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HomeMy WebLinkAbout02407 v v,e�w':m F:'+R?Pw4:°p'AeJAy�i: P!^.R'M.`�R}N�R.. '",TP�'�FlA'��MTMIY�r'R5?� °.�T{L R n+.yrp.yv:PTRw ^P Slr+m+ r.R"+�"'^rrs^nmmmn n •..:, Src ( e. L r v < .. IS ' t 4 GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N:.. `4 0 7 109 8th Street Sulte 303 Assessor's Parcel No. " Glenwood Springs, Colorado 81601 it Phone (303) 945-8212 if This does not constitute i i INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. LF PROPERTY f r Owner's Name Delve!' & Lynn Worley Present Address 0438 Roundtree Rd, Rifle Phone_ 625 = 9002 , Rifle N t h „ r,,, , a2 System Location 0438 Roundtree Road, 1 r Legal Description of Assessor's Parcel No. r SYSTEM DESIGN / /i /7 /I ; .n 0 Septi Tank Capacity allon) Ot f 0 / , c � t , ,, , Pereoleti n R • ( (' tes/i A. - n , % r • ' d ,, . I (or /1 ma —5 �S f..l 6 / / � L ([ } / Rate (m' utes /inc mbar Be s (or oth ) � ■ t Required Absorption Area - ee A ached a ' "" ' . / I �.,• F..,/ -� ". t . /' Special Setback Requirements: 2-C1 Q. 0 ,(n.l''»7Ri,, . r ' Date /.'' f • ` / Inspector � 1 .r.r•1..,1 ('1 /2^ j .. -IV / 4 FINAL SYSTEM INSPECTION AND APPROVAL (as installed) , Call for Inspection (24 hours notice) Before Covering Installation 0 Y(� ( S System Installer Cam/ 1/f h't o 0 0 6 £ a'. : - Septic Tank Capacity ) -A...4 4 bi ! I Septic Tank Manufacturer or Trade Name , Septic Tank Access within 8" of surface '^ 4 ' t .- - Absorption Area L� b -J i er e.,r -Q_ c // �a G ^ / � fa � Absorption Area Type and/or 'Manufacturer or Trade Name �,E / -^- - ti' � �-^ Adequate compliance with County and State regulations/requirements {�' Other _ 4 • y Date Inspector -'t? 0 ITC 41 4_ RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE (, *CONDITIONS: t 1. All installation must comply with all requirements of the Colorado State Board of Health lndividua(Sewage Disposal Systems Chapter k. 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- i nection to or use with any dwelling or structures not approved by the Building and Zoning office shall automatically be a violation or a j�! requirement of the permit and cause for both legal action and revocation of the permit. 4 3. Any person who constructs, alters, or installs an individual sewage disposal system in a manner which involves a knowing and materiel I variation from the terms or specifications contained In the application of permit commits a Class 1, Petty Offense ($500 fine — 6 months in jail or both).; Applicant: Green Copy Department: Pink Copy t 4 1 , g:) INDLYIDIJAI. SEWAGE DISPOSAL SYSTEM APPLICATION OWNER Defy a- LI) NA/ Worbev, k ADDRESS OO& dim .,1lrna O<(W), / R�)Q Cam)„ PHONE (Q5 -9002 w °r 9n/5-5:y7/ CONTRACTOR ADDRESS PI - LONE _ PERMIT REQUEST FOR ( ) NEW INSTALLATION () ALTERATION pQ 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). LOCA..IION OLPItOPOSED FAGILLTI: COUNTY G-a.r- ; a La En Near what City or Town R Lot Legal Description WASTES TYPE: (X) Dwelling ( ) Transient Use ( ) Commercial or Industrial ( ) Non - domestic Wastes ( ) Other - Describe BUILDING OR SERVICE TYPE: Number of bedrooms: 5 Number of persons 5 OC) Garbage Grinder (X) Automatic Washer ( )0 Dishwasher SOURCE AND TYPE OE.WATER SI JPPI,Y: Q(► WELL () SPRING () STREAM OR CREEK Give depth of all wells within 180 feet of system: If supplied by communtty water, give name of supplier: GHQ' IND 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: ( ) 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 THE STATE? PE1}COl ATION TEST REM II.TS: 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 appliction 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 pernit is subject to such terms and conditions as deemed necessary to inusre compliance with , rules and regulations adopted tinder Article 10, Title 25, C.R.S. 1973, as amended. The undersigned hereby certifies that all statements make, 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 bre relied on by the local department of health in evluating the same fro purposes of issuing the permit applied for herein. 1 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 , � Date s - / 7- 9 5 PI ,EASE DRAW AN ACCT IRATE MAP TO YOUR PROPERTY s WoasC {. m.iy ,T / �'Q ..`I ntk Re+■ \ A33 Rat Qit.rso" R. hit /er R.t1/4 , . PLOT PLAN AND DESIGN FFATI JRES. Include by measured distance location of wells, springs, potable water supply lines, cisterns, buildings, property lines, subsoil drains, lake, water course, stream, dry gulch and show location of proposed system by direction and distance from dwelling or other fixed reference object, and additional submissions in support of this application such as data, plans, specifications statements and commitments. • • f -• w S r WAr 5 © X 6 cevi 1 3 p p IF 4 X -e-t-tr d32A 7 ,T;s. ors . c 02h'a 7 : - -h 4,0i » ', si '7Af a fi S73 co Atunt q so _ /o : /s�� . (: 10" ? " UI 7 7 1 CJ '4 7 0 /'' 2 /S z - � z i r g ii i n