HomeMy WebLinkAbout02408 r% .. 4 / .■
r GARFIELD COUNTY BUILDING SANITATION DEPARTMENT Permit IV_ 24 0 8 -
109 8th Street Suite 303 Assessor's Parcel No. j
Glenwood Springs, Colorado 81601 }
Phone (303) 945 -8212 , F
This does not constitute
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit.
PROPERTY
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Owner's Name Tom Lacy Present Address P.C. Box 2481, Glenwood phone_ 945-2734
System Location
S y Wildwood Lane, No Natsa Glenwood springs
Legal Description of Assessor's Parcel No. gi
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SYSTEM DESIGN r
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Septic Tank Capacity (gallon) Other
Percolation Rate (minutes /inch) per of Bedrooms (or other) '
TJUr f,
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Required Absorption Area - See Attached / .,.,, . . ,,. 2 „
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Special Setback Requirements: P f
Date Inspector '. l
FINAL SYSTEM INSPECTION AND APPROVAL (as installed) k, (
Call for Inspection (24 hours notice) Before Covering Installation
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System Installer / fr 4'=a»4:(.A: 2'. . er O! /r_ /A 6
Septic Tank Capacity__/2 '> /7 4 - .44/ ,
Septic Tank Manufacturer or Trade Name 1 4 .W4a/ f
Septic Tank Access within 8" of surface / e24 2
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Absorption Area it , i ... ':. ?" t 4r I¢ +;
Absorption Area Type and /or Manufacturer or Trade Name `,aI ``' it' -' .�F ` 1:.'0•1 P
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Adequate compliance with County and State regulations /requirements ) e ].
Other f „ ''(
Inspector v,- t _ );
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
•CONDITIONS: k
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. II (
3. Any person who constructs, alters, or installs an individual sewage disposal system in a manner which involves a knowing and material ti 9
variation from the terms or specifications contained in the application of permit commits a Class I, Petty Offense ($500.00 fine — 8 1 C
mon hs in jail or both).
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reen Copy Department: Pink Copy t .
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INDIVIDUAL. SEWAGE DISPOSAL, SYSTEM APPLICATION
OWNER T /yrg
ADDRESS ■st.2 0/44/0" PHONE
CONTRACTOR X2n/,D,e /Ce octapAirmAJ
ADDRESS / Sox 23/7 G.S • PHONE 915 -
PERMIT REQUEST FOR (X) NEW 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 r to /C
Near what City or Town G'LCiI /L0ooD SP65 • Lot
Legal Description 4/6" % 5 41 5C r. 7 7".65 gn9 W 6 1-4 P41
WASTES TYPE: (A) Dwelling ( ) Transient Use
( ) Commercial or Industrial ( ) Non - domestic Wastes
( ) Other - Describe
BUILDING OR SERVICE TYPE: — CA A)K `I- 1'1
Number of bedrooms: 3 Number of persons Z
(/o Garbage Grinder (,r) Automatic Washer (x) Dishwasher
SOIJRCP, AND TYPE OF WATER SUPPLY: () WELL () SPRING (>) SToREAAM O $W /CT
Give depth of all wells within 180 feet of' system:
If supplied by communtiy water, give name of supplier: -t-t ,r/!i'a Zarr 2 S77r/c
GROUND CONDITIONS:
Depth to bedrock: Q -- 3— ' t — I/,r/,C,voc..0,e/
Depth to first Ground Water Table: RI dtR — 75 • /00
Percent Ground Slope: en/a", "%ler — c7ceren .9r .a/1, -'r of a i/6ie
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: 4 — r r7 - s
Was an effort made to connect to community system?
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(x) 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? A%
(- I. I
PERCOLATION TEST REMIT TS: To be completed by Registered Professional Engineer) 1
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:
a,¢4'779t. ? /c. q.:5 ? Z 3 G
Name, address and telephone of RPE responsible for design of the system: / .if' eaZLQ
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 permit is subject to such terms and conditions as deemed necessary to inusre compliance with ,
rules and regulations adopted under 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 /f.�A ! /� Date 3�/ 595
— r 41 � a p.d ST. a 6'C
PLEASE DRAW AN ACCIJRATE MAP TO YOIJR PROPERTY
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