HomeMy WebLinkAbout03360 GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N2 3 3 C 0 r �,t
` v Assessor's Parcel No.
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109 8th Street Suite 303 _ a
; 1 Glenwood Spil s, Colorado 81801 p
Phone (3) 945 -8212 _,
1 This does not constitute _ ;
INDIVIDUAL SEWAGE DISPOSAL PERMIT a building or use permit. f
e 1 PROPERTY (� ^� r" .
3 Owner's NameeR /'e Q \I (ii" r s xJ h H Present Address 3' /o0 58 CR3c4 491119-6 (I" 6,069,5 o e I $' 1 '
System P ? / SY COMM - 1 4 13 1 f - ,z cL CO V1,35 V1,35 >r f
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Legal Description of Assessor's Parcel No. _ r
q SYSTEM DESIGN '
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' C /r/a/V Septic Tank Capacity (gallon) Other
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4 1 S Percolation Rate (minutes Number of Bedrooms (or other) " 'r S7 i
• 3z 01 sr lbftb EL t tit cf 13th aK
t R equired Absorption Area- See Attached y p/ LEA CgM Bt &5 /n) B ., tz ��(*3 ti A.P S� o { ;
I Special Setback Requirements: 3 /e( " L�i +: � 8t 1N in-AC 5 (2, 7/Al/T t 9i 4 1
,. t Date 8 'o Inspector i -. 'tr. j t,
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i FINAL SYSTEM INSPECTION AND APPROVAL (as installed) 4 i
A k C'
I Call for Inspection (24 hours notice) Before Covering Installation j
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P ‘ , CAL_ System Installer - - -- -- - -- . t
-` + Septic Tank Capacity '..,zit - - - -. —
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Septic Tank Manufacturer or Trade Name C � — - --
a ' Septic Tank Access within 8" of surface VS ' '
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Absorption Area Z 0 L� C s I E-E/J C ff';;;) f
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Absorption Area Type and /or Manufacturer or Trade Name i i
k ' Adequate compliance with County and State regulations/requirements a
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Other — 17 ..
ii D W 77— 0) / Inspector I MJ ", .
P*
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE q +
4
` *CONDITIONS: r t
t i 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- 4 c
•' 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 , - r
r ' variation from the terms or specif ications contained in the application of permit commits a Class I, Petty Offense (5500.001 Ina —8 3 ;
!' months in Jail or both).
)
White - APPLICANT Yellow - DEPARTMENT ,'
May -09 -O0 09:18A P.02
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER 37;A er T_ RPor/,oeirk
ADDRESS 373"5 e, /2 30 / / /ale (o 'J$PHONE
CONTRACTOR _ S'r /0 — sc. /iti./ t/ f Jr s +raM.ba•-•
ADDRESS PHONE
PERMIT REQUEST FOR ( ) NEW INSTALLATION 90 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).
uW,ATION OF PROPOSED FAC]LITY:
Near what City of Town /AnA (7 Xi dr Sinn of Lot /riot
Legal Description or Address 373Y G 2 30 / /'44oIt6 co 5 /63 ,S
WASTES TYPE: ()() DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON - DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPE: sir Np-e ll 5
Number of Bedrooms 3 Number of Persons 3
(X) Garbage Grinder (y) Automatic Washer (4') Dishwasher
SOURCE AND TYPE OF WATER SUPPLY; (K) WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: N A
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: e ,,.sN 3 Venl/r
Was an effort made to connect to the Community System? A/o
A site ulna b reaaired to be submitted that indicates the folbwina MINIMUM distancest
Leach Field to Well: 100 feet
Septic Tank to Well: 50 feet
Leach Field to Irrlption 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,
GROUND CONDITIONS
Depth to fast Ground Water Table ° J ee "
Ic - hnan
Percent Ground Slope G 1 4
2
May -09 -O0 09:18A P.O3
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED: • -
.( y) SEPTIC TANK ( ) AERATION PLANT ( ) VAULT
( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POTABLE USE
( ) NT PRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
( ) CHEMICAL TOILET ( ) OTHER - DESCRIBE
FINAL DISPOSAL BY:
on ABSORPTION TRENCH, BED OR NT ( ) EVAPOTRANSPIRATION
( ) UNDERGROUND DISPERSAL ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
(!(') OTHER - DESCRIBE (•L,,,„ 4, A Leto,/ 'ho z/ , c 'Yne;VA-7,i ,6e r
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? HD
PERCOLATION TEST RESULTS; (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 fir Cher 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 bealth 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 stiles 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. 1 iiuther 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 inn legal action for perjury as provided by law.
Signed 2 4L„....4-1-[ Date f / /0o
PLE E DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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