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(~ GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
109 8th Str,eet Suite 303
Permit N~ .3680
Assessor's Parcel No.
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! Glenwood Springs, Colorado 81601
Phone (303) 945·8212 -----------'
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
This does not constitute
a building or use permit.
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Legal Description of Assessor's Parcel No. ------,.----------'1--------'--'-'-J.-------l
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SYSTEM DESIGN, '
-'-'/~O_tJ_O __ Septic Tank Capacity (gallon) Other
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--'~~--Percolation Rate (:lnutes/inch) Num~r of Bedrooms (or other) E -f &,._f,~ tJ.¥ • l
fc$:S 'fl ~ g:,~,,r . . l
Required Absorption Area· See Attached 3 93 dJ ~---:;,; ~ (3ll'b) 91.. :J~~/j (Zl('g) ~
J./ '7'J.. " & d.-~ 7 ~ ( 3'1.1-) I»-~~ ('-ll'"C') l Special Setback Requirements:
Date_~,~-~l~?~·~O~c~-----Inspector ,Oa,,h/~L l
FINAL SYSTEM INSPECTION AND APPROVAL (as Installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer ,e f 71yf¢'1(_
Septic Tank Capacity @tJlJ ~
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Septic Tank Manufacturer or Trade Name _I.A=~~+~--------------------------
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Septic Tank Access within 8" of surface ~"""~---------------------------
Absorption Area -"''4-------------------------------------
Absorption Area Type and/or Manufacturer or Trade Name -"~""'~°"""""=-o,.~,.,.·~"'·""''------------------
Adequate compliance with County and State regulations/requirements-'~~~-------------:.___ __
Date 7-( -0 Z....
RETAIN WITH RECEIPT RECORD
•CONDITIONS:
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.. INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
PERMIT REQUEST FOR <,>4 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:
NearwhatCityofTown Sit T SizeofLot 3 AC?
LegalDescriptionorAddress IJW/<f5W/t.( .5°"'? I} few•JCA·f':?., 5o,ifJ..,.4"f''i. £z tv ,pt:. pn.,
WASTES TYPE: <{4 DWELLING C ({. ~ I'-{ 5i //-( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER-DESCRIBE. _______________ _
BUILDING OR SERVICE TYPE: __ :5"°"/f+f--f>=iµ~e,~t\~;w"-"f--------------( ~
Number ofBedrooms _ _.-<,____________ Number of Persons _Z ____ _
~ Garbage Grinder <,)4 Automatic Washer
SOURCE AND TYPE OF WATER SUPPLY: 9(} WELL
~ Dishwasher
( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: _______________ _
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:_/,~Q'.~H~l<.~Nr%"""" .... ..t ... >=tJ~-----
Was an effort made to connect to the Community System?__.=-.!....1..------------
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
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITUOUT
A SITE PLAN.
GROUND CONDITIONS:
Depth to first Ground Water Table __ --'~"-()-""'ff_·,__. ----------------
Percent Ground Slope_~>.=-%. .... 5=..._~%.,__ ____________________ _
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'• TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
yq SEPTIC TANK ( ) AERATION PLANT ( ) VAULT
( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POTABLE USE
( ) PIT PRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
( ) CHEMICAL TOILET ( ) OTHER -DESCRIBE
FINAL DISPOSAL BY:
t:'t> ABSORPTION TRENCH, BED OR PIT ( ) EV APOTRANSPIRATION
oo UNDERGROUND DISPERSAL ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
( ) OTHER -DESCRIBE 2,v l-1 L../-rl!. ~ .§i.~.J€-fh.
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? 6)?J
PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer, ifthe Engineer does the
Percolation Test)
Minutes. ____ _..er inch in hole No. 1 Minutes _____ .per inch in hole NO. 3
Minutes per 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 application and in legal action for perjury as provided by law.
~ ::> • .e -L... _.J: .J A,KPI f-Date._£~· 11::_:&,,_-_,(J"-"?"'=='_'-------
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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Designate North Arrow t /JcJt'~ THIS FO!f"J CAN BE USED TO DAAW YOOR SITE Pl1>L" (Olestion Ill Qn questionnaire)
Your Neighbor's
N~&Address
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Your Plot -Shape to Fit
{No Scale)
C"UNfy Rd_, :Z/~ -Eo C. / J ,;J.? .;.
<.,,,.. ~ ,..e-300 .. 1 ~ -j"60 \ 1 rJ J.t3' {;,D'
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Locate wel~ al streams, irrigalion ditdl.\ and any wale( COIHses. lJraW in your MUSe,
septic tank & system, detached garages, and drivewa.y_
If a change of location is nereswy, you mwt submit a corrected drawing, before a
Certificate of Occupation will be issued.
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~ Your Neighbor's
Name&.. Address
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County Road (Note the lload Number and Name) • {YJ"
lllicc'a; ·a :' 'ale•
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