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. GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
109 Ith Street Sutte 303 ·
. GNnwood Springs, Color.do 81801
Phone (303) 945-8212
Percolation Rata (minutes/inch) Number of Bedrooms (or other) -----
Required Absorption Area -See Attached
Special Setbeck Requirements:
'illrlt.N~ "'· 3 2 7 n
A-110r'1 P•ri:el No.
This doss not constitute
a building or UH permit.
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Data_~l~l_-~8~-~'}-'~----lnspector _ _,_4.....,_tf\~b~'~C>~----------------
FINAL SYSTEM INSPECflON AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
Septic Tank Capacity_,l-tJ;Pc-5D-R..,,_--------~--------------------
Septlc Tank Manufacturer or Trede Name _.ery'"'-'<-i' ...... o ... G_.a .. -10""'-... M=--------------------
Septlc Tank Access within 8" ~f surfa~ ~~
Absorption Area d ~ I t,,MAib I"'~
Absorptl.on Area Type and/or Manu1acturer or Trade Name ~).J.~~~~Jfio,'-4tt.LJo<..U;L"-.t:-i..,,_._ __ .:.ll_._-...L-}..:D'---------
' Adequata complianca ~unty and Stata regulat1one/requ!:1ts._,,l+/-!!€></Y'~---------------
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1.._,
~ ~ "CONDITIONS:
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
, J 1. All installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chapter
j } 25, Article 10 C.R.S. 1973, Revised 1984.
-, ? 2. Thia permit is valid only for connection to structure which have tully complied with County zonlng and building requirements. Con-
. I nectlon to or use with any dwelling or structures not approved by the Building and Zoning offica shall automatically be a violation or a
) ·~ requirement of the permit and cause for both legal action and revocation of the permit.
I~ f,, 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 81J9Ciflcations contained In the application of permit commits a Clasa I, Patty Offense ($500.00 fine -6 , i. J months In jail or both). •
c-:J {:· While'-' APPLICANT YelloW' -DEPARTMENT
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' · INDlVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER f\R.Alo \~ \ ~.'\\,· t ~1--:~iltls v-
ADDRESS5'.'J,.QJ 31; .. J<d-rr.1..:1-Pi>Box. 4t2> PHONE Cf70-~76-2./€70
CONTRACTOR ___________________________ _
PERMIT REQUEST FOR (...rN'EW 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 CityofTown S ~ \!-~'> \\.'f I A
Legal Description or Address 5 .1 q I 3 f;..1. gd
Size of Lot LI 0 ~ ~-;. S.
WASTES TYPE: ( 0-BWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( )OTHER-DESCRIBE _______________ _
BUILDING OR SERVICE TYPE: ______________________ _
Number ofBedrooms ___ ....._ _________ _ Number of Persons -~Cd,.~----
( ) Garbage Grinder ( ) Automatic Washer ... _, ( ) Dishwasher
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SOURCEANDTYPEOFWATERSUPPLY: ( ) WELL . ( ) SPRING ( ) STREAMORCREEK
If supplied by Community Water, give name of supplier: _______________ _
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: ___________ _
Was an effort made to connect to the Community System? ______________ _
A site plan is reauired to be submitted that indicates the following MINIMUM distances:
Leach Field to WeU: 100 feet
Septic Tank to WeU: 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:
Depth to first Ground Water Table ______________________ _
Percent Ground Slope __________________________ _
2
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TYPE OF·INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
( ~. S~PTIC TANK ( ) AERATION PLANT (
( ) VAULT PRIVY ( ) COMPOSTING TOILET (
( ) PITPRIVY ( ) INCINERATION TOILET (
)
)
)
VAULT "f)
RECYCLING, POTABLE USE ~
RECYCLING, OTHER USE
( ) CHEMICAL TOILET ( ) OTHER -DESCRIBE
FINAL DISPOSAL BY:
( ) ABSORPTION TRENCH, BED OR PIT
( ) UNDERGROUND DISPERSAL
( ) EV APOTRANSPIRATION
( ) SAND FILTER
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A-
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
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WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? {ff D i !(
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 _____ p,er 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.
Date_-'-'/ {)"'----'d-=---<-9_-__,9__,9'----3 >51
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!! w ~ "i-Vrv-•
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Designate North Arrow
Your Neighbor's
Name & Address
Your Plot -Sh ape to Fit
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Locate well, all streams, irrigation di'tchs, 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.
County Road (Note the Road Number and Name)
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Your Neighbor's
Name & Address
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COUNTY OF GARFIELD -BUILDING DEPARTMENT
. C RRECTION NOTICE
108 8th St., Suite 201 Glenwood Springs, Colorado
Phone(970)945-8212
Job l~ted at 5AC// ~ .Jz 2-
Permit No. JJ1D {~)
I have this day inspected this structure and these
premises and found the following corrections needed:
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~1 -!ia-I ~ ~ ~ ~'-~ · frnr ~V?-, /999. IL~
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You are hereby notified that the above correction must be inspected
before covering.
When correction(s) have been made, call for inspection at 970-384-5003.
Date J # J8'-/) '3 20
~'lg'1rl'Spl1Ctor ;Qh};__Cf ~/J&d.-
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hone (970) 945-8212 ,. '