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Home My WebLink About04420c '5091 _kt 15o GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT 108 Eighth Street, Suite 201 Glenwood Springs, Coloradof 81601 Phone (970) 945»8212 INDIVIDUAL SEWAGE DISPOSAL. PERMIT PROPERTY `7� ! �j�' 4 4 Owner's Name bear) L U? iq System Location t ,i5 Present Address -. rc ,.) 6`3, 1 Permits Assessor's Parcel No.: - This does not constitute a building or use permit. r` - Phone t\ -) � ,.'.• Legal Description of Assessor's ParcelNo. ��` `)_{� ` ((M ) -w. SYSTEM DESIGN 100 0 Septic Tank Capacity (gallon) Other Percolation Rate (minutes/inch) Number of Bedrooms (or other) ) k'/.)j &rrP1)6,1..) Pole e{ Required Absorption Area - See Attached { {S(. fi C ( = Sc),)ti. i(h q Special Setback Requirements: 56H{,e44 i3e�l - ,'7 C? 1,, (t. Date 5 - 0 Inspector 11— FINAL SYSTEM INSPECTION 'AND APPROVAL (as installed) Call for Inspection (24 hours notice) Before Covering Installation System Installer Septic Tank Capacity f h A Septic Tank Manufacturer or Trade Name 1, Septic Tank Access within 8" of surface ti [) )Absorption Area 'tai ,11,t t-11 � r, ,• ✓"•/ // 1 ` / ,� Absorption Area Type and/or Manufacturer or Trade Nanie l% Adequate compliance with County and State regulations/requirements f1 Other Date 1 y Inspector nr .0 // AZ 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 1964, 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 ipboives a knowing and material variation from the terms or specifications contained in the application of permit commits a Class E, 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 970-384-34701 Inspection Line: 970-384-5003 ww w.garf i e l d -county. Dorm 1 Perk Fee: Parcel No: (th'ss information is available at the assessors office 970-945-9134) 4 p0 -t 1n`c)5 2 Septic Permit #: Job Address: (if an address has not been assigned, please provide Cr, Hwy or Street Name & City) or and legal description Olt Ck aC S -' \VII; 3 APPROVAL DATE Lot Size: Lot No: Block No: Subd./ . xemption: `i, °123 1+e,3 £ rik*� k. _,,,.1 4 Owner: (property owner) <04 rs.v- 4s Mailing Address G 1 L r i aCc S Ph: 66-5 - ns 3 Alt • h: 5 cgntractor: U - ' _ ` -.,. , LLL Mailing Address ev tS ► . ,0 ; Ph: - 0— , —. 07 (, Alt Ph: 6 Engineer: Mailing Address Ph: Alt Ph: 7 PERMIT REQUEST FOR: `v New Installation ( ) Alteration ( ) Repair S WASTE TYPE: ,.rrweiling ( )Transient Use ( )Commercial or industrial ( )Non- Domestic wastes ( )Other — Describe 9 BUILDING OR SERVICE TYPE: 1 i rr..:. Number o bedrooms Garbage Grinder Ne fes ( )No 10 SOURCE & TYPE OF WATER SUPPLY: ( )WELL ) •"lNG ( )STREAM OR CREEK ( )CISTERN If supplied by COMMUNITY WATER, give name of supplier: " :, 'o` - 1 i DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: Was an effort made to connect to the Community System? i _ YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN I2 GROUND CONDITIONS: Depth to 1sI Ground Water Table .6 Percent Ground Slope 13 TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS) PROPOSED: 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 I0 16 PERCOLATION TEST RESULT: (to be completed Registered Professional Engineer, if the Engineer does the Pe�rplation Test) Minutes per inch in hole No,1 ' Minutes 2.1 per inch in hole No.3 No. Minutes per inch in h e No.2 Minutes per inch in hole Name, address & telephone of RPE who made Name, address & telephone of RPE responsible soil absorption test: P (lee; % for design of the system: 1 7 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 und- tend that any falsificatio or misrepresentation may result in the denial of the application or revocation of any permit granted based upon said application acalon fo rjury rovided by law. 5 ,/O gyer ERS SIGNATURE DATE STAFF USE ONLY Permit Fee: Perk Fee: Total fees: Building permit #: Septic Permit #: Issue Date: Building & Planning Dept: APPROVAL DATE TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYS "I'EM PROPOSED: ( ) 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: ( ) 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? 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 d- per inch in hole No. 3 Minutes t 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: 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 evaluatin g 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 PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!! 3