HomeMy WebLinkAboutApplication- Permitt4
INDIVIDUAL SEWAGE DISPOSAL PERN4 T
PROPERTY
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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT- Permit tic 3 U 7 6
109 8th Street Suite 303 'Asse'ssors Parcel No.
Glenwood Springs, Colorado 81601
Phone (303) 945-8212
This does not constitute
a building or use permit.
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tOwner's Name1-61f1,3
O( i A ie, PresenLAddress � - C * 3) d 4J et.,zCo t C08P ro>�e 9/tf" 3Y9.7. i
0 A.$0 System Location 2253 CA �i I ) Cas-- `e. C $ (IA ,, i
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i # Legal Description of Assessor's Parcel Nq �-0ru /
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1 SYSTEM DESIGN
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t I 'g 7, Septic Tank Capacity (gat on) Other ' i
e coiation Rate (minute' ch) Number of Bedrooms (or other)_ t
Required Absorption Area - See Attached
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Special Setback Re�quxertien't/ s rr -
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• j78te 6 y/ '-- Y"7 Inspector p r
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FIN YSTEM INSPECTION AND APPROVAL (els installed)
Call ior nspection (24 hours notice) Before Covi riting Installation
System Installer 0 (4 1,1
SepticTank Capacity 1 5 0 o
r ` Septic Tank Manufacturer or Trade Name
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, *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 1, Petty Offense (5500.00 fine --8
is months in jail or bosh).
Septic Tank Access within 8" of surface
Absorption Area
Absorption Area Type and/or Manufacturer or Trade Name
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Adequate compliance with County and State regulations/requirements
Other
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= bate 1 !L —OD inspector
RETAIN WITH RECEIPT RECOOS AT CONSTRUCTION SITE
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While - APPLICANT Yellow - DEPARTMENT
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INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
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OWNER - u -Q 1,0 r`,
ADDRESS '7 7 0 1 C k/( -y . LL ll?ekc) CosFie PHONE (p7 9) ?p<r -3yga
CONTRACTOR D I
ADDRESS PHONE
PERMIT REQUEST FOR 90 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).
LOCATIOIN OF PROPOSED FACILITY:
Near what City of Town /0 c/cd CC_1/e Size of Lot 1 a c**- es
Legal Description or Address 'P 4,9 4 3 6, lc 1 ..,09.5' r19/1
WASTES TYPE: 00 DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPE: f& e S 3 A 4 -
Number of Bedrooms 3 Number of Persons °Z-
( v)
2(v) Garbage Grinder (X) Automatic Washer (k) 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: 'Pt
Was an effort made to connect to the Community System? /l%/ i -
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 to Property Lines: 10 feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT J3E ISSUED
WITHOUT A SITE PLAN,
GROUND CONDITIONS:
Depth to first Ground Water Table it Pm Q y pP 0
Percent Ground Slope /0
2
'TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(PQ
( )
SEPTIC TANK
VAULT PRIVY
PIT PRIVY
( ) CHEMICAL TOILET
FINAL DISPOSAL BY:
( ) ABSORPTION TRENCH, BED OR PIT
(s) UNDERGROUND DISPERSAL
( ) ABOVE GROUND DISPERSAL
( ) OTHER - DESCRIBE
(
AERATION PLANT ( ) VAULT
COMPOSTING TOILET ( ) RECYCLING, POTABLE USE
INCINERATION TOILET ( ) RECYCLING, OTHER USE
OTHER - DESCRIBE
EVAPOTRANSPIRATION
SAND FILTER
WASTEWATER POND
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE?
PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer, if the Engineer does
the Percolation Test)
Minutes per inch in hole No. I Minutes
Minutes per inch in hole No. 2 Minutes
per inch in hole NO. 3
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
Date
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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JAN -10-00 MON 3:04 PM ALPINE BANK -NEVI CASTLE
PELA D
CONGRETE INCORPORATeD
Manufacturers 0 Precast Concrete Products
Also Distributor or Fielated Items
26E103 US. Hwy 5 • Nil, Colorado 81650
• Phone 625-1112 Fax 625-1110
Prase The Lord" .. •
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FAX N
9709842551
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