HomeMy WebLinkAbout02195 1, 1 ."L. �
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GARFIELD COUNTY,BUILDING AND SANITATION DEPARTMENT Permit N- 2 1 9 5
- 109 8th Street Suite 303 \ , Assessor% Parcel No.
• Glenwood Springs, Colorado 81801
. Phon0303) 9484212' ' .
This does not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. A-- M
PROPERTY
Owner NameRichard Croswell & Nancy Asi %dress P.O. Box 624, Silt Phone 876-2376 }
System Location - -
0650 County Road 261, Silt
Legal Description of Assessor's Parcel No. - - .. ', o
SYSTEM DESIGN 1
Ids l `Q 6 S eptic Tank Capacity (gallon) '* Other ell /, Percolation Rate (minutes/inch) Numbe of Bedrooms (or other/ _ , le. ( r'
( r �.c ?/ Pore ,44,,t. _ , c p 9 ecL r e /, ' x i / 3 iarrh
Required Absorption Area - See Atti sOd • . T
("lr 3 /ti`' T. , ' t I �` e f 41 n T wY , / IC' . !. (...e. Q ,�.. I ,
A Special Setback Requirements: ). . C 1 :77 c.' f
, IL / 9 In spector /Q'l (32.4, `=n- -
FINAL SYSTEM INSPECTION AND APPROVAL (as Installed) I
Call for Inspection (24 hours notice) Before Covering Installation
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Sy{ llIn Lit &rnn- L ew /S
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Septic Tank Capacity /$ co - y
Septic Tank Manufacturer or Trade Name A - - -
Septic Tank Access within 8" of surface 9 c 1 (
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Absorption Area /el l m
Absorption Area Type angr Manufacturer or Trade Name
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Adequate compliance with County and State regulations/requirements (,) F.S /
Other / l
0e 4w I (r, f 7 - - Inspector 4 !j 7 1 O I. S•u �L , • t (
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE k
*CONDITIONS: t
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. 4
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 i
requirement of the permit and cause for both legal action and revocation of the permit.
I. 3. Any person who constructs, alters, or Installs an individual sewage disposal system In a manner which Involves a knowing and material 9
variation from the terms or specifications c ontained In t he application of permit commits a Class I Petty O ffense (5500.00 fine — 8 •
months In )ail or both).
Applicant: Green Copy Department: Pink Copy
App Iication
•` "' . �" INDIVIDUAL SEWAGE D SYSTEii AI'PI.ICATI011 Approval by •
OWNER R ;do-1 '9. Crpouotti /il 7. Alut County Official:
ADDRESS 190 6et C
Z 0 65 fL ti±4:1lion[ � � -2-326 ra
3 �. 450
CONTRACTOR � y f G - V , � �i � Vc}_ E� GG�v �T � _
ADDRESS �,j,�� <4,1 /1 33/ S i.1 -I- r,, I'61 rwE $l4 _ z3� —
PERMIT REQUEST FOR: (t/$ New InsLallation ( ) 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 Cb•ce -(A
Near what City of Town 6; 4 Lot Size 6 9 , 0 arc (J fs J
Legal Description j,�� ?1j& eft.f �coh�v. 3( %awn 65 r, ♦
WASTES TYPE: (1./) Dwelling ( ) Transient Use
( ) Commercial or Ins11lutional ( ) Non - domestic Wastes
( ) Other - Describe
BUILDING OR SERVICE TYPE:
Number of bedrooms 3 Number of persons
( ) Garbage grinder ((/) Automatic washer (1 Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: (/) wel 1 ( ) spring ( ) stream or creek
Give depth of all wells within 160 feel of system: UTD
If supplied by con wa ter, give name or suppl ier:__ ` ^ _�(_�
—
GROUND CONDITIONS:
Depth to bedrock: _� _ : . - - - .�
Depth to first Ground Water Table:__
Percent ground slope:
DISTANCE 10 NEAREST COMMUNITY SEWER SYSTEM: 3,'1'
Was an effort made to connect Lo connnunity system? {M
TYPE OF IND VIDUAL SEWAGE DISPOSAL SYSTEf1 PROPOSED:
(V) Septic Tank ( ) Aeral'ion Plant ( ) Vaul
( ) Vault Privy ( ) Composting Toilet ( ) Recycling, potable use
( ) Pit I'rivy ( ) Incineration Toilet ( ) Recycling, other use
( ) Chemical Toilet ( ) Other - Describer _
FIi2AL DISPOSAL BY:
(r) Absorption Trench, Bed or Pit ( ) Evapotranspiration
( ) Underground Dispersal ( ) Sand Filter
( ) Above Ground Dispersal ( ) Was Lewaler Pond
( ) other - Describe:
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF 1IlE STATE? Ito __
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•5011.. PERCOLATION TEST RESULTS: (To be completed by Rey istered Professional Eng(neer.)
Minutes per inch in hole tio. 1 Minutes _ _ per inch in hole No. 3
Minutes per inch in hole No. 2 Minutes per inch in hol e Plo.
Name, address and telephone of RPE who made soil absorption tests:
Name, address and telephone of RPE responsible for design o f the system:
Applleant acknowl edges 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 trade and furnished by the applicant or by the local health department for
purposes of the evaluation of the application; and the issuance of the per,uEtis 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 herewi th 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 bel lel 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 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 llllt /93 Signed . hit
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PLEASE DRAW AND ACCURATE MAP 10 YOUR PROPERTY o(ps' chi -a°(
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