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HomeMy WebLinkAbout02817 ,_ '9E9° „.„,.. ? ' 7 ,'. d ,, - ”.rogavx+slvp^ Kr; ,. ✓ r tarry. pogrzPre 1.$nµ7, ° '. ' ' t ' t 9 4 1 i 1 .- 4 GA COUNTY BUILDING AND SANITATION DEPARTMENT Permit 2817 Street Suite 303 Assessor's Parcel No. s Glenwood 109 8th Sp (Wp9, G o�rr 811101 1 t .. Phone (3 3) 9 V /\ 4 - This does not constitute INDIVIDUAL SEWAGE DISPOSAL PERMIT - a building or use permit. PROPERTY 1 ( "■ f ( d ' Owner's Name KylA F. 11An1 Harr 1awn Present Address '300 Evans Ave. Rifle Phone - 2135 +7756 System Location "7-9 I q (Lot #1) County Road 210, Rifle Legal Description of Assessor's Parcel No. I2 oC K - t e- 4 044 - F r e (U - ----- -''T c 174 1 ? SYSTEM DESIGN 31 Ir C (f A / 6c et Li E 0 —3 S e N 02 2.4 Nctcr SFT k If I 'tab,. Fnttil -GFT. 390 QS Septic Tank Capac (gallon) Other A pA A• f� AX, IQ f 1 It ■ ��PE 0 I T 4 h r c 4 Percolation Rate (minutes/inch) Number of Bedrooms (or other) 4 Required Absorption Area - See Attached Special Setback Requirements: �{ Date ) -- ( - 9 Inspector 14 an' FINAL SYSTEM INSPECTION AND APPROVAL (as installed) Call for Inspection (24 hours notice) & Be ef fore Covering Installation Oil. System Installer J 1 \ ID t. C " Septic Tank Capacity 1 • - S 0 • Septic Tank Manufacturer or Trade Name C 0 f°CCA/40 �^ C Septic Tank Access within 6" of surface ` c. J Absorption Area ' I ° 1 0 F 7(z7 3 rloi,.,S or £ Fe Es l/ f �1 A f C 2 4 - / q Absorption Area Type and /or Manufacturer or Trade Name ' / V 1- �� / L t 0 ` A t 0 A ` Adequate compliance with County and State regulations /requirements f c 5 Other ��.II. Date g -1 "( 1 r1 Inspector 1 ' ` ---' RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE *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 1964. 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 I, Petty Offense ($500.00 fine — 6 months in (all or both). White - APPLICANT Yellow - DEPARTMENT . -e, INDIVIDllAl. SEWAGE DISPOSAL SYSTEM APPLICATION OWNER _/ /A ✓_ )mist t077 ADDRESS //sf / ci/Uri97 �3 02 /D PHONE / fa CONTRACTOR 4/4, )f'ntSG ,4Y rr /St.Y) ADDRESS / PHONE PERMIT REQUEST FOR (V 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: Near what City of Town /e/r ee , , Size of Lot `�` ' 9 Legal Description or Address ( i a?( U WASTES TYPE ( TELLING ( ) TRANSIENT USE ( ) COMMERCIAL OR INDUSTRIAL ( ) NON- DOMESTIC WASTES ( ) OTHE - DESCRIBE BUILDING OR SERVICE TYPE: Number of Bedrooms V Number of Persons V ( ) Garbage Grinder (✓Automatic Washer (v) ishwasher SOIJRCE AND TYPE OF WATER SUPPLY: ('LL ( ) SPRING ( ) STREAM OR CREEK If supplied by Community Water, give name of supplier: DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: Was an effort made to connect to the Community System? A site plan is required to be submitted that indicates the following MINIMUM distances: Leach Field to Well: 100 feet Septic Tank to Well: 50 feet Leach Field to Irrigation Ditches, Stream or Water Course: 50 feet Septic System to Property Lines: 10 feet YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT A SITE PLAN. GROIJND CONDITIONS: Depth to first Ground Water Table Percent Ground Slope 2 'TYPE F 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 ISPOSAL BY: FINAL 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? PERCOLATION TEST RF,SIN,TS• (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 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 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 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 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 024' %4r ( 76.4.4.4 Date n/i�rc.e /4199j PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!! 3 .; '97 12:10 1D:GRAND RIVER HOSP DIST -MR FAX:970- 625 - 1510 -271 PAGE 2 - 1 t- i1 • 4 b 0 • Ili., - - V r- i9 '97 12 :10 ID :GRAND RIVER HOSP DI ST-MR FAX :970-625-1510-271 PAGE 1 , + rn � 1 w ) 'dr /410 s , A I rma r rt i „ 1 4::: ), 4 ‘ yti s ) -: ) t. R , `1 �► rte I, 4 ,_ 2 0 Oj s e ; I GRAND RIVER HOSPITAL DISTRICT 701 EAST 5TH STREET, RIFLE, CO 81650 (970) 625 -1510 FAX COVER SHEET DATE: _ i _ - TO: NAME: V� DEPARTMENT: 0' �f�i�L� p TELEPHONE: L -!!!U� NUMBER OF PAGES: • a y J�itzt2e NAME: 7) e / - �Q rrism DEPARTMENT: �} TELEPHONE. /R-C. -- -,'jj12 . -. C a/ __ v _ - NOTICE TO RECIPIENT: THIS INFORMATION HAS BEEN DISCLOSED TO YOU FROM RECORDS WHOSE CONFIDENTIALITY IS PROTECTED BY FEDERAL LAW. FEDERAL REGULATIONS (42•CFR•PART2) PROHIBIT YOU FROM MAKING ANY FURTHER DISCLOSURE OF IT WITHOUT THE SPECIFIC WRITTEN CONSENT OF THE PERSON TO WHOM IT PERTAINS, OR AS OTHERWISE PERMITTED BY SUCH REGULATIONS, A GENERAL AUTHORIZATION FOR THL RELEASE OF MEDICAL OR OTHER INFORMATION IS NOT SUFFICIENT FOR TI-418 PURPOSE NOTE: THE INFORMATION CONTAINED IN THIS FACSIMILE MESSAGE IS PRIVILEGED R CONFIDENTIAL INFORMATION INTENDED FOR THE USE OF THE INDIVIDUAL OR ENTITY NAMED ABOVE. IF THE READER OF THIS MESSAGE IS NOT THE INTENDED RECIPIENT OR THE EMPLOYEE OR AGENT RESPONSIBLE TO DELIVER IT TO THE INTENDED RECIPIENT, YOU ARE HEREBY NOTIFIED THAT ANY USE, REVIEW, DISSEMINATION, DISTRIBUTION OR COPYING OF THIS COMMUNICATION IS STRICTLY PROHIBITED. IF YOU HAVE RECEIVED THIS FACSIMILE IN ERROR. PLEASE NOTIFY US BV TEL IMMEDIATELY SO THAT WE CAN ARRANGE FOR THE RETRIEVAL OF THE ORIGINAL DOCUMENTS AT NO COST TO YOU. ■ Z § ( 2@ CM > j ƒ -- » £' \ CL .g 0 ' - \ / S `` Q. ' 7 Z 2 © co go Bt CD CD 0 \ _ — } {f§ B •••') * E J $ \|Ro/ a .-- 4 } - E « ( 7 a. _ ƒ \ 2 // — ( \� _ / cri a, _ , ¥ ^'. • e e It w w - ¥ cp • $\ y \\ ! — . — lw � �. • • — o \ r ._ , \ , tt,,,,.. t �� &/ \ ,‘ �/ \*. 1. Cl. \ . . . .