HomeMy WebLinkAbout03770GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
109 8th Street Suite 303
Glenwood Springs, Colorado 81601
Phone (303) 945 -8212
INDIVIDUA L SEWAGE DISPO SA L PERMIT
PROPERTY
BP-obL6
Permit N ~ J 7 7 0
Assessor 's Parcel No.
CX,/d.7-3t,J Mo/-oc >
This does not consti tute
a bu i ldin g or use permit.
Owner's Name _,,[Jc __ __,_h_....Q.,,__,._,G\YJ-Pi~f~)_M_'_,_.di~'~l/~o -Present Address ~-FJCf~lf~J __ c_~_r_~_W"'l_b Sfi=t /\:,.__,1 11.,,1~~L_r1_. Phone m6 -5 / J5'
System Location _____ ____,O=--=-'JS=---{p,___C~6 ..:....;{ IA,'"-"-b1L..:..Ll:lo/o_,_,1c..:...J' Af'-"-----_))-=---{'_\ _J __,,,,-L"'----_._5 _,_,_j 4 (_,_f __ Co __ · _:_¥_/_6__:o:~:___ __
~galDncri~ionofA~uor~~~No. __ ~l_o_-~f-~~---~-~-c_h_~~£~f~~~-=0~C~~~~~,~~=-~-~d~/~~~7_-_3_~_/~-
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SYSTEM DESIGN
______ Septi c Tank Capacity (gallon) ______ Other
______ Perco lation Rate (minutes/inch) Number of Bedrooms (or other) ____ _
Required Absorption Area -See Attached
Special Setback Requirements;
Date _____________ Inspector----------------------------
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Install ation
System Insta ller _________________________________________ _
Septic Ta nk Capacity _______________________________________ _
Septic Tank Manufacturer or Trade Name --------------------------------
Septi c Tank Access within 8" of surface ---------------------------------
Absorption Area-----------------------------------------
Absorption Area Type and/o r Manufacturer or Trade Name --------------------------
Adequate comp liance with County and State regulations/requirements. _____________________ _
Other __ -+--+--~'---------------1-----~-------~-~~--------~ b/t'f(o(,, ""'•"°'~~~~~~~~~ Date
{ RETA IN WITH RECEIPT RECORD AT CONSTRUCTION S IT E
*CONDITIONS:
1. All installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chapter
25, Articl e 10 C.R.S . 1973, Rev i sed 1984.
2. This permit is valid onl y for connection to structures which have fu lly complied with County zoning and building requirements. Con-
nection to or use with any dwelling or structures not approved b y the Building and Zoning office shall automaticall y be a violation or a
requirement of the permit and ca u se for both legal action and re vocation of the permit.
3. Any person w ho constructs , alters, or installs an indi vid u al sewage d isposal system in a manner which involves a knowing and material
variation from the terms or specifications contained in the appli cation of permit commits a Class I, Petty Offense ($500.00 fine -6
months in jai l or both).
White -APPLICANT Yellow -DEPARTMENT
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER £~','Mo OcZoc:....
ADDRESS O'tl(r CoLu.vib ,A,~ }ANL' ·
CONTRACTOR ~ t'-C (' 13 ;)I 1' le )
PHONE t/8 -'-It/ .J 7
PHONE 5re A}ft. L'(
PERMIT REQUEST FOR (~EW 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 ofTown. __ 5~J~'tj-____________ Size ofLot@ c.,.Cl't""/ /&?,
Legal Description or Address ~/-2c) /?ec.,_c £ {), //tCv Orch4f'C /
WASTES TYPE: (::n;WELLING QJ_c, IP Co(v-~,J'D ~'") TRANSIENT USE
( ) NON-DOMESTIC WASTES ( ) COMMERCIAL OR INDUSTRIAL
()OTHER-DESCRIBE~~~~~~~~~~~~~~~-
BIBWINGORSE~~E~E:_~B_f~~u_·_~_l_r __ £_c~~-·-,b_/e_~_c_e ____________ _
Number of Bedrooms Number of Persons -------.,-----------------~
( ) Garbage Grinder ( ) Automatic Washer
SOURCE AND TYPE OF WATER SUPPLY: (~LL
If supplied by Community Water, give name of supplier:
(Y}-Dishwasher
( ) SPRING ( ) STREAM OR CREEK
·DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM :~2~'~"'=-,"~/<~s __ 5_.-·_/f_. __
Was an effort made to connect to the Community System? ----r-.A ..... J__.o-=-----------
A site plan is required to be submitted that indicates the followint: 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:
I Depth to fir st Ground Water Table ___ ~......,,.._ ___________________ _
P G d SI /-....... c. t'/o ercent roun ope ____ ---=-...1_/_t:. _____________________ _
2
TYPE OF INDIVIDUA,L SEWAGE DISPOSAL SYSTEM PROPOSED:
CY? 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
(vf" UNDERGROUND DISPERSAL ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
( ) OTHER-DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? )Jo
PERCOLATION TEST RES UL TS: (To be completed by Registered Professional Engineer, if the Engineer does the
Percolation Test)
Minutes @
Minutes W
per inch in hole No. 1
per inch in hole No. 2
Minutes
Minutes
8'0 per inch in?e No. J _,,..;;--ti e/l ~ fa b · 1 S .per inch ~le Httia;
Name, address and telephone of RPE 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.
~~~~~~~OURPROP~~.tv-~~LJ~~_._.,_~~3-'--~~~~
3
~ ..,.,
Designate North Arrow "' "-S--
Your Neighbor's
Name & Address
Your Plot -Shape to Fit
(No Scale)
~
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...__
J
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.
County Road (Note the Road Number and Name)
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Your Neighbor's
Name & Address