HomeMy WebLinkAboutApplication- Permit(5 0 • cD) 4/111h
GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
108 Eighth Street, Suite 201
Glenwood Springs, Colorado( 81601
Phone (970) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
Permit c�
Assessor's Parcel No.
{/6r(— io CO -0C(6
This does not constitute
a building or use permit.
PROPERTY L1ry i 1n Ii ,L''I, / 112
�( 7
Owner's Name £ ka -` ;kir r i 'v CCVLA `^A Present Address 19 1 �^ rl 3("V 12a rte' 1&s Phone 70 9 °61-3
02411- tour Gln ! J (,
System Location 1 1 gr%l ; Vi �L `�' D r6
`rraario k i"))rf^i• n; a Mesa Ra nc h
Legal Description of Assessor's Parcel No
SYSTEM DESIGN
c<
Septic Tank Capacity (gallon)
Other
Percolation Rate (minutes/inch) Number of Bedrooms (or other)
Required Absorption Area - See Attached
Special Setback Fiequiremnts:
Date ' I -7- 4 IOcc
Inspector
11)(/'T er; r�
O 1 I TW] ' cz-k 'G c 2t9/(/
t a, : st.01 lc(
----i ° Y 1. n,
t -T f =tj2 p� \ 2x8
PL -
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours/notice) Before Covering Installation
System Installer LAG(. e
Septic Tank Capacity 7_2)_<-1
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 41; -
Other
Oats Inspector - '/ 1
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-
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 specif ications contained in the application of permit commits a Class 1, Petty Offense (5500.00 fine — 6
months in jail or both).
White - APPLICANT Yellow - DEPARTMENT
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER AL n SL,hcdPcc/
ADDRESS 17l to fy Lac.J 1lin 1',0J- Gc u PHONE
CONTRACTOR b w ne r—
ADDRESS PHONE
PERMIT REQUEST FOR OO 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 R. (1, 1,,
p'Zy4
Legal Description or Address stc,,re\
WASTES TYPE:
Size of Lot
Thin c -Lc
Yr) DWELLING
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER – DESCRIBE
( ) TRANSIENT USE
BUILDING OR SERVICE TYPE: Qz,, I'c,r,a-
Number of Bedrooms
(X) Garbage Grinder
( ) Automatic Washer
Number of Persons 3
()() Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: p() 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 Ian is re uired to be submitted that indicates the followin MINIM M distances:
Leach Field to Well: :1uu
Septic Tank to Well: f«-�
Leach Field to Irrigation Ditches, Stream or Water Course:
Septic System (septic tank & disposal field) to Property Lines:
100 feet
50 feet
50 feet
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 �.,
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
()Q 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:
(x) ABSORPTION 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? VD
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 famished 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 applicatiop and in legal action for perjury as provided by law.
Signed
PLEASE D
Date 9/
AN ACCURATE MAP TO YOUR PROPERTY!!
TRACT 62
PRIVATE ACCESS TO COUNTY :OA? 338
186.07'
6.17'
3
03
uj
r 'n
o 1/4�0
0
(1)
CENTERLINE
30' ACCESS &
UTIL. ESMT.
03.113yi''/44)
N99'
TRACT 61
BK.1135 PG.461
FOUND
REBAR & CAP,
P.LS. 10871
N13.42'21'WI
20.27' ,
11
0
x q
FOUND
PIPE ZcE
m 1` 1 11
1111
11 1 11
1 1 11
1 W1
I -
1.e
,-ice
1,1 \I
PROPOSED WELL
PERMIT #238263
TRACT 68
•
FOUND
REBAR & CAP
P.L.S. 10671
TRACT 67
TRACT 70
1
EXISTING
FENCE
15736'
;AT
'TRACT
8.;>98± ACRES
S89'49'04'E 498.91'
NAS 400' TO EAST
RS: SECTION LINE
0o PROPOSED WELL
zN PERMIT #238262
[...1mg TRACT 69
341.35'