HomeMy WebLinkAboutSeptic ApplicationI
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GARFIELD COUNTY SEPTIC PERMIT APPLICATION
I 08 8111 Street, Suite 401 , Glenwood Springs, Co 8160 I
Phone: 970-945-8212 /Fax: 970-384-3470 /Ins pection Line: 970-384-5003
www.!"a r1'icld·-"""ntv ~lm
Par~el No: (this inf01T11ation is available at the r sessors office 9711-945-9134) : i'il. as~ at<) 9...$:
Job Address: (if an address has not been assigned, please provide Cr, Hw; or Street Name & City) o+.d legal description
41 xv _ c.A-(A f~_g "=?1 L. .()J c2,,W c.rt s L:. C11 <Ct l{ '-1 1
Lot Size: .5 5 Jtlc .::l_No : Block No Subd./ Exemption.
Owner: (property owner) Mailing Address Ph:
Chu_~VI ( l/llL f'rn{_,1 .J... ,.-'-J 1 ffu ~ 31 'L R.tP tJ · '-'1'10 . c; 9 C,/ . <i7 {/<.
Contractor: I Mailing Address '6l\c,tf/ Ph : ....,...w Ill~ ......-
Engineer: Mai ling Address Ph :
PERMIT REQUEST FOR: P(_} New lnstanation ( ) Alteration
Alt Ph .
Alt Ph:
Alt Ph
( ) Repa·r
WASTE TYPE: ~Dwelling ( )Transient Use ( )Commercial or industrial ( )Non -Domestic wastes
( )Other -Describe -# . -
BUILDING OR SERVICE TYPE: r_ ,.,,paoc..~~ ~q. "'-UOClit. ~·" Number of bedrooms 2. , ..,.,, -Garbage Grinder ( )Yes i.(JNo
SOURCE & TYPE OF WATER SUPPLY: K )WELL ( )SPRING ( )STREAM OR CREEK ( )CISTERN
If supplied by COMMUNITY WATER, give name of supp lier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM : L Q. tla.& t... '2 ~
Was an effort made to connect to the Community System?
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN
GROUND CONDITIONS:
Depth to 151 Ground Water Table Percent Ground Slope
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS) PROPOSED:
(MSeptic Tank ( )Aeration Plant ( )Vault ( )Vault Pnvy ( )Composting Toilet
( )Recycling , Potable Use ( }Recycling, other use ( )Pit Privy ( )Incineration Toilet ( }Chemical Toilet
t lOlher-Describe
FINAL DISPOSAL BY:
(b4Absorption trench, Bed or Pit ~nderg round Dispersal ( )Above Ground Dispersal ( )Evapolranspiralion ( )Sand filter
( )Wastewater pond Other-Describe
Will effluent be dlscharued dlrecUy Into waters of the state? ( )YES ( )NO
, PERCOLATION TEST RESULT: (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 & telephone of RPE who made soil absorption test:
Name, address & telephone of RPE responsible for design of the system:
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17 Applicant acknowledges that the-completeness of the application is conditional upon such further mandatory and additional test and repOtts as may be requ ired by
i 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 perm it granted based upon said appl ication
and legal action for ~~ry ~s prov' by 4 _!/_ ~ z _ 3..::.LJ8 /~ I ,A L~ ---OWNERS SIGNA'RIRE " - / DATE
STAFF USE ONLY
Total fees: (? 3. (/Jc,.
Building Permit #:
/O°ICJ I
Permit Fee: Pe r k Fee:
(Ob.
Sep tic Permit #:
4
Issue Dae:
Li fl DCO
Building & Planning Dept:
DATE
GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
108 Eighth Street, Suite 201
Glenwood Springs, Coloradof 81601
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
Phone (970) 945-8212
Assessor's Parcel No.
This does not constitute
a building or use permit.
Owner's Name~•~ { Present Address Y-J l),{p lR ~l;) N • C,. Phone OJ8' lf · '17 {J;3
System Location W7BLo c.~ Sd 10 e l Q ~*' e
Legal Description of Assessor's Parcel No. d J BJ -df:.;:;:J -D)-;;;2 (5 }
SYSTEM DESIGN
-----Septic Tank Capac i ty (gallon) ______ Other
-----Percolation Rate (minutes/inch) Number of Bedrooms (or other) -----
Required Absorpti on 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 __ __:/~O:;..._cJ~~tJ--_;G;;;_;::A~.:::{_:....!..., -------------------
Sept i c Tank Manufacturer or Trade Name ___ c~ .... tJ'--~-"~---~-/1_t_A/_ ... !?;;._ ___ ..... G;:......;;..~ .... '&<-=--/...;c;:;;......;.,.{;....;.;..~-r_·c_r-= __
Septic Tank Access within 8" of surface -------------------------------
Absorption Area _____ :3=-··· _,_7 _· __.C.,.,..;t.L'2W"t:.....<........' n_~_· __ /_A_t l _ __;;~-~___;_£-:_iil_c_.,'-'//<-__ _
Absorption Area Type and/or Manufacturer or Trade Name -----------------------------
Adequate compliance with County and State regulations/requirements'----------------------
Other-------------------------------------------
Date / -9-'f:.l!} / z.._lnspector __ ~/tlt.~~ ....... rJ!.-...L.7_· ________ _
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 perm i t is valid only for connection to structures which have fully complied with County zon ing 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 whi ch Involves a knowing and material
variation from the term s or specifications contained In the application o f permit commi ts a Class I, Petty Offense ($500 .00 fine - 6
months in j ail or both).
White . APPLICANT Yellow . DEPARTMENT
,spectlon 'NuTlnsp P~Ject ,chedule oat;na ri lnspec .!1ed uled lln spectlon Tyr Status Priority __
INSP-13444 <NONE> 1/9/2012 Provost, Ma !final Passed
INSP-12975~ <NONE> '11/7/2011 Provost,~ iPerc Test I Passed
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