HomeMy WebLinkAbout04096GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
108 Eighth Street, Suite 201
Glenvrood Springs, Coloradof 81601
Phone (970) 9454212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
Owner's Name
System Location
Permit 4096
Assessor's Parcel No.
9%/1119/000-
This
11l• /9/•00 -
This does not constitute
a building or use permit.
r, 1Gwe3 +fu 6resentAddress /1 (� OA- 3`) ( ►C M4. C"PhoneCU5-j/b5
Sal Affie , C k/Geo
I?'3-
Legal Description of Assessor's Parcel No
para t a) r) /1- 19 I - 00 - t /9 y
SYSTEM DESIGN
/000 Septic Tank Capacity (gallon) Other
-51
+ Percolation Rate (minutes/inch) Number of Bedrooms (or other){l'
3cX 1J1 ^ [a —
few
Inspector ikf t r 1—J 11-t g L
Required Absorption Area - See Attached
4 Specie! Setback Requirements:
-Date/7- DS
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer 0 ` 5 •
V%-/\ t,/r
Septic Tank Capacity
p JU
Septic Tank Manufacturer or Trade Name
Septic Tank Access within 8" of surface
Absorption Area
iG cf.-01 tm Qm
Absorption Area Type and/or Manufacturer or Trade Name
Adequate compliance with County and State regulations/requirements i atti
Inspector
CLOSLA
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 System Chapter
25, Article 10 C.R.S. 1973, Revised 1984.
2. This permit Isvalid only tor connection to Structures which have fully complied with County zoning and building requlremen . Con-
nection to or use with any dwelling or structures not approved by the Building and Zoning office shall automstically be a viol on ora
requirement of the permit and cause for both legal action and revocation of the permit.
3. Any person who constructs, alters, or installs an individualsewagedisposal system in a manner which involves a knowing and material
variation from the terms or specifications contained in the application of permit commits a Claes I. Petty Offense (5500.00 fine— 6
months In jail or both).
UM1Y •ns, U...,! ..-•. .�-
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER .`Ikrr,e�S Q JwOy M"-jc2
ADDRESS Secq . ti -res R? 3 L' l7 -6/-P . C'C PHONE 5-6,S-- 377-/Ns'Z
CONTRACTOR 22BN.Z7VW11M91-7 oe;4L /n%C -
ADDRESS ?0.3jox 98, ,Sgm,'/(4 5 C: /v
PERMIT REQUEST FOR (k{ NEW INSTALLATION
PHONE SCJ S -FS - -r/60
( ) 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 A ¶Pfe, , R,,-. o Size of Lot 3 Si4'A'e5
Legal Description or Address Sec)- 1 q, T(o n , IZ 9 3 W , (,,Th P01, C>azPe/c? , tie a -r */
WASTES TYPE: M DWELLING ( ) TRANSIENT USE (t1/41<-3;) 1\11(C
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPE: lP-Ro•,oStrC 1c.s,r, ,v -n a.L P,Z'✓a+c I-terne-
Number of Bedrooms 3 Number of Persons
(AO Garbage Grinder (oCt_Automatic Washer (0) -Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: (4 -WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: 5 i'I't, (es
Was an effort made to connect to the Community System? rJ
A site plan is required to be submitted that indicates the following MINIMUM distances:
Leach Field to Well: 100 feet v- APP+z0)<,706+r
Septic Tank to Well: 50 feet / Sof
Leach Field to Irrigation Ditches, Stream or Water Course: 50 feet V " 2 o°
Septic System (septic tank & disposal field) to Property Lines: 10 feet v • / ° {
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 370
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
2
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? PERCOLATION TEST RESULTS: (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 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.
11
I
Signed
1
, �„l Date 7
C.- �
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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