HomeMy WebLinkAbout04381$S o C�e4)
GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
108 Eighth Street, Suite 201
Glenwood Springs, Coloradof 81601
Phone (970) 945-8212
INDIVIDUAL SEWAGE DISPOS L PERMIT
PROPERTY
Owner's Name
System Location
�-+ Present Address
Permit
381
Asses or's Parcel No.
This does not constitute
a building or use permit.
Phone ,1J �►
Cc L ParAc1au
Legal Description of Assessor's Parcel No
SYSTEM DESIGN
Septic Tank Capacity (gall n)
Percolation Rate (minutesli
Required Absorption Area - See Attached
Special Setback Requirements:
Date
Other
h) mber of Bedrooms (or other)
Inspect.' r
FINAL SYSTEM INSPECTION AND APPROVAL (as in tailed)
Call for Inspection (24 hours notice),Before Covering I stallation
System Installer
Septic Tank Capacity ,'
Septic Tank Manufacturer or Trade Name
Septic Tank AQcess within 8" of surface
Absorptio Area
Absorpion Area Type and/or Manufacturer or Trade Name
Ade uate compliance with County and State regulationslrequir=ments
0 her
Date Inspector
RETAIN WITH RECEIPT RECORDS T 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 omplied with County zoning and building requirements. Con-
nection to or use with any dwelling or structures not approved by the : uilding and Zoning office shall automatically be a violation or a
requirement of the permit and cause for both legal action and revo.ation of the permit.
3. Any person who constructs, alters, or installs an individual sewage disp• -al 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
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER (O'C--V) ' '
ADDRESS (At -C1 �j O/ Q PHONE .522 SZC5---
CONTRACTOR � •-- 3l
ADDRESS soy r` 14" cob "876E---2_ PHONE 3 3.2 �S
PERMIT REQUEST FOR (KNEW 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 PROPOSED FACILITY:
Near what City of Town (001ra eLO Size of Lot % AcreotS
Legal Description or Address Cirdi so' c c d27 fo W q2
WASTES TYPE:
( ) DWELLING ( ) TRANSIENT USE
(COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER — DESCRIBE
BUILDING OR SERVICE TYPE: Ate-- r V[' %4)(-06e-
Number
4) r �
Number of Bedrooms Number of Perkns V
( ) Garbage Grinder ( ) Automatic Washer
( ) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to the Community System? A10
A site plan is required to be submitted that indicates the following 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 (septic tank & disposal field) to Property Lines: 10 feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT
A SITE PLAN.
GROUND CONDITIONS:
Depth to first Ground Water Table
Percent Ground Slope
.3a
2
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(-e)' 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? d
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: KICS‘ex50,,
24d e s - lei ,n,.c,�ckcam. L �.
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. 1 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
Designate North Arrow
Your Neighbor's
Name & Address
Your Plot - Shape to Fit
(No Scale)
Locate well, all streams, irrigation ditchs, and any water courses. Draw in your house,
septic tank & system, detached garages. and driveway.
if a change of location is necessary, you must submit a corrected drawing, before a
Certificate of Occupation will be issued.
Your Neighbor's
Name & Address
County Road (Note the Road Number and Name)
erc c wrocuodswpciomtplot ioc
Garfield County I
endor Name and Address
Vendor `Nu bn etr Purchas Order #
-<j2YfC/44.4-
P- o . Anrc go9
Special Instructions For Warrant
Invoice
Date
Vendor Invoice
Number
Fund
Dept
Sub Dept
•
Account
Project # (if
applicable)
Line Item
(64 Characters or Less)
Brief Description
(64 Characters or Less)
Invoice
Dollar
Amount
Recr
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Prepared By:
Department Head Approval:
Financial Management Guide Limits:
(Needs to be signed by County Administer if Over $10,000)
DATE:
DATE:
Total $ -61)
Posted By:
Date Stamp:
(Accounting Use Only)
Invoice Accuracy Verified By:
2008 AP Voucher.xis