HomeMy WebLinkAboutApplication- PermitGARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
109 8th Street Suite 303
Glenwood Springs, Colorado 81601
Phone (303) 9454212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
._PROPERTY
Owner's Name `A7 ( (2J1-r/C Os -Present Address C1 1 Lk%
System Location J (71Y1 ka
��
.. Legal Description of Assessor's Parcel No
i
SYSTEM DESIGN
t
Permit ./""
Assessor's
3 9 9
Assessor's Parcel No.
This does not constitute
a building or use permit.
CoQci1/4---)
Phone
91'x-7- 1 -mac' imhc
1 a SD Septic Tank Capacity (gallon) Other (� 1T ,, (/h
Percolation Rate (minutes/inch),4' Number of Bedrooms (or other) 76�' ) YDZ () R-MOt
Required Absorption Area - See Attached )
Special Setback Requirements: X !,� �96't- s X $)
Date CU - - 0 y Inspector,`c�,}'(-(,� !
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer I tiMA(A,'4 A,
Septic Tank Capacity 12
Septic Tank Manufacturer or Trade Name `1"12)
Septic Tank Access within 8" of surface ') .21
P tI
Absorption Area Y 'i �'`� f'?`�`' �' �""\ 'J
Absorption Area Type and/or Manufacturer or Trade Name ."461,74-5-1-
Adequate compliance with County and State regulations/requirements i\
Cher
r•( "
Date t r I
Inspector yr\ Y(21)-1- �� ))\--eCL (
�(1
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 automathcal ly 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
OWNER
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
ADDRESS '90'4 7 f St -'5" PHONE 72CC" 9152-3
CONTRACTOR '511 -SN ..e SNS etecohl err N6
ADDRESS i70 4441 1.2 S RILE, £ Y/6S0
i,,,y (7d-atr GS 9/Loi
PERMIT REQUEST FOR
PHONE 625=031'f 379-57 39 C�—
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 Town g&t"uiCbti Sial "'Rs fie
r Size of Lot 5 3 Artier
Legal Description or Address QJ&D 33 k, •T (�
WASTES TYPE: (DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPES J f 33(oe I i' ^J`
Number of Bedrooms q
(4) Garbage Grinder (X1 Automatic Washer
SOURCE AND TYPE OF WATER SUPPLY: ( ) WELL
If supplied by Community Water, give name of supplier:
Number of Persons T
( 4' Dishwasher
( ) SPRING ( ) STREAM OR CREEK
Cart 45 esi - w,t1n. 7t.,..
COY °F SR -r
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: ,
Was an effort made to connect to the Community System? Nlq-
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 (septic tank & disposal field) to Property Lines: 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:
2
EPTIC TANK
( ) VAULT PRIVY
( ) PIT PRIVY
( ) CHEMICAL TOILET( )
FINAL DISPOSAL BY:
( ) AERATION PLANT ( ) VAULT
( ) COMPOSTING TOILET ( ) RECYCLING, POTABLE USE
( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
OTHER -DESCRIBE
ABSORPTION TRENCH, BED OR PIT
UNDERGROUND DISPERSAL
ABOVE GROUND DISPERSAL
OTHER -DESCRIBE
( ) EVAPOTRANSPIRATION
( ) SAND FILTER
( ) WASTEWATER POND
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE
STATE? PIO PERCOLATION TEST RESULTS: (To be completed by
Registered Professional Engineer, if the Engineer does the Percolation Test)
Minutes
Minutes
per inch in hole No. 1
per inch in hole No. 2
Minutes per inch in hole NO. 3
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
Date ( 2_7-0
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
3
A4sM T%ONI7
v
4
ov
F--
3