HomeMy WebLinkAboutApplication- PermitGARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
109 8th Street Suite 303
Glenwood Springs, Colorado 81801
Phone (303) 945-8212
{{i INDIVIDUAL SEWAGE DISPOSAL PERMIT
• PROPERTY
i" Owf4er's Nam QQ'Present Addres3InS 5wy(o.
J'` �'4
System Location 1QI5 1 �1% (LJ�
Permit N2 3740
Assessor's Parcel No.
This does not constitute
e building or use permit.
i‘ Legal Description of Assessor's Parcel No
SYSTEM DESIGN
Phone(Da 17 64,
1 )" 5b Septic Tank Capacity (gallon) Other
Percolation Rate (minutes/inch) Number of Bedrooms ( r other)
? 3 3 t v. - /gam C
y beef cD/A131 o t,
)04-0;e1
aJ--
Required Absorption Area - See Attached
Special Setbacky Requirements:
Date Q" /'� a'
Inspector
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours notice) Before Covering Installation
System. Installer / �t4
/ 23-0
Septic Tank Capacity
Septic Tank Manufacturer or Trade Name
(116)p'&--
Septic
118p.&- -
Septic Tank Access within 8" of surface
Absorption Area Dom""fi d""'"rr LO /40-04141
Absorption Area Type and/or Manufacturer or Trade Name
Adequate compliance.lgith County and State regulations/requirements�
Other
Date / 2e -o L Inspector /yyr
RETAIN WITH RECEIPT RECORDS AT CONSTR TION SITE
„ "4- 411.
•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 e
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 Ina 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
Sift months in jail or both).
White - APPLICANT Yellow - DEPARTMEN
r
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER 5 -1 L.4 -it& / (ct /r -a
ADDRESS 3/053 at (, 1
CONTRACTOR 4- /
/ S c a v a �`
ls
ADDRESS S." / t- (7 v
oio `jB7-5 4c
PHONE G.- S- (75'G
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 of Town 6t f -we / Size of Lot "T f aches
Legal Description or Address 3 (o S 3 fig/ G 1 71 Cc y s A 0 r n:(4,
WASTES TYPE: )C) DWELLING / ( ) TRANSIENT USE
1( )) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER -DESCRIBE
BUILDING OR SERVICE TYPE: T wi
Number of Bedrooms
( ) Garbage Grinder
1
Number of Persons
( ) Automatic Washer ( ) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: ( ) WELL K) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: 3 0-1,-/e
S
Was an effort made to connect to the Community System? G o
A site plan is required to be submitted that indicates the following MINIMUM distances:
Leach Field to Well:
Septic Tank to Well:
100 feet
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
2
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
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
OTHER -DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? %7 0
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 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.
iii
Signed - r Date
PLEASE DRAW AN A U';� E MAP TO YOUR PROPERTY!!
3
Book 1212,
Page 522
N63'29'26'W \Yqi
127.04'\
V
N32'31'13'W 6
109.91'
Railroad Post I
Bears N54'27'01'W
0.51 feet from point for comer
A
Pond
Book 709,
Page 646
A )( / N7844.35'EJ
. "sling Perc4(
a.\/`
E 265.55;`
l 2 we
---__..„�,Dyksr
Bdok 662,
Page 770
1/2"Iron Rod
in Place
6
ar 3 Cap 1
59in
5933 in Place
1
1
1
I
A
navvies
vv'.. Cbl
' \
44� 69 83726914�
▪ Pond
mvneF
0° 11 wl�\
;Id liA
\� Block anaat> \
92 Dykstra \ Frame
Book 662,y \�— *\ \
N
Page 770 r�\\\ °= \ a'
22.T
9e
Co \
\
Book 951,
Page 694
l✓/^of
gg6r'1, r°Ll
SEE DETAIL
Area of overlap
0.046 Acres
)1 Robinson
� Y Line (dashed)
\'1.10
j0
Robinson
▪ Book 347,
Page 478
NDt
Rebar and Cap
IS No. Illegible in Place
777.10'
alt Line Section 5 2648.70'
Highway 6
•
ZL
Rebar and Cap WC
LS No. 5933 in Place
Dykstra Line
(solid)
\▪ \ \ �•
11 \\
' 133.42' 165.15' A
86'20'57 W
Aiea of Overlap
0.216 Acres
40'50
W
If
11
I