HomeMy WebLinkAboutApplication.pdfGARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit
108 Eighth Street, Suite 201 Assessor's Parcel No.
Glenwood Springs, Coloradof 81601
Phone (970) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
IThis does not constitute
a building or use permit.
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Owner's Named A C.�` ( ° n Present Address.. /I -j
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Nth. Pa ((C.`D
Legal Description of Assessor's Parcel N
System Location
SYSTEM DESIGN
Septic Tank Capacity (gallon)
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Other
/O Percolation Rate (minutes/inch) Number of Bedrooms (or other)
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Required Absorption Area - See Attached /6 %
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Special Setback Requirements:
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Date Inspector
FINAL SYSTEM INSPECTION AND A.PPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
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System Installer ✓ �ULl "Cr -69-4
Septic Tank Capacity
Septic Tank Manufacturer or Trade Name �n�n�—'�`-
Absorption Area 02..) / 'r`f%il. 5-i.c- �7_F4) /.i1-7f�-�ti
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Absorption Area Type and/or Manufacturer or Trade Name PVii.(/.�✓,:- ,-fJ'Gr'vf
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Adequate compliance with County and State regulations/requirements ..ay -a_
Septic Tank Access within 8" of surface
Other :4`5/
Date i 1:..
9
Inspector
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 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 who installs individual
in a involvesknowing material
variation fromthe terms or specficationscontained thesewage
of permitcommis manner
I, PettyPey Offense ($50.00 fine
and
months in jail or both).
White - APPLICANT Yellow - DEPARTMENT
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER 5� u / , N4 1
ADDRESS 7DS olcf 4dj-e A/ PHONE 970
-7970 3O7 /3
(
CONTRACTOR ea , Nom- / o r K iia i k4/ Car) S?'
ADDRESS I /9 O. soy '%E ('Gt1O 4 c� PHONE / %o -3c 7- ya/3
PERMIT REQUEST FOR ( NEW INSTALLATION ( ) ALTERATION ( ) REPAIR
Attach separate sheets or report sh wing 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: /3� �
icdi Size of Lot_/ ,; 775; (00 ¥ '1
Near what City of Town � /i ell -Ai °0 el 5�
Legal Description or Address
WASTES TYPE: (X DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER -DESCRIBE
1cazi` d\tNe-•
C • . /1
BUILDING OR SERVICE TYPE:
s
Number of Bedrooms
Garbage Grinder
SOURCE AND TYPE OF WATER SUPPLY: (
Automatic Washer
AO - $'
(fg,1lisbk
Number of Persons
(Dishwasher
WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: C/tC.
Was an effort made to connect to the Community System? .AJ
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 / 5 -P4'.
Percent Ground Slope -3
770
2
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
KSEPTIC 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?
4)0
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 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 pennit 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 peiniit granted based
upon said application and in le1 action for perjury as provided by law.
Signed 4a LA) Date S- /1/ /
PLEASE DRAW AN AC t' TE TO YOUR PROPERTY!!
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