HomeMy WebLinkAboutSeptic Permit - 3544GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT)
109 8th Street 80 a 303 I_
Glenwood Springs, Colorado 81807
Phone (303) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
. PROPERTY
Ownitr's Name LOI OL.*2 1 ARTI{U?
Permit ni_ 3 5 4 4
Assessor's Parcel No.
This does not constitute
a building or use permit.
Present Address I (19 1_ 231 R \ 3 I LT Phone 7(o- 719
t System Location t tl01 j 131 Re -A f %iLi-
Legl11 Description of Assessor's Parcel No
7-16.9/} ✓fiR .iova uX 3 IFk:.� vµt . r?b \�a.K
SYSTEM DESIGN (t7�fS.v�P 4 ... rJ/'` „' R � 'n�wo r -e»[ . /FITC Cy4i �',.,w+r,,�. ,tl ). J S' /
ti4s-rA Sept(c Tenk'Capebhy'(gallon) Other lir 1 r
•
3S Percolation Rate (minutes/inch) Number of Bedrooms (or other) q
149( a y STD catE tt.f-e (/ ? is o
Required Absorption Area - See Attached dqy 0' L .ce mt. 8/9-46
wise/ CN C+ "sits /A) t7,llAkffitS 40
Special Setback Requirements:
Date 7 — 3l -D
Inspector
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer Jqot'1- fin
Septic Tank Capacity J� 1J
Govt.. 0
Septic Tank Manufacturer or Trade Name
Septic Tank Access within 8" of surface
Absorption Area
t KEW c H ES
Absorption Area Type and/or Manufacturer or Trade Name
s lit 4 7 -o/c s
Adequate compliance with�County and State regulations/requirementsd
Other J -Z- 0/ 2-#cx4, I1 MaoD n/j,??CCk 0. a/x;-D a/FLL
Date (-2f —
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- r
nection to or use with any dwelling or structures not approved by the Building and Zoning office shall automatically be a violation or a t
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 /9fl7-7/1tt f , lel NNr/{
ADDRESS A10/ 2 37 S/Lj" PHONE P76 7i / 7C
/V
CONTRACTOR 0ir%% 6-eLhP
ADDRESS + -E' PHONE
PERMIT REQUEST FOR ( ) NEW INSTALLATION ( ) ALTERATION (A 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 SILT Size of Lot / 0
Legal Description or Address 111/ g b 7 Lel PA C
WASTES TYPE: (7 DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPE: Ahyr2E=
Number of Bedrooms Number of Persons
( ) Garbage Grinder (0 Automatic Washer (A Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: Y l WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
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 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
2
FINDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
SEPTIC TANK
VAULT PRIVY
PIT PRIVY
CHEMICAL TOILET
FINAL DISPOSAL BY:
AERATION PLANT
COMPOSTING TOILET
INCINERATION TOILET
OTHER - DESCRIBE
VAULT
RECYCLING, POTABLE USE
RECYCLING, OTHER USE
ORPTION TRENCH, BED OR PIT ( ) EVAPOTRANSPIRATION
UNDERGROUND DISPERSAL ( ) SAND FILTER
ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
OTHER - DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? //U
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 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 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 O4t Date 7 - ;u -i9.7
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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