HomeMy WebLinkAbout03927GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
109 8th Street Suite 303
Glenwood Springs, Colorado 81601
Phone (303) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
Owners Nam~£vbtoc~wJi~ Present Address llJ:'"Si bJOlld Pw:J
Permit N~ 3927
Assessor's Parcel No.
This does not constitute
a building or use permit.
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system Locat•on __ .~::l~a""""(p__,_5~kLL)~/~~~· 4---'-'[)'-'--',=. ___ G="--=--'lU,,..._0=· _____ _
Legal Descroptoon of Assessor's Parcel No rY ]"/iii~ } -{) f -0 / <i,
SYSTEM DESIGN 1---Septic Tank Capacity {gallon)
• Percolat10~~1nutes/inch)
ReqJored Absorptoon Are./ See Att~ched (
Spec.al Setback Requo~//
_______ ,Other
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Date.__ _____________ Inspector _____________________________ _
FINAL SYSTE INSPEiCTION AND APPROVAL (as mstalled)
n (2 hours notice) Before Covering Installation
System Installer _____________________ _
Septic Tank Capacity ______________ _
Septic Tank Manufacturer or Trade Name ___ _
Septic Tank Access w1th1n a·· of surface _____ _
•CONDITIONS:
1. All 1nstalla11on must comply with all requrrements of the Colorado State Board of Health lnd1v1dual Sewage Disposal Systems Chapter
25, Article 10 CR S 1973, Revised 1984
2 This perm1t 1s 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 slructures not approved by the Bu1ld1ng and Zoning office shall automatrcally 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 1nd1v1dual sewage disposal system 1n a manner which involves a knowing and material
variation from the terms or specifications contained 1n the application of permit commits a Class I, Petty Offense ($500.00 fine - 6
months 1n 1a1I or both)
Whote -APPLICANT Yellow -DEPARTMENT
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER
ADDRESS \ lo~ ~ 6 fj)1J\J {'.) l)(
CONTRACTOR p)Cl\l € C n -!!>i '::::}"\ 1{°
ADDRESS ,.;;,;;i.L-?v.., 1<,:,.,, Dr.
tr l.Jt ~1 WtX'O ~~I';;..-"5> ~ t--~
t? bC J
PERMIT REQUEST FOR ( ) NEW INSTALLATION
PHONE
()(}AL TERA TION ( ) 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 & S r·, Size of Lot d r\C..r <:. 5
Legal Description or Address )) (., Sy V1 kr0J Qq/< Meu.Jo,vs Su':_il. 1-[f: 8 /. J_ Lot-lb
WASTES TYPE: i>() DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ) NON-DOMESTIC WASTES
( ) OTHER -DESCRIBE
BUILDING OR SERVICE TYPE:
Number of Bedrooms ___ _,_ __________ Number of Persons S
~) Garbage Grinder ~ Automatic Washer ~ Dishwasher
SOURCEANDTYPEOFWATERSUPPLY: ~WELL
If supplied by Community Water, give name of supplier:
( ) SPRING
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to the Community System? S M 1 )e_ ~
( ) STREAM OR CREEK
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: IO 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 ,) "'/ e;
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
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(
. ()()' '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
BE DISCHARGED DIRECTLY INTO WATERS OF THE WILL
STATE9
EFFLUENT
NO 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 ofRPE who made soil absorption tests:--------------
• Name. address and telephone ofRPE 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 submined herewith and required to be submined 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.
""' • S igned~,~~=-__,:::!.."_~~L!::.=----'-:£.~:S...-r:,..-Date_Y-'--~---===~=-=C::::,=-----'C:J=Y-+
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PLEASE DRAW AN ACCURATE
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