HomeMy WebLinkAbout03692GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
1 109 Sth Street Sults 303
Glenwood Springs, Colorado 81801
Phone (303) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
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Permit N° 3692
Assessor's Parcel No.
This does not constitute
a building or use permit.
It L r� Rnge'Rr�. c+h 11]x`1 ��� 2,� 3F�I - 0169 ,
1 Owner's Name 2 �,., - Present Address `j�,� ,, ti o Phone • '� [
System Location lam./ / SAl e%+)Qlc r.� , i /1C (�rnow%-4-
Legal Description of Assessor's Parcel No..�-
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SYSTEM DESIGN
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v ` Septic Tank Capacity (gallon) Other
gP� i
f Percolation Rate (minutes/inch) G}+gN,u�mber of Bedrooms (or other)
Required Absorption Area - See Attached —"
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Special Setback Requirements:
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Date -17- �0 - V F Inspector 0 W� .) &&A L."
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R FINAL SYSTEM INSPECTION AND. APPROVAL (as installedcoAtWta ,
Q Cell for Inspection (24,hourg notice) Before Covering Installation
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20 Sr+fn r�S 'aiLdtC
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System Installer 1/�r �-
Septic Tank Capacity /dC)
Septic Tank Manufacturer or Trade Name
Septic Tank Access within 8" of surface
Absorption Area
Absorption Area Type end/or Manufacturer or Trade NameOF
I
!Y 1
Adequate compliance w(th County and State regulations/requirements
Other
Date �`o Z Inspector
0 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. Y
q2. 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 o t
requirement of the permit and cause for both legal action and revocation of the permit. 94f
3. Any person whoconstructs,alters, orinstallsan Individual sewage disposal system in a mannerwhlch Involves a knowing and materiel
I variation from the terms or specifications contained In the application of permit commits a Class I, Petty Offense ($500.00 fine -8 °
{ months in )all or both).
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White -APPLICANT Yellow -DEPARTMENT i
WNER
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATIONj����
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�nDREss Mo Wl'4J5 <o S/G��i PHONE
.ONTRACTOR �� cA �� s/xdc ��g l�
ADDRESS k,61< /� G �s �C7 � /6 L— PHONE
PERMIT REQUEST FOR (>4 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
Legal Description or Address
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WASTES TYPE:
( )
DWELLING (
) TRANSIENT USE
( )
COMMERCIAL OR INDUSTRIAL (
) NON-DOMESTIC WASTES
QC)
OTHER -DESCRIBE 6-
P5� �f�- 140"
BUILDING OR SERVICE TYPE:
(7t),_ 2 C-5- -JR
>� 1
Number of Bedrooms HT1"
Number
,I
of Persons V,�[f `>
( ) 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: iA)&ioz/ _
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: l .—i L z -
Was an effort made to connect to the Community System? ),Aa
A site plan is reauired 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 to Property Lines: 10 feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH
A SITE PLAN.
GROUND CONDITIONS:
Depth to first Ground Water
Percent Ground
'YPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
SEPTIC TANK ( ) AERATION PLANT
(
)
VAULT
VAULT PRIVY ( ) COMPOSTING TOILET
(
)
RECYCLING, POTABLE USE
PIT PRIVY ( ) INCINERATION TOILET
(
)
RECYCLING, OTHER USE
CHEMICAL TOILET ( ) OTHER - DESCRIBE
?INAL 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. I
Minutes per inch in hole No. 2
Minutes ver inch in hole NO. 3
Minutes per inch in hole NO. _
Name, address and telephone of RPE who made soil absorption
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 oon ect 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 fiuther 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 act n for perjury as provided by law.
Signed
T= "� Date��`'
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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