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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit:
108 Eighth Street, Suite 201 Assessor's Parcel No.
Glenwood Springs, Coloradof 81601
Phone (970) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY ]�� rt (/� s�/� �p7 ��/�//�?� `(��q
Owner's Name U ° " ( in. present Address t.� C e �E2 I � % Phone 1 E ! I
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Legal Description of Assessor's Parcel No ?ATI - Doz.
SYSTEM DESIGN
This does not constitute
a building or use permit.
System Location �i
/1,906
Septic Tank Capacity (gallon) Other
Number of Bedrooms (or other)
' - Percolation Rate (minutes/inch)
Required Absorption Area - See Attached
Special Setback Requirements:
Date
Inspector
A0a4)d--2v-e4
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FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer (0.145-"
Septic Tank Capacity
0 0 L>•
Septic Tank Manufacturer or Trade Name
Septic Tank Access within 8" of surface //
Absorption Area 0 1`• i "!} / c:^_
Absorption Area Type and/or Manufacturer or Trade Name
Adequate compliance with County and State regulations/requirements /42,0=,"•--
Other
r 2�
Other
\1
Date
Inspector
);1./1( /z9- -27/
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.
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 automatically be a violation 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 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
GARFIELD COUNTY SEPTIC PERMIT APPLICATION
108 8'r' Street, Suite 401, Glenwood Springs, Co 81601
Phone: 970-945-8212 / Fax: 970-384-3470 / Inspection Line: 970-384-5003
www. garfi eld-countx.cQ n
1
Parcel No: (this information is available atle assessors office 970-945-9134)
2
,,,,..
Job Addr- : (if an address has not been assigned, please provide Cr, Hwy or Street -4m & City) or and l description
3
Lot Size: Lot,... No. Bloc . ,.„ 11bL .! , -motion:•
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te:
Owner: (property owner)
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Mailing Address
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Ph:
9(5' S7 7,'
Alt Ph;
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DATE
Contractor:
Mailing Address
Ph:
Alt Ph:
6
Engineer:
Mailing Address
Ph:
Alt Ph:
7
PERMIT REQUEST FOR: ( ) New installation ( ) Alteration ( ) Repair
8
WASTE TYPE: welling ( )Transient Use omrnercial or industrial ( )Non- Domestic wastes
( )Other — Describe
9
BUILDING OR SERVICE TYPE: r >"
Number of bedrooms % Garbage Grinder ( )Yes No
10
SOURCE & TYPE OF WATER SUPPLY:
If supplied by COMMUNITY WATER, give name
IrelVVELL ( )SPRING ( )STREAM OR CREEK ( )CISTERN
of supplier:
l 1
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to the Community System?
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YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN
12
GROUND CONDITIONS:
Depth to 1st Ground Water Table 35 Percent Ground Slope ,2-?'
. -
13
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS) PROPOSED:
(nSeptic Tank ( )Aeration Plant ( )Vault ( )Vault Privy ( )Composting Toilet
( )Recycling, Potable Use ( )Recycling, other use ( )Pit Privy ( )incineration Toilet ( }Chemical Toilet
( )Other- Describe
14
FINAL DISPOSAL BY:
r,('')Absorption trench, Bed or Pit ( }Underground
( )Wastewater pond ( )Other-
Dispersal ( )Above Ground Dispersal ( )Evapotranspiration ( )Sand filter
Describe
15
Will effluent be discharged directly into waters of the state? ( )YES (0)NO
16
PERCOLATION TEST RESULT: (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
No._
Minutes per inch in hole No.2 Minutes per inch in hole
Name, address & telephone of RPE who made
Name, address & telephone of RPE responsible
soil absorption test:
for design of the system:
17
Applicant acknowledges that the completeness of the application is conditional upon such further mandatory and additional test 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 o be elied on by the local department of health in evaluating the same for purposes of issuing the permit appli•.. for herein, I further
understand that,b ' ...kali n or mi presentation may result in the denial of the application or revocation of an permit gra! ed based upon said application
and legal- for prAir" ovi by law,
OWNER- UR DATE
A
STAFF USE ONLY
Permit Fee:
Perk Fee; .—
Total fees:
,,,,..
Building Permit #:
Septic Permit #:
14d g/
Issue
te:
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Build g & Plan i
1
APPRit . ,
DATE
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