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HomeMy WebLinkAboutApplication- PermitGARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N 3 61 C 109 8th Street Suite 303 Glenwood Springs, Colorado 81601 Phone (303) 945-8212 s INDIVIDUAL SEWAGE DISPOSAL PERMIT t -( 4 m PROPERTY Owner's Name. irl4a Lull , 5t -J v C'sPli Present Address Q.Qx (0 ate Assessor's Parcel No. �,{ /i j� '1 1'c,.+wc.b....71:�_ iS 11.35 lystem Location " t 13 Rid xig I � a r G._r .,L . i This does not constitute a building or use permit. Phone. -as -111 Legal Description of Assessor's Parcel No SYSTEM DESIGN Septic Tank Capacity (gallon) Percolation Rate (minutes/inch) Required Absorption Area - See Attached Special Setback Requirements: Date Other Number of Bedrooms (or other) Inspector FINAL SYSTEM INSPECTION AND APPROVAL (as -installed) Call for Inspection (24 hours notice) Before Covering Installation System Installer bpi Septic Tank Capacity Septic Tank Manufacturer or Trade Name Septic Tank Access within 8" of surface 6_a Absorption Area v �(.�`^" ✓� r-� Absorption Area Type and/or Manufacturer or ;Trade Name Adequate compliance with County and State regulations/requirements Other Date LI -S-n3 Inspector 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 Installsan individual sewage disposal system in a manner which involves a knowing and material 4 variation from the terms or specifications contained in the application of permit commits a Class I, Petty Offense (5500.00 fine — 6 months in jail or both). - f 5 White - APPLICANT Yellow - DEPARTMENT x .c. INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION OWNER S.tpuEfr ZrAin AUtA' ADDRESS 0933 Coimirr t2' .Z/ice gfeArtAr# CoPHONE 990 -b2 .5= ?/?0 CONTRACTOR /r'sz4- dF6rp (3ucsr, ADDRESS 6 F3 a r yen PHONE 990 -0 Y3 -V0Yf PERMIT REQUEST FOR (4 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 of Town PA,e.9t,vvr‘ coo Size of Lot /0 "ens Legal Description or Address O 933 Cov nt £t> 2 ir WASTES TYPE: (v)' DWELLING ( ) TRANSIENT USE ( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES ( ) OTHER - DESCRIBE BUILDING OR SERVICE TYPE: re Sraeevrfoc Number of Bedrooms -3 Number of Persons ( ) Garbage Grinder ("Automatic Washer (r"Dishwasher SOURCE AND TYPE OF WATER SUPPLY: ( ) WELL ( ) SPRING ( ) STREAM OR CREEK If supplied by Community Water, give name of supplier: err r aF PAadrn 'r 1 DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: r/N .e'..ezosi / ? Ar F Was an effort made to connect to the Community System? x/d A site nlan 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 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 AK if Percent Ground Slope P 'C 2 gYPE 6F INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED: ( 1 SEPTIC TANK ( ) AERATION PLANT ( ) VAULT ( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POTABLE USE ( ) PIT PRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE ( ) CHEMICAL TOILET ( ) OTHER - DESCRIBE FIN DISPOSAL BY: ( ✓)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? we PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer, if the Engineer does the Percolation Test) 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 purposed of the evaluation of the application; and the issuance of the permit is subject to such terms and conditions as deemed necessary to insure compliance 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 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. Signed rer f1 Date /7 2 4 - al PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!! 3 330 P02 NUG 03 '01 04 12 Field Ttcket 3 8 9 31 T by's Vs uum Truck S rvic , Inc. P.O. Box 615, Parachute, CO 81835 285.7271 Company . 1 A(P • J. ,, /4 v er� I Well 0 Driver y " - t III Truck # Date Description Hours Amount /l _ a s ©r Pim ,o Se,S,s rAI,,t / /57) D 0 /r)s--0 &sf 471. , 12 fn. isf e/ t ��t'e Per, J4� to `T1 ��!oo 1QCOd f ei Authorized by TOTAL$ 7 0 0 a 0 h N o0 L4 O COuNre ROAD ,2/3 at N re Oo N ..= V L • N M >• OD V C C A -0 "e b j