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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
108 Eighth Street, Suite 201
Glenwood Springs, Coloradof 81601
Phone (970) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY J
Owner's Name ' -� C L`
System Location
Permit
4118
Assessor's Parcel No.
1
Present Address 1 C I '1
This does not constitute
a building or use permit.
Phone I LI S- / r(4c
-
a
Legal Description of Assessor's Parcel No
SYSTEM DESIGN
9/27- 3(r,3- Co -/5-5
Septic Tank Capacity (gallon) Other
Percolation Rate (minutes/inch) Number of Bedrooms (or other)
t' /'a�;f
Required Absorption Area - See Attached
Special Setback Requirements:
Date Inspector
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer (PaltI.dae
Septic Tank Capacity -42 S -O
Septic Tank Manufacturer or Trade Name
Septic Tank Access within 8" of surface
Absorption Area
Absorption Area Type and/or Manufacturer or Trade Name 1/, fit,rS
I/10
Adequate compliance with County and State regulations/requirements J�
Other
Date /- Y =/d tpOr,,
Inspector
RETAIN WITH RECEIPT RECORDS AT'CONSTfiUCTION 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 o1 permit commits a Class I, Petty Offense ($500.00 fine — 6
months in jail or both).
white- APPI Ir`Akrr VSM., nCOaurru ,rr
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER )aro/ uecar P
ADDRESS 346/ C R l/? , la-wedn%yr, Co pilin/
PHONE 97a- 941S- 7490
CONTRACTOR A//fa
ADDRESS
PHONE
PERMIT REQUEST FOR: KNEW 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).
t5Z-1
LOCATION OF PROPOSED FACILITY: CR (( s
Near what City or Town 64.41-00i
Size of Lot
75 4c,t
G-
s,
gl:co
Legal Description or Address P..red C � ZT Pe.ti Tari C 11
it see )earl clef en' tio.,.44.4.4
WASTES TYPE:
QDwelling () Non -Domestic Wastes
() Transient Use () Commercial Or Industrial
() Other: Describe:
BUILDING OR SERVICE TYPE:
Number of Bedrooms J
Number of Persons Z
(*Garbage Grinder Q4 Automatic Washer p Dishwasher
SOURCE AND TYPE OF WATER SUPPLY:
QWELL () SPRING () STREAM OR CREEK
If supplied by Community Water, give name of supplier.
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: Z - $ ,,lo-
Was
..-,rb
Was an effort made to connect to the Community System? () Yes k'No
Number of Persons L
(*Garbage Grinder 9 Automatic Washer Dishwasher
SOURCE AND TYPE OF WATER SUPPLY:
WWELL () SPRING () STREAM OR CREEK
if supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: Z - S mall
Was an effort made to connect to the Community System? () Yes yWo
A site plan is required to be submitted that indicates the following MINIMUM distances:
Leach Field to Well: 100
feet
Septic Tank to Well:
feet
60
Leach Field to irrigation Ditches, Stream or Water Course: 50 feet
Septic System to Property Lines: 10 feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED
WITHOUT A SITE PLAN.
GROUND CONDITIONS:
Depth to first Ground
Water:
Table Percent Ground
Slope:
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
jn( Septic Tank () Aeration Plant () Vault
() Vault Privy () Composting Toilet ( )Recycling/ Potable
() Pit Privy () Incineration Toilet () Recycling/Other
() Chemical Toilet () Other —
Describe:
FINAL DISPOSAL BY:
orption Trench, Bed Or Pit () Evapotranspiration
() Underground Dispersal () Sand Filter
( ) Above Ground Dispersal () Wastewater Pond
() Other — Describe:
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE?
NO
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 per inch in hole No. 2 Minutes per inch in hole No. 4
RPE WHO MADE SOIL ABSORPTION TESTS:
Name:
Address:
Telephone:
RPE RESPONSIBLE FOR DESIGN OF THE SYSTEM:
Name:
Address:
Telephone:
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 action for perjury as provided by law.
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