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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
109 8th Street Suite 303
Glenwood Springs, Colorado 81601
Phone (303) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
Permit tU:l8
Assessor's Parcel No.
This does not constitute
a building or use permit.
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Legal Description of Assessor's Parcel No. _____ _,r_·,"-~1~~/-fG-. _Ja""·-~,_) _-~,-·,-.,,._ •. ,_1 _r'-"''"'"''=-=./_,,L~Y""""'.,"-'---l-/-'~--i1:s·-,,:"'2~ .. ~.)'-------'--
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SYSTEM DESIGN
Septic Tank Capacity (gallon)
IC.
! I:/ P · I --~7___ ercolat1on Rate (minutes inch)
Required Absorption Area w See Attached
______ Q,ther
Number of Bedrooms (or other) .-·:;;-3'".' __ _
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v/Ol {J.1 f I ''C5 .... "'' ·· ,., ·,1,
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,Special Setback Requirements: 11&/ [ti ?"' .... n,, . ;• ;J . .f{ Date_c_,)_~-_. _,tf~·--~o~l/~· _____ inspector.,. ·-'
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FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
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Septic Tank Access within 8" surface _ _Jf:!;2;;L ________________ c,.... _________ _
Adequate compliance with County and State regulations/requirements~·"°y,"i."{;'-')?::c--;;J_" _________________ _
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Other ---------------------,7----,7"-""""-----------------
t' ----·-···7·:--7 /7 "l'y' /',,,.. Date_;;~'---_· ~/~~~;:_-~c~·x_',.._/_· ______ Inspector -~/,._',l'~/-~,,·:~~(.~_,.:;:,.,.~f~-:~~;1~~;_P=--"'=;,."';:,z·:~-------------------
RETAIN WITH RECEIPT RECORDS AT o6~~TRUCTION 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 btiilding 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 i_n jail or both).
White· APPLICANT Yellow· DEPARTMENT
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER Gef\1 f~ ra.c~J. Li:} R.
f 0 fl-~• ~#---(~. S ,'i( I G. er
ADDRESS ' '""'"" -__ GIV_S~---
CONTRACTOR---. .. {)u)./]~
ADDRESS. .'HONE
PERMIT REQUEST FOR (IA-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 ____ _,<O,.,· <.::tYx.-S~,/'------LN"-'t""~1"""'-'c~:.fa'.:~rLJ1'-''"'-'t--Size of Lot Z !{'v-tl}VR.t!·S
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Legal Description or Address ··------· -'Z.12:5 U-j L.; C10 -It; Z.
WASTES TYPE: (\)() DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
()OTHER-DESCRIBE ________________ ~
BUILDING OR SERVICE TYPE: __ ~£~I~N~G=L-~t>~. ~f~A-~W\~t~k,,_,f,___f(_~"'-'6~1~!\~ef~M""Q,..,.l=·S _________ _
Number of Bedrooms --~.__ ________ Number of Persons 2-
\,() Garbage Grinder (~Automatic Washer
SOURCE AND TYPE OF WATER SUPPLY: (/19. WELL
If supplied by Community Water, give name of supplier:
0<Q. Dishwasher
( ) SPRING ( ) STREAM OR CREEK
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DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: 5oO·t--~~----------
Was an effort made to connect to the Community System? _LLµ:±"-------------
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 (septic tank & disposal field) 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 SEW AGE DISPOSAL SYSTEM PROPOSED:
(~ SEPTIC TANK
( ) VAULTPRIVY
( ) PITPRIVY
( ) AERATIONPLANT ( ) VAULT
( ) COMPOSTING TOILET ( ) RECYCLING, POTABLE USE
( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
( ) CHEMICAL TOILET( ) OTHER-DESCRIBE _______________ _
FINAL DISPOSAL BY:
(~ ABSORPTION TRENCH, BED OR PIT
( ) UNDERGROUND DISPERSAL
( ) ABOVE GROUND DISPERSAL
( ) EVAPOTRANSPIRATION
( ) SAND FILTER
( ) WASTEWATERPOND
( ) OTHER-DESCRIBE _______ ~----------------~
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? rJO
PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer, ifthe Engineer does the
Percolation Test)
Minutes _____ per inch in hole No. I Minutes ______ .per inch in hole No. 3
Minutes _____ per 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 furnished by the applicant
or by the local health department for purposed of the evaluation of the application; and the issuance of the pennit is
subject to such terms and conditions as deemed necessary to insure compliance with rules and regulations made,
infonnation 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.
Signe Date 20 00.J 2c>c:Ji J"
PLEA EDRAWAN ACCURATEMAPTOYOURPROPERTY!!
3
Designate North Arrow
Your Neighbor's
Name & Address
'E>e A-,7.. w~\...L.O"J
RA-1"1,!.,IA-
Your Plot -Shape to Fit
(No Scale)
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Locate well, all streams:'irfi'gation 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.
' '
Your Neighbor's
Name & Address
Eoo oo't)o
County Road (Note the Road Number and Name) c~'IOrli c-n.Ge"-12. \) c 11.. \ 5 ....,. ,
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