVI CE TY PE: _____ ~~~~~r---~--------~~~~----~----~-----
N umber of Bedrooms _ _..::.? ___________ N umb er ofPersons __ L. ___ _
('A.) Garbage Grinder (--A Automatic Washer
SOURCE AND TYPE OF WATER SU PPLY: (')()W ELL
If supplied by Community Water, give name of supplier:
(.x) Di shwasher
( ) SPRING
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
( ) STREAM OR CREEK
------------~
Was an effort made to connect to the Community Sys tem? _______________ _
A site pla n is required to be submitted that indicates the followin2 MINIMUM distances:
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 (se ptic tank & disposal field) to Property Lines: 10 feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT
A SITE PLAN.
GROUND CONDITIONS:
D~th~fu~Gro@dW~crT~k ________________________ _
Percent Ground Slope -------------------------------
2
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(~ 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:
(1--) 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? 1)0
PERCOLATION TEST RESULTS: (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 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.
Signed 1_ Jy ,@.;(!.. Date _ ___,__!--"-?'_-~0 "---7 __
PLEASE D-;t!!)J AN ACCURATE MAP TO YOUR PROPERTY!!
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Q;: ~ Locate well, all streatlls, irrigation ditchs, and any water courses. Draw in your house,
~ I , 1 septic tank & system, detached garages, and driveway.
C) , \::;). If a change of location is necessary, you must submit a corrected drawing, before a
('J 1 111 4-Wt.\. \ Certificate of Occupation will be issued.
~a. rr> L.a.n0=ounty Road (Note the Road Number and Name)
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