HomeMy WebLinkAbout02432~ .. · l
\ '
................................. ·.1
1
GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
109 8th Street Suite 303
Glenwood Springs, Colorado 81601
Phone (303) 945-6212
Permit N~ 2432
A1seBBor'1 Parcel No.
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
This does not constil'ute
a building or use permit.
Owner's Name __ ...,Mc,:a,,r"-k"---W-"=ag"'s'-"t'-"r-"o"'m'------Present Address ___ 3_4_2_7c.._Cc.R __ 2_2_6__,_,_R_i_f_l_e __ Phone, __ 9_4_5_-_2_3 __ 41 __
System Location __________ ...,3<:4,_,2°'7'-----'C"'o'--'u'--'n'--'t::,iYc._,R,:,:oc,:a,_,d'---!2:.!2:::6'..!,'--.'.:R..ci..cf..cl::::e:.._ _____________ _
Legal Description of Assessor's Parcel No. ---. .. >---,cc,----..,-----~----------------------1"909 R&.<!K Ji t.+,,cn i!\<t"l> ,//JO ~o % 1,>"76 El
SYSTEM DESIGN q..;.,f r,,z,,,c/1..,~rr->,,:,c,. :;-o 6 ~
</ + '-'" '13 ',._ -<J' F/C"e,J~ f'S b'D e,,t
J/c,.!i.._-..,c,"--"o"---Septic Tank Capacity (gallon) ______ Qt her
I., 1N ,27 itz, A) Percolation Rate (minutes/inch)
Required Absorption Area -See Attached
Number of Bedrooms (or other) ------"L.-
Special Setback Requirements:
Oat• 1::i.-'{--9:,-inspector....cl('.~,:,,,,"',u".,~::::;;z=i{,o,.,;;;• 1,,,~.,.<<-<,,_,,"':Z··.,,<k/.------------------
FINAL SYSTEM INSPECTION AND APPROVAL (as Installed)
Call for Inspection (24 hours notice) Before Covering Installation
--------System lnstaller ____________________________ __cµ.... __________ _
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~------------------------~------------------
/0 -::)_ (-o;i lnspector_...s....--J;--'--', ~--'---"----"'"--~-------Date
RETAIN WITH RECEIPT RECORD~ION 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 I, Petty Offense ($500.00 fine -6
months In Jail or both).
I
Applicant: Green Copy Department: Pink Copy
i
'·"" --------------------------------------------------------------------------------------l
Application
INDIVIDUAL SE\lAGE DISPOs,n,L SYSTEM APPLICATION Approval by
OllNER Mark wag:stni>ro
County Official:
ADDRESS 3422-226 Rd Rifle, ca PHONE 964-3166
CONTRACTOR_ -i;i-&alllm~e~~----------------
ADDRESS ____________________ __:PHONE ____ _
PERMIT REQUE~T FOR: ( ) New Installation (x) 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: County _ __,G""a'""r'--=f'--=i'-"e'-"l'-"d~-----
Near what City of Town,___-"'"......,"----------------'Lot Size i.section
Legal Description T, 5S, R, 92w,, SEl.r sec,
WASTES TYPE: ( X ) Dwe 11 i ng ( ) Transient Use
( ) Commercial or Institutional ( ) Non-domestic Wastes
( ) Other -Describe ___________________ _
BUILDING OR SERVICE TYPE: ___ R_e_s_id_e_n_c_e ___________________ _
Number of bedrooms. ___ 4:,__ __________ _;Number of persons __ ...,.__ ____ _
(X) Garbage grinder ( X) Automatic washer ( X) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: ( X ) we 11 ( ) spring ) stream or creek
Give depth of all wells within lBO feet of system: _______________ _
If supplied by community water, gi~e name or supplier: _____________ _
GROUND CONDITIONS:
Depth to bedrock: ____________________________ _
Depth to first Ground Water Table: _____________________ _
Percent ground slope: __ ....,., _______________________ _
DISTANCE TO NEAREST COMMUNITY SEHER SYSTEM:_....:1:.::0:....-..::.1.:::.5 ____________ _
Was an effort made to connect to convnunity system7_1ll-L-,.,__ ____________ _
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(x ) Septic Tank ( ) Aeration Plant
( ) Vault Privy ( ) Composting Toilet
( ) Pit Privy ( ) Incineration Toilet
( ) Vault
( ) Recycling, potable use
( ) Recycling, other use
( ) Chemical Toilet ( ) Other -Describe: ___________ _
FINAL DISPOSAL BY:
( xl Absorption Trench, Bed or Pit
( ) Underground Dispersal
( ) Above Ground Dispersal
( ) Other -Describe:
(
(
(
) Evapotranspiration
) Sand Filter
) llas tewa ter Pond
IHLL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF TIIE STATE? No -----------
----a1::~ ' . ', ' .. '
SOIL PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer.)
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
purposes of the evaluation of the a;ipl ication; and the issuance of the pcnui'.t,i-s subject to
such terms and conditions as deemed necessary to insure compliance with rules and regulations
adopted under Article 10, Title 25, C.R.S. 1973, as amended. The undersigned hereby certifies
that all statements 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 pennit applied for herein. I further under-
stand 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 per-
jury as provided by law .
.... ;llt,vi itJijk, Signed ~;/ /2 , / 1 fJ l
PLEASE DRAW AND ACCURATE MAP TO YOUR PROPERTY