HomeMy WebLinkAbout044477,77
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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit .4 4 7
108 Eighth Street, Suite 201
Glenwood Springs, Coloradof 81601
Phone (970) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
Assessor's Parcel No.
This does not constitute
a building or use permit.
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Owner's Name.: •
4-t i [; ,,I �f)><,t Present Address ci
- "7 Phone
System Location
Legal Description of Assessor's Parcel No,
SYSTEM DESIGN
�. . ;I/ :3 o f '-- (e- Co S IL
2.373- /72 00., 2
Septic Tank Capacity (gallon) Other
Percolation Rate minutes/inch Number of Bedrooms (or other) Acf)
Required Absorption Area - See Attached
Special Setback Requirements:
DateLo 131
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A-1"--6 -S /7a: i `7eM /1
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Inspector ,�^ �.�1, i/f/ t Cc
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer
Septic Tank Capacity //ot'' ev ,, L.
2 •
Septic Tank Manufacturer or Trade Name
�. W. tee)`
Septic Tank Access within 8" of surface )/1/
Absorption Area
Absorption Area Type and/or Manufacturer or Trade Name
Adequate compliance with County and State regulations/requirements \//e.
-
Other
i.2 r ,
if a
54.
Date F�_ a✓'
Inspector �"`` .r^"f!°^`9";.ia ""�,.✓'4'srY_'.`''^ r'c.-- ,..,
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 Yellow - DEPARTMENT •
GARFIELD COUNTY SEPTIC PERMIT APPLICATION
108 8th Street, Suite 401, Glenwood Springs, Co 81601
Phone: 970-945-82121 Fax: 970-384-3470 / Inspection Line: 970-384-5003
www. gar'fie1d-county.cor
1
Parcel No: (ibis information is available at the assessors office 970-945.9134) ry 3'7 9 `72. - co-- z41 9
2
Job ddress: (if an address has not been assigned, please provide Cr, Hwy or Street Name & City) or and legal description
Lope;,c7 Lot No: Block No: Subd./ Exemption:
F3
4
Owner: (property owner)
DRVto f $3 1206 /A/500
Mailing Address
/, Z -a 113 lc23
Ph:
9�P-s /7
Alt Ph:
98-56�
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Mai l g�Ad ,,,,,,,,, �� �
Ph:
Alt Ph:
7
PERMIT REQUEST FOR: (r)-- New Installation ( ) Alteration ( ) Repair
8
WASTE TYPE: ( )Dwelling }Transient Use ( )Commercial or industrial ( )Non- Domestic wastes
( )other - Describe /. ' U.,�r
9
BUILDING OR SERVICE TYPE: A 4r- '. ' 4"—lir `- ' ' /1` Vi
Number of bedrooms
t
Garbage Grinder ( )Yes (4-34 o-•
10
SOURCE & TYPE OF WATER SUPPLY: (L -)WELL ( )SPRING ( )STREAM OR CREEK ( )CISTERN
If supplied by COMMUNITY WATER, give name of supplier:
11
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:
Depth to 1,1 Ground
Water Table Percent Ground Slope
13
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS) PROPOSED:
(t4Septic 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 (I- NNO
16
PERCOLATION TEST RESULT: (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
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 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 al ac +n f perjury as provided by law. ,2' o0
OW'} EIS G ATUURE DATE
STAFF USE ONLY
Perk Fee:
JO(')
Total fees:
/73Et.00
DA ;I'E
Building Permit #:
P06,11)6 ai2 ems->>�
1 `\
W
HOUSE
Cgrj-t CRk_
F--76160