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GARFl,ru, COUNTY BUILDING AND SANITATION DE~~ENT
109 8th Street SuHe 303
Glenwood Spring., Coloredo 81801
Phone (303) 945-8212
Permit N~ 3 4 8 !i
f I 1NDIVIDUAL SEWAGE DISPOSAL PERMIT
~~PROPERTY
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This does not constttute
a buil,dlng or use permit.
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j ~ System Location 0 lPl+J1 C l\ 4-;-i I S l L "I~ () .,, ·-,
'j ~ Legal Description of Assessor's Parcel No. -----,-",2"-L/-'Jt:...L_-_O_;:J::.....:)..--=--_-_O_f_-~00,...·__,'f ______ f ___ ~
it sYSTEMDEsiGN DunscfM vv.,"t11or ,s-u,hd)t11sibrr Lo+Lf ··'. . f f , . I
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/ oof2 Septic Tank Capacity (gallon) -----~Other
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_..,Q......,d-.,___ Percolation Rate (minutes/Inch) Number of Bedrooms (or other)
£~"-~ ~ k...J Required Absorption Area -See Atteched
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) Special Setback Requirements:
Date 4-1\.-f)?
t i 1 ~ FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
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Call for Inspection (24 hours notice) Before Covering Installation
System Installer llt,tY I/ r" K
Septic Tank Capacity____,/.,_,'t/"-"=CJ'"-"=U"'"------------------------..::...----.,
Septic Tank Manufacturer or Trade Name -"-Ck&<,~P.=Vlf"-.1.t':..Jt/<L----------------------
Septic Tank Access within 8" of surface _ _.,µ.::__:5:::_ ______________________ _
Absorption Area ~"-"~'-"'-"'-"'5::-~-----------------------------
Absorption Area Type and/or Manuia::: or Trade Name _../;z""'-;7'/j-'-~-'/l_f_"?!;-'';fo-'-_1'_> ______________ _
Adequate compliance with County and State regulationa.'requlrements _ _,,,;s;,:.:...":7::<.... ______________ _
RETAIN WITH RECEIPT RECORDS AT
-CONDITIONS:
1. All Installation must comply with all requirements of th• Cotorado Sblte 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 hava fully complied wtth Counly zoning and building requirements. Con-
nection to or use with any dwelling or structures not approvad by the Building and Zoning office shall automatically be a violation or a
requirement of the permtt and cauae for both legal action and revocation of the permit
3. Any person who constructs, atteni, or Installs an Individual-age disposal system In a manner which Involves a knowing and material
variation from the terms or specifications contained In the appHcatlon of permit commits a Claaa I, Patty Offense ($500.00 fine -8
months In jail or both).
While-APPLICANT Yellow-DEPARTMENT
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' • INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
PERMIT REQUEST FOR (f) 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 FACilJTY:
Near what City ofTown. __ $..,.c.LA ... t"'--------------""Size,__,o""f...,Lot,,.__7__:_ . .:._7_(_9'_'-"_'"_5_
Legal Description or Address _l_ot-=-....,tf--=/)-'q'"'-"""'iJ.""""<!-'Jr_..ll ..... 'kl,'""."""<>r.__.h==--/.=J.....,·V.""''iu..o'Pu.'~6=x.._.o=,,.,~.F-dr"'"""""o_,_1fQ.,...."-~=6 ... B'--"C.'--o-X."'""~...__2._S;....i/
WASTES TYPE: ()() DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( )OTHER-DESCRIBE. _______________ _
BUILDING OR SERVICE TYPE:_.::;S_,_r-"" 2~/....,,.-_..P,.'--'q~W?'-'-"'-,'_,,./ }!!?=-_h-'--lJ-~-"-------------1
NumberofBedrooms _ ___.;;3;;__ _________ ~
Q<1 Garbage Grinder 9<1° Automatic Washer
SOURCE AND TYPE OF WATER SUPPLY: (;<) WELL
Number ofPersons --=-----
(XJ" Dishwasher
( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: ______________ _
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: __ ~~...::c.:...f_«:....:"--'1.1µ/e"'-----
Was an effort made to connect to the Community System.? _ _,_N....._..o"'-------------
A site plan is reouired to be submitted that indicates tbe following MINIMUM distances;
Leach Field to Well; 100 feet
Septic Tank to WeU; 50 feet
Leach Field to Irrlgadon Ditches, Stream or Water Course; 50 feet
Sepdc System to Property Lines; 10 feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT
A SITE PLAN.
GROUND CONDITTONS:
Depth to first Ground Water Table ____________________ _
Percent Ground Slope _________________________ _
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'TYPE OF IND~ SEWAGE DISPOSAL SYSTEMPROPOSEI>
('/! SEPTICTANK ( ) AERATIONPLANT ( ) VAULT
( ) VAULTPRIVY ( ) COMPOSTINGTOil..ET ( ) RECYCLING,POTABLEUSE
( ) PIT PRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
~-( ) CHEMICAL TOil..ET ( ) OTHER-DESCRIBE __________ _
FINAL DISPOSAL BY:
<:x.5 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? ,!\10
PER.COLATION 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
fidsifiwion 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 ~p Date 3 -r 7,__ O/ '---------------
PLEASE DRAW AN ACCURATEMAPTOYOURPROPERTY!!
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&-of cR lv1 a JI\ f'r>¥'"" 6-f er ~ ::::> ·\.
Designate North Arrow
Your Neighbor's
Name & Address
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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 of location is necessary, you must submit a corrected drawing, before a
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, «' I I Certificate of Occupation will be issued. I I
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County Road (Note the Road Number and Name) Co A
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