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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
109 8th Street Suite 303
Glenwood Springs, Colorado 81601
Phone (303) 945·8212 .. i ', INDIVIDUAL SEWAGE DISPOSAL PERMIT
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N" Permit -~1Qq
Aaaeaaor'a Parcel No.
This does not constitute
a building or use permit.
'I~ PROPERTY ~ !!::·::: lef&·~ '""tlif/J1Ji'!1&~b.
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l' t·. SYSTEM DESIGN ff ~ Cu.
Legal Description of Assessor's Parcel No. -:::--:-----:---..--:rT'-:n---=-:-c-:,----~~~------------
t'lOC r.:. -L-e ;11.c. H -F 1 e ~ o f?'2.-4 IS(
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1, 1· • ) .,,. ,,, 't I\. 'e:Ncµ _ '"t"Z... ( foFr-ur-rttr; f 0 o 0 Septic Tank Capacity (gallon) 0th-)) I ; ~ -~'-+--<f~Cf_,_ Percolation Rate (minutes/inch) Number of Bedrooms (or other) --'~"----
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Required Absorption Area • See Attached
Special Satback Requirements:
Date_9~-~<~~~-'f~'t __ Inspector ___ _,4"+_,f\.-~_f'-_(_()~----------------
:, f ! ; FINAL SYSTEM INSPECTION AND APPROVAL (as Installed)
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Call for Inspection (24 hours notice) Before Covering Installation
System lnstaller ____ ()=-___,,(A/= _ _,_'f,"'{'--C=~'--J1..-'"----------------------
Saptic Tank capac1ty ___ l_c> __ C_0"'-----'6=-_L __________________ _
Saptic Tank Manufacturer or Trade Name __ C' __ O~~p __ £_l.'--~l\.__-'f._c..l_.D ______________ _
Saptlc Tank Access within 8" of surface ____ Y~-=~~· _S~-----------------------
Absorption Area ~2~-1:~(L-~'-f..'-"-'fC"'--'IJ'-'-=c~S..__ __ O__c_/:' __ q_c_,_,_r --'-' o;::__----"'U-'-'r--f:_:l_7t-cJ::_____,['.__,_A-1--
Absorptlon Area Type and/or Manufacturer or Trade Name ---'-/-'('-'--l_F_l_L_T.:__fl __ A,.:_T:_O __ fl _ _:S:_ _______ _
Adequate compliance with County and State regulations/requirements ___________________ _
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Other II o u S "< +-T"AM "(: ' Yov f../£t.0 A CLLAN-Wr
Date _ _../_,/_-__._l_,)'--~q_a,~ ___ inspector _ __._ll~~-~~----------------
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. f
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 automatlcally be a vlolatlon 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 lndlvldual 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).
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White-APPLICANT Yellow' DEPARTMENT -'"""----------~--------·····-··---------------"--11
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INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
O~R~~>1i1~-~-t~~!_e~~~(~~~~~~~~~--=-~~~~-
ADDRESS /f ~ ( 5 ~ t) 2dk S / [/ PHONE $ ~) t_ ;i_,J C L
CONTRACTOR .-,< --~ 7 C ~ 7
ADDRESS I~ 143" £-.0 3:;.-t{ PHONE &;;) 7 c 6 I~/
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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:
Near what City of Town f-/ c-T" Size of Lot ~~ --;-fl C
Legal Description or Address ~ ~ / _,.;-,K?' ..0 2 er .C -S / C /
WASTES TYPE: ( vrDWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( )OTHER-DESCRIBE _______________ _
BUILDING OR SERVICE TYPE:-------------------~---
Number of Bedrooms ___ ">___________ Number of Persons _ _,j?,__· ___ _
( ) Garbage Grinder (..,-Automatic Washer
SOURCE AND TYPE OF WATER SUPPLY: (,_.,.---WELL
( "i""lJishwasher
( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: _______________ _
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: ___ -S---"---'-'/JJ~~( _____ _
. . ..,..., . c:..':> Was an effort made to connect to the Community System? ____ ,_._..-_________ _
A site plan is required to be submitted that indicates the following 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 to Property Lines: 10 feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT
A SITE PLAN.
GROUND CONDITIONS:
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Depth to first Ground Water Tabie. _____ /~-;::;,_·-_o _______________ _
Percent Ground Slope. ______ -=-....,,c;-------------------
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TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
( ~~PTIC TANK ( ) AERATION PLANT ( ) VAULT
( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POT ABLE USE
( ) PITPRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
( ) CHEMICAL TOILET ( ) OTHER -DESCRIBE
FINAL DISPOSAL BY:
(yJ ABSORPTION TRENCH, BED OR PIT ( ) EV APOTRANSPIRATION
( ) UNDERGROUND DISPERSAL ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
( ) OTHER -DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? /{_/CJ
PERCOLATION TEST RESULIS: (To be completed by Registered Professional Engineer, if the Engineer does the
Percolation Test)
Minutes. ____ -rer inch in hole No. I Minutes ______ per inch in hole NO. 3
Minutes per inch in hole No. 2 Minutes er 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 pennit 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 pennit applied for herein. I further understand that any
falsification or misrepresentation may result in the denial of the application or revocation of any pennit granted based
upon said application and in legal action for perjury as provided by law.
Date __ ·""'3>_..,.£~_<-.,_---_.,..h_c_?_5 __ _
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