HomeMy WebLinkAbout04353GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
108 Eighth Street, Suite 201
Glenwood Springs, Coloradof 81601
Phone (970) 945.8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
Permit '
Assessor's Parcel No.
This does not constitute
a building or use permit.
PROPERTY i:)1
4l y PM(Pres„t
�f p('Owner's Name OT } 1J1 01 r` Address �� ` C Q "UL �� 0. ° Phone 1, `r� C160- C L'K.
System Locationt 4 L bk(-11 4- J t`1 I "lincl ! u1�)
Legal Description of Assessor's Parcel No. res OCi T 000r'
SYSTEM DESIGN
Z -S-6) Septic Tank Capacity (gallon) Other
Percolation Rate (minutes/inch)
Required Absorption Area - See Attached
Special Setback Requirements:
Date ~/8
Number of Bedrooms (or other) 4 G" '4 , )5,
95'7 see, !`,; ,eac fit' /4--/4-40.
4 79 /N Zfc,vc,f/ -t--19 Q4 ///0
4 -sQ r /A/ C''74- '4
Inspector 5,4(1
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer
Ocx-xu,+ re
Septic Tank Capacity
Septic Tank Manufacturer or Trade Name � "" 7/C 12e7S/7—C_MI
Septic Tank Access within `8"of surface `
Absorption Area / 3 •-5'"i " / . / r A 4' ,
Absorption Area Type and/or Manufacturer or Trade Name /If - -s-
Adequate
s
Adequate compliance with County and State regulations/requirements
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. 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 fail or both).
While - APPLICANT Yellow - DEPARTMENT
7-18-17- ct /205
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER ` p-- 5To tt e/ j001-1
ADDRESS riVOX 41741. OjAck Opa.40.0d awe. 2d
CONTRACTOR y e 1 f=
PHONE goe 966 6 x q $
ADDRESS S
PHONE
PERMIT REQUEST FOR V) 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 PROPOSED FACILITY:
Near what City of Town ale W .(spr, i5 s Size of Lot_ `=1 ac
Legal Description or Address 041% -p) l c G K i cL vY' oind(hfM rye. 1 - (CA A(o)
WASTES TYPE: (yO DWELLING ( ) TRANSIENT USE G- .S.
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER —DESCRIBE
BUILDING OR SERVICE TYPE: S ir
Number of Bedrooms I Number of Persons
) Garbage Grinder (>() Automatic Washer (<) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: ()C) 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? ,Ifl
A site plan is required to be submitted that indicates the following MINIMUM distances:
Leach Field to Well:
Septic Tank to Well:
Leach Field to Irrigation Ditches, Stream or Water Course:
100 feet
50 feet
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 /,-C-‘ `` r
Percent Ground Slope %z
2
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(pc) SEPTIC TANK
( ) VAULT PRIVY
( ) PIT PRIVY
( ) CHEMICAL TOILET( ) OTHER -DESCRIBE
( ) AERATION PLANT
( ) COMPOSTING TOILET
( ) INCINERATION TOILET
FINAL DISPOSAL BY:
( )) ABSORPTION TRENCH, BED OR PIT
( ) UNDERGROUND DISPERSAL
( ) ABOVE GROUND DISPERSAL
( ) OTHER -DESCRIBE
VAULT
RECYCLING, POTABLE USE
) RECYCLING, OTHER USE
( ) EVAPOTRANSPIRATION
( ) SAND FILTER
( ) WASTEWATER POND
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? 414
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
Name, address and telephone of RPE who made soil absorption tests:
per inch in hole No. —
Name, address and telephone of RPE responsible for design ofthe 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.
Signed Date 7 18 0 7
PLEASE D AN ACCURATE MAP TO YOUR PROPERTY!!
3
Designate North Arrow
County Road (Note the Road Number and Name) 6kk 0141004 p2r,t,c iz . ty
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(30
Your
Plot - Shape to Fit
(No Scale)
F45 7"rte
be�7
Your Neighbor's
Name & Address
Your Neighbor's
Name & Address
--
0---.
------,--
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ce/k.`
Locate well, all streams, irrigation
ditchs, and any water courses. Draw n 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.
County Road (Note the Road Number and Name) 6kk 0141004 p2r,t,c iz . ty
eac c:1wpwin6O wpdocslploi.loc
(30