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GARFl!:LD COUNTY BUILDING AND SANITATION DEPARTMENT Permit
10~, 8th SJ,lee4 \• $}lite 303
Glen~pocl"sp~gs, clilotado 81601
fthone (~03) 94$le212
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INDIVIDUAL SEWAGE DISPOSAL PERMIT ~ •::._, .,,. C
~Thi'g-"\1088 not~~n•titWe;:
a building or ule permit.
PROPERTY .. ' \ , " • • <-~ ,, ... \ ~.. \ <
Owner's Name Bt~~ ti88\-0Ji1uln~}t-~,~ i'iisent Ad~-~~· ,."_b.R~. _1_1_7~,_(_:_.s_, __ ··-_.,.,_._Phone _9_4_S_-_0_7_8_2 __ ·~
System Location ________ ..c.8~1"'4~3_C~o_u~n'-t~Y~~-o_a_d_l_l_7~•~G_l_~_n_wo_o_d_S_,_p_r_i_n-"g'-s ____________ _
'-".• \"'-\> . \ L8gal Description of Assessor;s Parcel No.------------------------------------
1 Nv qP;,,I(/ /?P4K ; .J.t;A«-4 B/Jl' It
SYSTEM DESIGN J;; ;?J Cr / ;;< .T .r..-I'" 1.t. 7/li' ~1 7,e./i! S
§I :;, ? .ti I ,9. ~ I&; 'l> ' F~I< ,z:s:. /(;(_0 Septic Tan~'t:apacity (gallon) Other
I I 11 > Cz:..-oll\fercolation Rate (minutes/inch) Number of Bedrooms (or other) ---'~"'·","'---
Required Absorption Area -See Attached
Special Setbac~ Requirements:
J~ J· .
Date !J-11;-CJS' Inspector ~ b~"' $ ::~
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer __ µ.,,,,,n:,>;;:~'..<'.x>;;:_ __________________________ , ______ _
Septic Tank Capacity_--1/,,.:J. .... ..;iS:"'r'-~"-. __.CA..,,=~--~·l-f}.,-c...LdL5"'TC.L/_,t:'.~------------------------
Septic Tank Manufacturer or Trade Name ~•'-'(¥,.....?f'._.k.,?~C:-S~/~C>~_~J_,\~1='-~----------------~----
Septic Tank Access within 8" of surface ---lv-i:-::.::.------------------------------
Absorption Area Type and/or Manufacturer or Trade Name __.,."""'"'"'---_,,./):.<.</z£;:.:;<cc::._-_,,V("':.5""-'. ,1:,,,-"R""----------------
Adequate compliance with County and State regulations/requirements_).,:4".~::5~-----------·--------
Dat•~~lr~~~/~1+?~1--·~~~-------~lnspector-"1-'2""-C-------------------------~
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
•CONDITIONS:
1. All installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chapter
25, Article 10 C.R.S. 1973, Revised 1984.
2. This permit is valid only for connection to structures which have fully complied with County zoning and building requirements. Con-
nection to or use with any dwelling or structures not 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
variation 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).
Applicant: Green Copy Department: Pink Copy
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JNDl\llDU/'.LSEW.AGEJ.llSl'OSALSYSTEM.AP.ELICATION
OWN ER ZR IC. J h-&s fl CHt:5Allfl
ADDREss &2t/3 co RP. 1c7 ,c,wsP PnoNE ql/6-o?BbJ.
coN~11~~~~~~ ,~J ~ltf~~~~~ ~f;XIf~~~~IIONE qG3-8b3t}
PERMIT REQUEST FOR (Xl NEW INSTALLATION ( ) ALTERATION ( ) REPAIR
Attach separale sheels or reporl showing enlire area wilh respecl lo surrounding areas, topography of area,
habilable building, localion of potable waler wells, soil percolalion tesl holes, soil profiles in lest holes
(See page 4).
LOCATI n N. 01'.'.l)R OPQSEDJ'.AC! L!TY: COUNTY -~B~f-J~1?~F'--'1""'€_L ~D~------
Nca r wha 1 CilyorTown 18/?AJta';tJD :5Pg1Nb~ Loi _____________ _
1.egal Dcscriplion --·-····--·---·---
WASTES~LYl'E: ¢(l Dwelling ( ) Transient Use
( ) Commercial or lnduslrial ( ) Non-domeslic Wasles
( ) 01her -Describe------------------------
BU I I.DI NG OR SER VICE TYPE: ~R8~S~· ~I b~F:~M-C~f.,~-------,.,---------
Number of bedrooms: 3 Number of persons_ ..... ;;{"-.'--_________ _
( ) Garbage Grinder (j<) Aulomalic Washer ( )() Dishwasher
SOURCE.AND._::r_YJ~E . .01'.'.WATEILSU!'l'LY: O(l WELL ( ) SPRING ( ) STREAM OR CREEK
Givedeplh of all wells wilhin 180 feel ofsyslem: ____________________ _
If supplied by communliy water, give name of supplier: _________________ _
GROUNfll:OND.fJJONS:
Deplh lo bedrock: _______________________________ _
Deplh lo lirsl Ground Waler Table:
Percent Groi111d Slope: ------------------------------
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: 7 ~-------------
Was an effort made 10 connect lo communily syslem'! _""'"..c._----------------
TYPE OF INDIVIDlJAI. SEWAGE DISPOSAL SYSTEM PROPOSED:
06 Seplic Tank ( ) Aeralion Planl ( ) Vault
( ) Vault Privy ( ) Composling Toilel ( ) Recycling, potable use
( ) Pil Privy ( ) lncincralion Toilel ( ) Recycling, olher use
( ) Chemical Toilet ( ) Olher -Describe:------·--------------
PINAL DISPOSAL BY:
00 Absorplion Trench, Bed or Pit ( ) Evapolranspiration
( ) Underground Dispersal ( ) Sand Filter
( ) Above Ground Dispersal ( ) Waslewalcr Pond
( ) Other -Describe: __ _
WILL EPFLlJENTBE DISCllAl~GED DlllECl'LY INTO WATERS OFTllE STATE? l\b
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• c • •
!'ERCDLATJQl':l_TESTJU\SULTS: (To be complcled by Regislered Professional Engineer)
Minules per inch in hole No. 1 Minules per inch in Hole No. 3
Minules per inch in hole No. 2 Minutes per inch in Hole No. __
Name, address and lelcphonc of l~l'E who made soil absorplion lesls: ---------------
Name, address and lelephone of Rl'E responsible for design of the syslem: ------·------
Applicant acknowledges I hat lhecompleleness of I he appliclion is condilional upon such further mandatory
and addilional lesls and reporls as may be required by !he local heailh deparlmenl to be madeand furnished
by the applicant or by !he local heailh deparlment for purposes of the evaluation of the application; and the
issua nee of lhe permit is su hject to such terms and con di I ions as deemed necessary lo inusre compliance with
rules and regulations adopted tinder Arlicle 10, Tille 25, C.R .S. 1973, as amended. The undersigned hereby
certifies that all slatements make, informal ion and reports submilted herewith and required to be submitted
by the applicant are or will be represenled lo be true and correct to lhe best of my knowledge and belief and
are designed 10 bre relied on hy the local deparlment of heailh in evluating the same fro purposes of issuing
!he permit applied for herein. I further undersland that any falsificalion or misrepresentation may result in
the denial of the application or revocalion of any perm ii granted based upon said application and in legal
action for perjury ns provided by law.
Date _ ___,_t/:_,-L'""'"'Y_-_,_o/1.;?'"""'------
ELEASHJ2RAW_AN_ACCURATEMAl' ... TO_YQUJLl'ROl'ERT ... Y
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