Land Use Office Permit #__________________ PO Box 157, 6683 County Rd 13, Conejos CO 81129 Start Date: ______________________ Phone #: 719-376-2014 Fax: 719-376-6769 Expiration Date: __________________ Application for On-Site Wastewater Treatment System Permit FEES: (Permit Fees are payable to CONEJOS COUNTY TREASURER and are Non-Refundable.)  Install New System $325.00-Pre-construction  Repair Tank STA/Leach/Drain Field $200.00 POST CONSTRUCTION FEES:  Install New System $650.00  Repair Tank or STA/Leach/Drain Field $400.00 ADDRESS OF PROPERTY SERVED BY PROPOSED SYSTEM: Street Address: ___________________________________________________________________________ City: ______________________________________State: __________ Zip: _______________ Lot Size (in Acres): _________ Assessor’s Parcel Number: _______________________________ Legal Description: _________________________________ Subdivision ______________________________ Property Owner: Name: _______________________________________________________________ Address: ______________________________City: ____________________State: _______Zip Code: _______ Phone 1: ______________________Phone 2: _____________________ E-mail: ________________________ Applicant:  Same as Property Owner Name: _______________________________________________________________ Address: ______________________________City: ____________________State: _______Zip Code: _______ Phone 1: ______________________Phone 2: _____________________ E-mail: ________________________ PROPOSED FACILITY:  Single Family Dwelling  Multi-Family  Commercial  Other _____________ SINGLE FAMILY DWELLING GENERAL INFORMATION: Number of Bedrooms: _______ Additional Bedrooms Planned?  Yes  No Number of Bathrooms _____  Garbage Disposal  Hot Tub  Water Softener WATER AND SEWER INFORMATION: Water Supply:  Well Permit # ___________  Hauled Public Water System Supplier Name: (for Hauled or Public Water) _____________________________________________________ 1 Rev 02-01-2020  Land Use Office Permit #__________________ PO Box 157, 6683 County Rd 13, Conejos CO 81129 Start Date: ______________________ Phone #: 719-376-2014 Fax: 719-376-6769 Expiration Date: __________________ SYSTEM INFORMATION: Is property within boundaries of a sewer district?  No  Yes – name: __________________________________ Is property within 400’ of a sewer line?  Yes  No Waiver from the sewer/sanitation district?  Yes  No CONTRACTOR/ENGINEER INFORMATION Systems Installer: _________________________________________________ License #:_____________ Soil Evaluation Technician: __________________________________________ Job #: ________________ Design Engineer (if applicable): _______________________________________ Job #:_________________ Is this to be an Engineered System?  Yes (Complete page 1 and 2 only)  No (Complete page 1 threw 5) COMMERCIAL GENERAL INFORMATION (if applicable)  Section is not applicable Type of Business: __________________________________________________ Number of Employees: ___________ Must be designed by an Engineer – designed attached  Yes  No Design Flow > = 2,000 Gallons/Day  Yes  No If yes, attached CDPHE approval.  Yes  No (Note: Permit cannot be issued until the site approval is given from CDPHE) Are floor drains existing or proposed?  Yes  No For all work done under this permit the applicant and/or landowner accepts full responsibility for compliance with the State of Colorado and County Regulations. Applicant’s Signature: __________________________________ Date: ___________________ Permit Fee paid by:  Property Owner  Applicant  Other: _________________ Date Paid: ________________ Receipt # ____________ Type of Payment: ________________ Inspected by: ______________________________ Inspection Date: _____________________  Approved  Approved with Conditions ________________________________________________ 2 Rev 02-01-2020  Land Use Office Permit #__________________ PO Box 157, 6683 County Rd 13, Conejos CO 81129 Start Date: ______________________ Phone #: 719-376-2014 Fax: 719-376-6769 Expiration Date: __________________ SOIL INVESTIGATION FORM PROPERTY OWNER: _________________________________________________________________________ PROPERTY ADDRESS: ________________________________________________________________________ CONTRACTOR/ENGINEER: ____________________________________________________________________ Indicate which soil investigation method you performed: (Check One)  1. Visual and tactile evaluation from two or more soil profile test pit. Attach a Soil Profile Test Pit Log for each profile test pit.  2. Percolation test plus one or more soil profile test pit excavations. Attach a Percolation Test Summary and Result Form and Soil Profile Test Pit Log for each profile test pit.  3. Percolation test plus one or more soil profile holes (Not allowed after 07/01/2016) Attach a Soil Percolation Test Summary and Results. SOIL INVESTIGATION RESULTS: Is there a limiting condition with low permeability, bedrock, ground water or other condition that restricts the treatment capability of the soil?  No  Yes -- If yes, design document must explain how the limiting condition is addressed. Recommended Infiltrative Surface Elevation or Depth: ____________________________________________ Recommended Long Term Acceptance Rate (LTAR): _______________________________________________ Table 10-1 of Regulation 43 Soil Type: _________________ (Use this for the OWTS Design Worksheet) Completed by: ___________________________________ Date: ___________________________ 3 Rev 02-01-2020  Land Use Office Permit #__________________ PO Box 157, 6683 County Rd 13, Conejos CO 81129 Start Date: ______________________ Phone #: 719-376-2014 Fax: 719-376-6769 Expiration Date: __________________ OWTS DESIGN WORKSHEET (COMPLETED FOR ALL CONVENTIONAL DESIGNS) PROPERTY OWNER: _________________________________________________________________________ PROPERTY ADDRESS: ________________________________________________________________________ CONTRACTOR/ENGINEER: ____________________________________________________________________ 1. WATER FLOW: Number of bedrooms: ______ Design Wastewater Flow (gallons/day): ________ 2. SEPTIC TANK: Septic Tank Size in Gallons: __________ Maximum Tank Burial Depth from top of tank ________ inches Is tank certified for proposed burial depth  No  Yes Will groundwater affect tank:  No  Yes Include buoyancy calculation Will an effluent screen be installed  No  Yes Type _____________________ Manufacturer: ____________________ Will a secondary safety device be installed in the risers  No  Yes 3. METHOD OF SEPTIC TANK EFFLUENT APPLICATION:  Gravity  Dosed with Pump  Dosed with Siphon 4. TYPE OF MEDIA:  Rock & Pipe Tire Chips Chambers  Other: ________________________ 5. SOIL TYPE: _____________________________________________________________________ 6. SOIL TREATMENT AREA (STA) Long Term Acceptance Rate (Table 10-1 Regulation 43) ___________________________ Unadjusted STA Size – Show Calculation: ______________________________________ Trench or Bed (circle one) Size Adjustment 10-2: ________________________________ Size Adjustment 10-3: __________________________________ Rock & Pipe: _____________________________________________________________ Chambers: _______________________________________________________________ Other: __________________________________________________________________ Repairs:  Wide Bed  Deep Gravel Trenches  Mounded  Other: ____________________ 4 Rev 02-01-2020  Land Use Office Permit #__________________ PO Box 157, 6683 County Rd 13, Conejos CO 81129 Start Date: ______________________ Phone #: 719-376-2014 Fax: 719-376-6769 Expiration Date: __________________ CALCULATION SHEET – ADJUSTED STA SIZE (show calculation with adjustment factors utilized): Calculation for Square Foot needed for Drain Field (SQ/DF) SEE Table 6-1 Single Family Residential Design Flows The Design flow must be 150 (gpd) for each bedroom up to and including 3 bedrooms. The assumed number of people is two (2) per bedroom. Beyond the 3-bedrooms, the flow rate is adjusted to 75 (gpd) for each additional bedroom. # of Bedrooms = ______ (up to 3 bedrooms) x 150 Gallons Per Day per bedroom (GPD/BR) = _______ GPD * Extra bedrooms beyond three: _______ x 75 Gallons Per Day per bedroom (GPD/BR) = _______ GPD (extra) Soil Type __________ = _________ Gallons Per Square Foot (GPSF) __________ + __________ = __________ ÷ ____________ = ___________ GPD/3bdrm GPD/Extra Total GPD GPSF SQ FT for Drain Field (SQ/DF) Calculation for the Adjusted Square Footage (ASQFT) for the Drain Field Type (Trench & Bed) Pipe: Trench 1.0 X __________ SQ/DF = __________ SQ FT (No Reduction Allowed) = __________ ASQFT Bed 1.2 X __________ SQ/DF = __________ SQ FT (No Reduction Allowed) = __________ ASQFT Chambers: Trench 1.0 X _________ SQ/DF = __________ SQ FT X Reduction .7 = _________ASQFT Bed 1.2 X _________ SQ/DF = __________ SQ FT X Reduction .7 = __________ ASQFT Pressure Dosed system Trench 0.8 x __________ SQ/DF = __________ SQ FT X Reduction .7 = __________ ASQFT Bed 1.0 x __________ SQ/DF = __________ SQ FT X Reduction .7 = __________ ASQFT Calculation for type of Drain System (Chambers & Pipe) Chambers: _________________ ÷ __12___ = _____________________ ASQFT CHAMBERS NEEDED Pipe: ________________ ÷ __20__ = __________________ ASQFT FOR 10’ PIPE PIPE NEEDED NOTE: A scale drawing shall be provided with each design document, showing:  Location of each OWTS Component and distances to all applicable Physical features  Layout of Soil Treatment Area (STA)  Dimensions of trenches or beds  Depths of each component (or elevations relative to a designated benchmark) CERTIFICATION: I certify that I have all the competencies needed in accordance with Regulation 43. ___________________________ _______________________________ __________________ Signature Print Name/Company Name Date 5 SITE PLAN: Using basic shapes illustrate your lot, current structures in their locations on your lot, location of utilities, YOUR NEW PROPOSED CONSTRUCTION, and all setback measurements. Include: • Property Boundaries & Dimensions • All current structures • New proposed structure(s) • Utility locations (including well/water supply, septic, clean- out(s), and drain eld if applicable) • Roads & easements • Railroad (if applicable) • Creek, River, Ditches, Stream, Drains, Wetlands • Onsite features • Set backs • North Arrow Job site owner: __________________ Job site address: __________________ __________________ __________________ Phone Number: (____)-____-_______ Permit # __________________ N COLOR IN NORTH ARROW REVISED 01-08-2026 fi