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GARFIELD COUNTY BUILDING AND SA~ITl\'flON DEPARTMENT
. 109 8'11 Street • Su1tf 'f03
Glenwood Springs, Colorado 81801
Phone (303) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
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~·_e Permit l'I
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3751
Assessor's Parcel No.
This does not constitute
a building or use permit.
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an Dw '" e_, ' lo~S-11Col ___ ..,..,~_.,... _______ Phone. ______ _
1~*13,:
j15Z> Septic Tank Capacity (gallon)
--<1>-3 ___ Percolation Rate {minutes/inch)
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Required Absorption Area -See Attached
Special Setback Requirements:
Date /o//i, fo?--
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FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
\ i Call for Inspection (24 hours notice) Before Covering Installation . ~~I ,.,
System Installer+/'",' .',..cdk""cl'-_,,bvi=,.'1'-"'A<.>....N.__ ____ ~-'-----'-1_" __ -'\ _______ _.,._ ________ _
Septic }tlk Capacity~! ~c;D~=D------------,,.-------,----'llt----------SjTa~k Manufacturer orT;ade N&(lle -:'~~'::s..~f.!:::~.E~----=----'-.,..;.-;I.-'---_:. ________ _
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S Tank Access within 8" of surface -'"+'"""L---=:--ry--------.111-------------/'
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i · Abscrption Area .+C..:W~~:..L..U:~..IL.l."-~.(...n~--+~!!..::~"2.-,l---,-l.'..:.:. _____ -,:,;.;.,,e.~_:_---
; -:··· .. ?' Absorption Area Type and/or Manufacturer or ~rade Name -"~..::.-f~-,..f:~'-h,.·'-'-'a""'~'J·"'·"'' -~=~--'J/'-'-_-_;_(_,{),_·_·· __ ,.;1':4.· r------
. >~ ~ Adequate compliance with County and State regulations/requirements.~t..,,,.J .. ··.,·"·-----------itJ,_~_,,.7'-'-----
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_,; Other-----------------~-----------------------
-1 Date_~Q..,.__-_1 _1_-_=0~4 ___ Inspector -~A<-4-"~"'f--.,_,_.._..~'-4'...._~----''-""..i,.,.F'----~
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~. c.~·.:.... RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE -~ ··~
: '. ~~···· '::;;: .ltDmONS: --. . .
. ! ~; "'~·-;>~--.f~ ..\: --All Installation must comply with all requirements of the Cok>rado State Board of Health Individual Sewage Dls~aal Systems C
· . · · ., .. ,, .. , .. · 25, Article 10 C.R.S. 1973, Revised 1984. • .·> 1 · 2. This permit is valid only for connection to structures which have fully complied with County zoning and build!~ requirements.
I . . , nectlon to or use with any dwelling or structures not approved by the Building and Zoning office shall automatically be avlolatl
' • «, ~ _ requiremeril'of the permit and cause for both legal action and revocation of the permit. ' ~1
, :-, ... variation from the terms or specifications contained in the application of permit commits a Class I, Petty Offense ($500.00 fine.
. , ·· 7;111onths in jail or both). .
'. +.".. ~. I : White • APPLICANT Yellow • DEPARTMENT !i -~
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INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
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9712 lz-2;£17~1
CONTRACTOR 6'4a Al Otv1Ct
ADDRESS II tz ~ fa, r d dS'i PHONE If Zo lz .::i.;s? 7 6 f
PERMIT REQUEST FOR {i) 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 ofTown _ __,_fG.........,fj_,_(._._.,. _ _.(b......._ ________ Size of Lot
Legal Description or Address O~t3 C,f2._ ;t5"Cj 11-/i.1 ~
WASTES TYPE: (~WELLING ' ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER-DESCRIBE _______________ _
NumberofBedrooms_-=="-----------N.umberofPersons _ _.... __ _
( ) Garbage Grinder ( ) Automatic Washer ( ) Dishwasher
SOURCEANDTYPEOFWATERSUPPLY: (~LL ( )SPRING ( )STREAMORCREEK
If supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:._-"...::5'----=/71..._1,__""'k...,.,,._s-_____ _
Was an effort made to connect to the Community System? --+-<"-'-'-------------
A site plan is required to be submitted that indicates the followin& MINIMUM distances:
Leach Field to Well: 100 feet
Septic Tanlc to Well: SO feet
Leach Field to Irrigation Ditches, Stream or Water Course: SO feet
Septic System (septic tank & disposal field) to Property Lines: 10 feet
YOVRINDIYIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT
A SITE PLAN.
GROUND CONDITIONS:
Depth to first Ground Water Table. _ _.4"'+'0+'f?'-'~'--"-:''-¥"--'-1_,__fn~a.._.__.fe__,/'-""67_'-'V..._____,.H__.......f _______ _
Percent Ground Slope __ ___,::Z........_o ____ ,..de....._.~"11--.... '--' '"!'.. ...... ~e-------------------
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TYPE OF INDNIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
cv>' SEPTIC TANK ( ) AERATION PLANT ( ) VAULT
( ) VAULTPRNY ( ) COMPOSTING TOILET ( ) RECYCLING, POTABLE USE
( ) PITPRNY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
( ) CHEMICAL TOILET( ) OTHER-DESCRIBE
F~ DISPOSAL BY:
( ABSORPTION TRENCH, BED OR PIT ( ) EV APOTRANSPIRATION
cr//f UNDERGROUND DISPERSAL ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
( ) OTHER-DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? ffe
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 er 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 fi.nnished 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
falsification 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.
Sip t:4 ~ Dote @/-3-r;;;>.
PLEASEDRAW ACCURATEMAPTOYOURPROPERTY!! •
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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!ocation is necessary, you must submit a corrected drawing, before a
Certificate of Occupation will be issued.
County Road (Note the Road Number and Name)
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Your Neighbor's
Name & Address
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