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Home My WebLink About03912,, I ... I .,,..~ I I ) I I ' ' f _., .. F .5().6'0 :3/~r,701 · --~-- I ~F:z.TY BUILDING AND SANITATION DEPARTMENT 109 8th Street Suite 303 Glenwood Springs, Colorado 81601 Phona (303) 945-8212 t INDIVIDUAL SEWAGE DISPOSAL PERMIT l PROPERTY Permit N: 3912 Assessor's Parcel No. This does not constitute a building or use permit. I i Owner's Name -r c I 0 (I I t-bw o.rc.l Present Address 0 I 0 '1 \/a" )oM ~J. . ( . <; • Phone q <./5 -? 0 ~" ' ! system Location 0 I D '] Va. V\ 1>oRn K& (&, r'(~ I / + ~ \ 10..C. + 'J Che\ i,"' 0... C. (e~ 5.1 ~, ; '"l/Gr Cf G · $. Yfbo I , ; Legal Description of Assessor's Parcel No. __ _,o<"---'-"'~"':2""-_-_3~.L.o~J....-_O:c.,:,O"---=O=-=O_,,;?..,,.,,,,,._ _____________ _ • ' • SYSTEM DESIGN ______ Septic Tank Capacity (gallon) ______ ,Other ______ Percolation 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 Installation System lnstaller·_-t,.LJ~-1:!,'1..Ll..,,""--------------.------------------ Septic Tank Capac1ty· _ __,_l .ucOQ""-'Q"'-------=l:t--+_,~~"-'·~_....~"-'="""-i =+------- Septic Tank Manufacturer or Trade Name -~11'--'-')'-'0.L..l.f_.u..,)({5{"· .:-S,L.>-~"'1· -'-----~----'------------- Septic Tank Access within 8" of surface __ _i.l,,,1~fl.1.1:.<¥'+...-----· --.-,-:..· ------------------- Absorption Area ---------------'VL«=--'1~~"~k---1l------------------- Absorption Area Type and/or Manufacturer or Trade Name -------------------------- Other ______ -,-----------""'-----,---,,----~~------------- Date___,_1_...-/__._· o.__,_1 __ Inspector -Ax:~iaN-' j-(1...L-. L1--( -1.')-'-''TLX=':_tf_"'-". f:__f ____ _ 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 ii:t jail or both). 1 White· APPLICANT Yellow· DEPARTMENT INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION OWNER Howa.rc&... T&\otJ ADDRESS 0103-V•:v\ DoBN RJL. CONTRACTOR'---'~""""'==-=-------~~~~~~~~~~ ADDRESS. __ __,,S:~e!e:-:!::•::!"--"=--------PHONE ~ PERMIT REQUEST FOR ( ) NEW INSTALLATION (ll) 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: NearwhatCityofTown Gl~"-W~ &fr.'""y SizeofLot ;?. 40/Jc.. Legal Description or Address 0 I 0 t Vo."' 'D~ RA . WASTES TYPE: (") DWELLING ( ) TRANSIENT USE ( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES ( 'fJ OTHER-DESCRIBE A"fi';t. Smal\ M!\ k. .\.o ble. l!\{o <y/.S~•'"';i- /e" ,· .. /.t {b-?'""~ iool+-,.,,.,.,...... BUILDING OR SERVICE TYPE: __ .... ~"""~==--"'¥-°""=~---------------- NurnberofBedrooms ____ ~ _______ NurnberofPersons_<::)~--- ( ) 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: _ _.M"-'"=/.___.14=°'=""'=L=k_=----- Was an effort made to connect to the Community System? -----6-'>=---------- A site plan is required to be submitted that indicates the followinK 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 ASITE PLAN. GROUND CONDITIONS: I I Depth to first Ground Water Table ___ 'f ... o._.-__,_,/OQ~----------------- Percent Ground Slope __________________________ _ 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 APOTRANSPIRATION ( ) UNDERGROUND DISPERSAL ( ) SAND FILTER ( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND ( ) OTHER-DESCRIBE WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? Mo PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer, ifthe Engineer does the Percolation Test) Minutes. ____ _,,er inch in hole No. 1 Minutes _____ _,.er inch in hole No. 3 Minutes. ____ _,,er inch in hole No. 2 Minutes er 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: 1-\ot.o....c<cJI :t::,e.J o..J 010-+l/,,.n. "Dol?w .p.o Glgu .. a..R~se,, 91<!>-qyS-J.o:zc.a. 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. Si~ °"" ,J-.2 PLEAS~~ MAP TO YOUR PROPERITl! ·'CJ'/ ------ , (\. Designate North Arrow Your Neighbor's Name & Address ~~ Your Plot -Shape to Fit (No Scale) o i., .. \\ f/D<lst. ~ . ,, . ,,... \'.'. ~ : c-1i<t•7~ 1"4~ 'p ~·\·~ \ 1· ,,..,,,._, a~ ' ~ ~ '11 \ . ----- I :i~~ r E'flf''"~. ( 1 l-" J,, ,,· Y--·---~ .. -~~~----------·----- ' , N 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) enc c:\wpwin60\wpdocsipotJoc / 'J,p,) l. Your Neighbor's Name & Address 01b" fc.rn.,..,... 0 IO\ 1/0.11 Oet11