HomeMy WebLinkAboutApplication- PermitGARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT P-rmit N2 3773
109 8th Street Suite 303
Glenwood Springs, Colorado 81601
Phone (303) 945-8212
INDIVIDUAL SEWAGEDISPOSAL PERMIT
PROPERTY
Owner's Name • 6 WI.. at•_S
ge
System Location _�sm. r'-tws
'Gb
ess
ssessor's Parcel No.
This does not constitute
a building or use permit.
Phony
Legal Description of Assessor's Parcel No
SYSTEM DESIGN
Septic Tank Capacity (g:. Ion)
Percolation Rate (minutes/i h) I%imber of Bedrooms (or other)
/
Other
Required Absorption Area - See Attached
Special Setback Requirements:
Date
In pector
/
FINAL SYSTEM INSPECTION AND APPROL (as installed)
Call for Inspection (24 hours notice) Befor Covering Installat
J "
System Installer
Septic Tank Capacity
Septic Tank Manufacturer or Trade Name
Septic Tank Access withjh 8" of surface
Absorption Area
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 SI E
*CONDITIONS/
1. All installation must comply with all requirements of the Colorado State Board of Health lndividu.I 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).
While - APPLICANT Yellow - DEPARTMENT
t
Assessor's Parcel No. Permit h= 3 7 7 3
CHARGES
Percolation Test $100.00
(includes final inspection)
1 Permit Processing Fee $50.00
Cash
Money Order
ystem LocationO` C-
II U O v�
aid t t1 5y n��
Cashier
ALL CHE S ' E TO BE MADE PAYABLE TO GARFIELD COUNTY TREASURER
Whie -APPLICANT Yellow -DEPARTMENT
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER Linda inti '<cf rin e
ADDRESS 049a CR 337
CONTRACTOR Moe /' i f2 5; m mons
Lai -kern -tad /30/E r. /25; cj''1o.�s
PHONE 1.G -714a / .Q k's we-rk95,
ADDRESS e5 /1ori7on (tr.
PHONE, -225-'7101,4
PERMIT REQUEST FOR (1,-7 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 PROPOSEDFACILITY:
Near what City of Town Po r i4i t ci-e Size of Lot JO ct Cre .S
Legal Description or Address 049,1 C R 3 37
WASTES TYPE: (14 DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPE: 0 Sti Q I� CAwA` (gyp DW2 (� ri
Number of Bedrooms 3 J
( ) Garbage Grinder
Number of Persons 2
(4 -Automatic Washer (.'Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: (fr-rWELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier:
ISISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to the Community System?
A site uian is required to be submitted that indicates the follow ine 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 to Property Lines: (septic tank &leach field)10 feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT
A SITE PLAN.
GROUND CONDITIONS:
Depth to first Ground Water Table 220
Percent Ground Slope 4 Y
2
TYPE OF INDIVIDUAL SEWA DE
_sem.
(r4 , SEPTIC TANK Ij
( ) VAULT PRIVY
( ) PIT PRIVY
( ) CHEMICAL TOILET
FINAL DISPOSAL BY:
DISPOSAL SYSTEM PROPOSED:
AERATION PLANT ( ) VAULT
COMPOSTING TOILET ( ) RECYCLING, POTABLE USE
INCINERATION TOILET ( ) RECYCLING, OTHER USE
OTHER - DESCRIBE
(f/j 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?
/10
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: 'met Fr t254,4,61•#0.5
gig. Wotan) teak foe tst 970 99t ns!
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 ndes and regulations made,
information and reports submitted herewith and required to be submitted by the applicant are or will be represented to
be tole 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.
Signeda/f4L._
Date 1 /s 19R
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