HomeMy WebLinkAboutApplication- PermitGARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N`_ 3 8 3 8
109 8th Street Suite 303
Glenwood Springs, Colorado 81801
Phone (303) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY �/ ///��� �A Q n
Owner's Name /' ovi-t.�T/ �M�`S T. Present Address ,QNaf r 6a r1,' `/�� - 5p, �oneq� - 3b 7.3 7 y5
System Location / / (?1'�ir Sar /Cd . .Si 1- W O 165
Assessor's Parcel No.
&119/6 3oo65Y
This does not constitute
a building or use permit.
Legal Description of Assessor's Parcel No
SYSTEM DESIGN
hit S fry 446 (A) ea rat
/b0 D Septic Tank Capacity (gallon) Other
/3
Percolation Rate (minutes/inch)
Required Absorption Area - See Attached
Special Setback Requirements:
9.23-o3
Date
Number of Bedrooms (or oth r)
68/0
3V/ 14- Dr8
Inspector Ver
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Call for Inspection (24 hours
,ic
notice) Before Covering Installation
System Installer l/w ,tCA/l
Septic Tank Capacity /07:30
Septic Tank Manufacturer or Trade Name / i
Septic Tank Access within 8" of surface
�{�-Yr
Absorption Area I (1h,lA 1/31 V/ll
Absorption Area Type and/or Manufacturer or Trade Name Lt -C7 /0
Adequate compliance with County and State regulations/requirements
Other I �'
Date //l - C� - ✓ Inspector �!t%1AL---2,7" —/ --'���(///
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
•CONDITIONS: ' k
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. t
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 r
requirement of the permit and cause for both legal action and revocation of the permit. \ I
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).
4
White - APPLICANT Yellow- DEPARTMENT
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER t JWM H'S CT, mui T
ADDRESS C 112 g &t kOtTD - S IL* PHONE 30q— 3q49 Cg70)
CONTRACTOR G F
ADDRESS S Mit 6 PHONE Sfw L
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: n
Near what City of Town S 1 L� Size of Lot 40it £5
t.S ChMCirr Rd.
( ) TRANSIENT USE S 14
Legal Description or Address figyriPc C Ct>
WASTES TYPE: DWELLING
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER—DESCRIBE
BUILDING OR SERVICE TYPE:
2 S't'JOLE Few(lLy 2f3IDenCe
3 Number of Bedrooms Number of Persons r
( ) Garbage Grinder '<Automatic Washer (Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: �j,(jWELL /( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: C M 1 LES
Was an effort made to connect to the Community System? AJ 0
A site plan is required to be submitted that indicates the following 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
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
00 UNDERGROUND DISPERSAL ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
( ) OTHER -DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? A h _
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.
Signed
PLEASE DRAW AN AC
Date / / •Y� 2a'3
MAP TO YOUR PROPERTY
1.1
POWER
LINE
60 x60
GRAVEL
ROAD
• SS TO
SE
S
ix
342 /-
4SW 7/4
76
TO THE NOR
WATER LINE
Soo
31 Xb4-
mppdLPNL-
100 FT PSCO ESMT.
800K 325 PAGE 345
N
07.33'
1320.00'
BLM EASEMENT
BOOK 382 PAGE 41-3
DIRT
ROAD
FENCE /
43'52" W
1321.09'
0'
200'
400'
600'
PARCEL NO. 72 -CC
125' POWER LINE
BOOK 348 PAGE 368
• R&C L.S. 13501
CERTIFICATION
1, SmCc iL �s LEG4L DESCRIPTION
SE1/
331 SECTION /4SWI164
76S, R92W
OF7HE67HP.M.
I hereby certify that this Improvement Survey Plot was prepared for Commonwealth Tit/e.
I further certify that the improvements on the above described parcel on this
date, 5/08/03, except utility connections, are entirely within the
boundaries of the parcel, except as shown, that there ore no encroachments upon
the described premises by improvements on any aoyifffiThgttpremises, except as
indicated, and that there is no apparent evideo:rd n,,of� any easement
crossing or burdening any port of said p• e��.S �s4' fret?
t I � Q By Richard '� . pIL.S�H
4 Z �i F sunli, *