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HomeMy WebLinkAboutApplication.pdfGARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit 108 Eighth Street, Suite 201 Assessor's Parcel No. Glenwood Springs, Coloradof 81601 INDIVIDUAL SEWAGE DISPOSAL PERMIT Phone (970) 945-8212 ' `id,- 6©'-z%9 ( This does not constitute a building or use permit. PROPERTY /,) 4c. ✓'�,Q(K4-1ea�"e- f .©. • 6� Rifle �$Ib5o 6a � 3byyy Owner's Name t,_, % r 5 ' Present Address Phone System Location 0(4/ ! /.^-e i:C QU -c5 y -C 1 d\.E. t�l'.�U�i�" I CJ . bar i. �C( ` 8 %%SC's t Legal Description of Assessor's Parcel No L. . (�± �� Cc"�} It it 9vrS �ot � i SYSTEM DESIGN boo 2� S bsrreom5 1401d si9oto 944( '5/P'-) Septic Tank Capacity (gallon) Percolation Rate (minutes/inch) Required Absorption Area - See Attached Special Setback Requirements: /7l C Date Other Number of Bedrooms (or other) L,i�fu2 C) i m v� Inspector 6bled /5(54, Il? 1/ti r..1-e-i/� '-' 7-s '( 4, o) FINAL SYSTEM INSPECTION AND APPROVAL (as installed) CaII for Inspection (24 hours notice) Before Covering Installation System Installer ()Mil, \IA- Septic Tank Capacity Septic Tank Manufacturer or Trade Name Septic Tank Access within 8" of surface `\ 0. ' Absorption Area 61.PI4 �,'� l �� (e b) �� k�� 1'(IV» Absorption Area Type and/or Manufacturer or Trade Name Adequate compliance with County and State regulations/requirements 11 Other Date 1' 1 I - L•' 7 Inspector/Ctttlt ,. //i P,- d_ RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE u lD(.)4 / <. *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 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. 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 Classk,Petty Offense ($500.00 fine — 6 months in jail or both). White - APPLICANT Yellow - DEPARTMENT INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION OWNER Mat'C i S-t,I)h ADDRESS 4 o / a) t dilfj y CC_ (btio CONTRACTOR N;frr!L erS fLth ADDRESS fo 1 2y f ' Fl"1 co- X16 5o PHONE 97c (z51- 3 PHONE q7)-4, 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: Near what City of Town 1 �e- Size of Lot 35 - Legal 5 -Legal Description or Address lr*rc._1 2-to3_112_oa_cyk/ ,.edrrr 5r-7/15 &,.nc) /fid Laf"ft Lot F WASTES TYPE: (X) DWELLING ( ) TRANSIENT USE ( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES ( ) OTHER -DESCRIBE BUILDING OR SERVICE TYPE: ,5,F Number of Bedrooms 3 Number of Persons z- (1() Garbage Grinder ( ) Automatic Washer (0c) Dishwasher SOURCE AND TYPE OF WATER SUPPLY: (X) WELL ( ) SPRING ( ) STREAM OR CREEK If supplied by Community Water, give name of supplier: DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: 5 Was an effort made to connect to the Community System? /No 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 (septic tank & disposal field) to Property Lines: 10 feet YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT A SITE PLAN. GROUND CONDITIONS: Depth to first Ground Water Table w"/(/)=IVh j oh rot d 1. A A) l J Percent Ground Slope 2 TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED: (A, 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: (X) 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? N© 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: M' -/'r- ott, !, J&tax t -JR f) C6. Flrt,so 17°-k -2-5--53(H Applicant acicnowledges 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 Date >./ ijf© PLEASE W AN CCURATE MAP TO YOUR PROPERTY!! tal a 2 E 4 8 3 8 a a 6 8 E 1 a • 9 P r 0 • 1 tn 6,1 C 1-3 tri tvesp �ob Nbr fib. Co :N9C+7 b 0)rn y� b oo ti ox� b co t V tri EEFE69E@9EE5,....._e.ccrrcrrcI �s�3�?pp •ad={$i<idxx{s,S EEa$� ?=ff3ea$s: Yxaad7Ed2`afd�ditiExx�x�i a gE�w 1 i B xR a`•Ck58:82888.Y�&�e6%e�Y5L 88: 85o 88a tal a 2 E 4 8 3 8 a a 6 8 E 1 a • 9 P r 0 • 1 tn 6,1 C 1-3 tri tvesp �ob Nbr fib. Co :N9C+7 b 0)rn y� b oo ti ox� b co t V tri J_...-- — .- ▪ A""—� ® I• ✓® • �/ MOMS,. _® — oma• w.- ....° .u•• ®T®�.........'._.V�r �rLJ.GVePOS / 1 ®`® > ir .e O H T.� Pr n l ! a'`. 9s° i9 •i8� sT9 1 ti ▪ V // pppp 1TT P..§ 1 1, �` 1 1 11 a. m % tc C t �� 11 Copeland Concrete, Inc. 28803 Highway 6 Rifle, CO 81650-9452 Invoice Date Invoice # 9/5/2007 27330 Bill To Mark Opstein P.O. Box 62 Rifle, CO 81650 Ship To South of Rifle 0694 N. Cedar Springs Ranch Road take 319 south four miles to right to top of hill green cabin on left to top of hill Mark Opstein 625-3844 Person Calling P.O. No. Customer Phone Ship Date Job # Phone # Salesman Charge 625-3844 9/5/2007 (970) 625-1112 weight Item Quantity Description Rate Amount 13560 R-71000 1 1500 gallon septic tank 1,486.00 1,486.00T 250 R-76000 1 8 hole distribution box 0.00 0.00T 960 R-131000 96 Quick 4 EQ 36 Infiltrator (2' x4') 15.00 1,440.00T 96 R-132000 12 Quick 4 EQ 36 end plate 11.50 138.00T R -Rifle Delivery charge to Rifle 143.00 143.00 discount Discount -300.00 -300.00 Subtotal $2,907.00 Sales Tax (3.9%) $119.50 Driver Signature Total S3 026 50