HomeMy WebLinkAbout03643r
:i;
' ; ·:1' ,.
·~I:
I
l .. . , J~?O\:v ~ ,~\~ {t,?<t
..
109 8th Street Suite 303
GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N:: ~ 6 •.S
A11eaeor'e Parcel Mo.
f,
I
I
!
l Glenwood Springe, Colorado 81601
Phone (303) 845·8212 -----------~
INDIVIDUAL SEWAOE DISPOSAL PERMIT ~ PROPERTY
This does not constitute
a building or use permit.
I Owner's Name 1.µ_.,,,...""-"'-"'lr'"'~=..:::i:'-'-=-4'1-Present Address ·p 0 l)ol! '"\3"J
I 6f'. o "'"fY'4 >5, 'ii I (g ~ iOI
' I
~ •
' I
I
I • ~ ,
' +
f
1 • I
' ,
,,
!
t
' I
~
·t ' ' l
' ~
I
! ,
I
t
l
)
I
I
' ~
l
~
"
SY@TEM DESIGN
~
_,,/,,.J'-".=5"0=-Septic Tank Capacity (gallon) ------'Other
--~1~--Percolation Rate (minutes/Inch) Number of Bedrooms (or other) </-f {,~£ 6-, f)
&:v r/I Jl.e....,A l1:.ef! cl .
Required Absorption Area· See Attached '/ OO 'ti ,-~~ ~ :} / t-<--<~
Special Setback A~qulrements: I/ 8'0 If B d : ;) t,u.--..,;J;r/g;("))
"' 3o L<A ..J:, ( _,,_ ,( f? Date_-'~~0"'.?o=:.;/.'-'C>'->-______ Inspector _ _,&J=..,1£-i=',.::.;r'-<-ff<--'?'.-'h-'="=•"''""'-.L-""'===--------------
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer-:-,~
Septic Tank CapacltY--''->£-""5(<..::0:::... ______________________________ _
Septic Tank Manufacturer or Trade Name __.C'-""~""tl""''"J,"""4""4'"<"-<h==::o__------------------
Septlc Tank Access within 8" of surface -l<J~r:_--------------------------
Absorption Area 3;ty.-'\\.J, M= J [A.1J1 e&vf,
Absorption Area Type and/or Manufacturer or Trade Name _;,'J"°1-il"if}.,.<1
. <e.·. v .... t,,,rcc• i-lci±c.J. \,J@';@+'~<~---------------
Other----------------~-~----------~---------~~
Date _1.._( _· J.-9_· -=0_,')-'------Inspector --+-/J,,... ""-'.,.@"" . .._J-_,,t · .... r1"-_;;,2_,,J_,·ILA:=u-.,.0""L_..::::.-_______ _
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 w~lch have fully complied with County zoning and building requirements. Con·
nection to or use with any dwelling orstructures not approved by the Building and Zoning office shall automatically be a violation or a
requirement of the permit and cause for both legal a.btion and revocation of the perll'.'lt.
3. Any person who constructs, alters, or Installs an lndlvldual 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 ($500.00 fine - 6
months In jail or both).
White. APPLICANT Yellow. DEPARTMENT
!
t
I
' I
' t
' ;,
I
i
I
i
I
·' t
i
;
' ~
' r
" I
I
I
i'
l ~l •
i
l
"
INDIYJDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
\\\ o\\\-~-")
PHONE C\\Q-C\~1-<J.$'1~
. O~R J:::>o\\G. L'\'::. ~i-0' Q\ ~\ b;
ADDRESS 1\ \ L-h '§ ") G-L 13. \"}
CONTRACTOR_....~E~L~\=-,___ ______________________ _
ADDRESS _______________ ~
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).
LOCATION OF PRQPOSED FACILITY:
Near what City ofTown~~..:....>.. ..... 1...:..r..1:L~E...._ ___________ __.S,,,ize""--"o,,..fLo"""'t'--"'lc~.£,...__,.,c.N\.8.0~:.=:..1__
Legal Description or Address 0 I 0 & 1\j \:..S1, ,£'> \(, ) V f
WASTES TYPE: °\>4 DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( )OTHER-DESCRIBE _______________ _
BUILDING OR SERVICE TYPE: _ _,_h...i.=:°'--=U..~S...,f:.:..:_,,__ ________________ _
Number ofBedrooms __ ...._ __________ _ Number of Persons _ _,,.. ___ _
{)() Garbage Grinder ~ Automatic Washer 9() Dishwasher
SQURCEANPTYPEOFWATERSUPPLY: ( ) WELL ( ) SP~G ( ) STREAM.ORCREEK
If supplied by Community Water, give name of supplier0~ 1 v l ~ \ 'b }\ <:.. o ~\ \.:\,,Y\ \\~
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:_~.-...\,_'f~\..-...1.h"""--------
Was an effort made to connect to the Community System? __ ....L.>._,,,,_ __________ _
A site plan ls required to be submitted that Indicates the following MINIMUM distances;
Leach Field to Well: 100 feet
Septic Tank to Well; SO feet
Leach Field to Irrigation Ditches, Stream or Water Course; SO feet
Septic System to Property Lines: 10 feet
YQUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT
A SITE PLAN.
GRQUNP CONDITIONS:
Depth to first Ground Water Table ______________________ _
Percent Ground Slope. __________________________ _
2
TVPE'OF INDIVIDUAL SE\\(,AGE DISPOSAL SYSTEM PROPOSED:
' ·ci<> 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:
t;4 ABSORPTION TRENCH, BED OR PIT ( ) EV APOTRANSPIRATION
( ) UNDERGROUND DISPERSAL ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
( ) OTHER -DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? ______ _
PERCOLATION TEST BESULIS: (To be completed by Registered Professional Engineer, if the Engineer does the
Percolation Test)
Minutes ____ ..,.er inch in hole No. 1 Minutes _____ _,.er inch in hole NO. 3
Minutes er inch in hole No. 2 Minutes per inch in hole NO. _
Name, address and telephone ofRPE who made soil absorption tests: _____________ _
Name, address and telephone ofRPE 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.
C) I -Sign~J:N§.lli 0. '\'\'""\ ~'~ Date i -cile -0 ~,
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY! I
3
. .
-I I ll l ,o·o, il. I I
. -fl I
~ I
i r---til I I~
:~l.11:
I iit : ~
L. --1
f :J
i
i
'>-v-'<j~ ~~
£ ,,,..
"' ,~
•
I
I
I I
I
I l I I ' -;.
I I il I I
I . I
\ ._ __ i--l--,
I I
I ~
I
I
--1-1 I -------4
I I
LJ