HomeMy WebLinkAbout03140'
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PROPERTY
GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT
109 8th Street Suite 303
Glenwood Springs, Colorado 81601
Phone (303) 945-8212
Permit N~ 3140
Asseaaor'• Parcel No.
This does not constitute
a building or use permit.
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System Location-----~--'"+--~~------"C~JZ..,"-"''-'2Q=-=-----f;ki-"''--"'11F~-='-"-------------Phone CPZ.5-flol 5
Legal Description of Assessor's Parcel No . .-cc:--,~-,---,---,--:--::-co-------,..---.~~-----------~----
L C AC 1-1-Ci H >.I--< (3£.-i. ~ D EO ~ L. / tJl·<t 1.5
SYSTEM DESIGN '-"" --'f I\. E f-• C 1-f C: S :: "L f /f f-r V f-' 1 l J
{ 60 0
1 /'l_ 0
Septic Tank Capacity (gallon)
Percolation Rate (minutes/inch)
Required Absorption Area· See Attached
Special Setback Requirements:
______ .Other i../ ( ''
Number of Bedrooms (or other) _.J='---
G -1-q -<1 a. Date-------~( ____ Inspector _________________________ _
System lnstaller ___ ~(')"-L--"l,._....=~N~~t~_V\...~-------;--+---------------
Septlc Tank Capaclty ___ ,1--0>L-'O"'-'D~-...,.."'\.1.~------· ---------------
O r-Q .,., ~ l i\ .,..110
Septic Tank Manufacturer or Trade Name ___ _,,,_,..__,_~,,,__,r:.'----"'-"--'-----'-='='"---------------
Septic Tank Access within 8" of surface ----~---------------------------
Absorption Area ___,1_,,,_,_/_· _ _,,,V'--'-N_,_,_1 _.1~J"'--_l,_,_tJ"-----"J_]=_.__,/l.-'"-'f..,-'-!V-(._ff:...c·--=l:..,,,.[.___ _____ _
Absorption Area Type and/or Manufacturer or Trade Name _ __..(_,_f.--"-{~f:._____,_/_L=-_1,__,/l'-"~A'--'-_7,__D_'}t:..:.~f.__ ______ _
Adequate compliance with County and State regulations/requirements ___________________ _
Other-----------------------~-----------------
ru -'L -Cf"' __J_ ---.s::--oate __ ~~-~----~! ____ Inspector rt-
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
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25, Article 10 C.R.S. 1973, Revised 1984. ~-f 2. This permit Is valid only for connection to structures which have fully complied with County zoning and building requirements. Con· ;· ~
' t nection to or use with any dwelling or structures not approved by the Building and Zoning office shall automatically be a violation or a Ji
:. \ requirement of the Permit and cause for both 1'¥!al action and revocation of the permit. t ~
} ?. 3. Any person who constructs, alters, or installs an Individual sewage disposal system In a manner which Involves a knowing and material ~ \
·. ~ variation frJVthe terms or specifications contaln9d In the application of permit commits a Class I, Petty Offense ($500.00 flne-6 ·i·-; !' months In or"t>~t~).
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ff . ,\ ( ~le -APPLICANT Yellow -DEPARTMENT . ' '
-----~-------------.._ _____ .............. -----------____________ ....._......_._..........._____ -----------__ _... __ ~.-~-"-_.........._~ ~ --~
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INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER_~'--7'~--'~'">f-------------------------~
ADDRESS-'-~---'--------------
CONTRACTOR ____ ..l[l,e]~~::'.--------------------
ADDRESS S"t >'1 CR C3 .Ito PHONE t'.:? f"-I 6? f'
PERMIT REQUEST FOR VI() NEW INST ALLA TI ON ( ) 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, _________________ .... S...,jz.._e -"'of._.L...,o,.t_9.:....:._. ::....f'."°'9.?"-'A..:..c.;::..·;__ __
Legal Description or Address ~Pf 31 lfrr/A.;i,t lr tJ;eJ,ud
WASTES TYPE: (X) DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER-DESCRIBE _______________ _
BUILDING OR SERVICE TYPE: _______________________ _
Number of Persons....,.....~----
( «) Dishwasher
Number of Bedrooms~'--------------
( ) Garbage Grinder (X) Automatic Washer
SOURCE AND TypE OF WATER SUPPLY. ()() WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: ________________ _
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:__,_7_.""'--'-, ..... /.._eJ.._ ________ _
Was an effort made to connect to the Community Systern?_'-N....:o'---------------
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 to Property Lines: 10 feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED
WIWOUT A SITE PLAN.
GROUND CQNDITIQNS:
Depth to first Ground Water Table __ :t_O. __ 'O"'--,,,--------------------
Percent Ground Slope._--'6"---'....._ _______________________ _
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• PE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
_,r) SEPTIC TANK ( ) AERATION PLANT ( ) VAULT
( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POT ABLE USE
( ) PIT PRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
( ) CHEMICAL TOILET ( ) OTHER -DESCRIBE
FINAL DISPOSAL BY:
(/>() ABSORPTION TRENCH, BED OR PIT ( ) EV APOTRANSPIRA TION
( ) UNDERGROUND DISPERSAL ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
( ) OTHER -DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE?_A/~'°---
PeRCOLATION TEST RESULTS· (To be completed by Registered Professional Engineer, if the Engineer does
the Percolation Test)
Minutes. _____ p1 er 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 ofRPE who made soil absorption tests: ______________ _
Name, address and telephone ofRPE 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 --"4=---.::.;;_;;;,.t-,;....-L_-"'--==p-...,.----
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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