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Permit N~ 3754
Aese11or'1 Parcel No.
i r ' ~~~ ~o , Gle11wood Springs, Colorado 81801
Phone (303) 845·8212 -----------!
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! f ~NDIVIDUAL SEWAGE DISPOSAL PERMIT
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This dOes not constitute
a building or use permit.
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~: I PROPERTY
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f System Location ;).J~O C.R.. 3\l\-~.Q ()is\\ .Q)
Phone {cG5-Q'l3;tj
, ' ~i ~e;!lal Oescrlptl~n "1'Assesso;'s Parcel No.--------------------------------
. f SYSTEM OESIGN
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.,l,.O~O~O~--Septic Tank Capacity (gallon)
r /£... -~---Percolation Rate (minutes/inch) ~umber of ~e. d.r90l)1S (.or other) -~--;3.....-__ _ fr ~ :S .t±:l I, t l' Jr. l ~a~)......_ 1=""1 (fJ/d.
______ Other
Required Absorption Area • See Attached 3 7 7 r.:!:l l • '" 1 'r'{ '~~'3• R T.1> ,, 0 h 3 Y '?f 1 7 ;.:>0 S
'3"13 C'::l ''""'' riJ.t,~lu17 \3.,.-1) 3,x(., ti fX· s~
;,'I "J::l ( • ·~'' (' """'br1t i)ED .K J<'O' f'-{ P<' S Special Setback Requirements:
Date / /_ (,, -(} "?.--Inspector -r:::-J4
FINAL SYSTEM INSPECTION AND APPROVAL (as Installed) '\_
Call for Inspection (24 hours notice) Before Covering Installation -
/ /f:.··_-_, System lnstailer_J~4'Ci..0"1..&...""'--4L2.,~,,1c:i___:._ _______________ _,,;.._ _________ _
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Septic Tdnk Capaclty~/~0~0~6~---------..------~----f ________ _
' Septic Tank Manufacturer or Trade Name _,(.,. .... b_,,p...,.e.~\o:~=x.=J"-·"----------.,.-------------
Septic Tank Access within 8" of surface -'~~=-------------------------
Absorption Area~~~-<--~-----------------------------------
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Absorption Area Type and/or Marlufacturar or Trade Name -''.,,-=:.·,_,i''""-'. _· -''~>1-'-<""'. /.'--',_,.-c'-'··1t."'· ;i'-------------'--------
Adequate compliance with County and State regulatlons/requirements~'"'--'--·c _' _. _______________ _.-:,:,·.(-·
i Other_~---------------------~-----~-----..--------
Date_lw..I 1-/=J-""C,-I-'/ O"'--"'J-.-'-----Inspector _ _,;{2'--t.L-.... (),,,,'-"';J'---""--"· "-'-1/"-'U-"'-'--d--_~----~--/ I
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
•CONDITIONS: . . i
1. All lnstailatlon must comply with all requirements of th$ Colorado State Board of Health Individual Sewage Disposal Systems Chail\er
25, Article 10 C.R.S. 1973, Revised 1984. •'.
2. This permit ls valid only for connection to structur~f which have fully complied with County zoning and building requirements. Ol)n-
nectlon to or use with any dwelling or structures not approved by the Bulldlng and Zoning office shall automatlcaily 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 lndlvld~al sewage disposal system In a manner which Involves a knowing and matllr'lal
variation from the terms or specifications contained Ir'! the application of permit commits a Class I, Petty Offense ($500.00 fine -6
months In Jail or both).
White. APPLICANT Yellow. DEPARTMENT
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INDIVIDUAL SEW AGE DISPOSAL SYSTEM APPLICATION
OWNER \2 ~~ 4 \<Q ~~ 11..,/.c,e:~ ~~fD ADDRESS·~. D. ~.(20, IL
CONTRACTOR !?'1 'F" 'e \)n.._c;,...., ~ell-'
ADDRESS ~ 'd-~ 7 A\{)_ Q 0'2-0 flb, \)~Fie-
PERMIT REQUEST FOR (~INSTALLATION
PHONE -----
PHONE
( ) ALTERATION ( ) REPAIR
Attach separate sheets or report showing entire area with respect to surrounding areas, topography of area, habitable
building, location of potable water welJs, soil percolation test holes, soil profiles in test holes (See page 4).
LOCATION OF PROPOSED FACILITY:
NearwhatCityofTown (1 eLO c~s (1 ~ Size of Lot ")_. 'i J4 UZ (;"'
Legal Description or Address S e-e l<l '111'1 C. Vt ~ 0 0R31l/ }.,J.C.
WAS TES TYPE: (t.,.rDWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WAS TES
()OTHER-DESCRIBE ________________ _
BUILDING OR SERVICE TYPE: i/Y)C [) Uk A/\..-X:{::° Ill ~ \-19 } )
Number of Bedrooms ----'~=---------Number of Persons~S~---
( ) Garbage Grinder ( ) Automatic Washer/ (~hwasher
SOURCEANDTYPEOFWATERSUPPLY: (..,fWELL ( )SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: L\ 'fVI: leS-_ _,__ _ _,__ _______ ~
Was an effort made to connect to the Community System? ---------------
A site plan is required to be submitted that indicates the followini= 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 (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 __________________________ _
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- - - - - - - - - - - - - - - - - - - - --------,----------,
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TYPE 9F INDIVIDUAL SEWAGE 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
(Ly--"UNDERGROUND DISPERSAL
( ) ABOVE GROUND DISPERSAL
( ) EVAPOTRANSPIRATION
( ) SAND FILTER
( ) WASTEWATER POND
( ) OTHER-DESCRIBE·------------------------
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? llCJ
PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer, ifthe Engineer does the
Percolation Test)
Minutes. ____ _,..er inch in hole No. 1 Minutes _____ .,,er inch in hole No. 3
Minutes. ____ _,,er 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
suit in the denial of the application or revocation of any permit granted based
for perjury as provided by Jaw.
Date [ C)~J-0).
MAP TO YOUR PROPERTY!!
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Designate North Arrow
Your Neighbor's
Name & Address
()e>n IT,...
Your Plot -Shape to Fit
(No Scale)
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Locate well, all streams, irrigation ditchs, and any water courses. Draw in your house,
septic tank & system, detached garages, and driveway.
If a change oflocation is necessary, you must submit a corrected drawing, before a
Certificate of Occupation will be issued.
County Road (Note the Road Number and Name) -:S IL/
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Your Neighbor's
Name & Address
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