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Home My WebLink About040001 • 4 GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT 109 8th Street Suite 803-DCYI Glenwood Springs, Colorado 81801 Phone (303) 945-8212 INDIVIDUAL SEWAGE DISPOSAL PERMIT PROPERTY r Owner's Name 4 n '' Permit 1'4 - Assessor's Parcel No. ..� I �� L VY 1M Present Address 'CJ'.t )L ifl Phone I c2,12S - c- I System LocatioCL ,' 5 CO—Lk) 1a This does not constitute a building or use permit. Legal Description of Assessor's Parcel No. C a`Tb !aa' -C1 ` SYSTEM DESIGN 7✓ " Septic Tank Capacity (gallon) /6 Percolation Rate (minutes/inch) Required Absorption Area - See Attached Special Setback LRyequirem�ents: Date 9 - / fit//Inspector Other Number of Bedrooms (or other) / af9er s 21 r S 2ciar 13frrj FINAL SYSTEM INSPECTION AND APPROVAL (as installed) Call for Inspection (24 hours notice) Before Covering Installation t• System Installer C�CU^'eft C Septic Tank Capacity 1 at, Septic Tank Manufacturer or Trade Name "2497,0.-- Septic Tank Access within 8" of surface Absorption Area/ /(nate% Absorption Area Type and/or Manufacturer or Trade Name Adequate compliance with County and State regulations/requirements J/ 9067 Other Date d / *CONDITIONS: 1. All installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Displosal Systems Chapter 25`1. ticle 10 C.R.S. 1973, Revised 1984. 2. Thispeiiait is valid only for connection to structures which have fully complied with County zoning and buildeig requirements. Con- nection to or usd*Vlth-anydvrelli ng or structures not approved by the Building and Zoning office shall automatically be aviolation or a requirement of the permit and cause forboth legal action and revocation of the permit. 3. Any person who constructs,alters, or installs an individual sewageasposal 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 in jail or both). RETAIN WITH RECEIPT RECORDS AYCONSTRUCTION SITE White - APPLICANT Yellow - DEPARTMENT INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION OWNER J /. * FA_Am /71'•,46 ADDRESS mo 3 !S S . 0;4 4 L,�n,y �_u/_ i� PHONE tap —?54/6 CONTRACTOR /Bzy, y ADDRESS /2 at /3n_ Arc', r PHONE 2 v 2 —5s 5,0 PERMIT REQUEST FOR Q) 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 PROPOSEDAFACILITY: l Near what City of Town 4%-�C,dwm,o d so, 5 Size of Lot 7(r, Q C, Legal Description or Address apo 3 $ $ r G SA' v1 ty% WASTES TYPE: .DWELLING ( ) TRANSIENT USE ( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES ( ) OTHER—DESCRIBE BUILDING OR SERVICE TYPE: 44R4.5, rirx ,1e/5- %j o 0 Number of Bedrooms Number of Persons ( ) 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: Was an effort made to connect to the Community System? A site plan is required to be submitted that indicates the following 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: Depth to first Ground Water Table Percent Ground Slope TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED: (%g, 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: (>1) 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? X5/0 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 /i//' %. Date 7.- PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!