HomeMy WebLinkAboutApplication- PermitGARFIELD COUNTY BIIILOING AND SANITATION DEPARTMENT
108„Eighth Street, Suite 401
Glenwood Springs, Colorado 81601
Phone (970) 945-8212
Permit
Assessor's Parcel No.
INDIVIDUAL SEWAGE DISPOSAL PERMIT
4622
This does not const'tute
a building or use permit.
PROPERTY
Owner's Nam0 (jE11,r, )0)-\ Present Address
System Location, 2 ~.f.
Legal Description of Assessor's Parcel No. 2 R 0 _ ()
SYSTEM DESIGN
75-0
Septic Tank Capacity (gallon)
Percolation Rate (minutes/inch)
Required Absorption Area - See Attached
Special Setback Requirements:
Date
Other
PhoneL4 ;r O.T2 —19
Number of Bedrooms (or other) r�
":7F0
7.-„0 54),
C/. g ;e,
90 $4 - ,":"V :1:009w/131 - lo c'4-. // 0
16
Inspector
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer `f' % ✓eY'-`..04 ."YYC 1'.4
Septic Tthnk Capacity /10r. t C=4
Septic Tank Manufacturer or Trade Name Cc e.7 5' • '4J
Septic Tank Access within 8" of surface
0:77C
Absorption Area .5 ,S , 4/ 7ZZ-ilerb%
Absorption Area Type and/or Manufacturer or Trade Name
- j J/r67 4- ,.//6 -
Adequate compliance with County and State regulations/requirements Vior'
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. Connection 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 ($500.00 fine - 6 months in jail or both). .. .
White - APPLICANT Yellow - DEPARTMENT
GARFIELD COUNTY SEPTIC PERMIT` APPLICATION
108 8'h Street, Suite 401, Glenwood Springs, Co 81601
Phone: 970-945-82121 Pax: 970-384-3470! Inspection Line: 970-384-5003
www. aarfield-co unty.com
l
Perk Fee:
100
Parcel No: (this information is available at the assessors office 970.945.9134)
a1a-1 aS a000si
2
Wing Permit #:
I I2-Lici
Job Address: (if an address has not been assigned, please provide Cr, Hwy or Street Name & City) or and legal description
Cf: 23-"1 , S 1 L-1- C g LS ?--
3
Building & Planni g Dept: Y
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Lot Size: Lot No: 4-0/,,c,Slow,. SubdJ Exemption:
.
4
Owner: (properly owner)
JoH t•-1 2- a Hn5Aty et+� oF-ctE
Mailing Address
Qct box b -t b G -i tc-s`1 w"ti Ve-A S
Ph:
l to - 45gn -a 111
Alt Ph:
`l i O - kk to —Pi 1q
5
Contractor:
hdU le -Y IAMeie PC -J AE
Mailing Address
Po f3D` 51 ie G-Tt-ENV c D S -n-- a
Ph:
`{10-t1sio—'),.A-vi
Alt Ph:
6
Engineer:
3tG eG? ANiakUrr(1
Mailing Address
2.0k 5, 41`'`'t 2.„ YWkSSoui.A,MTs psi
Ph:
40te-1a.1-1553'3
Alt Ph:
7
PERMIT REQUEST FOR: ()() New Installation ( ) Alteration ( ) Repair
8
WASTE TYPE: { K;Dweliing ( }Transient Use { }Commercial or industrial { }Non- Domestic wastes
( }Other -Describe
9
BUILDING OR SERVICE TYPE: SktAcle 'FfivnnU .- RE5tpertcra
Number of bedrooms 1 Garbage Grinder ( }Yes ' }No
10
SOURCE & TYPE OF WATER SUPPLY: ()()WELL ( )SPRING ( )STREAM OR CREEK ( )CISTERN
If supplied by COMMUNITY WATER, give name of supplier:
1 1
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to the Community System?
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN
12
GROUND CONDITIONS: '1$t'
Depth to 151 Ground Water Table Percent Ground Slope
13
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISM) PROPOSED:
(y Septic 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 (,NO
16
PERCOLATION TEST RESULT: (to be completed by Registered Professional Engineer, if the Engineer does the Percolation Test)
r ,13Minutes 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 mandatory and additional test and
the local health department to be made and furnished by the applicant or by the local health department for purposed of the evaluation
issuance of the permit is subject to such terms and conditions as deemed necessary to insure compliance with rules and regulations
reports submitted herewith and required to be submitted by the applicant are or will be represented to be true and correct to the best
and are designed to be relied on by the local department of health in evaluating the same for purposes of issuing the permit applied
understand that any falsification or misrepresentation may result in the denial of the application or revocation of any permit granted
and legion f. .erju s provided by law.
_ Z-27— 4317
27-
reports as may be required by
of the application; and the
made, information and
of my knowledge and belief
for herein. 1 further
based upon said application
0 , ' ERS SIGNATUR DATE
0
STAFF USE ONLY
Permit Fee:
T
Perk Fee:
100
Total fees:
1173,E
Bo
Wing Permit #:
I I2-Lici
Septic Permit #:
L41p2,2-
Issue Date:
3. It. 01
Building & Planni g Dept: Y
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APPROVAL DATE