HomeMy WebLinkAbout-2415.pdf.-....... , • ~. ' . .-.•..•. . . ~A I GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT 109 8th Streel · Suite 303 Glenwood Springs, Colorado 81601 Phone (303) 945·8212 INDIVIDUAL
SEWAGE DISPOSAL PERMIT PROPERTY Permit This does not constitute 8 building or use permit. Owner's Nams _ _Ji_m_ Z-'e'-g--a-_uk_1_ ____ Present Address _5_22_ _N. _T_ra_v_er_ T_r_a i-l",
_ C_.S_. Phone _9_It5_-6_/,2_0 __ System Location _ _____-=0-=2:.:3:.4-= --S2.:p:.r::i:n.:.g:.r!~1::d..:g::e=.: :.D~~::r:.i.v:.~e..,.. ::L::.o.:.t: ::.2.:.0..,. .:~S___I.:,_r=_1_=n_~g...r.:1_=d__e=_.
..P.:.l..a.:c..:e..,.. ..G..:l.:o.:..m. _f_O_o_ o= __S_.p.:r.:1.:.n.._g.s:. ._ Legal Description of Assessor's Parcel No. ___________________________ ________ _ SYSTEM DESIGN ~"':..:
: --..... ... ----___ ___ Septic Tank Capacity (gallon) _ _____' Olhe"r' ----------.--...... _ _____ Percolation Rate (minutes/inch) Number of Bedrooms (or other) 5 '-----. -Required
Absorption Area -See Attached Speoial Setback Requirements: Dats _____________ lnspeclor ____________________________ _ FINAL SYSTEM INSPECTION AND APPROVAL (as installed) Call fo, Inspection
(24 hou,s notice) Befo,e Covering Installation System'ns',"e, 47M ~ Septic Tank CBPlllcltYfL-+"'~-/.r.· y'-_~-1'-l:Z= __ -----------------------------Septic Tank Manufacturer or Trade
Name --.L!.e.'I."z."" .. ",.~t"d:"tJt."'"--------------------------Septic Tank Access within 8" of surface -lY'",:.,~.·S. ----------------------.-------Absorption Area -''1'1-'e~,,,,(22..t)
________ _____________________. _ _______ Absorption Area Type and/or Manufacturer or Trade Name ~;:L,..t'., .," 'L'-"..l.(-·.JF'· ,,1-,,1r "t';:,·,.Lt<"-'c..~ _______. _ _______ Adequate
compliance with County and State regulatjonSlfeqUjrements-'yI·::....<:(~<.,"_ _________________ _ Othe' _________________________________________________________________________________
___ Date :i -.:1 . '1 s: Inspector ), /"" .. .,14 W, .' <'&'·r"" ' RETAIN WITH RECEIPT RECORDS AT CONS·T~UCTION . TE ·CONDITIONS: 1. All installation must comply with all requirements
of th6 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. Connection to or use with any dwelling or structures not approved by the Building and Zoning office shallautomaticelly
be e violation or a requirement of the permit and cause for both legal action and revocation of the permit. 3, Any person who constructs, allers, orinstalls an individual sewage disposal
system in a manner which involves e knowing end material variation from the terms or specifications contained In the application of permIt commits a Class I, Petty Offense ($500,00 fine
-6 months in jailor both). Appli cant: Green Copy Department: Pink Copy -----------------~-::f:'·'· f~
" ~. i .. INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION /50 , -'.1' :/OWNER :T,6MES 12 ZEBAfs,sKf ADDRESS 52.?-d f itA ,/ER, TRAli< PHONE rtf$"-?'feJO CONTRACTOR ____ ~S~AM~E~ _______________________
_________ __ ADDRESS PHONE ______ _ PERMIT REQUEST FOR (0 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 proftles in test holes (See page 4). LOCATION OF PROPOSED FACILITY:
COUNTY -I.;G;:u:lA>£C...l:E:...J!~F:.JIL.Dl.,;·L -_______________ _ Near what City or Town G LEI,)" 100 Q ?ee t! IG S' Lot __ £.2..,\0'--________________ _ Legal Description Seg /!!G
"RIDGE S'" 1'1 a III! SI a AJ WASTES TYpE: (t{Dwelling ( ) Transient Use ( ) Commercial or Industrial ( ) Non-domestic Wastes ( ) Other -Describe ______ -:-______________________________
_ BUILDING OR SERVICE TYPE: --"S....wl tJ~Gu.l""E"__cEit!o.A,.c:M1JI~l....ly'__ ________ -:-______________ _ Number of bedrooms: L{: a!?. S Number of persons ___ 4-1--______________
(nGarbage Grinder (f') Automatic Washer (/I}'Dishwasher SOl !ReE AND TYPE OF WATER SUPPLY: (;1 WELL () SPRING ( ) STREAM OR CREEK Give depth of all wells within 180 feet of system: ____
--:::::-____ ---,, ___ --,o::::-____________ _ If supplied by communtiy water, give name of supplier: $'PIWJG-{(lOG fi SUa h IUI.lIG IJ GROl !ND CONDITIONS: Depth to bedrock: ____________~
SLE~F___1.4::I,..LT-l.T..tlA.L.C..tH:!1E~OLL-~S;u.{).wB::I_'.~'\OOLULI _ _~ I....LIT_l.(.L/. uO....lV'__ ______ Depth to first Ground Water Table: _______________________________ _ Percent
Ground Slope: _____________________________ _ DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: ____________ _ Was an effort made to connect to community system? _--l.N:>I..J.QI _____________
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED: (0' Septic Tank ( ) Aeration Plant ( ) Vault ( ) Vault Privy ( ) Composting Toilet () Recycling, potable use ( ) Pit Privy ( ) Incineration
Toilet () Recycling, other use () Chemical Toilet () Other-Describe: ThUD/II';;" By h\W.H CO(WH.Y fi.JrS, FINAL D!§>POSAL BY: (0' 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?---L:l.t-,)u.o'--__ T "', I .
" <I ••. ... • PERCQ] .ATION TEST RESl JI .IS: (To be completed by Registered Professional Engineer) Minutes per inch in hole No. I Minutes per inch in Hole No.3 Minutes per inch in
hole No.2 Minutes per inch in Hole No. _ , S El; AT[Ac..I--\~D 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 ofthe evaluation of the application; and the issuance
of the permit is subject to such terms and conditions as deemed necessary to inusrecompliance 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. 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. 'r