HomeMy WebLinkAbout3975GARFIELD COUNTY BUILDING AND SANITAT ION DEPARTMENT
109 8th Street Suite 303
Glenwood Springs, Colorado 81601
Phone (303) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
_ _,_7_<;4_()'-"---Septic Tank Capacity (gal lon)
_ _.__J-._~~---Percolation Rate (minutes/inch)
______ Other
Number of B ed rooms (or other)-+/ ___ _
Perm it N~
Assessor's Parcel No.
{"1,1 I
This does not const itute
a building or use permit.
317 t:6 d 17 ;JOS 32.-D~c.d
Special Setback Requirements: ---r_
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( .,t:/'p? f A.. S. f· 2 Q f..JJ.t
Required Absorption Area -See Attached
Date 1-/) ~nt{ In spector -~---f~-~-~LJ':!<::J;J'I-~~=~~~=-=~--------------
FINAL SYSTEM INSPECTION AND APPROVAL (as installed) •
Ca ll fo r Inspection (24 hours notice) Before Cove ring Installation
System Installer _______________________________________ _
Septic Tank Capacity _ _:(f;J:....:.:(_g::-=:(;J:.__ ________________________________ _
Septic Ta nk Manufacturer or Trade Name _'__;:,~F:.::....::==--------------------------
Septic Tank Access within 8 " of surface _ _,.'.K/.J_.::::._::;__ ___________________________ _
Absorption Area --"-'-~~c::"/.:..:o:/c...:::..'...:::..,..._,=-::::.._--------------------------------
Absorption Area Type and/or Manufacturer or Trad e Name ---"-;,~1-:fA""gf_~~~=~~~==-.J~3:.__1~fl~~-"=~~----------
Adequate compliance with County and State regulations/requ irements,_-=--i--=-.Q_k'l=-----------------
(J
Other----------------------~-~-------------------
Date -----'-' ----=-;_J 1_-=.o-,:.(./~----Inspector ____ d __ ~_~_:/-__ """--'--/.1-.!f M:__yiHHuo~I/.Lll ti.L!Ja~\/-----
RE TA IN WITH RECEIPT RECO RDS AT CONSTRUCTION SITE
*CONDITIONS :
1. All install ati on 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 requ irements. Con-
nection to or use with any dwelling or structures not approved by the Bu i lding 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 invo l ves a knowing and material
variati on from t he terms or specifications contained i n the applicatio n of per mit comm its a Cl ass I, Petty O ffe nse ($500.00 fine-6
months in jail or both).
White-APPLICANT Yellow-DEPARTMENT
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER Anthony & Teressa Perry
ADDRESS 157 Blake Ave.Glenwood Springs Co. PHONE970-476-5454
CONTRACTOR Bob's Excavating and Home Repair
ADDRESS box 273 McCoy c. 80463 PHONE 970-653-4281
PERMIT REQUEST FOR (x) 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. _ __,G"-LJ"-'s"'u"'m"-____________ Size of Lot / 3o ~
LegalDescriptionorAddress El/2 of Sec 20 Wl/2 of Sec 21
WASTES TYPE: ( x) DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( )OTHER-DESCruBE ______________________________ __
BUILDING OR SERVICE TYPE: __ R""e._.s,_,.~--'-·-_,__fr_,_,-=-D_L_{ _________________ _
Number of Bedrooms _ _..._ ____________ Number ofPersons __ 2 ____ _
( ) Garbage Grinder ( ) Automatic Washer
SOURCE AND TYPE OF WATER SUPPLY: (X) WELL
If supplied by Community Water, give name of supplier:
( ) Dishwasher
( ) SPRING ( ) STREAM OR CREEK
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:_~2"""0'---'-'M""i-=-l"'-'es"".,___ _____ _
Was an effort made to connect to the Community System?-----------------
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 __________________________ _
PercentGroundSlope_4~%~-----------------------------
2
TYPE OF INDIVIDUAL SEW AGE DISPOSAL SYSTEM PROPOSED:
(X) SEPTIC TANK ( ) AERATION PLANT ( ) VAULT
( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POT ABLE USE
( ) PIT PRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
( ) CHEMICAL TOILET( ) OTHER-DESCRIBE
FINAL DISPOSAL BY:
(x) 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? ___ _
PERCOLATION TEST RESULTS: (To be completed by Regi stered Profess ional Engineer, if the Engineer do es the
Percolation Test)
Minutes _____ per inch in ho le No. 1 Minutes ______ per inch in hole No. 3
Minutes _____ per inch in hole No. 2 Minutes per inch in ho le No._
Name, address and telephone ofRPE who made soil absorption tests:------------~-
Name, address and telephone ofRPE responsib le for design ofthe system: __________ _
Applicant acknowledges that the completeness of the application is conditional up on su ch 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 s uch terms and conditions as deemed necessary to insure compliance with rule s and regulations made,
information and reports submitted herewith and required to be submitted b y the applicant are or will be represented to
be true and correct to the best of my knowledge and belief and are design ed to be relied on by the local dep artment 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 deni al of the application or revocation of any permit granted based
upon said application and in legal action for perjury as provided by law.
Signed '~ DateS Jz4ui-J
PLEASE DRAW AN ACCURATE MAP To" YOUR PROPERTY! V
3
Designate North Arrow
Your Neighbor's
Name & Address
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Your Plot -Shape to Fit
(No Scale)
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Locate well, all streams, irrigation ditchs, and any water courses. Draw in your house,
septic tank & system, detached garages, and driveway.
If a change of location is necessary, you must submit a corrected drawing, before a
Certificate of Occupation will be issued.
County Road (Note the Road Number and Name)
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Your Neighbor's
Name & Address
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