HomeMy WebLinkAboutApplication-PermitGARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
109 8th Street Suite 303
Glenwood Springs, Colorado 81601
Phone (303) 9454212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
Owner's Name Lon & Debra Winston
System Location
Permit N:. 205
Assessor's Parcel No.
2393-144.00-073
This does not constitute
a building or use permit.
Present Address 1266 CR 112, Carbondale Phone 963—A399
1266 'County Roedo112, Carbondale
Legal Description of Assessor's Parcel No
SYSTEM DESIGN
.11)
Septic Tank Capacity (gallon) Other
Percolation Rate (minutes/inch) Number of Bedrooms (or other) 2
Required Absorption Area - See Attached 56, - 2
Special Setback Requirements:
Date
Inspector 7/1
7" t
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
CaII for Inspection (24 hours notice) Before Covering Installation
_--_-- 4err=oes
System installer
wM'
Septic Tank Capacity
C/1i.A.csrk
Septic Tank Manufacturer or Trade Name
T",e,VGN i�1=
__,f. A11`,.1 rc)
Septic Tank Access within 8" of surface
.,.,.. �- /g"
Absorption Area
Absorption Area Type and/or Manufacturer or Trade Name
Adequate compliance with County and State regulations/requirements
Other
Date
Inspector/-•Grs ,¢jam
‘se
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 ($500.00 flne — 6
months in jail or both).
M
Applicant: Green Copy Department: Pink Copy
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER ] ie# )1 h,N 42ws7-A/
ADDRESS /42
CONTRACTOR
%/z PHONE 16,E )3 ?
ADDRESS PHONE
PERMIT REQUEST FOR: (>C) New Installation ( ) Alteration
Attach separate sheets or report showing entire area with respect
topography of area, habitable building, location of potable water
test holes, soil profiles in test holes. (See page 4
LOCATION OF PROPOSED FACILITY: County 6:7,i4.?/W.4%,
Near what City of Town CA--,e10A/ 4/Ze"
Legal Description -1- t 4
)
Application
Approval by
County Official:
) Repair
to surrounding areas,
wells, soil percolation
s4-# See
Lot Size /0/16,E'
r 75, R 88lii ; c l PH
WASTES TYPE: ( Dwelling
( ) Commercial or Institutional
( ) Other - Describe
( ) Transient Use
( ) Non-domestic Wastes
BUILDING OR SERVICE TYPE: /7/0/14'
Number of bedrooms
Number of persons
( ) ia$vsdr_ixidar (){) Automatic washer tom) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: (X') well ( ) spring ( ) stream or creek
Give depth of all wells within 180 feet of system: /1'p 4044tv/' .40 ./i7xYswe
If supplied by community water, give name or supplier:
GROUND CONDITIONS:
Depth to bedrock:
Depth to first Ground Water Table:
Percent ground slope:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: jr-R1/41:1
Was an effort made to connect to community system? /VJo
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
Nri Septic Tank
( ) Vault Privy
( ) Pit Privy
( ) Chemical Toilet
FINAL DISPOSAL BY:
( ) Absorption Trench, Bed or Pit
(Al Underground Dispersal
( ) Above Ground Dispersal
( ) Other - Describe:
) Aeration Plant ( ) Vault
) Composting Toilet
) Incineration Toilet ( ) Recycling, other use
) Other - Describe:
( ) Recycling, potable use
( ) Evapotranspiration
( ) Sand Filter
( ) Wastewater Pond
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF TIIE STATE?
SOIL PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer.)
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 furnished by the applicant or by the local health department for
purposes of the evaluation of the application; and the issuance of the pernii'ti-s subject to
such terms and conditions as deemed necessary to insure compliance with rules and regulations
adopted under Article 10, Title 25, C.R.S. 1973, as amended. The undersigned hereby certifies
that all statements 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 under-
stand 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 per-
jury as provided by law.
Date
Signe
PLEASE DRAW AND ACCURATE MAP TO YOUR PROPERTY
Page 3
PLOT PLAN AND DESIGN FEATURES:
Include by measured distance location of wells, springs, potable water supply
lines, cisterns, buildings, property lines, subsoil drains, lake, water course,
stream, dry gulch and show location of proposed system by direction and distance
from dwelling or other fixed reference object, and additional submissions in
support of this application such as data, plans, specifications, statements and
commitments.
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