HomeMy WebLinkAboutApplication- Permitt.
GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N- 2 1 4 1
Assessor's Parcel No.
109 8th Street Suite 303
Glenwood Springs, Colorado 81801
Phone (303) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
L. 4 ` ;lit 7 O 1..) ; f'f�
Owner's NameJO esent Address
1D19$- "%
�. one 945_419..
0029 Vest Dora Road, Chelyn Acme, Glenwood Syringe
This does not constitute
a building or use permit.
System Location
Legal Description of Assessor's Parcel No
SYSTEM DESIGN
%46c, Septic Tank Capacity (gallon) Other
/V (N 9
/ N IIJ 4 Percolation Rate (minutes/inch) Number of Bedrooms (or other)
Y "�°' 444144 "-al Ap x.21'''44 6"54rrs G1u1 "c ICI i
Required Area Absorption- See Attached �T #10 - 0, 61C'04fj 5.5 vAJ 17$
•
I l! I fl
Special Setback Requirements: it) 1% .T/G' F• 4,7P41-0125 '? 3 mu 173
Dale /6 " 9' 94.Inspector � ` ,
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Cali for Inspection (24 hours notice) Before Covering Installation •
System Installer M. r 400.34)ALi
Septic Tank Capacity %l0494)
Septic Tank Manufacturer or Trade Name 00,PiuCL
Septic Tank Access within 8" of surface `fie-"
Ott
Absorption Area / c / S
Absorption Area Type and/or Manufacturer or Trade Name /IN° 1 /4f I - tiffI/ .
Adequate compliance with County and State regulations/requirements
Other t,
Date AO: ''Z
ti
Inspector
RETAIN WITH RECEIPT RECORDS AT COIQSTRUCTION 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 connectiori 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
installs sewage lomanner which involves a 0and neerial
vaiton fom the terms or specificationscontained in the application ofpermit In
a Class I, Petty Offense ($50.00 fine 6
months in jail or both).
Applicant: Green Copy Department: Pink Copy
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER
4D Ai
ADDRESS IAbo beWtal / PHONE 93
CONTRACTOR '504 -Ai e- ,45 ,4/60Ve"
ADDRESS kvo 44- stn° - ,0,¢. PHONE 96- 93
Application
Approval by
County Official:
/I°igb
9
PERMIT REQUEST FOR: ( ) 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(qpage 4.)
LOCATION OF PROPOSED FACILITY: County 6414P-1 ellA
4(.f-40g0c60 ,,02i41‘6
Near what City of Town
Lot Size 5
Legal Description
WASTES TYPE: ( ✓) Dwelling ( ) Transient Use
( ) Commercial or Institutional ( ) Non-domestic Wastes
( ) Other - D -scribe
BUILDING OR SERVICE TYPE: /D_�,.
Numb of bedrooms Number of persons 3
9
( Garbage grinder (14 Automatic was r ) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: ( well ( ) spring ( ) stream or creek
Give depth of all wells within 180 feet of system: 35 / 1
If supplied by community water, give name or supplier:
GROUND CONDITIONS:
Depth to bedrock:
Depth to first Ground Water Table:
Percent ground slope:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: Al
Was an effort made to connect to community system? jOb....
TYPE OF IND DUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(
) Septic Tank
( ) Vault Privy
( ) Pit Privy
( ) Chenyical Toilet
( ) Aeration Plant
( ) Composting Toilet
( ) Incineration Toilet
( ) Other - Describe:
FINAL DISPO BY:
( ) Absorption Trench, Bed or Pit
( ) Underground Dispersal
( ) Above Ground Dispersal
( ) Other - Describe:
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF TIIE STATE?
( ) Vault
( ) Recycling, potable use
( ) Recycling, other use
( ) Evapotranspiration
( ) Sand Filter
( ) Wastewater Pond
Panf+ 2
A/O
OP
)OIC: PElkOLATION TEST RESULTS: (To be completed by Registered Professional Engineer.)
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
purposes of the evaluation of the application; and the issuance of the periui't,is subject to
such terms and conditions as deemed necessary to insure compliance with rules and regulations
adopted under Article 10, Title 25, C.R.S. 1973, as amended. The undersigned hereby certifies
that all statements 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 under-
stand 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 per-
jury as provided by law.
Date Signed
PLEASE DRAW AND ACCURATE MAP TO YOUR PROPERTY
Page 3
PLOT PLAN AND DESIGN FEATURES:
Include by measured distance location of wells, springs, potable water supply
lines, cisterns, buildings, property lines, subsoil drains, lake, water course,
stream, dry gulch and show location of proposed system by direction and distance
from dwelling or other fixed reference object, and additional submissions in
support of this application such as data, plans, specifications, statements and
comni tments
Page 4