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Home My WebLink About04121GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit 108 Eighth Street, Suite 201 Glenwood Springs, Coloradof 81601 Phone (970) 945-8212 INDIVIDUAL SEWAGE DISPOSAL PERMIT Assessor's Parcel No. This does not constitute a building or use permit. PROPERTY {�1 Owner's Name i, i 61 1 )6 e 1 I Present Address Phone System Location 3 Legal Description of Assessor's Parcel No �' -03/ 6 ` / SYSTEM DESIGN Septic Tank Capacity (gallon) Other Percolation Rate (minutes/inch) Number of Bedrooms (or other) Required Absorption Area See Attached. '., el W 1 ; = 7 r12 I T.�I L , , Special Setback Requirements: i, Date Inspector FINAL SYSTEM INSPECTION AND APPROVAL (as installed) Call for Inspection (24 hours notice) Before Covering Installation System Installer Septic Tank Capacity Septic Tank Manufacturer or Trade Name Septic Tank Access within 8" of surface Absorption Area Absorption Area Type and/or Manufacturer or Trade Name Adequate compliance with County and State regulations/requirements Other Date Inspector 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 1, Petty Offense ($500.00 fine — 6 months in jail or both). White - APPLICANT Yellow - DEPARTMENT INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION OWNER ' � 12: c? r 5,L ADDRESS f , C Cq . R._ .3 3 PHONE e: CONTRACTOR 0 W 01�-4— ADDRESS PHONE PERMIT REQUEST FOR ('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 Size of Lot f74 JtlCL Legal Description or Address S7A..i rti Ng- fy 7y 6.5", WASTES TYPE: (10 DWELLING C (I-01-.3 3 �(�) TRANSIENT USE7�'.:. ( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC ViNTEQ ' e ( ) OTHER – DESCRIBE BUILDING OR SERVICE TYPE: )L) /11/4/0`,/ FA ta<ti Myyig Ki `, 1 . p &c e_ Number of Bedrooms 3 Number of Persons ( Garbage Grinder ( r, 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: 44 Was an effort made to connect to the Community System? /05 A site plan is rewired to be submitted that indicates the following 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 /Zc Percent Ground Slope CP M ,r' / e 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 ( ) EVAPOTRANSPIRATION UNDERGROUND DISPERSAL ( ) SAND FILTER ABOVE GROUND DISPERSAL ( ) WASTEWATER POND OTHER -DESCRIBE WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? Ale PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer, if the Engineer does the Percolation Test) Minutes per inch in hole No. 1 Minutes per inch in hole No. 3 Minutes per inch in hole No. 2 Minutes per inch in hole No. 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 Date PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!! Designate North Arrow Your Neighbor's Name & Address Your Plot - Shape to Fit (No Scale) /2t(9/ 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. Your Neighbor's Name & Address County Road (Note the Road Number and Name) crit clwpwin601wpdocslplottoc 217702204005 217703104AF 217702204004 217702300440 r 2'17703101001 7703200006 r 03300011 • xt i 217702205026 217703100019 217703400027 213101002. I C • 217702205026 217703100437 2177031010Q8: 2-iy7o22o';0gt • 217703104001 217703400439 Account Account: R211022 ,21/4 Q a3.5 d3t t r8 Page 1 of 1 sI https://act. Barfield-county.com/assessor/taxweb/account.jsp?accountNurn—R211022&doc=... 3/9/2010 R aro 39(-/ 16sa Cvt. 01,35 b /-oo -00 i J-cy< oor6(53 000 (0 (q cedA 70111°/9, /bQJ Al-- fr°--fid-e b),64.4 aei.A q5-04 iL ct4-- 9(-710 (k6(it;A125)-t <e i'Lt cce.)-33 y cry;j94 4--LAA-(41/.5-7q3 41. ( !( CA,? -33 OlALI 41.1 l / c -70paieV44 )(7r7 -°3/.0o -cf3 01054 C44 -c c; 053 1ti(fio - Ned 'n0-64-- 44 u 00 -(13 .7- 7 yece3 l -)od- — ioigsl wa.e, /c.6 9 (-3/ 3 1),qfL,Th_ sJ / Of i&geP t e 7-,(z.4L3-2/0 Qr-DA - .9_60 .-77/17 ccryl,54\ a=� UEw1ca Vflf f Vie. 3/0-Y7 9r) 0 ), bc5v/lAa_e 12914 ram- x.33 )2.1"11 -oil -on -c-(.2 45j,„9, 10041o.c pfi' c q{,'.( - (L(([.4, c)-(f/ a 6 D. Co xi, Sd 7 (134 31,11 '7 9(�/oSf 20/7- o3/- 60-et/(so cv.k33 4(17 63N- 6 -43 7 1ci54- cpLA36 �-�¢ )7pQ ?&3/°_;