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HomeMy WebLinkAbout04154GARHELD COUNTY BUILDING AND SANITATION DEPARTMENT 108 Eighth Street, Suite 201 Glenwood Springs, Coloradof 81601 Phone (970) 945-8212 INDIVIDUAL SEWAGE DISPOSAL PERMIT PROPERTY Owner's Name 7 l rm 1�' „ System Location l ',f'-'11-1 _Cs C'Ci-, Present Address /Q, Permit 4 Assessor's Parcel No. This does not constitute a building or use permit. \ Phone G Y 1 Legal Description of Assessor's Parcel No ` (-) 1 �l C ',I i SYSTEM DESIGN Septic Tank Capacity (gallon) Percolation Rate (minutes/inch) Required Absorption Area - See Attached n 1crCLC(''ui Other Number of Bedrooms (or other) IE 7 •lfe's�1 e Special Setback Requirements: 233 W '(: r (77L1 Date Inspector (2 FINAL SYSTEM INSPECTION AND APPROVAL (as installed) Call for Inspection (24 hours notice) Before Covering Installation System Installer ` �' �' A 17 ,1' Septic Tank Capacity ' J J -- Septic Tank Manufacturer or Trade Name Septic Tank Access within 8" of surface 1%''• - Absorption Area Absorption Area Type and/or Manufacturer or Trade Name pp i' (0'_(j2 Adequate compliance with County and State regulations/requirements II, Other Date Inspector jlL.t%Z 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 ($500.001ine-6 months in jail or both). 1 INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION S --)A- OWNER c�Q-�Xa�.A- 1 "`a �SS ADDRESS 0'-tr{`l kt.,41.0,0 ck CONTRACTOR ems; -\obe C .A-S-cv ADDRESS rl3` -I tW c�-cezir PERMIT REQUEST FOR (74. NEW INSTALLATION PHONE '110 571,2 S"ZZ. 0 1 PHONE 9`704710 Szz 6 ( ) 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 Leeal Description or Address WASTES TYPE: Size of Lot 2,0 IS / trc-.5 o` -{.'l -1 I)or\k, K s 4 o,..) Lit f (ei S'az fikia 4" (1() DWELLING ( ) TRANSIENT USE ( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES ( ) OTHER—DESCRIBE BUILDING OR SERVICE TYPE C - C Number of Bedrooms 3 (y) Garbage Grinder 99 Automatic Washer SOURCE AND TYPE OF WATER SUPPLY: (X) WELL Number of Persons \ •6J (,) Dishwasher ( ) SPRING If supplied by Community Water, give name of supplier: So.'. i -^42-0,d au-> DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: t ( ) STREAM OR CREEK Us -s Was an effort made to connect to the Community System? A©E G. thJ0 h A site ' Ian is re uired to be submitted that indicates the followin MINIMUM distances: Leach Field to Well: Septic Tank to Well: Leach Field to Irrigation Ditches, Stream or Water Course: Septic System (septic tank & disposal field) to Property Lines: 100 feet 50 feet 50 feet 10 feet YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT A SITE PLAN. GROUND CONDITIONS: Depth to first Ground Water Table Percent Ground Slope TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED: SEPTIC TANK VAULT PRIVY PIT PRIVY CHEMICAL TOILET( ) AERATION PLANT COMPOSTING TOILET INCINERATION TOILET ( ) VAULT ( ) ( ) RECYCLING, POTABLE USE RECYCLING, OTHER USE OTHER -DESCRIBE FINAL DISPOSAL BY: (OJ 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? L20 PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer, if the Engineer does the Percolation Test) '/ �y [� Minutes t y per inch in hole No. 1 Minutes JSl / per inch in hole No. 3 Minutes n per inch in hole No. 2 Minutes 47 -pe o. _ Name, address and telephone of RPE who made soil absorption tests: 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 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 W Date 1123 I (by PLEASE W AN ACCURATE MAP TO YOUR PROPERTY!! L d 60ZZ9L90L6 Jeweo weH 0 0 (0 11 1 1 1 11 1 d00 40 90 4Z uer 60ZZ9L80L6 JBJJBQ %JJBH r 50 J a , ww H2 O 0 co 11 1 1 1 1 d0040 80 VZ UB1'