HomeMy WebLinkAbout02102 it .
GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit . N: 2 1 0 a
109 8th Street Suite 308 A rat Parcel No
Glenwood S{i('Ings, Colorado 81601
Phone(303) 945.8212
This does not constitute '
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. '
4 PROPERTY
Jack & Lisa Davie 0187 County Road 259, Rif Ph aone 625 -4129
Owner's Name Present Address
$r
System Location 0187 County Road 259, Rif la
1 Legal Description of Assessor's Parcel No
SYSTEMM DESIGN w
7 ', Septic Tank Capacity (gallon) Other r 0
82
• ,bM / Fe" - percoiatioh Rate ( nutes/inch) Number of Begrooms (or other) i i ';,
6 3c Mock- t- r-ebch l"stdcrrl2`X 'X3` (z Tire
- Required Absorption Area • SefalMeebed or 3 2 1 A r Z til j"t , ) ± i? N 701 L✓ N/ #' lit .44 / 7, ", . I ,. aof
Special / Setback � Requirements: cry 3� �� - I - �^1} '' C ( � ` /{tt , 17 / iP .,,
I " r Date V '� / " r / - ! 3 Inspector n[ + Oil t -
FINAL SYSTEM INSPECTION AND APPROVAL (as Installed)
Call for Inspection (24 hours notl clef a Covering Installation
System Installer J
Septic Tank Capacity J, 0 -' G i ayl
Septic Tank Manufacturer or Trade Name C - 4 -Ci D y
,
Septic Tank Acgess within 8" of surface d,11/ (/
Absorption Area / ,(�./krinr ` /f / /
y'
Y
Absorption Area Type and /or Manufacturer or Trade Name ' MI,..(i_ -
Adequate compliance with County and State regulationahequirements 4- ----
Other ° \
Date 7•• 7" 9' 3 Inspector, C rY en ( 3 1 a.
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
I "CONDITIONS: t k
1. All Installation must comply with all requirements of the Colorado State Board of Health Individual Sew0 A posal Systems Chapter 1
25, Article 10 C.R.S. 1873, Revised 1984. + �1 $
2. This permit is valid only for connection to structures which have fully compiled with County zoning a 1.1f
3 • '• requirements. Con- fi Rf3
nection to or use With any dwelling or structures not approved by the Building and Zoning offloe sh18% I' : yl 1 • Ily be aviolation or a
requirement of the permit and cause for both legal 001idn and revocation of the permit 1, ,.1 1 11
3. Any person who constructs, alters, or installs an individual seWage disposal system Inc manner which' '1 a Ing and material
variation from the terms or specifications contained In the application of permit commits a Gees I, Pet Offe .00 fine —8
months In )ail or bolt). "
Applicant: Green Copy Department: Pink Copy (1,044,
A II
Application
,‘ INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION Approval by
County Official:
OWNER axe.? = (,SA ¶Nru 5
ADDRESS IRS: Qs PHONE WS - 4+2
CONTRACTOR_ b LA
ADDRESS _ PHONE
PERMIT REQUEST FOR: (i%Illew 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: County Coarc:el
Near what City of Town '1?;cl1e Lot Size
Legal Description _1$l a Q_l —
WASTES TYPE: ( )C ) Dwelling ( ) Transient Use
( ) Commercial or Institutional ( ) Non- domestic Wastes
( ) Other - Describe
BUILDING OR SERVICE TYPE:
Number of bedrooms v Number of persons
( ) Garbage grinder ( ) Automatic washer ( ) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: ( j ) well ( ) spring ( ) stream or creek
Give depth of all wells within 180 feet of system:
If supplied by community water, give name or supplier:
GROUND CONDITIONS:
Depth to bedrock: —
Depth to first Ground Water Table:
Percent ground slope:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to community system?
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
( y.) 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:
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF TIIE STATE?_
•
•
rte, ' .
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 tIo.
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 application; and the issuance of the permtt 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 permit applied for herein. 1 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.
Date (n.lt. eta Signed`
PLEASE DRAW AND ACCURATE MAP TO YOUR PROPERTY
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