HomeMy WebLinkAboutApplication- Permitt
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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit N'_' 35 3 ?
109 8th Street Suite 303
Glenwood Springs, Colorado 81601
Phone (303) 945-8212
INDIVIDUAL SEWAGE DISPOSAL PERMIT
PROPERTY
Owner's Name vpaad W
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Systm LocatioMOO „ 3 Si 14- W R / G
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SYSTEM DESIGN 4 ea I Chan!
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= a p � +
/tV v Septic Tank Capacity (gallon) 'KFC Other
/ N� �1 c1„y/ Percolation Rate (minutes/inch) Number of Bedrooms (or other)
Required Absorption Area - See Attached
Assessor's Parcel No.
This does not constitute
a building or use permit.
*
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Present Address 4i a0 3 metedS' Phone 6 a 5-3 syr
Legal Description of Assessor's Parcel No.
Special Setback Requirements:
Date (95 6 / 0 .2—
Inspector
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FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
"Call for Inspection (24 hours notice) Before Covering Installation
System Installer v22
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Septic Tank Capacity /6.-01:7
Septic Tank Manufacturer or Trade Name
Septic Tank Access within 8" of surface
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Absorption Area C9\ 6) G a
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Absorption Area Type end/or Manufacturer or Trade Name --- / (,- i ,✓
Adequate compliance with bounty and State regulations/requirements
Other
Date._(/ 2C AO .2••
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 specif ications contained in the application of permit commits a Class I, Petty Offense ($500.00 fine — 6
months in jail or both).
White -APPLICANT Yellow -DEPARTMENT
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER LJ)e vprrl`hl I %oll
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ADDRESS 1-j / 2 0 32-0 ✓2 PHONE 17o - t 2,SR- •S S`y
CONTRACTOR S 'e—
ADDRESS PHONE
PERMIT REQUEST FOR ($.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 of Town 4i ll— Size of Lot /6 BrRes
Legal Description or Address 3
WASTES TYPE: ($)NDWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPE: C* .J
Number of Bedrooms 3 Number of Persons
( ) Garbage Grinder ()C) Automatic Washer ( ) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: (+c) WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: 20 n jes
Was an effort made to connect to the Community System?
A site plan is required to be submitted that indicates the following MINIMUM distances:
Leach Field to Well:
Septic Tank to Well:
Leach Field to Irrigation Ditches, Stream or Water Course:
Septic System 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
2
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
SEPTIC TANK
VAULT PRIVY
PIT PRIVY
CHEMICAL TOILET
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AERATION PLANT ( ) VAULT
COMPOSTING TOILET ( ) RECYCLING, POTABLE USE
INCINERATION TOILET ( ) RECYCLING, OTHER USE
OTHER - DESCRIBE
FINAL DISPOSAL BY:
(pc-) 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?
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.
Signedat3 se.,,1 ,d it j I C
Date S''— l i! -
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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