HomeMy WebLinkAbout03765GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N~ 3765
109 8th Street Suite 303 Assessor's Parcel No.
Glenwood Springs, Colorado 111601
Phone (303) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
This does not constitute
a bu1/d1ng or use permit.
PROPERTY ~ ... .-... ScJiwcili/kr°!-... ., .. ,,, .. kill eA-ai-1-d.~aL .. n.;-3?il>
System Location j dz6"';?3 c£ aft/-/\1. c ?((a y J
Legel Description of Assessor's Parcel No. ____ c}. __ (_;?'_/_-_0_5~/_-_0_D __ -_l_O"D _________________ _
SYSTEM DESIGN
______ Septic Tank Capacity (gallon) _______ Other
______ Percolation Rate (minutes/inch) Number of Bedrooms (or other) _____ _
Required Absorption Area -See Attached
Special Selback Requirements
Date ______________ Inspector
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) B~o: C:ering Installation ?'-,..---
System Installer ™@ jZ'.Q ~A-'--~ c• IW ./Ee {i-ti c;rC
Septic Tank Capac1ty·-------------~f<--"-+-~=CCJ.~L-'--'~-=~---F=--'--'='"""'-----'"D_._.,_---l(_~c=.="-----~/~ ~,.----~ .ll• D,-,
Sept1c Tank Manufacturer or Trade Name ______ /! ___ ~;.__.~~)-~II 0 ~--~~~~~~~~6J=)~----------
Septic Tank Access w1lh1n 8"" of surface
Absorplion Area-------------------------------------------
Absorption Area Type and/or Manufacturer or Trade Name
Adequate compliance with County and State regulat1ons/requ1rements ______________________ _
Other -----------------------------------------------~
Date ______________ Inspector
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
•CONDITIONS:
All 1nstallat1on must comply with all requirements 01 the Colorado State Board of Health Individual Sewage Disposal Systems Chapter
25, Article 10 C.R S 1973, Revised 1984.
2 This permit 1s vahd only tor connect1on to structures which have fully complied with County zoning and bu1ld1ng requirements Con-
nect1on to or use with any dwelling or structures not approved by the Building and Zoning office shall automatically be a viola11on or a
requirement of the permit and cause for both legal action and revocation of the permit
3 Any person who construcls. alters, or installs an 1ndiv1dual sewage disposal system 1n a manner which involves a knowing and material
vanat1on from the terms or spec1hcat1ons contained 1n the appl1cat1on of perm1I commits a Class I, Petty Offense ($500 00 fine - 6
months 1n 1a1I or both)
White· APPLICANT Yellow -DEPARTMENT
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
~ it-~NE Cf1o 'fSi./.33'80
PERMIT REQUEST FOR ( ) NEW INSTALLATION ~ALTERATION ,k?'JREPAIR
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 ILJ Q.\>.. \ C~5i \ Size of Lot . • 1 S" ~c;t-,
Legal Description or Address _________________________ _
WASTES TYPE: ~) DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
()OTHER-DESCRIBE _______________ _
BUILDING OR SERVICE TYPE:_,/D-'-'--¢1"""""d"-'-'", l~\1.......,,\._.1'------------------
Number of Bedrooms __ .c........ __________ Number of Persons_.:2-____ _
( ) Garbage Grinder (7\) Automatic Washer
SOURCE AND TYPE OF WATER SUPPLY: (X) WELL
If supplied by Community Water, give name of supplier:
(..{) Dishwasher
( ) SPRING ( ) STREAM OR CREEK
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: __ ..,./p'---'n'--'--'-'l_,_ _____ _
Was an effort made to connect to the Community System? ---"CJ..<:>..L------------
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_-1--"'-L----------------------
Percent Ground Slope_~~-------------------------
2
. i
•
TYPE 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
FINAL DISPOSAL BY:
( ~) ABSORPTION TRENCH, BED OR PIT ( ) EV APOTRANSPIRA TION
( ) UNDERGROUND DISPERSAL ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
( ) OTHER-DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? ilO --"-'=---
PERCOLATION TEST RES UL TS: (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. 3
Minutes _____ ,per inch in hole No. 2 Minutes ______ ,per inch in hole No. _
Name, address and telephone ofRPE who made soil absorption tests:--------------
Name, address and telephone ofRPE 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 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 LJl4/ LJ' &<2 Date /,4, -/ &, ~ 0 2.
PLEASE DRAWACCURATE MAP TO YOUR PROPERTY!!
3