HomeMy WebLinkAboutApplication.pdfGARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
108 Eighth Street, Suite 201,
Glenwood Springs, Coloradof 81601
Phone (970) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
Owner's Name
Permit
Assessor's Parcel No.
,,CIOs- \ i D-00 —Cray '.
31
This does not constitute
a building or use permit.
,,1,[ l r_ ( c
Present Address A I C i �A1111) kFt,SS �� ({.,,I Phone h?,`�
System Location 0,23-3 r ) kvv•-s-V\ Ck 1
Legal Description of Assessor's Parcel No
SYSTEM DESIGN
DL1(5:5- 1 \ 3 - too - OO 76
4-2 CO Septic Tank Capacity (gallon) Other
Percolation Rate (minutes/inch) Number of Bedrooms (or other)
Required Absorption Area - See Attached
l;C /ft2
4/ Ifs d e..,
Special Setback Requirements:
Date /° -0-23 ^a Inspector
Lf Gds C= 42L (
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for. Inspection (24 hours notice) Before Cowering Installation
System Installer ("y /3 /,t-Pi2!4t-&1�z1/
Septic Tank Capacity
.:-Septic Tank Manufacturer or Trade Name
Septic Tank Access within 8" of surface 41,04
Absorption Area ft%% '1-1:`,1-1_� 61' --1/2-6:-1t-c....-4)
Absorption Area ,Type and/or, Manufacturer or Trade Name
Adequate compliance with County and State regulations/requirements i/40.-
%
Other
Date
/7 -9 - D7
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 adtion 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 jail or both).
White- APPLICANT Yellow DEPARTMENT
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER To ri 61 rQ' ahr iH,,tin I IU
�(�Z
ADDRESS � ( ib -t e Ftl'ARht c* lZveiv,CO sP ONE 0110,1-05- 9U313
CONTRACTOR 5 of'
u
ADDRESS n A PHONE 1111
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
Legal Description or Address 73I� 6 , CeotOr njs ?
WASTES TYPE: (X) DWELLING
( ) COMMERCIAL OR INDUSTRIAL
Size of Lot 35.oaa Dares
?ea
riL7aacP , . fle, (0 $ILso
( ) TRANSIENT USE
( ) NON-DOMESTIC WASTES
( ) OTHER—DESCRIBE
BUILDING OR SERVICE TYPE: 6ng It FG rn i I -Ze6i otCn Ce- ' f
Number of Bedrooms Number of Persons �I
(X) Garbage Grinder (X) Automatic Washer (X) 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: (I/ iq
Was an effort made to connect to the Community System? n/
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 )44(1Dt.,J1
-7
Percent Ground Slope
et DTh
is
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(X)
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? II)
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 syste
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
evaluatin g 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.
Date S - e
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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