HomeMy WebLinkAboutApplication- PermitGARFIELD COUNTY SEPTIC PERMIT APPLICATION
108 8th Street, Suite 401, Glenwood Springs, Co 81601
Phone: 970-945-8212 / Fax: 970-384-3470 / Inspection Line: 970-384-5003
www.garfield-county.com
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Parcel No: (this information is available at the assessors office 970-945-9134) 2/ 77 g 5 �,h ,7 35,7
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Job Address: (if an addr has of been assi ed, please provide Cr, H or Street Name &CiigQ,or and legalaldescription/ti
'�// (r4255 - C= 5,� 14 ,-4 (e-- Fl 6 CD
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Lot Size: /7//j Lot No: Block No: Subdi Exemption:
7 sS e S ce aria
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Owner: (property owner)
Mailing Address </-
`/158,ely����/�yi�U
Ph:
114 13% Z 2Z/702
Alt Ph:
33g 706
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ractor: e
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Ph: "1UL3 e/x5._271
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Engineer:
Mailing Address
Ph:
Alt Ph:
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PERMIT REQUEST FOR: New Installation ( ) Alteration ( ) Repair
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WASTE TYPE: .) welling ( )Transient Use ( )Commercial or industrial ( )Non- Domestic wastes
( )Other — Describe
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BUILDING OR SERVICE TYPE: f/Ot/56"
Number of bedrooms ,3 Garbage Grinder ( )Yes ( )No
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SOURCE & TYPE OF WATER SUPPLY:
If supplied by COMMUNITY WATER, give name
(/) 1ELL ( )SPRING ( )STREAM OR CREEK ( )CISTERN
of supplier:
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DISTANCE NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to the Community System?
, `e)
9 .i(/ "eJ
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN
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GROUND CONDITIONS:
Depth to 15t Ground
Water Table 2 ¶ 0 Percent Ground Slope
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TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS) PROPOSED:
eptic Tank ( )Aeration Plant ( )Vault ( )Vault Privy ( )Composting Toilet
( )Recycling, Potable Use ( }Recycling, other use ( )Pit Privy ( )Incineration Toilet ( )Chemical Toilet
( )Other- Describe
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FI AL DISPOSAL BY:
)Absorption trench, Bed or Pit ( )Underground
( )Wastewater pond • ( )Other-
Dispersal ( )Above Ground Dispersal ( )Evapotranspiration ( )Sand filter
Describe
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Will effluent be discharged directly into waters of the state? ( )YES ( )NO
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PERCOLATION TEST RESULT: (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
No._
Minutes per inch in hole No.2 Minutes per inch in hole
Name, address & telephone of RPE who made soil
Name, address & telephone of RPE responsible
absorption test:
for design of the system:
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Applicant acknowledges that the completeness of the application is conditional upon such further mandatory and additional test 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 e mi: --sentation may result in the denial of the application or revocation of any permit granted based upon said application
and legal action for perjury .: p . ,,r « law. ---- 1. ---- 26- a
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OWNERS SIGNATU' _ DATE
STAFF USE ONLY
Permit Fee:
3,�
Perk Fee:
(ate . csu
Total fees:
M3•61
Building Permit #:
/o9
Septic Permit #:
Building & Planning Dept:
cf. cis°
Issue Date:
3f
—3v- or
DATE
6/0)*X t0 -&Q (9S'
GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit 4 4 5 0
108 Eighth Street, Suite 201 Assessor's Parcel No.
Glenwood Springs, Coloradof 81601 07 (f3
Phone (970) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
Owner's Name %TS keVOCa6(e
System Location
ct ScOk Qui 89
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S4-• Las V�
Jr sen Address �tj
(40 SS versa 1(4 . 'I� �t -
Legal Description of Assessor's Parcel No.
SYSTEM DESIGN
1-0±- L d'a S s
3E
This doe- not constitute
a bui . ing or use permit.
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Phone �a-3yo -saga.
Septic Tank Capacity (gallon)
Percolation Rate (minutes/inch) Number . Bedrooms (or other)
Required Absorption Area - See Attached )VO
Special Setback Requirements: Afilmp VO 1
Date Ins. -ctor
lToFINAL SYSTEM INSPECTION AND APPROV L (as installed) `�i u 5
Call for Inspection (24 hours notice) Befo-- Covering Installation I`W� 6
System Installer fui
Septic Tank Capacity Cbtg.K4.-t Pit_041
Septic Tank Manufact er or Trade Name
Septic Tank Acce within 8" of surface
Absorption ea
Absorp '.n Area Type and/or Manufacturer or Trade Name
Ad uate compliance with County and State regulations/requirements
ther
Date Inspector
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
ther
*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 1, Petty Offense ($500.00 fine — 6
months in jail or both).
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