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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
109 8th Street Suite 303
Glenwood Springs, Colorado 81601
Phone (303) 945·8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
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Permit '"-3667
Assessor's Parcel No.
This does not constitute
a bullding or use permit.
Owner's Nam.;f'5rortb )fS;ve1f== Pre;A Addres'J?D."dJ":>R ~&?o sit PhoneL]lo-cilo()S
'. System Location ~~'";§ -~-1 o± 3'1 Aot\ecs Q-c 001J <1J.i -84D'6'
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~:-Legal Description of Assessor's Parcel Nb. l ·
SYSTEM DESIGN
_l_,1 ~0~0~0~_ Septic Tank Capacity (gallon)
__ '1_,_,,._0,___ __ Percolation Rate (minutes/inch)
Required Absorption Area • See Attached
Special Setback Requirements:
______ Other
Number of Bedrooms (or other) ?, ..j. ~ b01JR Q__,4-'\'J
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08 I ~ ,;.... -f ,,,,,fl ./_)<-Ji -:3 ,/ "':-"'--v~
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Date .:$-,-~ -Dd-ill'•' -c..()t (/ !J/R,;t L .. lnspector_~/~t-~-!?~-------------------------
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for lnspettion (24 hours notice) Before Covering Installation
.i/( o!< lo <'11>of.j{ Up lo Tt111k 7-f!>·-oz,.<:$
Septic Tank Capacity_,_,,~tf~o~----------------------------------
Septic Tank Manufacturer or Trade Name -~('~v~"--"i:J,~·~u~n/t-.fi~------------------------1
A~oorption Area Type and/or Manufacturer or Trade Name -~J~n~r~l~1~1"-Ht~772~Lr'l~>~----------------
Adequate compliance with County and State regulations/requirements_~l'f._v'--"5 _________________ _
\ Other _____________________ _,_·~·--r------1+---------------Date_,~'( -~i_5-_r"V __ Inspector-~{(:""--') ~-A)~i{~\ _,_ft~\ Y~(l-"---!£; ____ _
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.$. 1973, Revised 1984. ·
2. This permit Is valid only for connection \O structures which have fully complied with County zoning and building requirements. Con~
nection to or use with any dwelling 9r structures not approved by the Building and Zoning office shall automatically be a violation or a
requirement of the permit11.n.d cause for both legal action and revocation of the permit.
3. Any person who constrUets, 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).
White. APPLICANT Yellow -DEPARTMENT
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, __ ..... ,,, .. INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER (. hrl.stopb E. R €.. l~rTl ,'-f-h ,I Dor/ /() k. .·11eTT
ADDREssf/2 BQ'f rP-/38' B0sqft Co 816;;.../ PHONE _______ _
coNTRAcToR Home. ow VI ecs
ADDRESS /Jo t3ox £t38-&srAt co ?ii{ ~I PHONE ~ ~ ---------
PERMIT REQUEST FOR <)Q 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._....,R...,.i..c..F:..Ll_,.e~. ___________ __,.S,,.ize"'-"'of._,Lo.,..__t _,/C..>Q"'-'-, ""8'...::S=-<.A""'C.""f'_,.e'-"S'--
Legal Description or Address A t)'tle rs orcl.ia,fd Pw. i ro.cT 37
WASTES TYPE: <)Q DWELLING
6ec,,33 ,r~s, B.1.;i. \j}, '1 Th f.PJ.
( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER-DESCRIBE _______________ _
BUILDING OR SERVICE TYPE: ?-i 1 'f.. 6'6 \ tnodu [q I' Home
Number ofBedrooms _...._ ___________ _ Number of Persons ----'S'------
<)<) Garbage Grinder ~ Automatic Washer OQ Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: 9(1 WELL ( ) SPRING ( ) STREAM OR CREEK
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?_,_/)+--"'O.,__ ___________ _
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: (septic tank &leach field)lO feet
YQUR 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
.. OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED: ...
(~ SEPTICTANK ( ) AERATION PLANT ( ) VAULT
( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POTABLE USE
( ) PIT PRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTIIBR USE
( ) CHEMICAL TOILET ( ) OTIIBR -DESCRIBE
FINAL DISPOSAL BY:
(~ ABSORPTION TRENCH, BED OR PIT ( ) EV APOTRANSPIRATION
( ) UNDERGROUND DISPERSAL ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
( ) OTIIBR -DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF TiiE STATE?__,f>_,_,,Q"------
PERCOLATION TEST RESULIS: (To be completed by Registered Professional Engineer, if the Engineer does the
Percolation Test)
Minutes. ____ _,,er inch in hole No. I Minutes _____ _,,.er inch in hole NO. 3
Minutes er 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 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 app ·cation and in legal action for perjury as provided by law.
Date cj-' J -o d-
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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