HomeMy WebLinkAboutApplication- PermitGARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
108 Eighth Street, Suite 201
Glenwood Springs, Coloradof 81601
Phone (970) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY 1�e.�) ///1/)j
owner'sNamejt)Ci'(Ar4JICc4a[th//,!/Y r/1 /k
-System Location V/Oq Ck 330 V
Present Address 103 Mak Bozo Ik
Permit
4033
Assessor's Parcel No.
This does not constitute
a building or use permit.
Phona9i'r -7051
„Legal Description of Assessor's Parcel No
SYSTEM DESIGN
ai75'-_34-o0-��
Septic Tank Capacity (gallon) Other
13 Percolation Rate (minutes/inch) Number of Bedrooms (or oother)}a^s-n
Required Absorption Area - See Attached 970 40/0,:--60„„d
(00 he d —
Special Setback Requirements:
Date C) - Inspector ' v .71c ° a`
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer Cin' Q- --
Septic Tank Capacity lb C
2 274 -
Septic Tank Manufacturer or Trade Name %
•
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER 1 , f (3,10 k, LtrekfD�
ADDRESS F3fl C.11- — I o 3 IIe V* w ke PHONEQ'a 3111 tt l
CONTRACTOR 5E1
ADDRESS PHONE
PERMIT REQUEST FOR (y') 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 Townl ?It Size of Lot 35 + ac .
Legal Description or Address Ate yv sty., 1 se At SEYv of thee .9i T5 foS. R9Vai' to4Rm 0)(k3a0
WASTES TYPE:
({DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER—DESCRIBE
BUILDING OR SERVICE TYPE: U& 3 gp Ak irte_
Number of Bedrooms 3 Number of Persons 3 pe pio
(✓f Garbage Grinder (.Automatic Washer (erbishwasher f— T
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: W + mc.Ic
Was an effort made to connect to the Community System? AAA, ,qtn' /h
A site plan is required to be submitted that indicates the following MINIMUM distances:
Leach Field to Well:
Septic Tank to Well:
Leach Field to Irrigation Ditches, Stream or Water Course:
Septic System (septic tank & disposal field) to Property Lines:
100 feet
50 feet
50 feet
10 feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT
A SITE PLAN.
GROUND CONDITIONS:
Depth to first Ground Water Table
Percent Ground Slope
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
( ,' SEPTIC TANK ( ) AERATION PLANT ( ) VAULT
( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POTABLE USE
( ) PIT PRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
( ) CHEMICAL TOILET( ) OTHER -DESCRIBE
FINAL DISPOSAL BY:
(ill 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 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 ail/(
Date I 75—OS
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY! On �� prrech w
711726,„ C. R. 3.2o fizum Fle 1L
props v) sup+ pool- mile roa tker 1 on k296, ay, -n±.5lde (ciaiyinin, pal)
erx mPrY Dory( 1/2.- lisesi di ?oink() Pitth fort ranch