HomeMy WebLinkAboutApplication- PermitGARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit
Assessor's Parcel No.
29C3
109 8th Street Suite 303
Glenwood Springs, Colorado 81801
Phone (303) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
Owner's Name
System Location
Phil Lacerte
Legal Description of
SYSTEM DESIGN
000
2Or
962
This does not constitute
a building or use permit.
Present Address 13155 Noel Rd 02200, Dallahone 972-770.0604
County Road 107, Carbondale
sensor's Parcel No
IA 0C 44. Cf,c-15Cr) + o lUid1 IR
f,
;Septic Tank Cepa allon)
ifr
Percolation Rate (minutes/inch)
Required Absorption Area - See Attached
Special Setback Requirements:
2-2'749x'
Date
Inspector
CF+ CSC o 33 ( Fr,Crr f7(cCES) Cif IV
11 1 COO”, t', 14 I/ &-.09
Other1 1 ('A Ft ,t r r, / it f R
3
Number of Bedrooms (or other)
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer A.4/+!%�
Septic Tank Capacity / ? S13
Septic Tank Manufacturer or Trail° Name
Septic Tank Access within 8" of surface T 4,
Absorption Area
Absorption Area Type and/or Manufacturer or Trade Name +�
Adequate compliance with County and State regulations/requirements I
Other
soy4 T #"/ 1-+ 16 ;71 E.4
Date ?'--� `5"" /'fes Inspector A-,�
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 G.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 Pb LAcEP-T
ADDRESS 136E, Hind IBJ Su,i2.2ixb 1' 2.4O- iaae6PHONE q-12.---1-to kce4
CONTRACTOR `.24 2,44,1%Lit L s tNL,
ADDRESS (30g th-gNuCk CARcAt CA.EAuDia(e, Co 8ib25 PHONE CM3 4S-re:A-
PERMIT REQUEST FOR (4 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 CAR r iDak . Size of Lot 1G l a qt._
Legal Description or Address MVV Cocr;e - OF (JC iucl 1Z . 1 , e ( f c f) U Lv\c.)
WASTES TYPE: (V) DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPE:
Number of Bedrooms J Number of Persons 3
(� Garbage Grinder (✓S Automatic Washer (1 Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: (4 WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: N/
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: zz tv.ttc-S
Was an effort made to connect to the Community System? i\Jo
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 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
2
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
SEPTIC TANK
VAULT PRIVY
PIT PRIVY
CHEMICAL TOILET
AERATION PLANT ( ) VAULT
COMPOSTING TOILET ( ) RECYCLING, POTABLE USE
INCINERATION TOILET ( ) RECYCLING, OTHER USE
OTHER - DESCRIBE
FINAL DISPOSAL BY:
(> ABSORPTION TRENCH, BED OR NT ( ) 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. 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 A jfkit./(
Date i a1
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