HomeMy WebLinkAboutApplication- Permit`§I CN
7 -;q -o'
GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
108 Eighth Street, Suite 201
Glenwood Springs, Coloradof 81601
Phone (970) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
\ . Ie ( .tg,
Owner's Name �t'%h C3 W Q I I, t40 r(Present Address 6 ?s C12 -.)-R3
System Location
1(03S C Q a n
Legal Description of Assessor's Parcel No
SYSTEM DESIGN
4 - Ito 8'7
Permit 40' 7
Assessor's Parcel No.
oV i n - o 3y- oa -575)
This does not constitute
a building or use permit.
Phone(D J - ✓gsG
coo Septic Tank Capacity (gallon) Other/
Percolation Rate (minutes/inch) Number of Bedrooms (or other) ✓
75-/- l21 i�r G' i_ 0
Required Absorption Area - See Attached
Special Setback Requirements:
-/
- S
Date
Inspector
� j s
iO4ify
/t
C
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering
^Installatipn
I
y ti\ (I, C A `)� i.'N�/17p I
stem Installer 7l ` �� �'-��
System
Septic Tank Capacity V O 0
Septic Tank Manufacturer or Trade Name
Septic Tank Access within 8" of surface
Absorption Area 11a
liPlr
7
-7
)
Absorption Area Type and/or Manufacturer or Trade Name
Adequate compliance with County and State regulations/requirements
Other
Date "6:1"� - � (r S Inspector 10,R/LY d .) - �
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 Vallewd- nrosinuarrr
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
•
OWNER '4[;I,u(Ard v.] Il
ADDRESS V� 7 c C,e Ca 93 �k
CONTRACTOR Q(A>in.r
ADDRESS SCt MQ . PHONE
PHONE tratiH (0
a CP—
PERMIT REQUEST FOR ( ) NEW INSTALLATION ALTERATI N '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:
rr ,�,
Near what City of Town k t t � . Size of Lot [�[/ # !6 Atr e s
Legal Description or Address
WASTES TYPE:
(>().. DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER–DESCRIBE
BUILDING OR SERVICE TYPE:
Number of Bedrooms Number of Persons
(X) Garbage Grinder 6') Automatic Washer (4 Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: ( ) WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: CI Sitrr
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: '.
Was an effort made to connect to the Community System? -
l� s
A site
Ian is re' uired to be submitted that indicates the followin
UM 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 Lin
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PE
A SITE PLAN.
GROUND CONDITIONS:
Depth to first Ground Water Table
100 feet
50 feet
50 feet
10 feet
WI
OT BE ISSUED WITHOUT
Percent Ground Slope
2
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
V) 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:
( ) 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 02-0 per inch in hole No. 1 Minutes ( per inch in hole No. 3
Minutes / 7 per inch in hole No. 2 Minutes (74) ite/u i o
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 pciuiit granted based
upon said application and in legal action for perjury as provided by law.
Signed ---r 9 ) CIC.10 � L.;� Date
:29 c 9
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
3
r
:Artier Section 2
t Cap in Place
-- 220'
39.57
N 46°16'06•
Irrigation Pipeline
Easement (For the Use of
Lots 1, 2 and T.R.O.A.)
30.0'
/
/
/
/ /
/ /
/ Building
/ / Envelope
G
/ Lot 3
4.325 Acres
/
Weil Access and Utility Easement
(For the Use of Lots 1, 3 and T.R.O.A.)
48.99' �� \
I75.
i — 30.0' /( `l 20.0' N 4 38.10,R
eltq\ 3j37,
Utility and Irrigation 4,1/
�orthe�°8 20.0'
Pipeline Easement �% �40' Diameter Easement for f!� °et otsU b F��\ r /
e and Related
I For the Use of Lots 1, 3 ,4 Those Welt No. 1, Aemp, 12, 31"''+7ent\ \/
andT.R.OA.J //OPe�Pumphousion, sutionaruirF�q•�J
30.0' pipe •8�
L16
Pipeline Facilities
Fa
1-
39 �AdVO(d Ler-)eLI
Lech F:eIJ
Iwc
—BuTding (
10 Envelope ech
1)t
— —
i
.N 00°1942' W
260.79'
r L34
necV 5'Plic Lot 2
)W2' 4.450Aaes
a�'o Tro rk I{OUSe
N 82'01'54" E
—520.75'
UtilityEasement and T.R OA•1Y
(For the Use of tots 1 •
Building
2 Envelope
w
Lot 1
3.742 Acres
Well Access and
Utility Easement
(For the Use of Lots 4, 6
andT.R.OA.) /
N 61 '3702' W
71.72'
/
V
I Lot 4
I3.541 Acres
/
/
20.0' I 3
/
I
20.0'
71.95' N 89°54'36' E
i
—417.11 —
/ / Utility Easement...i
(For the Use of Lots 4, 5, 6 and
t `N2123.24'E
20.0' 165.72' r L28
1/ Utility Easement 1
t /For the Use of Lots 4, 6 1
— and T.R.OA.)
I Building
/
A—
/
/
L23
Buildins
Envelop
L21