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HomeMy WebLinkAboutSP-4080GARFIELD 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 System Location Legal Description of Assessor's. Parcel No. SYSTEM DESIGN Permit 4080 Assessor's Parcel No. resent Address 1 CJrit This does not constitute a building or use permit. Phone 70-1-- -- C Septic Tank Capacity (gallon) Percolation Rate (minutes/inch) Number of Bedrooms (or other) Required Absorption Area See Attached ,y5 t Other Special Setback Requirements: Date Inspector FINAL SYSTEM INSPECTION AND APPROVAL (as installed) Call for Inspection (24 hours notice) Before Covering Installation System Installer Septic Tank Capacity Septic Tank Manufacturer or Trade Name Septic Tank Access within $" of surface Absorption Area Absorption Area Type andlor Manufacturer or Trade Name Adequate compliance with County and State regulations/requirements Other Date __ 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 INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION OWNER " '. 0 rC. ADDRESS i 0- 1 3 C JJ okoi, CONTRACT R / oro ' x' 7 CAI` PHONE -2" -©w6 9 (;') 74 ADDRESS O. COX ) C1C� G +e n;; c n Cu 8- 16.0 2. PERMIT REQUEST FOR ( ) NEW INSTALLATION PHONES vs.._SS / 53 617v) 2c) 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 CLIVITDw! ¢ (c, Size of Lot Legal Description or Address WASTES TYPE: {DWELLING ( ) TRANSIENT USE ✓( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES ( ) OTHER — DESCRIBE ( } ALTERATION BUILDING OR SERVICE TYPE: Number of Bedrooms kortA-52-- Number of Persons (Garbage Grinder Automatic Washer Dishwasher WELL ( ) SPRING ( ) STREAM OR CREEK SOURCE AND TYPE OF WATER SUPPLY: ( If supplied by Community Water, give name of supplier: DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: 171 r /t Was an effort made to connect to the Community System? 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 TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED: ( ( ( ) ) SEPTIC TANK VAULT PRIVY NT PRIVY CHEMICAL TOILET( ) AERATION PLANT ( ) VAULT COMPOSTING TOILET ( ) RECYCLING, POTABLE USE INCINERATION TOILET ( ) RECYCLING, OTHER USE OTHER -DESCRIBE -DISPOSAL BY: ABSORPTION TRENCH, BED OR PIT UNDERGROUND DISPERSAL ABOVE GROUND DISPERSAL OTHER -DESCRIBE ( ) EVAPOTRANSPIRATION ( ) SAND FILTER ( ) WASTEWATER POND WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? 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 Minutes per inch in hole No. 2 Minutes per inch in hole No. 3 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 famished 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 pennit granted based upon said application and in legal action for perjury as provided by law. Signed Sr AiLe64-7& 62Y7 Date 7 PLEA RAW AN ACCURATE MAP TO YOUR PROPERTY!! 3 Designate North Arrow Your Neighbor's Name & Address 94. Your Plot - Shape to Fit (No Scale) peVLie A7' • /-213 Locate well, all streams, irrigation ditchs, and any water courses. Draw in your house, septic tank & system, detached garages, and driveway. If a change of location is necessary, you must submit a corrected drawing, before a Certificate of Occupation will he issued YourNeighbor's Name & Address • County Road (Note the Road Number and Name) eric c:'.wpw:1301wpdncs410:bc L3