HomeMy WebLinkAboutApplication- Permit1
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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
108 Eighth Street, Suite 201
Glenwood Springs, Coloradof 81601
Phone (970) 9454212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
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Owner's Namerex( ara n {141 I")rese ddretsss 3ID 3,4 �c� (Phone 73 9'
System Location 0 5 ��-�' y `�- - t`- 0 C4
) '1'JTh a39� 17u oi-
Legal Description of Assessor's Parcel No DA- ClCOlin S\Ct V\1lr1_ 1�-r-tv1 (- C1l1 1
Permft 40/C
Assessor's Parcel No.
62311- /t74 -0(-0V9
This does not constitute
a building or use permit.
SYSTEM DESIGN
15-6 Pi I N Septic Tank Capacity (gallon) Other
I1
Percolation Rate (minutes/inch)
Required Absorption Area - See Attached
Special Setback Requirements:
Date 7 %-es--
Inspector
Number of Bedrooms (or other)
a 52 it A / 3Pes i l .z ter
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer //
Septic Tank Capacity � - � lw
P
Septic Tank Manufacturer or Trade Name `-4/ "`
Septic Tank Access within 8" of surface "
Absorption Area i' o I.
Absorption Area Type and/or Manufacturer or Trade Name
Adequate compliance with County and State regulations/requirements 4
Other
Date 7-- ), c3" Inspector- ;fes r P
RETAIN WITH RECEIPT RECORDS AVCONSTRUCTION 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 individualsewage disposal system in a manner which i nvolves a knowing and material
variation from the terms or specifications contained in the application of permit commits a Class I, Petty Offense (5500.00 fine — 6
months in jail or both).
White - APPLICANT Vomits_ nFpararucr.rr
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER 1- Tt2 -k- w by rE2RARA
ADDRESS 310 S • 4-044 ST. T!ovLOB'r-
CONTRACTOR
C PHONE 303- 63 c3-13 7q
2,0303'
ADDRESS PHONE
PERMIT REQUEST FOR (X) 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 page 4).
LOCATION OF PROPOSED FACILITY:
Near what City of Town CAA-6ON6A Gor4l�9 tee—
Legal Description or Address P4^+04.4^^4 f.m..ri+aq PAitt1 # 2,39 I r' -f- 01 0"4-1
WASTES TYPE:DWELLING P.%"5 EI 1< e (CC( ) TRANSIENT USE c.
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER -DESCRIBE
Size of Lot -r Ac. e5
BUILDING OR SERVICE TYPE: S -274
Number of Bedrooms
( 0. Garbage Grinder
�-Amz L Y t) wtAcu,O
(4Automatic Washer
SOURCE AND TYPE OF WATER SUPPLY:
WELL
Number of Persons 0
())(bishwasher
( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: p P- o,r.rn1/4 Rb.Ncu VZs
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: NA-
Was
AWas an effort made to connect to the Community System? NA-
A site • Ian is re uired to be submitted that indicates the followin 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
1
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
te< SEPTIC TANK ( ) AERATION PLANT ( ) VAULT
( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POTABLE USE
( ) PIT PRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
( ) CHEMICAL TOILET( ) OTHER -DESCRIBE
FINAL DISPOSAL BY:
( ) ABSORPTION TRENCH, BED OR PIT ( ) EVAPOTRANSPIRATION
( ) UNDERGROUND DISPERSAL ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
('4 OTHER -DESCRIBE AS brt94^^_«» (Sti �icaw�
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? N 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 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 misrepresen ation may result in the denial of the application or revocation of any permit granted based
upon said applica on an i, legal action for perjury as provided by law.
Signed Date ® 4-- "°2 tor
PLEASE DRAW'AN ACCURATE MAP TO YOUR PROPERTY!!