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G.GA~ COUNTY BUILDING AND SANITATION DEPARTMENT '~It N~ J J 7 0
/· · .• 109 8th Street Suite 303 A-•10r'a Parcel No.
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! f '(INDl_,OOAL 8£WAGE DISPOSAL PERii• l i PROPERTY ,, lb~ 14 4 l,1iGPLr
Glenwood Sprlnga, Colorado 81801
Phone (303) 945-8212
This does not constitute
a building or use permit.
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,1.°"'* .. ~SttYH ) Xa1Jl Present Address l\2 c-12.J c R G11.~Phone 9 45-50 I l
J J System Location I 170 -\ 2.l Cl J G w..'.>l:::> StGs / C..0
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! ~ Legal Deecriptlon of -or's Parcel No. ~ { 8'2-~ -;)...-00 -0 3 /
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I ! SYSTEM DESIGN ••
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-f-'f CJl50~"""""-Septic Tank Capacity (gallon) _____ Qt.her
' ~ -t-' bl~'f' :1 Percolation Rate (minutes/inch) Nu?'ber of Bedrooms (or other) • ' lo
-b'ff El snf.?J M*-b /i!L)C /<... J,..µlc.~b c:r!:..1 ' i
RequiredAbsorptlonArea-SeeAttached 35'1 o' L£A-c.H Clf71-M~~ 1,J . ~lf!t)
-;z. '1'1 °fi!:_~~I3U-$ 1JJ c~"<f.t-~:; Special Setback Requirements:
Da\e _ _,('.._.n ... _-_,/.uo.,_'_.,O't) ..... ..__ ___ Inspector ~ ~ ~ 1
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M INSPECTION AND APPROVAL (as installed)
Inspection (24 l)ours notice) Before Covering Installation
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System Installer a~
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Septic Tank Catty,-' +-'~~.L------------------------------
Septlc Tank M,111ufacturer or Trade Name _;J'-"-,,,,O"'R-"-'W<"-1(_</ ..... ,J"'-')'---------------,..-----
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Absorption Area .U..11--µd--1&_J.L\.!~:d:.~-_J-~~~L-----------------
Absorptlon Area Type and/or Manuf~urer or Trede Name ..b~L~~!*~~:::_ ___ .....:'-!t!IL------.,
Adequata compliance with County and State regulalionslrequlrements._lJ."'F/2"":h-'~---------------
•'-l .-.. , .. _ Other
"'·-__._,! O...._-_._rj,__1i..-'-"@~ __ Inspector ~Nr-=--· LiJ~<..__-n"--'-'lVt-_..._tf!.<=---'----------
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SIT!:
-CONDITIONS;
1. All "" 'I 91tjon mull comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal si,.tame, Chapter
25, ~ 10 C.R.S. 1tn, -111114. '
2. This permit i. "9fld only for connection tq_~uctures which have fully complied with County zoning and building requirements. Con,
nectlon to or UM wltll ~~ng or otructures not approved by tha Building and Zoning office shall automatically be a violation or a
requirement of the ptnlllt lllJd oauae for both legal actlo~ and revocation of the parmlt .
3. Any person who conalrUtl8. ilte!'a. orlllllalls an lndivldual sa'Nage disposal system In a mannarwhich lnvolvas a knowing and malarial
variation from the ~.Or 9"iflcallons contained in the "l"'lication of permit commits a Class I, Patty Offense ($500.00 fine -6
months In jail or -r /' .. " . ·''·"·~: . . I
l •,. ··· · · ", : •• -,.Wllile-APPUCAl'IT Yellow -DEPARTMENf
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7 INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION ,-.
PHONE C/115= r±/)
PERMIT REQUEST FOR (~W 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 FA ILITY:
Near what City ofTown. _ __c:>_L~!1....i~~'ai-S/.~:L!'.!~~-----,._fil~~:2L_.::!_~:.....!...~~~~
Legal Description or Address ...L.~~~--L~_._-..!:~=..!:.!...:~::::£.i-.-i.......~Ja..11~=-.....Jl.""""l..Llt:~-
W ASTES TYPE: (tf'DWELLING (
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER-DESCRIBE. __ ~~---~--~.-t--~~
BUILDING OR SERVICE TYPE: /2: Jif; Sqjffe tizroJwl?# S(f ~ .. 6/;l.-7 fat
Number of Bedrooms S" J Number of Per~__,,2......._ ___ _
( ) Garbage Grinder ( j'Alltomatic Washer ( ~ishwasher
SOURCEANDTYPEOFWATERSUPPLY: (~LL ( ) SPRING ( ) STREAMORCREEK
If supplied by Cormmmity Water, give name of supplier: _______________ _
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:__.1.lf/'-1£_~A~_· -------
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:
Depth to first Ground Water Table_,,Ac..e~· ::::•==-,~./------------------
Percent Ground Slope __________________________ _
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s Try-OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED: • ( l/ SEPTIC TANK ' ( ) AERATION PLANT ( ) VAULT
( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POTABLE USE
( ) PIT PRIVY ( ) INCINERATION TOILET ( ) RECYCL~G, OTHER l}S~
( ) CHEMICAL TOILET ( ) OTIIER -DESCRIBE w&;t ~ LM // u,,o~l-'J /$
FINAL DISPOSAL BY: c.o Sf Q, it1vO,
( ,j ABSORPTION TRENCH, BED OR PIT ( ) EV APOTRANSPIRATION
( ) UNDERGROUND DISPERSAL ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ~ ( ) WASTEWATER POND
( ) OTIIER -DESCRIBE,-+(/,,_,.a .... o,.,,.cl~1 -----"E'c;"-'.g,.._.(=Jj+------------
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF TIIE STATE?hto ~------
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
fillsification 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 &J '{_ ~,,,, > ...,---=-s-__._/;~14/;....._:19-=-o=->o<.D_
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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