HomeMy WebLinkAboutApplication- Permit4-
•
GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit IVB' 3 9 25
109 9th Street Suite 303
Glenwood Springs, Colorado 81801
Phone (303) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY I_ / {�/� 'l 9I ,�� �J Olt Owner's Nam ?t 01S 11 t ` V t_A Present Address 1 . X 'Pt eJ QJ-, e
System Location ---SSS/91/� el , ��
'1 Legal Description of Assessor's Parcel No
SYSTEM DESIGN
2cd
I
Septic Tank Capacity (gallon)
Assessor's Parcel No.
This does not constitute
a building or use permit.
Phone L3 -C?D 3VJ
Other
2 U Percolation Rate (1inuteslinch) Number of Bedrooms (or other)
//27Ey) Roe,kGediJaD
Required Absorption Area See Attached ,
4'y • - Lt
Special Setback Requirement`s:
Date r- 3 -0 tf IrilFector
50 3 wa rtF gdooe!
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer /OP KY
Septic Tank Capacity / ? rO
tl/,i
Septic Tank Manufacturer or Trade Name Illy 4An/!(
Septic Tank Access within 8" of surface
Absorption Area / () (di Cr
il
r
Absorption Area Type andlor Manufacturer or Trade Name n -t l /it rig 1045
Adequate compliance with County and State regulations/requirements
Other
Date S — f 8 - y
Inspector
RETAIN WITH RECEIPT RECORDS AT'tONSTRUCTION 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
f
Y
INDIVIDUAL SEW AGE DISPOSAL SYSTEM APPLDATIDN
a
OW NEI;
ADDRESS r'300 Vairu C -- C,Aacrao4-,Q
CONTRACTOR
ADDRESS 5A--vYti
PHONE 3-.)03(,)
PHONE
PERM IT REQUEST FOR (X1 NEW INSTALLATION ( )ALTERATION ( ) REPAIR
A tfach saparate ±sets orieportshow ing aithe ama w ith xeseectm snounding areas, mpogmphy ofaiea, habitable
building, location ofpotable w aterw ells, soilpe>mlation testholes, soilpnalas in lestho its (See page 4 ).
LOCATDN OF PROPOSED FACILITY:
N earw hatC ity of T ow n (i&a. ,ctjoAacuj5 Size ofLot 5 Iv_
Legath escriptionorAddmss 'mgt Cam -4-9 1)--b VAS
WASTES TYPE: ()G) DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON -DOM ESTD W ASTES
( ) OTHER -DESCRIBE
BUILDING OR SERVICE TYPE:
N um berof B edroan s Number of Persons
()4 G aibage G render (jd A utnn atic W ather (]Q D ishw ather
SOURCE AND TYPE OFW ATER SUPPLY : g) W ELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by C om m unity W atEr, give nam e of supplier:
DISTANCE TO NEAREST COM M UNITY SEW ER SYSTEM :
W as an effnrtm ade to connectto the C om m unity Sys1Em ?
A site plan is required to be subm itted thatindicates the follow ing M IN IM UM distances:
L each Field to W ell:100 feet
Septic Tank to ell:50 feet
L each Field to Irrigation D imhes, Stream or W ater C ourse: 50 feet
Septic System (septic tank & disposalfield) to Property L Ines: 10 feet
YOUR INDIVIDUAL SEW AGE DISPOSAL SYSTEM PERM IT W ILL NOT BE ISSUED W TPHOUT
A SITE PLAN.
GROUND CONDEMNS:
D epth to fistG round W aterTable
PercentG round Slope
TYPE OF INDIVIDUAL SEW AGE DISPOSAL SYSTEM PROPOSED :
2
()(J SEPTIC TANK
( ') . 37AULT PRIVY
( ) PII' PR IV Y
( ) AERATION PLANT ( ) VAULT
( ) COM POST]NG TOILET ( ) RECYCLING, POTABLE USE
( ) INCINERATION TOILET ( ) RECYCLING ,OTHER USE
( ) CHEMICAL TOILET( ) OTHER -DESCRIBE
F]NAL DISPOSAL BY :
(Q ABSORPTDN TRENCH ,BED OR PIT ( ) EVAPOTRANSPIRATION
( ) UNDERGROUND D]SPERSAL ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) W ASTEW ATER POND
( ) OTHER -DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE
STATE? kb
PERCOLATION TEST RESULTS: (To becanpbtedby
Registered PuofessionalEngneer, if the Engneerdoes the Percolation Test)
M sautes per inch in hob N o.1 M mutes perncn n hole N 0 .3
M sautes per inch in hole N o.2 M .mutes per inch in hole N 0 .
N an e, address and telephone ofR PE w ho m ace soilabsohption nests:
N an e, address and telephone ofRPE requonsiok fordesign of the sys an
App]icantadmow ledges thatthe can pletaiess of the application is conditional upon such further andahory and
additionallestsand reports asm ay be required by the ]ocalhealth deparim antto bem ade and famished by the applicant
orby the bcalheaLh deparim antforpurposed of the evaluation of the application; and the issuance of the pear tis
subject to such term s and a nditions as dean ed necessary to inane compliance w ith rules and regulations made,
infrurm atian and reports autnn tied herrn ith and required to be sutra itted by the appliantare ori i]]be represented to
be true and conectto the bPstofm y know ]edge and heNPfand are designed to be relied on by the bcaldepar r artof
health n evaluating the sari e frrpmposes of issuing the perm $applied for herein. I further understand that any
falsification onn isagrresentationm ay martin the dandalofthe application onevocation ofany pear itgranted based
upon said application and in ]egalaction forperjny as pmvided by law .
Date
PLEASE DRAW AN ACCURATE M AP TO YOUR PROPERTY !!
4/0 it
194