HomeMy WebLinkAboutOld Septic Permit.pdf• GARFIELD COUNTY BULDING AND SANITATION DEPARTMENT 108 EIghth $INIt, SuiIII201 GI...-od """' .. CoIondof8t801 Phone (mil MH212 INIIVlDUAL IeWAGE Dl8P08AL PERMIT lNI_ nol 00111'_ • building
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. . INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION OWNER RohYn:r. /t1i1er ADDRESS 53IIq rka"f{ri ItJD (fM6-PHONE q~d''hbz CONTRACTOR OW7?U ADDRESS PHONE'---__ _ PERMIT REQUEST FOR ()
NEW INSTALLATION ( ) ALTERATION IX) REPAIR Attadt separate sheets or report showing entire area with respect to surrounding areas, topography of area, habitable building, location ofpot&ble
water wells, soil percolation test holes, soil profiles in test holes (See page 4). LOCATION OF PRopoSED F4CILlTY: NearwhatCityOfTown(1fbO'nda.& Size of Lot ~;). GtCS. Legal Description
or Address 53'1'1 CoWlfr.( Rd· /00 WASTES TYPE: (;9 DWELLING ( ) TRANSIENf USE ( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES ( ) O1HER-DESCRIBE _____________ _ BUILDJNG OR SERVICE
TYPE: si1!jle... jamlfj Number of Bedrooms .3 NumberofPmous'--""'¥<--__ ( ) Garbage Grinder ( ) Automatic Washer ( ) Dishwasher SOURCE AND TYPe OF WATER SUPPLY: ~ WELL ( ) SPRING ()
STREAM OR CREEK If supplied by Community Water, give name of supplier: • DISTANCE TO NEAREST COMMUNITY SEWER SySTEM:,_7~.:..:.rn.:.!../.:....I~:::....-s""__ ___ _ Was an effort made
to connect to the Community System? --l.h-uo"-_________ _ A lite 1""1s required to be lubmJlted thet 'D'lptes the follom •• MINIMUM dlstmces: Leacb Field to WeD: 100 feet SeptIc Taak
to WeD: 50 feet Leach Field to Irrigadon Dltcbes. Stream or Water Course: SO feet Sepdc S)'Item (septic tank" dllposal field) to Property Lines: 10 feet YOUItINDMDUAL SEWAGE DISPOSAL
SYSTEM PERMIT WILL NOT BE ISSUED wrmOUT ASlTEPLAN· GROUND CONDITIONS; Depth to first Ground Water TablC:--'IL,.:1,.....;...6..J../i....:..-. ____________ Percent(lroundSlope __ =g.~pLl/!.......!.:.%=
--------------_ 2
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED: <)() SEPTIC TANK ( ) AERATION PLANT ( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) PIT PRIVY ( ) INCINERATION TOILET ( ) CHEMICAL TOILET(
> OTHER.DESCRIBE FINAL DISPOSAL BY: (.>r> ABSORPTION TRENCH, BED OR PIT ( ) UNDERGROUND DISPERSAL ( ) ABOVE GROUND DISPERSAL ( ) VAULT ( ) RECYCLING, POTABLE USE ( ) RECYCLING, O1HER
USE ( ) EVAPOTRANSPIRATION ( ) SAND FILTER ( ) 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, __ --I'per inch in hole No. I Minutes --__ -tper inch in hole
No. 3 Minutes per inch in hole No.2 Minutes'--___ --J:pe!' inch in hole No. _ Name, address and telephone ofRPB who made soil absorption tests: _________ -_ Name, address and telephone
ofRPE responsible for desip. of the system: ________ _ Applicant acknowledges that the completeness of the application is conditional upon SIIch further mandatory and additional tests
and reports as may be required by the local health department to be made and liu:nished bY the appIicanl or by the local beaIth department for purposed of the evaluation of the application;
and the issuance of the pennit is subject to such terms and conditions as domned UCQCSsary to insure complianoe 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 ate 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 ormisreptesentation may result in the denial of the
application or revocation of any permit granted based upon said applieation and in legal action for perjury as provided by law. _~LA. "'" //to106 PLEASED Vi cc :rn MAP TO YOUR PROPERTY!!
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DeaignllleNorthArrow Yoo,Neigbbo(s NIUIIO &: Address Y cur Plot -Shope 10 Fit (No Scale) Locate well, III streams. irrigatioo ditchs. and any water courses. Draw in your boo.., teptic
tank "-syJtem, detaobod garages. and dri_y, If. change oflocation i. _. you must submit. corrected drawing, before • Certificate of Oo::upation will be is.....!. County Road (Not. the
Road Numlm' and Name) Your Neighbor. Name "-Address
RESUL TS OF PERCOLATION TEST BUI PROJ£CT # J! !r_c~. _X_2_,_ C_3_ __ ADDRESS [)[SCRIP1ION_.§.~rJ_ _~ j()(J_~~.wU; __ OATE_j-~-~ I DEPlH AND DIAMETER or HOLt ,I _I} ___ " 4) ----" , #2
_____ • 0 ______ ". ,J _____ . 0 ____ •• APPROX, GALS. ADDED HOLE" _~__ HOLE ,2 _f..._ HOlE ,3 _Lz __ lEST HOlES WERE PRE-SOAKED FROM: (Oate)~~ (Time}j~'p"~_ TO: (Dot.}JJ1J1I..~ (Time>i~
___ , I HOLE #1 HOLE #2 HOLE #3 TIME R~H~K • fAll e4 1111£ ww • en: llllE R~b ~~K • fALL ./1.% /:J"f;.. ..---' /5 ---15 ----O.go J' o·w -z.o;. ,../~."S 'Z.'i l£p ".---II,. ...-' It,
/5 O.~l ~z. 0.50 :32. /' ~,l{O IjO ~-.-15 ----J5 ",....--O.<.f5 1.'1 Ij ---~ 1,'-1 .....-0.35 ~~, /5 15 /' I ()·I{O :3~ -----16, <fQ. ~& 0,30 ~ J5 15 IS ...-()J/O I-;~ lo,/{o '?><6 (1,"30
.5D I. PERCOLAllON RATE: ~'2 MPI I PROFILE HOLE AND SOL DESCRlPllDN JSIt~~-21 )C.:50' OF /X.~~, IlM:I!. 0( _'10%. R_ ,,,,-, ~ L. A'"
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