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Home My WebLink AboutApplication{~t). rD GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT 108 Eighth Street, Suite 201 Glenwood Springs, Coloradof 81601 INDIVIDUAL SEWAGE DISPOSAL PERMIT PROPERTY Phone (970) 945-8212 Permit 4 17 9 Ass-::on: Parcel No. ~( '?il_-O~d--oo J.<ty This does not constitute a building or use permit. Owner's Name {].q / /q(l1NJv1 I .JefJA,resent Address ~;<~ 1f.;;. bfQ,1"-J 14Ve "-'f G'~fo~e 1J.o -3Jo -5( .;lj System Location ___ ____.._C~~----'3~/___.tf------'-,0____._,.,_e,u.=.....)~C="Q=SJ'-!....:/-{:.......::...<-_Cc_P__,_/_fo _,__C{_._7 __ ~~~~~~~~~~~~~N~---~---~ __ / __ G __ ~-~~-'-~-'~e-~_~_s_~~---~s~~~'~'~·------ SYSTEM DESIGN _____ Septic Tank Capacity (gallon) ______ Other ------Percolation Rate (minutes/inch) Number of Bedrooms (or other)----- Required Absorption Area· See Attached 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 8" of surface------------------------------- Absorption Area--------------------------------------- Absorption Area Type and/or 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 ol 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 ol 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 ~ GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT 108 Eighth Street, Suite 201 Glenwood Springs, Coloradof 81601 Phone (970) 945-8212 INDIVIDUAL SEWAGE DISPOSAL PERMIT SYSTEM DESIGN ----,==---o---:~ Septic Tank Capacity (gallon) ______ Other ~=::.....,,,=,_.. Percolation Rate (minutes/inch) Number of Bedrooms (or other) ----~==I Required Absorption Area • See Attached Special Setback Requ irements : This does not constitute a building or use permit, Date ___ .....;;..__;___;;;.,:..._ ______ Inspector ---------------------------- FINAL SYSTEM INSPECTION AND APPROVAL (as installed) Call for Inspection (24 hours notice) Before Covering Installation System Installe r ________ --=-----------------==--------------- Septic Tank Capacity __ "--"'---'--...;:._-="-----==;;...;:..-"-""-'-"""'"""'=------=='""".;..;;_-============--==-~===;..._- Septic Tank Manufacturer or Trade Name ---"-----==----..;;;;~==-----======---=========-";;;......------= Seplic Tank Access within B" of surface --"-~--'-~----~------=----------===,.......,.====,........J Absorption Area Type and/or Manufacturer or Trade Name --~-~~-~------==------=..,.,-..,._-======= Adequate compliance with County and State regulations /requ1rements _______ ...,,.... ___ ,....._~---==,.------~ Other __ _ Date_-===----==-------Inspector ----------------------======= RE TAIN WITH RE CEIPT RECORD S 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 -~z.x"\ Gy& a.I\~&"' ADDRESS~ \.S>. ~'t'O'\~l ~vl G;\~\W~ S~t:-'~1? PHONE 1Jt<) -3ri.<y G'IJ. 3 CONTRACTOR lMln 9tc PHONE ..__ PERMIT REQUEST FOR l'j) NEW INSTALLATION ( ) AL TERA TION ( ) 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 ofTown h.\ iM \....:,, ':;U\> Size of Lot S\?:/6 Ac. 're Legal Description or Address ___ C_()-=---~_.......---"~---\_\.\.....__, ..... ti...._, =t-.-<>J,,.,._C%___. ..... ~ ......... "'""e.,'--_____ _ WASTES TYPE: ()() DWELLING { ) TRANSIENT USE ( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WAS TES ~~~OOSE~~TYPE: ____ s_,_~--~---------------- Number of Bedrooms __ ..... ~ __________ Number of Persons __ \ ___ _ { 'iJ Garbage Grinder ( )0 Automatic Washer (~Dishwasher SOURCE AND TYPE OF WATER SUPPLY: ( '/.) WELL { ) SPRING ( ) STREAM OR CREEK If supplied by Community Water, give name of supplier: DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:__,,3 __ \'C\.;..;__ .• _\.g,_t>....__ _____ _ Was an effort made to connect to the Community System? __ {\l ............ 0 ___________ _ A site plan is required to be submitted that indicates the followint: 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 _______ \_S __ bf-1<-------------------- TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED: C"JJ SEPTIC TANK ( ) AERATION PLANT ( ) VAULT ( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POT ABLE USE ( ) PIT PRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE ( ) CHEMICAL TOILET( ) OTHER-DESCRIBE FINAL DISPOSAL BY: Ci) ABSORPTION TRENCH, BED OR PIT ( ) EV APOTRANSPIRA TION ( ) UNDERGROUND DISPERSAL ( ) SAND FILTER ( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND ( ) OTHER-DESCRIBE WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE?_._.[\_~o __ 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 ______ p.er 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 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 permit granted based upon said application and in legal action for perjury as provided by law. Signed ~~ Date ii JI o<O PLEASE DRA ~URA TE .MAP TO YOUR PROPERTY!! I I