HomeMy WebLinkAboutApplication- PermitGARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit Nr 211 6
109 8th Street Suite 303
Glenwood Springs, Colorado 81801
Phone (303) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
Assessor's Parcel No.
This does not constitute
a building or use permit.
Owner's NameRichard & Connie !'ICG tsdd',sent Address 0499 Wooden !Mar Rd. a Ctda]one 963-3136
System Location
0499 Wooden Deer Road, Carbondale
Legal Description of Assessor's Parcel No
SYSTEM DESIGN
�s f) 0 0 Septic Tank Capacity (gallon) Other
4, 1 Percolation Rate (minute inch) Number of
Bedrooms (or other) 3 �y
•
Required Absorption Area - See AMaehed3 /I Ar , 1— .2 e
Special Setback Requirements: •+y�, ca• .y Ai 3 gl "` 4 /0...4 r,
P
Date T -
Inspector _�}_fie �9 1.. .-(.•i1 c, L
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for inspection (24 hours notice) Before Covering Installation
System Installer
Septic Tank Capacity
Septic Tank Manufacturer or Trade Name
Septic Tank Access within 8" of surface
Absorption Area 3 pi• �.•�,
L-7
Absorption Area Type and/or Manufacturer or Trade Name
V:, ".„'` i --:r [-f...:,_
Adequate compliance with County and State regulations/requirements
Other
Date 5' i r 2 Inspector ''1 1 14) -
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 1, Petty Offense ($500.00 fine — 6
months in jail or both).
Applicant: Green Copy Department: Pink Copy
INDIVIDUAL SEWAGE DISSPOSALL SYSTEM APPLICATION��
AD5f ere
Raik/C/ OWNER 9/6/9/7/e.---9/6/9/7/e.---/l�l��,CGllj� f'i icy
ORESS 10 4 •-111GE97,3-3/ 3
CONTRACTOR , fad 22Qfz
ADDRESS PHONE
PERMIT REQUEST FOR: ( 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 f /2/
Near what City of Town
Legal Description
N1ppl� n
i pproval by
County Official:
) Repair
to surrounding areas,
wells, soil percolation
Lot Size /- .'5"-�e
WASTES TYPE:
(
�Dwelling
) Commercial or Institutional
) Other - Describe
BUILDING OR SERVICE TYPE:
Number of bedrooms
Garbage grinder (1,r& tomatic washer (
SOURCE AND TYPE OF WATER SUPPLY: (I/) ell
( ) Transient Use
( ) Non-domestic Wastes
Number of persons
Tishwasher
( ) spring
Give depth of all wells within 180 feet of system:
If supplied by community water, give name or supplier:
GROUND CONDITIONS:
Depth to bedrock:
(
) stream or creek
Depth to first Ground Water Table:
Percent ground slope:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to community system? '
TYPE OF INDI LDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
( 'Septic Tank
( ) Vault Privy
( ) Pit Privy
( ) Chemical Toilet
FINAL DISPOSAL Y:
( Absorption Trench, Bed
( ) Underground Dispersal
( ) Above Ground Dispersal
( ) Other - Describe:
(
(
(
or
) Aeration Plant
) Composting Toilet
) Incineration Toilet
) Other - Describe:
Pit
( ) Vault
( ) Recycling, potable use
( ) Recycling, other use
( ) Evapotranspiration
( ) Sand Filter
( ) Wastewater Pond
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? /0
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 perriri't. i 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. 1 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 j_7 -24.(5,''c2
PLEASE DRAW AND ACCURATE MAP TO YOUR PROPERTY
Signed
Page 3