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
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System Location ().J-
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Permit C.o _•
Assessor's P-celNo.1ST ig%
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This does not constitute
a building or use permit.
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Present Address
Legal Description of Assessor's Parcel No.
SYSTEM DESIGN
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Septic Tank Capacity (gallon) 4"/4 Other
Percolation Rate (minutes/inch)
Required Absorption Area - See Attached
100 -r''A°%
Special Setback Requirements: Geo
Date ? 9 07 Inspector
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Number of Bedrooms (or other)
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FINAL. SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before CoveringeInstallation
System Installer re; ifr/i2-/2tXx.
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Septic Tank Capacity
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Septic Tank Manufacturer or Trade Name dere /t%(
Septic Tank Access within 8" of surface
Absorption Area ite7e, Afee.ez-tcregai „ley 2,0/
Absorption Area Type and/or Manufacturer or Trade Name
Adequate compliance with County and State regulations/requirements
Other
Date -617 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 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 ($500.00 fine — 6
months in jail or both).
White - APPLICANT Yellow - DEPARTMENT
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INDIVIDUAL SEWAGE DISPOSAL SYS l'bM APPLICATION
ADDRESS 730 rl o eA¢ C74) 1,-)'\o'Aneec. 16.3 8OO.77PHONE JU.7-`S'0 3'' <Iyen
CONTRACTORt5 0k akin r...ckA94w-e j on
ADDRESS S%(o3 G gd. loo Car bond A 4 PHONE R(03 — 344
PERMIT REQUEST FOR (>4) NEW INSTALLATION ( ) ALTERATION ( ) REPAIR
Attach separate sheets or report showing entire area with respect to surrounding areas, topography of area, habitable
building, location of potable water wells, soil percolation test holes, soil profiles in test holes (See page 4).
LOCATION OF PROPOSED FACILITY: ""
Near what City of Town C"(k..4a •-&
Legal Description or Address Lo}" 2- n a cv.
WASTES TYPE: (4 DWELLING
( ) COMMERCIAL OR INDUSTRIAL
Size of Lot i I , 44 ac.n9 S
Wcic 5 SoL6dt A5 L e n b3$ ` jC--'
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( ) TRANSIENT USE <ScAXV'
( ) NON-DOMESTIC WASTES
( ) OTHER—DESCRIBE
BUILDING OR SERVICE TYPE: 7rt As It d GZ n".1 j re setep
Number of Bedrooms 4 Number of Persons
(c) Garbage Grinder (,e) Automatic Washer (X) Dishwasher
SOURCE AND TYPE OF WA fhR SUPPLY: ( ) WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: ?crtia0A Peexlcs
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: > Z "..an s
Was an effort made to connect to the Community System? "0
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
Percent Ground Slope 25 %,
2
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
SEPTIC TANK ( ) AERATION PLANT
VAULT PRIVY ( ) COMPOSTING TOILET
PIT PRIVY ( ) INCINERATION TOILET
CHEMICAL TOILET( ) OTHER -DESCRIBE
VAULT
RECYCLING, POTABLE USE
RECYCLING, OTHER USE
FINAL DISPOSAL BY:
(t) ABSORPTION TRENCH, BED OR PIT ( ) EVAPOTRANSPIRATION
( ) UNDERGROUND DISPERSAL ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WAS1EWA 1ER POND
( ) OTHER -DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? tn0
PERCOLATION 1 EST 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 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.
Signed U `' CA L-� 7 C_ Date Y /?A 7
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY::
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