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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
Permit
Assessor's Parcel No.
This does not constitute
a building or use permit.
PROPERTY
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Owner's Name ! I Prgsent Address ( Phone
System
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Legal Description of Assesae1xs P3FceI No
SYSTEM DESIGN
Septic Tank Capacity (gallon) Other
at a3- 34 -bo-
Percolation Rate (minutes/inch) Number of Bedrooms (or other)
Required Absorption Area - See Attached r0
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" eft 6. 2- 6) y
Special Setback Requirements: T
Date Inspector k':44 L
FINAL SYSTEM INSPECTION AND APFROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer
Septic Tank Capacity r; '
1/
Septic Tank Manufacturer or Trade Name
Septic Tank Access within 8" of surface
Absorption Area
Absorption Area Type and/or Manufacturer or Trade Name
Adequate compliance with County and State regulations/requirements
Other
Date Inspector
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
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER . �'- r ►' Jc ��/ Se_ t~
ADDRESS 4L/ % // &>/ 6./�/fPL, �c1.S t/' PHONE (%
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
SEPTIC TANK
VAULT PRIVY
PIT PRIVY
AERATION PLANT ( ) VAULT
COMPOSTING TOILET ( ) RECYCLING, POTABLE USE
INCINERATION TOILET ( ) RECYCLING, OTHER USE
CHEMICAL TOILET( ) OTHER -DESCRIBE
FINAL DISPOSAL BY:
ABSORPTION 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? W 0
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.
Name, address and telephone of RPE who made soil absorption tests:
Name, address and telephone of RPE 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 famished 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.
Signed \Z AA
PLEASE
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J:>tan?l Date 0(T 10 03
ACCURATE MAP TO YOUR PROPERTY!!
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Designate North Arrow
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County Road (Note the Road Number and Name)
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