HomeMy WebLinkAboutApplication- PermitGARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N-
3985
109 8th Street Suite 303
Glenwood Springs, Colorado 81601
, Phone (303) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
( PROPERTY
Owner's Nam
System Location
t
t s
1
Assessor's Parcel No.
This does not constitute
a building or use permit.
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4193 M 30/-t�r)nac 1ILL r95,1
Legal Description of Assessor's Parcel No a/ 76<- L -I CO— C) ouy
SYSTEM DESIGN
Septic Tank Capacity (gallon) Other
Percolation Rate (minutes/inch) Number of Bedrooms (or oth'er)) er3
Required Absorption Area - See Attached ,- i� * & A ; 2 7 p c 1
Special Setback Requirements: 5 4 3i' p-c(
Y K
Date [/ Inspector �'✓�'°/
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System Installer
Septic Tank Capacity /60o
Septic Tank Manufacturer or Trade Name
Septic Tank Access within 8" of surface t7 Q/3.-
Absorption Area:) > [AAA -LA �^" A (s- - 6- 6,!
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Absorption Area Type and/or Manufacturer or Trade Name'
Adequate compliance with County and State regulations/requirements Y"��
Other
Date
/D—/q-4V
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-
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
GARFIELD COUNTY Page 2 of 9
r
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER ADDRESS 8q93 3o\ it ? gNCA'su-n On
PHONE g \O - 67-4 -14470
CONTRACTOR ADDRESS
PHONE
PERMIT REQUEST FOR: (.)'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 or Town acettCrtuTt (RIAtSCO QRaiF IiZttfrk Qe.4�a
Size of Lot 5 (site s. P.5
Legal Description or Address 8493 Sol Rn Rpte.Acw,ie . C14, Rlb-R2,
WASTES TYPE:
(i4'Dwelling ( ) Non -Domestic Wastes
( ) Transient Use ( ) Commercial Or Industrial
( ) Other: Describe:
BUILDING OR SERVICE TYPE:
Number of Bedrooms 3
Number of Persons c2
(vrGarbage Grinder ("Automatic Washer (t4'Dishwasher
SOURCE AND TYPE OF WATER SUPPLY:
(a'WELL () SPRING () STREAM OR CREEK
If supplied by Community Water, give name of supplier: nIIA
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to the Community
System? ( ) Yes (4 No
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GARFIELD COUNTY
Page 3 of 9
A site plan is required to be submitted that indicates the following MINIMUM distances:
Leach Field to Well:
Septic Tank to Well: A\ °% S"''ta '`4 M+}?
Leach Field to Irrigation Ditches, Stream or Water Course
Septic System to Property Lines:
YOUR INDIVIDUAL SEWAGE
WITHOUT A SITE PLAN.
GROUND CONDITIONS:
100 feet
50 feet
50 feet
10 feet
DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED
Depth to first Ground Water:
Table Percent Ground Slope:
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
((Septic Tank
() Vault Privy
() Pit Privy
() Chemical Toilet
() Aeration Plant () Vault
() Composting Toilet ( )Recycling/ Potable Use
() Incineration Toilet ( ) Recycling/Other Use
( ) Other — Describe:
FINAL DISPOSAL BY:
(vrAbsorption 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? No
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. 4
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GARFIELD COUNTY Page 4 of 9
RPE WHO MADE SOIL ABSORPTION TESTS:
Name:
Address:
Telephone:
RPE RESPONSIBLE FOR DESIGN OF THE SYSTEM:
Name:
Address:
Telephone:
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 fumished 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.
Signa
Date: "i -IQ - to -1
48°
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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