HomeMy WebLinkAbout3808GARFIELD COUNTY
BUILDING, SANITATION and PLANNING DEPARTMENT
109 8th Stmt suite 303
Glenwood Springs, Colorado 81001
(309) 946.8212
15 3
3584 312 Rd. New Castle
Job Address
Nature of Work
Use of Building _ replace Mobile HCme
Owner John Ragle
Contractor Ow37er
AmountofPermit: $ 3000 Date:
I:. 1mring
��_.._...-� Clerk
White-Treas.
Canary -Office
Pink -Applicant
Gold - Duplicate
'~ GARFIELD COUNTY
a APPLICATION FOR BUILDING PERMIT
please print or type
TO BE FILLED OUT BY APPLICANT
ADDRESS
a SUBDIVISION
6 FILING # LOT # BLOCK
TAX SCHEDULE #
LEGAL (SEC/TWN/RNG)
u NAME d
MAILING AD��D�71RgEss
p CITY /U. l i95i '� PHONE .,_7
NAME
ADDRESS CITY
W NAME
ADDRESS
CITY
PHONE LICENSE N
NEWx ALTERATION ADDITION
DEMOLI H REPAIR MOVE
MOBILE HOME (make/model) frff 6vN/u9U/_. A
S. F. OF BUILDING 44 $ ^ S. F. OF LOT
# OF FLOORS z HEIGHT
# OF FAMILY UNITS / #. OF BEDROOMS
INTENDED USE OF BUILDING
GARAGE: SINGLE_ DBL_ CARPORT: SINGLE DHL
FIREPLACE
WATER SUPPLY y' (J
DRIVEWAY PERMIT ^
SITE PLAN
BUILDING PLANS
SANITARY SEWER CLEARANCE 1}"
ON SITE SEWAGE DISPOSAL PERMIT �.
OTHER DOCUMENTS (specify)
PERMIT NUMBER p /
DATE
PLOT PLAN
NOTE: Show easements, property line dimensions
all other structures, specify north, and street
name. For odd shaped lots, or if space is
too small, provide separate plot plan.
OF BUILDINGS NOW ON PARCEL
USE OF BUILDIN=0W ON PARCEL
f"� S i� Pvrc�
r4 /s le- mUSP��r"L
/r
n f W 5 F -/A
)�6 f -
FRONT PROPERTY LINE
STREET NAME/ROAD NUMBER
CHECK IF CORNER LOT _
DESCRIPT,rON OF WORK PL
JANNED
zot-�fg
r
I ifereby acknowledge that I have read this
application and the above is correct and I
agree to comply with all county ordinances
and state laws egulating building construction.
'AM, _
GNATURE
FOR OFFICE USE ONLY
VALUATION FLOOD HAZARD
PERMIT FEE $ O,0 v PLAN CHECK FEE $ CERTIFIED BLDG ELEVATION
TOTAL FEE $ To.p o SCHOOL IMPACT FEE $ SPECIAL CONDITIONS
DATE PERMIT ISSUED
ZONING DISTRICT ,b
TYPE OF OCCUPANCY -- 3
TYPE OF CONSTRUCTION
S. F. OF BUILDING [�p r.] o S. F, OF LOT z+ a
MAX. HEIGHT _ / 2-_ �_ ROAD CLASS.
SETBACKS FROM PROPERTY LINE: FRONT
REAR RIGHT LEFT r
OFF STREET PARKING SPACES REQUIRED
APPROVED:
PROBLEMS WITH PERMIT
ADDITIONAL INFORMATION NEEDED
CERTIFIED BY COLORADO REGISTERED LAND SURVEYOR
OR ENGINEER
% INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
Approval by
County Official:
014HER V\t,3
ADDRESS . -PHONE
CONTRACTOR
ADDRESS PHONE e e F
PERMIT REQUEST FOR: ) New Installation ( ) Alteration ( ) Repair keVion ,wv1
Attach separate sheetslirt
report showing entire area with respect to surrounding areas, WJ s
topography of area, haable building, location of potable water wells, soil percolation/- v 1
test holes, soil profiles in test holes. (See page 4.)
LOCATION OF PROPOSED FACILITY: County_ (A&q,6£1a[
Near what City of Town C end e- ___ ____ _____ ____Lot Size
Legal Description ....
WASTES TYPE: Dwelling
y/ ) Commercial or Institutional
( ) Other - Describe
BUILDING OR SERVICE TYPE:
( ) Transient Use
( ) Non-domestic Wastes
Number of bedrooms Number of
persons
( ) Garbage grinder ( ) Automatic asher ( ) Dishwasher
SOURCE AND TYPE OF WATER SUPPLY: ( ) well ( ) spring
( ) stream or creek
Give depth of all wells within 18 feet of system: In ky,p
If supplied by community water, give name or supplier:
GROUND CONDITIONS:
Depth to bedrock:mm
Depth to first Ground Water Table: % �a
Percent ground slope: -� F•• fi.
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: ./ LE' 5
Was an effort made to connect to community system? I o
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
1 Chemical Toilet ( 1 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? r:)U
ti
SOILfPERCOLATION
TEST RESULTS: (To be completed
by Registered
Professional Engineer.)
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
purposes of the evaluation of the application; and the issuance of the permi'•t.is subject to
such terms and conditions as deemed necessary to insure compliance with rules and regulations
adopted under Article 10, Title 25, C.R.S. 1973, as amended. The undersigned hereby certifies
that all statements 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 under-
stand 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 per-
jury as provided by law.
Date 10 Signe
PLEASE DRAW AND ACCURATE MAP TO YOUR PROPERTY
Page 3
PLOT PLAN AND DESIGN FEATURES:
Include by measured distance location of wells, springs, potable water supply
lines, cisterns, buildings, property lines, subsoil drains, lake, water course,
stream, dry gulch and show location of proposed system by direction and distance
from dwelling or other fixed reference object, and additional submissions in
support of this application such as data, plans, specifications, statements and
commitments.
Page 4
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