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Home My WebLink AboutApplication- Permit(51.) 17, -7 ..,2)0/D GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT 108 Eighth Street, Suite 201 Glenwood Springs, Coloradof 81601 Phone (970) 945-8212 INDIVIDUAL SEWAGE DISPOSAL PERMIT PROPERTY Owner's Name < c �< System Location Present Address _ ) J`2_ AL TA Legal Description of Assessor's Parcel No, a Permit �;,. 3 8 Assessor's Parcel No. This does not constitute a building or use permit. 1 . ,4 , 1&Scr mPFhone. j ' •_ 12.) t iMc7 , r d . .., ; ' - SYSTEM DESIGN Caci 0 Septic Tank Capacity (gallon) Other Percolation Rate (minutes/inch) Required Absorption Area - See Attached Special Setback Requirements: Date ^ 9) Inspector Number of Bedrooms (or other) 3ci a 171 .f rY. 4MC y FINAL SYSTEM INSPECTION AND APPROVAL (as installed) Call for Inspection (24 hours notice) Before Covering Installation System Installer Septic Tank Capacity itt 115 5- 04, Septic Tank Manufacturer or Trade Naine Septic Tank Access within 8" of surface Absorption Area M fr Absorption Area Type and/or Manufacturer or Trade Name Adequate compliance with County and State regulations/requirements Other Date / , 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 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 I, Petty Offense ($500.00 fine - 6 months in jail or both). White - APPLICANT Yellow - DEPARTMENT GARFIELD COUNTY SEPTIC PERMIT APPLICATION 108 8th Street, Suite 401, Glenwood Springs, Co 81601 Phone: 970-945-8212 / Fax: 970-384-34701 Inspection Line: 970-384-5003 www.garfield-county.com I Perk Fee: Totalfeej/• ) {rox Raiev j I X114,Q11f . la la Septic Permit #: 2 Building & Job Address: (Wan address has not been assigned, please provide Cr, wy or treet Name & Cityj„pi? d legal crtplio� �� t 1.1-- �A Y ? ,9 Kd • r 3 Lot Size: n Lot No: vv v i gii K Block p -vv No: Subd.I Exemption: 4 Owner: (property ow \ee— 1 1,5O n Mailing Address P.D., Bo X ll r] ` s, LT 81 S), Ph: a `int S 0-16? Alt Ph: 5 Contractor: Mailing Address Ph: Alt Ph: 6 Engineer: Mailing Address Ph: Alt Ph: 7 PERMIT REQUEST FOR: ( ) New Installation Alteration ( ) Repair 8 WASTE TYPE: welling ( )Transient Use ( )Commercial or industrial ( )Non- Domestic wastes ( )Other — Describe 9 BUILDING OR SERVICE TYPE: C S wd Number of bedrooms ' Garbage Grinder WYes ( )No 10 SOURCE & TYPE OF WATER SUPPLY: OdWELL ( )SPRING ( )STREAM OR CREEK (CISTERN If supplied by COMMUNITY WATER, give name of supplier: 11 DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: Was an effort made to connect to the Community System? YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN 12 GROUND CONDITIONS: Depth to 1sIGround Water Table Percent Ground Slope 13 TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISOs) PROPOSED: XSeptic Tank ( }Aeration Plant ( )Vault ( )Vault Privy ( )Composting Toilet ( )Recycling, Potable Use ( )Recycling, other use ( )Pit Privy ( )Incineration Toilet ( )Chemical Toilet ( )Other- Describe 14 FINAL DISPOSAL BY: absorption trench, Bed or Pit ( )Underground ( )Wastewater pond ( )Other- Dispersal ( )Above Ground Dispersal ( )Evapotranspiration ( )Sand filter Describe 15 Will effluent be discharged directly into waters of the state? ( )YES jNO 16 ", PERCOLATION TEST RESULT: (to be completed by Registered Professional Engineer, tf the Engineer does the Percolation Test) Minutes per inch in hole No.1 Minutes per inch in hole No.3 No. Minutes per inch in hole No.2 Minutes per inch in hole Name, address & telephone of RPE who made Name, address & telephone of RPE responsible soil absorption test: for design of the system: °17 Applicant acknowledges that the completeness of the application is conditional upon such further mandatoryand additional test 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 depa a - • : • • lth in evaluating the same for purposes of issuing the permit applied for herein. 1 further understand that any falsification or misreprese . r e . ma su in the denial of the application or revocation of any pe it granted based upo -said application and legal action for perjury as provided by I. . OWNERS SIGNATURE DATE STAFF USE ONLY Permit Fee: �� j�j Perk Fee: Totalfeej/• ) Building Permit #: Septic Permit #: Issue Date: Building & Planning Dept: �li APPROVAi ` "' DATE �. 0 \ \E 41{- R -a` 0,5 s -10 Pcts-H 1 1 1 1 1 1 1 1 1 1 1 1 rnis..rat?rarPspiree?iOstRW9{OittaNINetir''fillaP7w`m°stry r w kk11 GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit Iii.. 2 3 9 9 108 ath Street Suite 303 Glenwood Springs, Colorado 81601 Phone (303) 948-8212 INDIVIDUAL SEWAGE DISPOSAL PERMIT PROPERTY Assessor's Parcel No. t4 i i 1!a �i pppA; This does not constitute a building or use permit. Owner's Name Rebecca Perieon Present Address P.O. Boi 926$ Glenwood Phone 945-0453 J//3 System Location 3'+r-44Mltit�4-2, Silt 3^ Legal Description of Assessor's Parcel No. SYSTEM DESIGN • J f "' I ' ~ Septic Tank Capacity (gallon) Other I Percolation Rate (minutes/inch) Number of BetiroQPiis (or other) 3 r c. ! �., .& �' ,; c. 1 H . �. Inspector ''1 '`f'+A, ✓N:_ Required Absorption Area - See Attached Special Setback Requirements: Dale .23 / — ' r PI ' L SYSTEM INSPECTION AND APPROVAL (as installed) Cal .for Inspection (24• hours notice) Before Covering Installation ' :y System Installer 1 / .' r (i" eptic Tank Capacity /And) Tank Manufacturer or Trade Name Septic k Access within 8" of surface Absorption Area Cuff tr Absorption Area Type and/or Manufacturer or Trade Name Cg, t2/ , 4 r- L`;j Adequate compliance with County and State regulations/requirements ,.• Other Da 61.— /J... QS_ Inspector f RETAIN WITH RECEIPT RECORDS AT CONSTRUCT! SIT *CONDITIONS: 1. Ail installation must comply with all requirements of 1hr Colorado State Board of Health IRdivid4 Sewage Disposal Systems Chapter 25, Article 10 G.R.S. 1973, Revised 1984. 2. This permit is valid only for connection to structures which have fully complied with Co my zoning and building requirements. Con- nection tour use with any dwelling or structures not approved by the Building end Zoni office }Shat' automatically be a violation or a requirement of the permit and cause for both legal action and revocation of the per. i1. 3. Any person who constructs, alters, or installs en.individuai sewage disposal system in a manner hick involves a knowing and material variation from the terms or specifications conti3!Ined in the application of permit commits a Class 1, Petty Offense ($500.00 fine — 8 months in Ian or both). Applicant: Green Copy DepartMent: Pink Copy h INDIVIDUAL SEWAGE DISPOSAL SY M APPLICATION OWNER �e.,. E',CG r-PeA son ADDRESS `. Q . P,o)S ` ((O 0-.. PHONE (3C- )x'76 - 3 a rt X ► 3 CONTRACTOR 5 c3 ADDRESS PHONE PERMIT REQUEST FOR 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). LOCATIONyF PROPOSED FACILITY: COUNTY r c, c Near what City or Town � j T , Lot t 'a -- Legal Description 4? -- ) l j` . (x Th WASTES TYPE: Dwelling ( ) Transient Use ( ) Commercial or Industrial ( ) Non-domestic Wastes ( ) Other - Describe BUILDING OR SERVICE TYPE: '.4)-1 e li R LJ tAi- Number of bedrooms. Num of persons ( ) Garbage Grinder Automatic Washer Dishwasher SOURCE AND TYPE OF WATER SUPPLY: ( WELL () SPRING () STREAM OR CREED. Give depth or all wells within 180 feet of system. If supplied by communtiy water, give name of supplier: GRQU UND CONDITIONS: Depth to bedrock. 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 INDIVIDUAL SEWAGE DISPOSAL SYSTEM Septic Tank ( ) Aeration Plant ( ) ( ) Vault Privy` ( ) Composting Toilet ( ) ( ) Pit Privy ( ) Incineration Toilet ( ) ( ) Chemical Toilet ( ) Other - Describe: FINAL DISPOSAL BY: ( ) Absorption Trench, Bed or Pit ( ) Underground Dispersal ( ) Above Ground Dispersal () Other - Describe. WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE?_ PROPOSED: Vault Recycling, potable use Recycling, other use ( ) Evapotranspiration ( ) Sand Filter ( ) Wastewater Pond . LA. PERCOLATION TEST RESULT,: (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 appliction 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 permit is subject to such terms and conditions as deemed necessary to inusre compliance with rules and regulations adopted under Article 10, Title 25, C.R.S. 1973, as amended. The undersigned hereby certifies that all statements make, 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 bre relied on by the local department of health in evluating the same fro purposes of issuing the permit applied for herein. 1 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. C � Signed Date 0 95 PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY 1 0 • x (w; (\ l {•'Cleo col- -} elri eOoky Ca, C) i`.rii�j .Y.tT GtloCLC� t � it � / COr Roil, r ��,� 4i i o, • C o\IACar D ! 3.f) t Ci"'»}t out, PLOT PLAN AND DBSICT.N FEATURES Include by measured distance location of wells, springs, potable water supply lines, cisterns, buildings, property lines, subsoil drains, lake, water course, stream, dry gulch and show location of proposed system by direction and distance from dwelling or other fixed reference object, and additional submissions in support of this application such as data, plans, specifications statements and commitments. 5-1\ C, 0, C. POO 0 fr4S / 3"