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, J, ~' /~ .ffD GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N: 3 7 5 3 ;
• 109 8th Street Suite 303 A88e88or's Parcel No. '
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' Glenwood Springs, Colorado 81601 ;, J , Phone (303) 945-8212 .;
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·· . J l_~IVIDUAL SEWAGE DISPOSAL PERMIT
f Pl\OPERTY
This does not constitute
a building or use permit.
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("'oJner's Name Lf yg f (ft\ Ke Vi(\ Present Address ~fo/0 £ .jfve_ t_(p{f '?£1,,\l>Phonoq <((-3 /;).. { i S~em Location 0 td-1> c ~ 30 3 ff?.._ rfA ch u+e
i Lerjl.1 DescripJ'.i ,Assessor's Parcel No, m 0 7 -(?._ ~,;). -O"b -I 1 'f .
) ~·SYSTEM DESIGN Lo-f ;).., Ca. r (Je.nf-er-Ma.r-H ~ sUJ>.J.
I I 0 C> D Septic Tank Capacity (gallon)
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-----~Other
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Required Absorption Area -See Attached
Number of Be,g:oo")'/ (or~ o~hher) 1;, ,_ 'H J!.Qo..d', ~
2 bb iji fA.1-A. ;:)<) pc_.. ( 3i <,.)
1f3qtA & & c9..5f'-3lib)
--~}-~~-Percolation Rate (minutes/inch) .... ··
Special Setback Requirements:
Date Io { <-"l.. /o-z._ Inspector _ _,_,4J_,,.'-'~"'-'"---"·ef,__· ~ ____ -a __ ;f._· -----------
FINAL SYSTEM INSPECTION AND APPROVAL (as Installed) ,.;
Call for Inspection (24 hours notice) Before Covering Installation
System lnstaller~D~z.,.t,,.)L@~-"C ___________ ,··-----------~.ii··-·· ----------
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Septic link Capacity-J.Cl..<IL,r,.L~---------------------'------------
Septli,Tank Manufacturer or Trade Name --'<4n"""4-'"'e""'..P"""'{"'.-.....=-'e£"-"'-·------~_._.,...__''' __________ _
Septic Tank Access within 8" of surface ~ i·-
Absorption Area ;? ~ < Jl.. ,,.) 6/&f 1 f.l-<.-:/'JM= I cf;, f' C-,
Absorption Area Type and/or Manufacturer or Trade Name >ihf ,/l;f;;i tffu d) ()
Adequate compliance with County and State regulatlons/requlrements_~~'l'Q"""~""-----------------
Other _____ ~-----------------~------~----------
Date __._.I ").,""'-/-/q,__,..,,~~?--~--1nspector _.,_,,(J,..,..,,kla=' ~H~·~j_;/ ,_,)YL.U_L-=o.=-=-...c...· · _------/ I
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
•CO~DITIONS: · ···· .i 1. All Installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chaeter
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 bull ding requirements. Oon*
nection to or use with any dwelling or structures not apj:>reved by the Building and Zoning office shall automatlcally be a violation or a
requlrement of the permit and cause for both legal action and revocation of the permit.
3. Any person who constructs, alters, or Installs an Individual sewagfdisposal system in a manner which Involves a knowing and mat1irla1
\,:'\\ 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 S~WAGE DISPOSAL SYSTEM APPLICATION
OWNER __ K't.~£_v_1_#_5_,~{~Gu----,..._~_Li......,,._~~--------------
ADDRESS ___ J....._(q_,_f D__..f,_._. -<-'· A_u'""""~'---'-l_,_i_,_{ "'""(e~, __ _
:=~-TO-R~~-:r;"-'_""-'-H:ttl~s:·d:N=:c'.hv::Sli::/5.:'2:::~:Z~a:7.-,'-------P-H-ONE--9,--;:_l? ___ 6..,...J._S' ____ _
PERMIT REQUEST FOR (~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 81k{T1£m,r,,;r i116.!¥/ Size of Lot ), t1 llC
Legal Description or Address (!,ltf¥h/rb2 l11MXr1,I Uh""f'TttJP ld T ;Z.. 0,Q-83
WASTES TYPE: ( 0'DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( )OTHER-DESCRIBE ______________ ~
BUILDING OR SERVICE TYPE:_~/'fl_(Y.J~IA~ll11'?~~-----------------
Number of Persons __ 5<-----
( I/{ Dishwasher
Number ofBedrooms _ __,~----------
( ) Garbage Grinder (v{'Automatic Washer
SQURCE AND TypE OF WATER SUPPLY: (J;{' WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: _______________ _
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: _ ____,/'-L.---------
Was an effort made to connect to the Community System? ______________ _
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 WITHOUT
A SITE PLAN.
GROUND CONDITIONS:
Depth to first Ground Water Table __ ~i.J./J_/'J~M~"-""~V~ ___ '-J~6'-L~~~;l~aJ_F_'T._. -------
Percent Ground Slope _ ___.l=€=%0L.----1.5_,~ ......... -------------------
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TYPE OF INDIVIDUAL SEWAGE DISP'OSAL. SYSTEM PROPOSED:
(..{ SEPTIC TANK ( ) AERATION PLANT ( ) VAULT
( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POT ABLE USE
( ) PIT PRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
( ) CHEMICAL TOILET ( ) OTHER -DESCRIBE
FINAL DISPOSAL BY:
( v( ABSORPTION TRENCH, BED OR PIT ( ) EV APOTRANSPIRATION
('II/If' UNDERGROUND DISPERSAL ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
( ) OTHER -DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE?_--'-N"-t)"'-----
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 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
falsification or misrepresentation may result in the denial of the application or revocation of any permit granted based
upon said application and in legal ion for perjury as provided by law.
Date _ ___,/~(}~~-?-_-o~;z..__----
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Designate North Arrow
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Name & Address
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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 oflocation 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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