HomeMy WebLinkAboutApplication- PermitC1.•
-73 c
GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
108 Eighth Street, Suite 201
Glenwood Springs, Coloradof 81601
Phone (970) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
\(,
Dp-1)
Permit °`3
Assessor's Parcel No.
Owner's Name aX l 1 # • \a (L. Present Address4'37)9 ` \ \1 YJ " " S
System Location LI'5 '1 C- \-1 C WS
( 1
Legal Description of Assessor's Parcel No. / r)O C ..) . )' 'CL. 0.✓5. )
SYSTEM DESIGN
/000
Septic Tank Capacity (gallon) Other
Percolation Rate (minutes/inch) Number of Bedrooms (or other)
This does not constitute
a building or use permit.
Phone ``L()
1 4,41
Required Absorption Area - See Attached egrc)..� ��"' �" fi�`�
Special Setback Requirements:
Date q Ig -Of
inspector ,�
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
C
System Installer E i ('\ i i� > -' ;.(
1
Septic Tank Capacity n ✓
?
/I 31
dr.
Septic Tank Manufacturer or Trade Narne
Septic Tank Access within 8" of surface
Absorption Area 05 1��j if
r r".
or
Absorption Area Type and/or Manufacturer or Trade Name
Adequate compliance with County andi State regulations/requirements 1 1
i
Other
Date LP 7 Inspector .Y'1(A ( \.Q.tt.,1k.
*CONDITIONS:
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
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
Parcel No: (this information is
GARFIELD COUNTY SEPTIC PERMIT APPLICATION
108 8th Street, Suite 401, Glenwood Springs, Co 81601
Phone: 970-945-8212 / Fax: 970-384-3470/ Inspection Line: 970-384-5003
www.aarfield-county.com
available at the assessors office 970-945.9134) -8 ra 315„ 633—
33— 6 o —0
53
2
Job Address: (if an address has not been assigned, please provide Cr, Hwy or Street Name & City) and legal description o
qr'"" a COvtJr' l 1 A tek4 % 1..E rro.,P
3
emption:
Lot Size: Lot No: Block No:Subd em tion:
�r•�i�S,a-KP
rare a *shy.- a.. .....4 -ay.,,
4
0mier: (property owner)
1/411.4.11 41 l ei f
__. _..., ._..
Mailing Address 11get
-foofit_t_e&f
Ph: 4at,,, _43 z
% 51410014-
Alt Ph:
5
Contractor.
Mailing Address
: —ilk U► int
Ph: #21tvz,,,,
A.1— ry
Alt Ph:
6
• .! . t• emze.-ice
Arecu
Maili g Address
=.
Ph:
PIA -1.
t Ph: %it, 4114VP--Lif
IM.i4Tta
7
3
PERMIT REQUEST FOR: (K, New Installation ( ) Alteration ( ) Repair
8
WASTE TYPE: Dwelling ( )Transient Use ( )Commercial or industrial ( )Non- Domestic wastes
Pther--Describe
9
BUILDING OR SERVICE TYPE:
Number of ,,edrooms 11, 1111 Garbage Grinder Yes ( }No
10
SOURCE & TYPE OF WATER SUPPLY: f(NELL ( )SPRING ( }STREAM OR CREEK ( )CISTERN
If supplied by COMMUNITY WATER, give name of supplier. /
11
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
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
12
GROUND CONDITIONS: Opifir' 04
L
Depth to 151 Ground Water Table Percent Ground Slope T — r
13
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM (ISDS) PROPOSED:
Septic Tank ( )Aeration Plant ( }Vault ( }Vault Privy ( )Composting Toiiet
}Recycling, Potable Use ( Recycling,_other use ( )Pit Pri ( )Incineration Toilet )Chemical Toilet
{ )Other Describe Ag -4- .."
14
FINAL DISPOSAL BY:
( sorption trench, Bed or Pit underground Dispersal ( )Above Ground Dispersal ( )Evapotranspiration ( }Sand filter
}Wastewater pond ( )other- Describe
Issue DI
,1 CW:;°
15
Will effluent be discharged directly into waters of the state? ( )YES ?(N0
16
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:
17
Applicant acknowledges that the completeness of the application is conditional upon such further mandatory and additional test 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. 1 further
understand tha y Wal ' lc...• on or ' isrepresentation may result in the denial of the application or revocation of any permit granted based upon said application
and legal ac'a rp- f /Sspro'fedbylaw. "" S7d0
�, /
OWNERS - NAT 0E DATE
STAFF USE ONLY
Chi 2_& -(c
Permit Fee:
7 '42
Perk Fee:
' too , u --g-
Total fees:
141 75. 00
Building
1
Permit #:
I C`1 i`
Septic Permit #:s
Issue DI
,1 CW:;°
Ruildin & Planning D. e •
APPROVAL DATE
yj Liu
.,' , -= - - {-- — _ ..„ r - • _.,...-,. .
i
... . .
Hi
tj
D',!)
6